Tamil Nadu

South Chennai

CC/58/2021

Ramakant Kapoor - Complainant(s)

Versus

United India Insurance, Rep by its Managing Director and others - Opp.Party(s)

M/s V.Shankar

29 May 2023

ORDER

                                                                                                                                    Date of Complaint Filed : 15.12.2020

                                                                                                                                     Date of Reservation      : 03.05.2023

                                                                                                                                     Date of Order               : 29.05.2023

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT: TMT. B. JIJAA, M.L.,                                          : PRESIDENT

                    THIRU. T.R. SIVAKUMHAR, B.A., B.L.,          :  MEMBER  I 

                   THIRU. S. NANDAGOPALAN., B.Sc., MBA.,    : MEMBER II

               

CONSUMER COMPLAINT No.58/2021

MONDAY, THE 29^th DAY OF MAY 2023

Ramakant Kapoor,

S/o. Sh. Kundan Lal Kapoor,

Flat No.8, Amar Apartments,

98/45, 2^nd Main Road, Gandhinagar,

Adyar, Chennai – 600 020.                                                                                                                …Complainant.

..Vs..

1.United India Insurance Co. Limited,

   Rep by its Managing Director,

   24, Whites Road,

   Chennai – 600 014.

 

2.Ericson Insurance TPA Pvt Ltd.,

   Rep by its Managing Director,

   1-G, No.22, Prince Arcade,

   Cathedral Road, Gopalapuram,

   Chennai – 600 086.                                                                                                                           .. Opposite Parties.

                                                                 

                                                                                           * * * * *

Counsel for the Complainant   : M/s. V. Shankar, Lavanya Shankar

Counsel for 1^st Opposite Party: M/s. S. Dhakshanamoorthy

Counsel for 2^nd Opposite Party : Exparte on 10.05.022

 

On perusal of records and having heard the oral arguments of the Counsel for the Complainant and the Counsel for the 1^st Opposite Party, this Commission delivered the following:

ORDER

Pronounced by Member-I, Thiru. T.R. Sivakumhar., B.A., B.L.,

(i)  The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to reimburse a sum of Rs.24.169.13/- with interest 18% p.a., from 11.10.2018 till date of reimbursement of the claim, being the amount entitled by the Complainant under the policy and to pay a sum of Rs.4,00,000/- as compensation for causing unwarranted mental agony and hardship along with cost of Rs.50,000/-.

I.  The averments of Complaint in brief are as follows:-

1.     The present Complaint was filed attributing the laidback approach of the Opposite Parties for non reimbursement of the claims submitted with them on the strength of a Medical Insurance Policy, under Indian Banks Association Scheme (IBA-Scheme), availed by his employer for the period 01.11.2018- 31.10.2019.

2.     He was absorbed by Dena Bank in the year 1984, the said bank got merged with Bank of Baroda in the year 2019 and as a part of his employment benefits he and his family members were entitled for reimbursement of medical expenses both inpatient & outpatient and the premium amounts were paid directly by his employer as his employment perks against the medical expenses reimbursement scheme for the employees as per the Dena Bank Officers' Service Regulations, 1979.

3.     He was told that the Opposite Parties would be service friendly, trustworthy and for sure he will not feel let down such health insurance cover was provided by his employer for himself, his Spouse, his Mother Daughter & Son and such a decision was arrived by the Indian Bankers Association (IBA) for the Bank Officers as per the Joint Note signed by the participating Bank taking into consideration to safeguard from any unexpected sicknesses, which is quite common in the present situation coupled with inflating cost towards hospitalization.

4.     He has been availing the services of the Opposite Parties since 2015-2016 and his employer been annually renewing the policy without any break and it would be valuable to note that as a matter of protocol his employer always retain the Insurance Policy with themselves.

5.     He was reported to Ruby Hospital, Mumbai on 19.02.2018 for treatment of his thumb, his spouse also reported to Ruby Hospital on 19.02.2018 for Triger Finger treatment and reported to Fortis Malar Hospital on 25.09.2018 for treatment of Heart ailment, Diabetes and High Blood Pressure etc., and his daughter was reported to Parsu Dental Clinic on 06.09.2018 and Fortis Malar Hospital 25.09.2018 for treatment of Teeth and acute gastroenteritis, thus he had incurred a sum of Rs.99,796/- towards the same and he had remitted the payments to the Clinic/Hospitals through his credit card as he was confident that the Opposite Parties will reimburse the same on submission.

