Baisani Krishnaiah Sathyanarayana

S/o. B.Krishnaiah,

Hindu, aged about 68 years,

Retired Regional Joint Director of Technical Education, Govt. of A.P.,

D.No.6-1-22/3, Opp. to I.T.Quarters,

Chennareddy Colony,

Tirupati. … Complainant



vs



1. The Branch Manager,

Bank of India,

V.V.Mahal Road,

Tirupati.



2. The Chairman,

Bank of India (Regd. Office),

Plot No.C-5, C-Block, Bandrakwrla Complex,

Bandra East,

Mumbai – 400 051.



3. The Chairman,

T.T.K. Health Care Services Pvt. Ltd., (Regd.Office),

AFL House, Lok Bharathi Complex,

Marol Maroshi Road, Andheri East,

Mumbai – 400 059.



4. The Chairman,

National Insurance Company Limited,

Mumbai Division,

Commercial Union House,

Behind Exvesior Theatre,

No.9, Wallace Street,

Mumbai – 400 001. Opposite parties.







ORDER






2. The factual matrix leading to filing of this complaint is set-out as hereunder:-

a. The case of the complainant is that the 1st opposite party is canvassed to have medical insurance, which was tie-up with National Insurance Company Ltd., Bombay (4th opposite party) and T.T.K. Health Care Services Private Ltd., Bombay (3rd opposite party). The complainant is having a bank account with the Bank of India, Tirupati branch (1st opposite party) and on persuasion by opposite party No.1, he had the medical insurance under certificate bearing No.260700/46-42/2008/341 through Master Card bearing No.5420-3430-0455-2308 for himself and for his wife B.Vanaja under the name and style of Bank of India’s unique Security Plan, which is valid from 01.01.2008 to 31.12.2008 and it is issued by the 4th opposite party by its authorized signatory.


The premium was paid through the 1st opposite party Bank of India’s credit card. So, the premium certificate issued by the 4th opposite party clearly shows that the total premium was paid Rs.11,694/- and the policy number is 260700/46/2008/8500000053. So, the opposite parties 2 to 4 jointly issued the policy to the complainant.

b. Thereafter sometime, the complainant suffered with illness, while he was at Bangalore and admitted in Sagar Appollo Hospital at Bangalore on 05.01.2008 at 10 a.m. as in-patient and got treatment from the said hospital authorities for his disease and discharged on 09.01.2008 at 12.40 p.m. as per the discharge summary certificate issued by the above said hospital at Bangalore. The entire medical expenses incurred by the complainant during his stay in the said hospital from 05.01.2008 to 09.01.2008 is Rs.37,678-35ps. and the said hospital authorities gave bill and receipt under the bill bearing No.58447. So, the complainant paid the said bill amount to the said hospital authorities and got the receipt.

c. The complainant further presented the claim bill to T.T.K. Health Care Services Pvt. Ltd., Bangalore (3rd opposite party) and got acknowledgement under receipt bearing No.16685 dt:13.03.2008. Later, 3rd opposite party wrote a letter to the complainant to submit the further copies to settle the claim. So, the complainant presented the required documents at Bangalore office and got acknowledgement under receipt No.3073 dt:08.04.2008. Again on 05.05.2008, the 3rd opposite party addressed a letter to the complainant to submit the same documents once again to finalize the policy amount. Subsequently, the complainant has informed the same that he submitted the necessary forms at Bangalore office.


