State Consumer Disputes Redressal Commission
Smita Raikar vs National Insurance Ltd. & Others on 12 October, 2015
1
BEFORE THE GOA STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
PANAJI - GOA
FA No. 66/2015
Smt. Smita Raikar
Kamakshi Vihar, 145 G/1
Fatima Colony
Alto Dabolim Goa. .....Appellant/Complainant
V/s.
1. National Insurance Ltd.
Div. IX, 1st floor, DO No. 260800
Commercial Unit
9-Wallace Street
Greater Bombay-400 001 ....Respondent 1/OP 1
2. Paramount Health Services Ltd.,
(TPA) Pvt. Ltd.
D-39, Okhia Industrial Area
Phase-I, New Delhi-110020 ....Respondent 2/OP 2
3. Zuari Agro Chemicals Ltd.
Jai Kisaan Bhawan
Zuarinagar Goa. ....Respondent 3/OP 3
Appellant's husband Adv. Shri. S. Raikar is present.
Dated: 12/10/2015
ORDER
[Per Justice Shri. N. A. Britto, President] Heard Shri. S. Raikar, the lr. advocate and husband of Complainant Smt. Raikar. at the stage of the admission of this appeal.
2. Some facts are required to be stated to dispose off this appeal.
3. The complainant, as a former employee of OP No. 3, Zuari Agro Chemicals Ltd., was covered by group insurance scheme, though the complainant nor her husband adv. Shri. Raikar has placed on record 2 the said group insurance scheme. The said scheme was to be operated through Paramount Health Services, OP No. 2, and National Insurance Company Ltd., OP No. 1.
4. The complainant was admitted in Kamakshi ArogyaDhama, an ayurvedic hospital at Shiroda Goa from 25/9/13 to 28/9/13 for "Vatvyadhi" (knee pain) and during the said admission, the complainant did a number of tests such as for haemoglobin, blood sugar, liver functions, kidney functions, etc., as can be seen from the reports produced on record. The complainant incurred an expenditure of Rs. 11,994/- and raised a claim for the said sum, presumably with OP No. 1, which came to be repudiated by OP No. 2 by letter dated 18/12/13, addressed to OP No. 3, Zuari Agro Chemicals Ltd., stating that:
"Smita Raikar 55 years has been hospitalized on 25/09/2013 as a case of Vatavayadhi (Knee pain) during hospitalization Ayurvedic treatment given is discharged on 28/09/2013. As per policy term and condition, Ayurvedic treatment are not covered. Hence this claim stands repudiated under clause 4.13."
5. The complainant was advised by the said letter that the complainant could approach the grievance cell of the insurer, if not satisfied by the decision and that they were unable to reimburse/admit any amount under the captioned claim; whereupon Adv. Shri. Raikar claiming that he was engaged by his wife, the complainant, sent notice dated 3/2/14 to all the OPs and then filed the consumer complaint on 11/6/14 to recover the said amount of Rs. 11994.00 and in all to recover an amount of Rs. 5 lacs. The complaint was contested by OP No. 1 stating that Ayurvedic and alike treatments are specifically excluded from the terms and conditions of the policy and that the complainant could not be 3 considered to be a consumer. OP No. 3 was proceeded exparte, and, the complainant was required to take steps to serve OP No. 2. This was on 16/10/14. Eventually the complaint came to be dismissed by order dated 4/8/15 which reads as follows:
"Matter called out today at 11.20 a.m. on second round. None present for the complainant. Adv. R.M. Lotlikar present for OP No. 1. None present for OP No. 3.
From the Roznamas it is observed that the complainant has failed, refused and neglected to take steps to serve OP No. 2 (Paramount Health Services) since 16/10/14. Directions were issued to the complainant to take necessary steps to get the OP No. 2 served, on 16/10/14 and thereafter on 17/11/14, 29/12/14, 16/01/15, 19/02/15, 19/03/15, 13/04/15, 03/06/15 and 03/07/15, yet the complainant did not take effective steps to serve OP No. 2.