6.     As per the practice the claim for a sum of Rs.99,796/- dated 11.10.2018 along with original medical records was submitted with his employer Dena Bank, Zonal Office, Chennai for onward submission to the Insurance Company's TPA representative at Mumbai and he was under the bonafide impression that the claim being genuine should be definitely approved since earlier claims submitted by him were honoured by the Opposite Parties without any demur.

7.     Out of the total claim of Rs.99,796.60p the Opposite Parties proceeded to settle only a sum Rs 74,968.23p that to in bits &pieces and without rhyme or reason continue to withhold a sum of Rs.24,169.13p and the last payment towards the Claim made was remitted on 07.05.2019.

8.     When he had contacted the 2^nd Opposite Party, who is none other than the extended arm of the 1^st Opposite Party and to his shock and surprise the 2^nd Opposite Party replied that the documents in support of the claims have not reached them and when the Complainant quizzed if be so then how did 4 claims out of 8 claims have been settled upon which the 2^nd Opposite Party agreed to get back.

9.     As he had settled the Clinic/Hospital bills through his credit card and has been duly discharging the liability that arose there under by paying 3% p.m. interest for the amounts which he felt was unwarranted and the casual approach of the 2^ndOpposite Party aggravated the situation. Hence, he had contacted the 2^nd Opposite Party, who confirmed having received the documents, but failed to answer straight forward as to when the amounts shall be disbursed and the relentless careless of the Opposite Parties to sit over the claim needs to be deprecated in the strongest possible terms.

10.    The Opposite Parties' negligence has resulted him undergoing enormous mental agony & hardships. Though no amount of compensation would mitigate the hardships and loss he suffered, nevertheless he is of the considered opinion that the Opposite Parties are jointly and severally liable to compensate him a sum of Rs 4,00,000/-.

11.    The manner in which the Opposite Parties have not proceeded to reimburse his claim since 2018 is a glowing illustration of deficiency of service as enunciated under the Act.

12.    The relationship between himself and the Opposite Parties are that of a consumer and service provider, thus he is entitled to invoke the jurisdiction of this Commission for apposite remedy. Hence the complaint.

II. Written Version Of 1^st Opposite Party in brief is as follows:

13.    The complaint is about the baseless allegation and filed without impleading the Insured/Employer of the Complainant who is a necessary party to the dispute as rejection of claim by insurer was based upon the documents submitted by the Insured. Non impleading of the Insured/Employer of the Complainant proves lack of bonafide in the complaint.

14.    They issued a group Medicaim policy to INDIAN BANKS ASSOCIATION A/C: DENA BANK under which Complainant as an employee was covered along with his family members.

15.    The Complainant has listed out 8 separate claims in the Complaint whereas the Insurance company has processed all the claims which were received by it towards Domiciliary treatment. It is pertinent to submit that the Claims are liable to be reimbursed only if it is within the terms and conditions of the Policy. In this case, for claiming the reimbursement of Domiciliary treatment expenses, the Complainant need to submit all the requisite documents inter alia the prescriptions of the Doctor and the Original Bills. But the Complainant failed to submit the same.

16.    The Opposite Party has not committed any deficiency in service. The rejection of the claim is on bonafide reason and based on non submission of required documents by the Complainant.

17.    The Opposite Party is expected to submit the requisite documents for settlement of the claim. The duty is cast upon the Complainant to submit the required documents which includes the prescription of doctor which necessitated the medical treatment and Original Bills that would substantiate the actual expenses incurred.

18.    The Complainant has placed the alleged claim documents with his employer, hence the employer/Bank is the necessary party to these proceedings since they are privy to all these transactions and the Complainant failed to implead the employer for the reason that the lapses of "non submission of Documents" by the Complainant would be exposed. Without discharging his duty under the terms of the policy, the Complainant cannot expect settlement of the claim.