The 3rd opposite party did not verify the documents presented by the complainant, whether they are sufficient or require any other documents gave a letter to the complainant on 15.05.2008 stating that they are closing the claim form due to the non-submission of the necessary documents. The said letter was acknowledged by the complainant on 19.05.2008 and the complainant gave a letter to the 3rd opposite party mentioning all the details on 20.05.2008 and copy is also marked to the National Insurance Co. Ltd., Bombay. Again the complainant gave a letter on 26-05-2008 requiring to settle the bill as he submitted all the documents under acknowledgements which were issued by the 3rd opposite party Bangalore Branch.

d. The complainant further submitted that he sent email references on 13.08.2008 and 23.09.2008 requesting the 3rd opposite party to settle the claim. Though the opposite party No.3 received the e-mails and also to the 4th opposite party National Insurance Co. Ltd., both opposite parties acknowledged the e-mails and did not give reply. So, the complainant was forced to issue legal notice on 25.02.2009 to all the opposite parties by enclosing the necessary documents. Even though the opposite parties acknowledged the same did not give any reply to the complainant.

e. The complainant further submitted that even though the 3rd opposite party branch received the additional documents as per the acknowledgement receipt issued on 08.04.2008 shows that they received the documents of short fall compliance. The 3rd opposite party gave I.D. Card known as T.T.K. I.D.No.MUM-NC-B274-01-00341-A of B.K.Sathyanarayana. This acknowledgement receipt clearly shows that the shortfall documents were received by the 3rd opposite party branch at Bangalore.


When the 3rd opposite party verified the documents, which were submitted at Bangalore Branch as per the prior acknowledgement receipt No.16685 dt:13.05.2008 and they gave response stating that some of the documents are required. The said documents were presented and acknowledged by the 3rd opposite party at Bangalore branch under receipt No.3073 dt:08.04.2008. The 3rd opposite party without verifying the shortfall documents submitted by the complainant to the opposite party No.3’s branch at Bangalore, the Bombay office gave letter stating that they are closing the file dt:15.05.2008, as they are not in receipt of the shortfall documents, which is negligent by the 3rd opposite party in verifying the documents, when they are presented at the same branch at Bangalore. So, the 3rd opposite party negligently closed the complainant’s claim, even though they got all the material papers from the complainant to pay the medical bill.


The complainant further submitted that the opposite parties 1 to 4 are necessary and proper parties to settle the claim. Since it is a joint venture or tie-up venture by all the opposite parties 1 to 4. The medical policy was issued by the opposite party No.4, which is in tie-up with the opposite parties 1 and 2. The 3rd opposite party is their agent or tie-up organization to settle the claims covered under the medical policies issued by the opposite party No.4. So, when the complainant paid the policy amount through opposite party No.1, which is in confirmation with the orders issued by the opposite party No.2 to 1 with a tie-up agreement with opposite parties Nos.3 and 4 by opposite party No.2. So, the opposite parties 1, 2 and 4 are also liable to pay the amount to the complainant. The complainant purchased the policy under the recommendations of opposite parties Nos.1 and 2, so they are also liable to pay the claim amount to the complainant independently or jointly with other opposite parties.

f. The complainant further submitted that as he is having a valid policy of medical claim issued by the opposite parties, they are liable to pay the amount. The claim is submitted immediately within the time and notice also issued to all the parties, which is within time. So, the complainant is claiming the medical bill and the mental agony suffered by the complainant due to non-compliance of the claims and negligently given wrong reply by the opposite party No.3 without verifying the records and other opposite parties are liable to pay the amount to the complainant, since it is a joint venture. The complainant now without any option has to file this complaint before this Hon’ble Forum redressal for his reliefs by way of complaint.

3(a). In response, 1st opposite party resisted the complaint by filing written version and also affidavit, denying the allegations set out in the complaint except those which are specifically admitted in the written version. The complainant is put to strict proof of every one of the remaining allegations mentioned in the complaint. It is true that the complainant is the credit card holder of the 1st opposite party bank.


