KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No. 510/2018

JUDGMENT DATED: 18.12.2024

(Against the Order in C.C. 60/2016 of DCDRC, Kasaragod)

PRESENT:

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR             : PRESIDENT

SRI. AJITH KUMAR D.                                                                 : JUDICIAL MEMBER

APPELLANT:

The Manager, Oriental Insurance Co. Ltd., Corporate Regd. Office-Oriental House, P.B. No. 7037, A-25/27, Asaf Ali Road, New Delhi, represented by its Deputy Manager, T.P. Hub, DO II, Ulloor, Thiruvananthapuram.

(By Adv. Varkala B. Ravikumar)

                                                Vs.

RESPONDENTS:

1. T.P. Ummer Kunhi, Chattamchal House, Post Thekkil, Kasaragod Taluk-671 541.

(By Adv. Shihabudeen Kariyath)

2. The Manager, Oriental Bank of Commerce, K.C. Building, Aswini Nagar, Kasaragod Branch.

3. The Manager, Medi Assist India (TPA), Silpa Vidya, III Floor, 49, 1^st Main Road, Sarakki Industrial Layout, III Stage, JP Nagar, Bangaluru-560 078.

JUDGMENT

HON’BLE JUSTICE SRI. B. SUDHEENDRA KUMAR  : PRESIDENT

The appellant is the 1^st opposite party in C.C. No. 60/2016 on the files of the District Consumer Disputes Redressal Commission, Kasaragod (for short “the District Commission), who in this appeal challenges the order passed by the District Commission directing the opposite parties      1 and 3 jointly and severally to pay Rs. 1,16,510/- (Rupees One Lakh Sixteen Thousand Five Hundred and Ten only), being the mediclaim amount, with 12% interest per annum, Rs. 25,000/- (Rupees Twenty Five Thousand only) as compensation and Rs. 3,000/- (Rupees Three Thousand only) as litigation costs.  The 1^st respondent herein is the complainant before the District Commission.

2.  The complainant had taken an insurance policy in the year 2015.   The said policy was valid from 16.04.2015 to 15.04.2016.  The complainant was admitted in the hospital for treatment in connection with diabetic care from 14.04.2015 to 18.05.2015.  The complainant is a senior citizen whose right leg was already amputated prior to the above said admission to the hospital.  The complainant had to spend a total amount of Rs. 1,16,510/- (Rupees One Lakh Sixteen Thousand Five Hundred and Ten only).  The said claim was submitted by the complainant before the 3^rd opposite party.  The 1^st opposite party is the insurer and the 3^rd opposite party is the agent who was to process and transmit the application form and records to the 1^st opposite party.  However, the claim was not granted contending that the claimant did not produce the original advance payment bill for Rs. 60,000/- (Rupees Sixty Thousand only). 

3.  The 1^st opposite party filed version admitting the coverage of the insurance policy during the period of hospitalization.  However, the 1^st opposite party had contended that since the complainant had not submitted all records including the original record relating to the advance payment of Rs. 60,000/- (Rupees Sixty Thousand only) to the 3^rd opposite party, the 3^rd opposite party could not transmit the records to the 1^st opposite party for disbursing the claim amount.  There is no deficiency in service at all on the part of the 1^st opposite party. 

4.  The 3^rd opposite party had adopted the version of the 1^st opposite party. 

5.  The 2^nd opposite party is the manager of the bank who filed version stating that the 2^nd opposite party was an unnecessary party to the complaint.  The 2^nd opposite party had no knowledge about the alleged claim made by the complainant and the rejection of the said claim by the opposite parties except that the complainant was insured with the 1^st opposite party through the 2^nd opposite party.  The 2^nd opposite party had no other role in the matter.

6.  Before the District Commission, PW1 was examined and Exhibits A1 to A9 were marked for the complainant.  No evidence was adduced by the opposite parties.  After evaluating the evidence, the District Commission directed the opposite parties 1 and 3 to pay the amount as already mentioned above.