19.    The Opposite Party did not sit on the claim, it was only the Complainant who has failed to submit the required documents and also the claim forms filed by the Complainant would demonstrate the fact that there was huge delay on the part of the Complainant to submit the claims. These facts would explicitly demonstrates that the Complainant has not come with clean hands before this Honourable Commission, and this is evident from the very fact that the employer/Bank has not been impleaded in the present proceedings who is privy to all these transactions.

20.    The Complainant has not brought in any fact that would demonstrate the deficiency of service. The non settlement of the claim was solely due to non submission of the documents by the Complainant. There is no cause of action for the complaint. The various reliefs sought are unsustainable under law and facts. Hence prayed to dismiss the complaint.

III.    The Complainant has filed his proof affidavit, in support of his claim in the complaint and has filed documents which are marked as Ex.A1 to A8. The 1^st Opposite Party had submitted its proof affidavit and Written Arguments and no document marked on its side. 

IV. The 2^nd Opposite Party  set ex parte:

     Notice was sent to the 2^nd Opposite Party and was duly served to the 2^nd Opposite Party. Despite the notice being served the 2^nd Opposite Party failed to appear before this Commission either in person or by an Advocate on the hearing date and not filed any written version on their side.  Hence the 2^nd Opposite Party called absent and set ex-parte. subsequently, the case was proceeded to be heard on merits.

V.  Points for Consideration:-

1.Whether the Complaint is bad for non-joinder of necessary parties?

2.Whether there is any deficiency in service on the part of the Opposite Parties?

3.Whether the Complainant is entitled for the reliefs sought for?

4. To what other relief, the Complainant is entitled to?

Point No.1 and 2:

21.    It is an undisputed fact that the 1^st Opposite Party had provided group Mediclaim policy to INDIAN BANKS ASSOCIATION A/C: DENA BANK under which the Complainant is an employee and he is covered along with his family members.

22.    It is also not in dispute that the Complainant had submitted 8 separate claims in the year 2018 through his employer, Dena Bank, for the treatments taken by him and his family members at various Hospitals/Clinics.

23.    The dispute arose when the Opposite Parties had settled 4 claims out of the admitted 8 claims of the Complainant and the remaining 4 claims of the Complainant left unanswered/unsettled by the Opposite Parties.

24.    The Contentions of the Complainant are that he has submitted 8 claims through his employer, Dena Bank, for a sum of Rs.99,796.60p, to the Opposite Parties and the Opposite Parties had settled only a sum of Rs.74,968.23p that too in bits & pieces and a sum of Rs.24,169.13p remain unsettled. Further contended that it was informed by the 2^nd Opposite Party that they have not received the documents in support of the remaining claims, when it was questioned by the Complainant that how they have settled the other claims, it was agreed by the 2^nd Opposite Party to revert back to the Complainant. Further contended that as his earlier claims were settled by the Opposite Parties, he was with a fond hope that the 8 claims submitted by him would also be settled by the Opposite Parties, hence he had remitted the respective amounts to the Hospitals/Clinics where he and his family members took treatment. Having paid the necessary bills through his credit card he is bearing unnecessary interest at 3% per month because of the causal approach of the 2^nd Opposite Party, who is none other than Third Party Administrator of the 1^st Opposite Party, to settle the claims. Further contended that the relationship between the Complainant and the Opposite Parties are that as a consumer and service provider, hence he is entitled to invoke the Jurisdiction of this Commission.

25.    The Contentions of the Opposite Parties are that the Group Mediclaim policy was issued to the Indian Bank Association A/c.Dena Bank and the claims of the Complainant has been submitted through his employer, Dena Bank, hence having failed to array Dena Bank, the employer, who is a necessary party to the present complaint, the complaint is liable to dismissed for non-joinder of necessary party. Further contended that for claiming the reimbursement of Domiciliary treatment expenses, the Complainant need to submit all the requisite documents inter alia the prescriptions of the Doctor and the Original Bills. But the Complainant failed to submit the required documents in respect of 4 claims as per the terms and conditions of the policy and for the said reasons the alleged 4 claims were not settled, hence the question of non-settling of the alleged claims would not arise and there is no deficiency of service on their part.