In order to provide the benefit of the policy in question to the credit card customers, the Bank of India as facilitator, it issued medi-claim policy on discounted rate. The medi-claim policy is floated by National Insurance Company Ltd. (4th opposite party) and the 1st opposite party bank is the facilitator for the policy i.e., the policy premium may be paid through Bank of India’s credit card on a special discounted rate. It was made clear to every policy purchaser in the terms and conditions of the policy that “Bank of India is only a facilitator to form the group and do not hold any assurance or responsibility on claim processing”. The terms and conditions of the above said policy are very clear in its terms of it that the rights and duties of the service provider, National Insurance Company Ltd. (4th opposite party) and the insurance purchaser. It was provided to the complainant along with the application form. The service connected with the 4th opposite party National Insurance Co. Ltd., with the insurance of the complainant that full responsibility will be National Insurance Co. Ltd. The Bank of India i.e. 1st opposite party do not have any responsibility for processing the complainant’s claim under the above said policy.

(b). Further, it is mentioned in para-8 of written version of 1st opposite party is that even as per the case of the complainant the claim is closed by 3rd opposite party due to non-furnishing the material papers. So, the dispute if any, it is between the complainant and the opposite parties 3 and 4 and at any point of time, there is no deficiency in service on the part of the opposite parties 1 and 2 of Bank of India. The opposite party No.1 is unnecessarily impleaded in this consumer case. So, the complaint is devoid of merits and it is liable to be dismissed against opposite party No.1 with exemplary costs.

4. In support of the allegations made in the complaint, the complainant filed 13 documents, which are marked as Exs. A1 to A13. Ex.A1 is the Photostat copy of medi-claim policy issued by authorized signatory of opposite party No.4 i.e. National Insurance Co.Ltd., in the name of the complainant and his wife / spouse B.Vanaja. Ex.A2 is the Photostat copy of in-patient bill issued by the Sagar Appollo Hospital, Bangalore, in favour of the complainant. Ex.A3 is the original acknowledgement receipt bearing No.16685 issued by the T.T.K. Health Care Services Pvt. Ltd. Bangalore, in the name of the complainant, establishing that receiving claim / short fall compliance on 13.03.2008 and signed by customary care exemtive. Ex.A4 is the Photostat copy of the letter dt:21.03.2008 issued by the opposite party No.3 herein to the complainant seeking the documents (6) within 7 days to submit for processing the claim of the complainant. Ex.A5 is another original acknowledgement receipt bearing No.3073 dt:08.04.2008 issued by opposite party No.3, Bangalore branch, in the name of the complainant stating that acknowledging having received the claim / short fall compliance and signed by customer care exemtive.


Ex.A6 is the Photostat copy of discharge summary of treatment of the complainant issued by Sagar Appollo Hospital, Bangalore. Ex.A7 is the original copy of letter dt:05.05.2008 issued by opposite party No.3, Bangalore branch, to the complainant seeking further documents (3) for submission for processing of the claim of the complainant within 7 days from the date of issue of the letter. Ex.A8 is the original copy of letter dt:20.05.2008 addressed to T.T.K. Health Care Services, Mumbai, by the complainant and the same copy marked to Bangalore office of opposite party No.3 with DTDC courier receipts dt:21.05.2008. Ex.A9 is the letter dt:15.05.2008 issued by the T.T.K. Health Care Services Pvt. Ltd., Mumbai to the complainant / claimant, intimating claim file is closed.


Ex.A10 is the bunch of email statements relating to the complainant and opposite parties 3 and 4. Ex.A11 is the copy of email sent by the complainant to the opposite parties 3 and 4. Ex.A12 is the office copy of legal notice dt:25.02.2009 issued by the complainant’s advocate to the Chairman of National Insurance Co. Ltd., Mumbai, to the Chairman of T.T.K. Health Care Services Pvt. Ltd., Mumbai, and also to the Chairman, Bank of India, Mumbai, and copy is also marked to opposite party No.1 bank at Tirupati branch. Ex.A13 are the postal acknowledgements received by the complainant from the opposite party No.1 and Bank of India, Mumbai and also T.T.K. Health Care Services Pvt. Ltd., Mumbai.