7.  Heard both sides.  Perused the records.

8.  It is not disputed that the complainant was treated in the hospital as inpatient from 14.04.2015 to 18.05.2015.  It is also not disputed that during the said period, there was insurance coverage provided by the 1^st opposite party.  It is also not disputed that the complainant had to spend a total amount of Rs. 1,16,510/- (Rupees One Lakh Sixteen Thousand Five Hundred and Ten only) towards the treatment expenses.  The complainant would contend that the complainant had submitted the claim form along with the original bills to the 3^rd opposite party for being transmitted to the 1^st opposite party.  However, the 1^st opposite party and the 3^rd opposite party would contend that the 3^rd opposite party did not receive the original of the advance payment bill for Rs. 60,000/- (Rupees Sixty Thousand only) and hence the claim could not be processed.  So, the only question to be decided is as to whether the opposite parties 1 and 3 received the original bill of advance payment of Rs. 60,000/- (Rupees Sixty Thousand only).  It is not disputed that the original of Exhibit A3 was received by the 3^rd opposite party.  Exhibit A3 is the final bill in respect of the treatment of the complainant wherein it is clearly stated that the amount paid towards advance was Rs. 60,000/- (Rupees Sixty Thousand only).  Thus, Exhibit A3 original bill itself would show that the amount mentioned therein included Rs. 60,000/- (Rupees Sixty Thousand only) paid by the complainant as advance.  Since the original of Exhibit A3 was with the 3^rd opposite party, there was no room for the 3^rd opposite party to contend that since the original of advance payment bills were not produced, the claim could not be processed.  It is also to be noted that Exhibits A6 to A8 are the copies of advance bills for Rs. 60,000/- (Rupees Sixty Thousand only).  The 1^st and the 3^rd opposite party would say that Exhibits A6 to A8 are the original bills.  However, when PW1 was examined, he categorically stated that Exhibits A6 to A8 are copies collected by him subsequently from the hospital.  It is also preposterous to conceive that the complainant did not give the originals of Exhibits A6 to A8 to the 3^rd opposite party for the purpose of processing the claim.  Exhibit A9 is the acknowledgement card evidencing the receipt of the original of Exhibits A6 to A8 by the 3^rd opposite party as spoken to by PW1.  There is absolutely no evidence inconsistent with the evidence of PW1 in this regard.  That apart, the 1^st opposite party has no authority to say anything about that since the documents were transmitted only to the 3^rd opposite party and not to the 1^st opposite party directly.  The 3^rd opposite party has not filed any appeal challenging the order impugned.  In the said circumstances, the order impugned has become final so far as the 3^rd opposite party is concerned.

9.  The upshot of the above discussion is that even though the complainant had handed over the claim form along with the original medical bills including the bills for the advance payment of Rs. 60,000/- (Rupees Sixty Thousand only) to the 3^rd opposite party, the opposite parties 1 and 3 did not process the same. 

10.  The learned counsel for the appellant has submitted that opposite parties 1 and 3 have no connection at all in this matter.  However, it appears that the same lawyer appeared for opposite parties 1 and 3 before the District Commission.  The cross-examination was also jointly conducted for opposite parties 1 and 3.  The 3^rd opposite party had also adopted the version of the 1^st opposite party.  Therefore, the submission of the learned counsel for the appellant that the 1^st and the 3^rd opposite parties have no joint business at all in this matter, cannot be accepted.  Having gone through the relevant inputs, we are satisfied that since the opposite parties 1 and 3 failed to process the claim even after accepting the original bills for the advance payment made by the complainant, there is absolutely, no doubt, that there was deficiency in service on the part of the opposite parties 1 and 3 in this regard.  In the said circumstances, we do not find any reason to interfere with the finding of the District Commission that there was deficiency in service on the part of the opposite parties 1 and 3.  The District Commission had directed the opposite parties 1 and 3 to pay Rs. 1,16,510/- (Rupees One Lakh Sixteen Thousand Five Hundred and Ten only) being the mediclaim amount to the complainant with 12 % interest per annum from the date of complaint till realization.  The opposite parties 1 and 3 were further directed to pay     Rs. 25,000/- (Rupees Twenty Five Thousand only) towards compensation and Rs. 3,000/- (Rupees Three Thousand only) towards costs. 

11.  Having gone tough the relevant inputs, we are of the view that the interest ordered by the District Commission is on the higher side.  In the said circumstances, we modify and reduce the interest to 9% per annum.   The compensation ordered by the District Commission also appears to be on the higher side.  Therefore, the compensation ordered by the District Commission is modified and reduced to Rs. 15,000/- (Rupees Fifteen Thousand only) to secure the ends of justice. The costs ordered by the District Commission stands confirmed. 

In the result, this appeal stands allowed in part, confirming the order passed by the District Commission in every respect,  except to the extent of modifying and reducing the interest ordered by the District Commission from 12% to 9% per annum and the compensation from Rs. 25,000/- (Rupees Twenty Five Thousand only) to Rs. 15,000/- (Rupees Fifteen Thousand only).  In the circumstances of the case, there is no order as to costs in this judgment. 

The statutory deposit made by the appellant shall be given to the 1^st respondent, to be adjusted/credited towards the amount ordered by the District Commission, on proper acknowledgement.

JUSTICE B. SUDHEENDRA KUMAR: PRESIDENT

jb                                                         AJITH KUMAR D. : JUDICIAL MEMBER