STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Indian Overseas Bank, a body corporate duly constituted under the Banking Companies (Acquisition and Transfer of Undertakings) Act, 1970 having its Central Office at 762, Anna Salai Chennai 2 and Inter-alia a Branch office at SCO No.11, Sector 7, Madhya Marg, Chandigarh through its Principal Officer and Constituted Attorney Sh. Ashok Kumar, Chief Manager.

 …Appellant.

Versus

1.Sh. N. R. Chauhan S/o Late Sh. Jagan Nath R/o House No.5097/1, Modern Housing Complex, Manimajra, Chandigarh.

2.E-Meditech (TPA) Services Limitedk SCO No.56, First Floor, Sector 30-C, Chandigarh.

3.M/s Universal Sompo General Insurance Co. Ltd., SCO No.72, First Floor, Swastik Vihar, Sector 5, MDC, Panchkula.

…Respondents.

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:   

Argued by: 

Service of respondent No.2 already dispensed with vide order dated 19.02.2014.

PER DEV RAJ, MEMBER

“11.       

i)           

ii)           To make payment of an amount of Rs.10,000/- to the complainant as compensation for mental agony and harassment.

iii)          To make payment of an amount of Rs.7500/- towards litigation cost.

The complaint fails against OPs No.2 and 3.

12.          This order shall be complied with by OP No.1 within one month from the date of receipt of its certified copy, failing which, OP No.1 shall be liable to refund the above said awarded amount to the complainant along with interest @12% p.a. from the date of filing of the present complaint, till its realization, besides costs of litigation, as mentioned above.” 

However, the complaint qua Opposite Parties No.2 and 3 was dismissed by the District Forum.

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“You were admitted for treatment of osteoarthritis both knee Geeta C admitted with c/o pain and tenderness in both knee, difficulty in walking and weight bearing diagnosed as osteoarthritis, underwent surgery bilateral knee surgery during hospitalization. Joint replacement surgery is not payable for the first two years of the policy coverage as per coverage as per Basic Coverage Exclusion (2). This policy incepts on 1/07/2012 and 2 years of continuous policy coverage have not been completed. Hence the claim stands rejected as per policy terms and conditions.

We invite your attention to the following exclusions in the policy

The said terms and conditions duly highlighted are attached herewith for your ready reference.

In view of the foregoing, we regret our inability to consider the claim lodged by you. Should you believe that we have over looked any material facts or circumstances, or should you wish to present an alternative interpretation of any relevant policy provisions, please draw the same to our attention for our further consideration.”

15.        

“The salient features of the Group Health Insurance scheme are as under: 

·   Treatments in the hospitals/nursing homes in India are covered.

·   Limit per family shall be Rs.1,50,000/- covering self and spouse on family floater basis.

·   Members will be benefited out of cash less facility for their hospitalization claims subject to 20% of co payment clause.

Add on benefits

ØPre existing diseases will be covered.

ØWaiver of exclusion of waiting period of 30 days.

ØWaiver of exclusion of first year.

ØPolicy covers the age band of 50-90 years.

ØCoverage of death due to accident of retiree (not spouse) for Rs.2 lacs.

Xxxxxx

1.COVERAGE:

Those who have retired from services of Bank on superannuation.

The scheme will also cover the following staff

·   Those who have been allowed to retire from bank service on medical grounds.

·   Those who have taken voluntary retirement from bank’s service in terms of the provisions of Indian Overseas Bank (Officers’) Service Regulations, 1979 and who are not gainfully employed.

·   Those who have taken voluntary retirement from bank’s service in terms of the provisions of IOB Employees Pension Regulations, 1995.

·   Those who have retired under VRS 2000 scheme.

Spouses of those retired employees mentioned above if they are not gainfully employed.”

16.        , the principle of law, laid down, was to the effect, that it is the fundamental principle of Insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew. The insured has a duty to disclose all the facts, and similarly it was the duty of the Insurance Company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applies to both equally. It was, thus, the duty of Opposite Party No.1 to disclose all the facts and circumstances, relating to the insurance cover, to the complainant to which the Insurance Policy was supplied by Opposite Party No.3. It was also required of Opposite Party No.1, to apprise the complainant of the benefits of insurance, exclusion clauses, contained therein, and the warranties referred to, in the same. It was, under these circumstances, the utmost duty of Opposite Party No.1 to supply the Insurance Policy and the terms and conditions thereof, to the complainant, so as to enable him (complainant) to go through the same and understand the clauses contained therein.In,it was observed that being aware of the existence of the policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. Under these circumstances, the claim of respondent No.1/complainant was wrongly repudiated and the same clearly happened due to deficiency on the part of appellant/Opposite Party No.1. In the instant case, respondent No.1/complainant subscribed to the Policy, in question, by paying subscription fee of Rs.15,750/-, on the basis of Circular dated 26.07.2012 and it was, therefore, incumbent upon the appellant/Opposite Party No.1 to make the respondent No.1/complainant aware of the terms and conditions by supplying a copy thereof to him. The complainant protested repudiation of claim, vide his letter dated 11.1.2013 addressed to the appellant/Opposite Party No.1, interalia, pleading that under the highlighted benefits of Circular dated 26.7.2012, declining of claim was ridiculous, evasive. Apparently, the appellant/Opposite Party No.1, was deficient in rendering service.

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19.        

(i) 

(ii)  

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Pronounced.

March 03, 2014.

Sd/-

  Sd/-

                                                                  [DEV RAJ]

Sd/-

                                     [PADMA PANDEY]

                                                                            Ad/-

STATE COMMISSION

(First Appeal No.19 of 2014)

Argued by: 

Service of respondent No.2 already dispensed with vide order dated 19.02.2014.

Dated the 

ORDER

                  Vide our detailed order of the even date, recorded separately, the appeal filed by the appellant/Opposite Party No.1, has been partly accepted, with no order as to cost. The impugned order, passed by the District Forum, has been modified.

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