5. In support of the averments made in the written version, the 1st opposite party i.e. Bank of India, Tirupati branch, represented by authorized signatory Mr. D.V.Rao, Hyderabad, filed 4 documents, which are marked as Exs. B1 to B4. Ex.B1 is the model Credit Card Application Form and Credit Card Agreement terms and conditions. Ex.B2 is the credit card holder application (empty) form for BOI’s unique Security Plan-2008 for insurance purpose addressed to the National Insurance Company Ltd., Divisional Office, Mumbai. Ex.B3 is the credit card holder’s brochure for obtaining of medi-claim and personal accident insurance, Bank of India’s unique Security Plan. Ex.B4 is the Photostat copy of reply legal notice dt:18.04.2009 issued by the Zonal Manager, Bank of India, Hyderabad, addressed to the complainant’s advocate Sri.Kesarla Chandrasekhar, Tirupati.

6. The complainant and 1st opposite party filed affidavits in support of their case reiterating the contents contained in the complaint and written version respectively. Both the learned counsels appearing for their parties have filed their written arguments.

7. On the basis of the pleadings and documentary evidence, the points that arise for determination are:-

1. Whether there is any deficiency in service on the part of opposite parties towards the complainant?

2. Whether the complainant is entitled to the reliefs as prayed for? If so, to what extent?

3. To what result?

8. Point No.1:- (a) The basic facts of this consumer case are not disputed such as payment of premium by the complainant to the 4th opposite party and obtaining of the policy from National Insurance Company Ltd., Mumbai. The learned counsel for the complainant Sri.Kesarla Chandrasekhar has vehemently argued that the complainant presented the bill to claim as per the terms and conditions of the Insurance Certificate to the 3rd opposite party on 13.03.2008 at Bangalore office, who gave acknowledgement on 13.03.2008 under the receipt. He also further argued that the 3rd opposite party wrote a letter to the complainant to submit additional information on 21.03.2008 and accordingly the complainant presented additional information and material available with him to opposite party No.3 at Bangalore on 08.04.2008 and he got the acknowledgement.


Again 3rd opposite party wrote a letter on 05.05.2008 to the complainant to submit additional documents. Accordingly on 20.05.2008, the complainant submitted the available records and material to the 3rd and 4th opposite parties, but unfortunately without verifying the records on 15.05.2008, the 3rd opposite party office at Mumbai, what are all the documents submitted by the complainant to opposite party No.3 branch at Bangalore stated that the claim file has been closed for which the complainant gave number of letters and also sent emails to 3rd opposite party on 13.08.2008 and 23.09.2008 and also inspite of several telephonic calls with the 3rd and 4th opposite parties, but they did not comply anything to the complainant’s demands.

The above said learned counsel for the complainant further argued that he had issued a legal notice to the opposite parties 1 to 4 on 25.02.2009 on behalf of the complainant. There was no reply or compliance of the notice from the opposite parties, on 18.04.2009, the opposite party No.1 and 2nd opposite party office at Hyderabad gave a reply without any basis whatsoever. He also further argued that the opposite parties 1 and 2 is a banking concern and the banks will not do any work at free of cost or did not do anything as charity.


The institution is started with business motive and it is a commercial transaction institution only. The responsibility lies with the opposite parties 1 and 2 to its customers / consumers and towards the complainant in particular herein, when he had policy of opposite parties 3 and 4 which is propagandas by the opposite parties 1 and 2. So, the failure of sending any documents within reasonable time by opposite parties 1 and 2 is not valid and they have not disclosed or sent any communication to the complainant. So, the reply sent by opposite party No.1 and 2 is not valid and what are the transactions between opposite party No.2 with opposite party No.3 and 4 is not at all even informed to the Forum. So, the 1st and 2nd opposite parties are also jointly and vicariously liable to pay the complainant’s amount as claimed in this consumer case and on behalf of the 3rd and 4th opposite parties jointly liable to pay the claim amount as the case may be.