On 03/07/15 the complainant was given last and final opportunity to take necessary steps to serve OP No. 2. We find the complainant is not interested in prosecuting the OP No. 2. The complainant has filed the complaint against all the OPs and the reliefs sought are joint and several as against the OPs. As such the complaint without the OP No. 2 is not sustainable.
Accordingly complaint stands dismissed for non-prosecution."
6. From the documents now produced before this Commission, it can be seen that adv. Shri. Raikar wrote a letter dated 10/7/15 to the Postmaster, Margao, to find out whether the notice of the complaint sent by the District Forum on 11/8/14 under receipt No. 491127945 was served or not and Adv. Shri. Raikar got a reply dated 14/7/15 stating that the notice was delivered on 21/8/14.
47. Shri. Raikar, lr. advocate would submit that the Lr. District Forum ought to have made enquiries and find out whether OP No. 2, Paramount Health Services, were served or not with the notice of the complaint sent to OP No. 2 on 11/8/14 (or is it on 4/8/14?). However, lr. advocate does not explain as to why he did not request the Lr. District Forum to write a letter to the Postmaster to verify whether the notice sent to OP No. 2 was delivered or not. Lr. advocate also does not explain as to why he remained inactive and indolent and did not avail of the opportunities given from 16/10/14 for nearly 9 months and waited to send the letter only on 10/7/15. The Lr. District Forum having ordered the complainant to take steps to serve OP No. 2, time and again, complainant had no other option but to comply the said orders or appeal against the same. Complainant has been consistently negligent in not complying the Orders passed, and, therefore, the complainant now cannot turn round and say that it was the duty of the Forum to find out whether OP No. 2 was served or not. The effort made by complainant on 10/7/15 could have been made earlier. Least which was expected of the complainant is to have remained present before the Lr. District Forum on 4/8/15 and produce the said letter dated 10/7/15 issued by the postmaster. This only shows that the complainant was not at all diligent in prosecuting his complaint and therefore the dismissal of the complaint against the OPs and particularly against OP No. 2, cannot be faulted. Letter dated 18/12/13 shows that the payment, if at all, was required to be made by OP No. 2 and not by OP No. 1 or OP No. 3.
8. There is another aspect which also needs to be looked into, atleast, prima facie. As already stated, the complainant has not produced on record the insurance policy. I do not know what clause 4.13 of the policy is; but the complainant has produced on record certain 5 exclusion clauses, which according to the complainant, form part of the policy obtained by him. One of the said general policy exclusions, reads as follows:
"Naturopathy, unproven procedure/treatment, experimental or alternative medicine/treatment including acupuncture, acupressure, magneto therapy etc." (at page 54).
9. In other words, treatment taken or expenditure incurred by alternative medicines is not included within the ambit of the policy. Shri. Raikar, lr. advocate would submit that in the past he had claimed expenditure on Ayurvedic treatment and it was reimbursed but lr. advocate has not been able to produce on record any evidence to that effect, or give the details of the same. Lr. advocate would next submit that an Ayurvedic degree (BAMS) can be obtained only after five years of rigorous study and therefore Ayurveda cannot be considered to be an alternative system of medicine.
10. I am not impressed by this submission. The claim of the complainant appears to have been repudiated both by OP No. 1 and OP No. 2 on the ground that Ayurvedic treatment is not covered. Shri. Raikar may be right in stating that a rigorous study is required to obtain a degree in Ayurveda but till date Ayurveda is still considered as alternative and traditional system of medicine, Ayurveda is based on the idea of balance in bodily system which uses diet, herbal treatment and yogic breathing for treatment of ailments (see Concise Oxford Dictionary). Viewed thus, the repudiation of the claim of complainant cannot be faulted. In other words, no useful purpose will be served even in case the order is set aside and the case is remanded for trial. It will only waste time and energy of the parties.
611. I therefore proceed to dismiss the appeal at the stage of admission.
[Justice Shri N. A. Britto] President sp/-