Jayasree Kallat, Member The petition was filed on 01.06.2009. The complainant had joined AB Arogyadaan Mediclaim Policy jointly sponsored by Andhra Bank & united India Insurance Co. Ltd., from 12.01.2005 onwards. He had remitted premiums Rs.431/- on 12.01.2005, Rs.1005/- on 06.06.2006, Rs.969/- on 07.06.2007 and Rs.990/- on 09.06.2007 at Andhra Bank,Calicut Branch. Complainant have not claimed any Mediclaim re-imbursement until the Maturity period of the policy on 02.08.2008. On June 2008 complainant had contacted PVS Hospital, AL-SAFA Calicut, and Santhigiri Ayurvedic Hospitals. The complainant then came to know that these hospitals did not have a tie-up with the 3rd opposite party Bank or the first opposite party Insurance company. Complainant alleges that the opposite party-3 had given improper information and hence complainant could not avail mediclaim reimbursement from the hospital in which he was treated . The complainant is alleging deficiency on the part of opposite party and has filed the petition before the Forum. Opposite party No.1 has filed a version. The complainant is not maintainable. Opposite party denies the allegation in the complaint except those that are expressly admitted. The petition is liable to be dismissed. There is no cause of action for the complainant to file the petition before the court. First opposite party admits that complainant has obtained AB Arogyadaan Mediclaim policy during the year 2005, which commenced from 14.01.2005 to 08.06.2005. The policy was renewed for another 3 years which closed on 08.06.2008. Within this period of the valid policy the complainant has not claimed for any reimbursement amount. Opposite party denies that complainant had contacted PVS Hospital during May, June 2008, and it was informed to the opposite parties. The complainant has not availed the service of any of the approved hospitals, for his treatment purpose, during the policy period. Complainant has not shown any proof that he has contacted the hospitals and undergone treatment and expenses incurred upon. The opposite party is not liable to pay any amount to the complainant as there was no deficiency on the part of opposite party. Opposite party-1 prays to dismiss the complaint. Opposite party-2 has not appeared before the forum or filed any version, even though notices was served. Opposite party-3 filed a version denying the averments in the complaint. The complainant is not a consumer. It is true that the complainant had joined AB Arogydaan Mediclaim Insurance Scheme. The scheme is specifically meant for the group mediclaim insurance proposal for the account holders of the opposite party. The complainant joined the scheme by paying premium amount to the opposite party-No1. Certain hospitals are designated for cash less services which is rendered through the 3rd party administrators. After the insured undergoes treatment in non-designated hospitals, the party will be indemnified subsequently. A booklet with identity card will be issued to the insured through TPA. The complainant has not availed any facility from any of the hospitals in the list. He had no occasion to make use of the hospital facility. As the complainant has not raised any claim there was no chance for denial of the claim. The complainant has filed a petition without any base. Opposite party -3 is only an agent who collects the premium on behalf of their customers. There was no deficiency on the part of Opposite party-3. Opposite party is not liable to pay any amount to the complainant, Opposite party-3 prays to dismiss the petition. The only point for consideration is whether the complainant is entitled as prayed in the petition ? The complainant was examined as PW1 and Exts. A1 to A8 were marked on complainant’s side. Opposite party-1 and Opposite Pary-3 did not have any oral or documentary evidence. The case of the complainant is that attracted by the advertisements displayed by the opposite party-3 Andhra Bank, he had joined in the AB Arogyadan Scheme of the insurance company Opposite Party- No.1. According to the complainant a number of hospitels were listed in which the policy holders could have treatment and avail cashless facility as the opposite party have tie-up with these hospitals. Complainant had paid premium for three consecutive years from 12.01.2005 to 09.06.2008. The complainant did not avail the service of the opposite party, as there was no cause for him to avail the services at that time. During the month of May, June2008, according to the complainant he had contacted three prescribed hospitals listed in this scheme, such as PVS Hospital, AL-SAFA, Calicut and Santhigiri Ayurvedic Hospital. When the complainant enquired whether these hospitals had the facility under the AB Arogydaan Scheme he received a reply that these hospitals did not have any tie-up with the opposite parties under the particular policy. The complainant had approached Opposite party-No.3 but the opposite party has not given any reply. The opposite parties 1 & 3 have filed version contending that the complainant had taken policy under AB Arogydaan scheme but did not avail the service of the opposite parties during the policy period. The complainant had contacted PVS Hospital after the policy, for which the opposite parties are not liable. Opposite parties specifically have stated that out patient treatment and admission for evaluation and investigation strictly not covered. Ext.A5 produced by the the complainant shows the reverse side of the Good Health Plan card, in which it is clearly stated . Another contention raised by the opposite parti is that the list of hospitals under the prescribed scheme will differ from period to period. It is clearly mentioned in the booklet given to the complainant. Opposite party-3 states that they are only an agent of the insurance company, they collect the money and remit to the opposite party-1 company. Accordingly they have not received any money from the complainant for the service rendered by opposite party-3. Opposite party No.1 has categorically stated that the complainant could have availed the services of the opposite party at any time during the valid policy period. But the complainant did not undergo any treatment at that time .So he could not avail the services at a later stage. He has alleged that he had approached PVS Hospitals for treatment. From there he got the information that there was no tie-up with the opposite parties for the particular scheme. Opposite parties submit that the list of hospitals changes from period to period which is already informed to the complainant by the booklet given to him while taking the policy. In addition the facility of the particular scheme does not cover for outpatient treatment or investigations. The complainant has not undergone treatment as impatient hence he could not avail the facility under the scheme. There was no deficiency on the part of the opposite parties. After hearing both sides in detail the forum has been convinced that there was no deficiency on the part of opposite parties and hence the complainant in not entitled for the relief sought in the petition. In the result we are of the opinion that the petition is liable to be dismissed. Pronounced in the open court this the5th day of July 2010 Date of filing : 1—6—2009. SD/- PRESIDENT SD/- MEMBER SD/- MEMBER APPENDIX Document exhibited for the complainant: A1. Prescription issued by Dr.Ram Manohar of P.V.S.Hospital A2. Copy of Registered letter with postal receipt and acknowledgement card. A3. Copy of letter(Reminder-2) dtd.28.07.08 A4. copy of letter dtd.01.06.2008 A5.Photocopy of Good Health Plan card of AB Arogyadaan issued to Rajan. A.K. A6. Photo copy of Renewal Authorization letter of AB-Arogyadaan. A7. Photocopy of GHPL- Network Hospitals list-Kerala. A8. Photocopy of credit advice of Anthra Bank ( 4 in number series.) Documents exhibited for the opposite party Nil Witness examined for the complainant: PW1.A.K.Rajan (Complainant) Witness examined for the opposite party: None SD/- PRESIDENT //True Copy// //Forwarded /By order SENIOR SUPERINTENDENT
| | [HONOURABLE MRS. Jayasree Kallat, MA.,] Member[HONOURABLE MR. G Yadunadhan, BA.,LLB.,] PRESIDENT[HONOURABLE MR. L Jyothikumar, LLB.,] Member | | 