He also further agued that the 3rd and 4th opposite parties did not file any objections or written version in this consumer case and so indirectly they are admitting the claim of the complainant The Hon’ble Forum has to draw an adverse inference against 3rd and 4th opposite parties for non-reply to the complainant’s several notices in writing and also through emails and also for advocate’s notice as per the judgment of our A.P.High Court which is reported in 2008(2) Law summary at page No.279 pronounced by the Hon’ble Justice P.S.Narayana. Finally, he argued that Hon’ble Forum may be pleased to allow the complaint by directing the opposite parties 1 to 4 jointly and severally to pay the claim amount as prayed in the complaint to the complainant with further interest and costs.

(b). In response, the learned counsel for the 1st and 2nd opposite parties, Sri.K.Ajeya Kumar has also vehemently argued that the 1st and 2nd opposite parties are not necessary parties to this consumer dispute and no way connected with the claim settlement of the complainant. The complainant did not submit any claim form with relevant documents to forward the same to 3rd or 4th opposite parties through 1st opposite party at any point of time. He further argued that when legal notice was issued to opposite parties 1 and 2 by the complainant’s counsel, a suitable reply was given on 18.04.2009 denying the liability.


He also further argued that with regard medi-claim policy plan of 4th opposite party and Bank of India (opposite parties 1 and 2) is only facilitator i.e. if the policy premium is paid through Bank of India Credit Card, there will be some special discount to the credit card holders and in the credit card application it is clearly mentioned that the Bank of India is a facilitator to form group and do not hold responsibility of complainant on claim processing and full responsibility will be if any of the 4th opposite party. Finally, he further argued that by mentioning model credit card application and terms and conditions in it, clause 11.02 is referred and it reads as follows: “In the event any insurance cover or benefit of any insurance cover is made available to the card holder by an insurance company at the request of the Bank, the card holder specifically acknowledges that the Bank will not be liable in any manner whatsoever and that the insurance company will be solely liable for all claims thereunder.


The card holder and / or his legal heirs shall not hold the Bank responsible for any matter arising out of or in connection with such insurance cover, whether for or in respect of any deficiency or defect in such insurance cover. Recovery or payment of compensation, processing or settlement of claims or any other matter in relation to the insurance cover shall be addressed to and resolved directly by the legal heirs of the card holder with the insurance company”. So, this complaint is devoid of merits and is liable to be dismissed against the opposite parties 3 and 4 also.

©. Forum findings and observations:

Heard the learned counsel for the parties and we have gone through the material on record. To determine this consumer case between the parties, it is required to analyse the documents filed by them carefully. There is no dispute with regard to payment of premium towards the policy by the complainant. The whole trouble arose between them, is only non-submission of relevant and required documents within the time frame by the complainant to 3rd and 4th opposite parties in order to process the claim of the complainant. It is also crystal clear that the claim form and what are the documents attached to it are not known to us, because a copy of set of them are not filed before us, to verify its description of every one of it. But it is evident that Ex.A4 and Ex.A7 are the letters addressed to the complainant by 3rd opposite party, Mumbai, on 21.03.2008 and 05.05.2008 mentioning the description of documents required to forward them to process the claim of the complainant. This is not related to additional information that is required as alleged by the complainant and it is specifically mentioned the documents (6) to be submitted to process his claim.


The contention of the said learned counsel for the complainant that the complainant presented the bills to 3rd opposite party at Bangalore office on 13.03.2008 and 08.04.2008 and got acknowledgements Ex.A3 and Ex.A5. But in those said acknowledgements, We acknowledge having received claim / short fall compliance and not more than that and the description of the documents and its importance, serially not found in it. The complainant did not present the required documents to 3rd opposite party by 05.05.2008 to process his claim. Ultimately on 15.05.2008 the 3rd opposite party addressed a letter (Ex.A9) to the complainant stating that “Sir, Please note that we had informed you about documents to be submitted for us to proceed with your claim. However regret to note that till date you have not submitted the same. Inspite of letters / reminders sent to you, you have not complied with the required papers / documents. We are now closing your claim file due to non submission of necessary documents.