26.    The first and foremost point to be decided is that whether the Employer, Dena Bank is a necessary party to the present complaint. Though the Group Mediclaim policy has been issued in the name of Dena Bank, the beneficiaries under the said policy are the employees of Dena Bank, as such the Complainant as an employee was covered under the policy along with his family members, which was admitted by the Opposite Parties and as evidenced from Ex.A-1 Card issued in the name of the Complainant. Further, though the claims has been submitted to the employer of the Complainant and the same was received by the Opposite Parties from the employer of the Complainant, the settlement under the claims found to be remitted directly to the account of the Complainant, as evidenced from Ex.A-8, Account Details and Transactions List of the Complainant. Therefore, this Commission of the considered view that the employer of the Complainant, namely, Dena Bank, is not a necessary party to the present complaint and the complaint filed by the Complainant is not affected by non-joinder of necessary party and the same is maintainable. Accordingly Point Nos.1 and 2 are answered.

Point Nos.3 and 4:-

27.    On perusal of records, from Ex.A-7 Letter dated 11.10.2018 sent by the Deputy Zonal Manager, Dena Bank to The Chief Manager (HRD), Dena Bank Head Office, it would be clear that 8 claims of the Complainant containing Claim Intimation Forms along with all originals has been forwarded for reimbursement from TPA : Chennai Zone. The Copies of the Respective Claim Form along with the details of Fees paid to Doctors and to Pharmacy has been marked as Ex.A-2 to A-6. Having admitted by the Opposite Parties that the Complainant had submitted 8 separate claims through his employer, but contended that having failed to submit the prescriptions of the Doctor and the Original Bills being the required documents for reimbursement claim of Domiciliary treatment expenses, as a reason for non-settlement of the alleged claims is not legally sustainable, as the Opposite Parties when had settled 4 claims out of 8 claims of the Complainant and remitted the claim amounts to the Bank Account of the Complainant, they should have intimated either to the Employer of the Complainant, Dena Bank, or to the Complainant, about the non-submission of the documents that are required to process the claim of the Complainant, as per their terms and conditions, which the Opposite Parties had failed to do so in the instant case and mere pleading would in no manner support the contention of the Opposite Parties and further pleaded that the claim of the Complainant has been submitted belatedly, is also not legally sustainable, when the Opposite Parties has not chosen file their terms and conditions to establish their stand. Hence, it is clear that the Opposite Parties had acted lethargically and negligently in settling the 4 claims of the Complainant amounting to Rs.24,169.13p by having failed to intimate about the non-submission of the documents that are required to process the claim of the Complainant either to the Employer of the Complainant, Dena Bank, or to the Complainant and the said act of the Opposite Parties clearly amounts to deficiency of service on the part of the Opposite Parties. Therefore, this Commission is of the considered view that the Opposite Parties had committed deficiency of service and thereby had caused mental agony to the Complainant. Accordingly Point No.3 and 4 are answered.

In the result, this complaint is allowed in part. The Opposite Parties 1 & 2 are directed jointly and severally to reimburse a sum of Rs.24,169.13p together with interest @ 9% per annum from 11.10.2018 to till the date of realisation and also to pay a sum of Rs.10,000/- towards compensation for deficiency in service and mental agony caused by the Opposite Parties along with costs of Rs.5,000/- to the Complainant within 8 weeks from the date or receipt of this order.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 29^th of May 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                        MEMBER I                         PRESIDENT

 

List of documents filed on the side of the Complainant:-

 

Ex.A1	01.10.2018	Policy card issued by the 1st Opposite Party
Ex.A2	10.10.2018	Claim form of the Complainant
Ex.A3	10.10.2018	Claim form of the Complainant
Ex.A4	10.10.2018	Claim form of the Complainant’s wife
Ex.A5	10.10.2018	Claim form of the Complainant’s daughter
Ex.A6	10.10.2018	Claim form of the Complainant’s daughter
Ex.A7	11.10.2018	Claim form submitted by the Complainant with his employer
Ex.A8	07.05.2019	Statement of accounts evidencing receipt of a sum of Rs.8,206/- from the 1st Opposite Party

 

List of documents filed on the side of the Opposite Parties:-

 

-NIL-

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                        MEMBER I                         PRESIDENT