AGAIN IN SHORTFALL:- (a). All prior policy copies with previous claim settlement details from insurance company. (b). Complete photocopies of indoor cae papers. (c) Medical certificate from treating doctor stating the exact cause and odp of cva”. Thereafter, the complainant wrote a letter dt:20.05.2008 addressed to 3rd opposite party by mentioning 8 documents which are already submitted to 3rd opposite party branch at Bangalore and contact it and get the papers to process his claim. How, the complainant submitted the relevant and required documents sent or submission by way of courier or registered post with acknowledgement due to 3rd opposite party branch at Bangalore is not explained to us and to that affect not filed any receipts before us to establish the fact. Later on, emails (Exs.A10 and A11), legal notice Ex.A12 and Ex.A13 postal acknowledgement on behalf of the complainant filed to prove his case and by that time already 3rd opposite party closed the claim file of the complainant by stating the reasons for it as stated supra.


It is also evident that the complainant did not prefer to submit the required documents for processing his claim as mentioned in Ex.A4 by 3rd opposite party, Mumbai office. Again in Ex.A7 letter by opposite party No.3 to the complainant 3 documents short fall mentioned in it for submission by the complainant and he mentioned about the documents sent as per Ex.A8 by complainant to 3rd opposite party. The xerox copies of those alleged documents sent by the complainant to 3rd opposite party at Bangalore office are not before us, to assess and verify its nature and importance and in the absence of proof of them, we cannot assume and believe that the complainant submitted those documents within the time to 3rd opposite party branch at Bangalore to forward it to Mumbai office. Time and again, the 3rd opposite party corresponding with the complainant about these documents short fall 3 in number by mentioning them in its letter dt:05.05.2008 (Ex.A7).

In Ex.B3 i.e. Card Holder’s brochure, it is mentioned under the head, Role of Card Issuers: The role of card issuers (Bank of India) under the scheme would be purely to facilitate the Card Holders to form a group. Card issuers do not hold out any assurance and do not make any representation on claims processing or whatsoever. For other matters connected with the insurance, full responsibility will be of M/s. National Insurance Co.Ltd. The details given above are indicative and not exhaustive and for information only. For more details, please refer to the Certificate of Insurance issued to the applicants. For that reason only, the complainant, instead of opposite party No.1, preferred to send required documents through opposite party No.3 branch office at Bangalore to forward the same to opposite party No.3, Mumbai. He did not choose directly to send them to opposite party No.3 for the reasons best known to him.

He, who seeks equity from the Courts must come with clean hands. The complainant should prove his case by coherent and cogent evidence to establish the fact alleged by him. What he is alleged must be proved by placing reliable evidence. That has not been fulfilled for the reasons best known to the complainant. The opposite parties 3 and 4 are called absent and exparte. The role of 1st opposite party is only facilitator and it is proved through the documents Exs.B1 to B4 and it is also mentioned in Ex.B4 by 1st opposite party in its letter dt:18.04.2009 addressed to the learned counsel for the complainant.

The complainant has not proved his case to claim any reliefs against the opposite parties 1 to 4. He is not justified to allege that opposite party No.3 is at fault in view of the documentary evidence as stated supra. There is no deficiency in service on the part of the 1st and 2nd opposite parties as well as 3rd and 4th opposite parties also towards the complainant. The 3rd opposite party sent letters to the complainant (Exs.A4 and A7) to submit relevant documents to process his claim but for the reasons best known to him, did not act or respond properly and hence 3rd opposite party through its letter (Ex.A9) intimated to the complainant about closure of his claim file for non-submission of documents required for it. There is no substance in the complaint filed by the complainant. This issue is answered accordingly.

9. Point No.(2):- In view of the facts and circumstances of the case discussed above, in the interests of principles of natural justice, we are of the opinion that complainant is miserably failed to prove deficiency in service against opposite parties. So, the complainant is not entitled to any reliefs sought for. This issue is answered accordingly.

10. Point No.(3):- In the result, the complaint is dismissed without costs. This issue is answered accordingly.