| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA C.C. No. 767 of 16-12-2014 Decided on 15-01-2016 Mangat Rai, aged about 45 years S/o Sham Lal R/o C/o Sham Lal Mangat Rai, Iron Merchants, Raman Mandi, Tehsil Talwandi Sabo, District Bathinda. …...Complainant Versus Apollo Munich Health Insurance Co. Ltd., Regd. Office, Apollo Hospital Complex, Jubilee Hills, Hyderabad 500033, through its Managing Director The Area Manager, Apollo Munich Health Insurance Co. Ltd., 1, Lab Centre 2. 3rd Floor, Plot No. 404, 405, Udyog Vihar, Phase 3, Gurgaon 122002 (Haryana)
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986. Quorum : Sh. M.P.Singh. Pahwa, President Smt. Sukhwinder Kaur, Member Sh. Jarnail Singh, Member Present : For the Complainant : Sh. Sanjay Goyal, Advocate. For the opposite parties : Sh. Vinod Garg, Advocate. O R D E R M. P. Singh Pahwa, President This complaint has been filed by Mangat Rai, complainant against Apollo Munich Health Insurance Co. Ltd., & Others, opposite parties under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act'). Briefly stated the case of the complainant is that opposite parties carries on business of insurance throughout India including Raman Mandi, District Bathinda. In lieu of payment of requisite premium through their agents, the opposite parties issue health insurance policies and promise to pay the medical expenses in case of any eventuality during the period of policy. They hire out their service, assure payment of the amount incurred on treatment to subscriber of policy on the occurance of the risk covered by the policy. It is pleaded that in the month of December, 2010, representative of opposite parties at Raman Mandi contacted the complainant and allured him by claiming various schemes of insurance and their benefits. He further claimed that Apollo Munich Health Insurance Co. Ltd., is the best service provider in the field of health insurance. The complainant being allured by tall claims, purchased an insurance policy at Raman Mandi namely Easy Health Floater Standard Policy covering his four family members i.e. complainant himself, his wife Mrs. Reeta Rani, son Ankush Garg and daughter Tania Garg. He paid a premium of Rs. 12,616/-. He was issued policy No. 110100/11051/1000144214 by the opposite parties. It is further pleaded that complainant is regular subscriber. He got his policy continuously renewed from time to time by paying due premium as demanded by the opposite parties. Lastly, complainant paid premium of Rs. 17,813/- vide vide DD No. 549713 dated 5-5-2014 for renewal of his above said policy, but he was issued only three insurance policies, one policy for complainant himself, one for his wife and another for his daughter. The insurance policy No. 110103/11051/1000144214-03 of Ankush Garg son of complainant was not issued by the opposite parties. The complainant approached opposite parties many times and requested them time and again to issue insurance policy of his son, but all in vain. Ultimately, opposite parties told the complainant that a separate policy shall be issued in the name of Ankush Garg and demanded separate premium for the same alongwith ID proof self attested by Ankush Garg. As per requirement of the opposite parties, complainant sent premium amount to them through bank draft and copy of ID proof duly signed by Ankush Gag, but thereafter no insurance policy has been issued by opposite parties to the complainant, rather an amount of Rs. 6,017/- was refunded to him vide cheque No. 112212 dated 23-6-2014. Thereafter complainant approached the opposite parties and asked for reason for non issuance of insurance policy by them despite receipt of premium in this regard but the officials of the opposite parties refused to divulge any information or reason for not issuing any policy to complainant. It is alleged that non issuance of policy by the opposite parties despite payment is an arbitrary on the part of the opposite parties. This act and conduct of the opposite parties is illegal, malafide and amounts to deficiency in service and unfair trade practice on their part. Further averments of the complainant is that he had lodged a claim of Rs. 12,334/- incurred by him on treatment from 17-8-2014 to 19-8-2014. He completed all the formalities and supplied all the documents as required by the opposite parties but till date no payment of claimed amount has been paid by them. Due to this act of the opposite parties, the complainant has also suffered mental tension, shock and agony. He has been harassed a lot without any fault. Financial loss has also been suffered by him. The complainant has claimed compensation to the tune of Rs. 50,000/- for this loss. It is also pleaded that on 21-10-2014, the complainant got served legal notice upon the opposite parties but notice sent to opposite party No. 2 has been received back with the endorsement 'Left'. In the meantime, the complainant received two more letters from the opposite parties demanding again similar documents i.e. cancelled cheque copy with payee name etc., original consolidated final bill with break up details and original detailed discharge summary etc., which had already been supplied to them. By demanding the same documents again and again which have already been supplied to them, the opposite parties are trying to create false ground to avoid their liability under the policy in question. First reminder was also served upon the opposite parties on 4-11-2014 but to no effect. On this backdrop of facts, the complainant has alleged deficiency in service and unfair trade practice on the part of the opposite parties. He has prayed for directions to the opposite parties to pay Rs. 12,334/- with interest @ 18% p.a from due date and Rs. 50,000/- as compensation. Upon notice, the opposite parties appeared through their counsel and contested the complaint by filing joint written reply. In written reply, the opposite parties raised legal objections that intricate questions of law and facts are involved in the present complaint which require voluminous evidence. That complainant has concealed material documents from this Forum as well as from the opposite parties. He is not entitled to any relief. The complainant has concealed the fact that he submitted claim for reimbursement on 2-9-2014. He got admitted in Ravinder Hospital, Bathinda, with complaint of fever with date of admission as 17-8-2014 and date of discharge as 19-8-2014 with final claimed amount of Rs. 12,354/-. On reviewing the documents on 18-9-2014, the query was raised and cancelled cheque copy with payees name (Mangat Rai) Bank Passbook statement of proposal/payee in the policy to get claim paid electronically, original consolidated final bills with breakup details on hospital letter head and original detailed discharge summary with exact diagnosis on hospital letter head and investigation report. The opposite parties received reply on 7-10-2014 and post reviewing the documents on 21-10-2014, the same queries were sent again but to no effect. Therefore on 20-10-2014, the claim was closed as till date the complainant did not respond to the query letter and did not submit the documents for processing and finalization of the claim as per terms and conditions of the policy. The son of the complainant namely Ankush Garg had attained the age of more than 21 years. He was no longer dependent upon the complainant as per clause of dependents in the terms and conditions of the policy. The policy being a family floater policy could cover only the complainant, his wife and dependent child upto the age of 21 years. Since, Ankush Garg had attained the age of more than 21 years policy No. 110103/11051/1000144214-03 from 13-5-2014 to 12-5-2014 was issued only for complainant, his wife and daughter and Rs. 6137/- were refunded to the complainant vide DD No. 549866 dated 1-9-2014/ The complainant could get separate independent policy for Ankush Garg. It is also pleaded that discharge summary presented by the complainant do not contain the following important points :- (a) Exact Diagnosis (b) Temperature at the time of admission The complainant has also not provided investigation reports, treatment chart of hospital and his daily progress report. All these are mandatory documents for processing the case. The further legal objections are that this Forum has got no territorial jurisdiction to try and decide the complaint as the opposite parties have no branch within the territorial jurisdiction of this Forum and no cause of action has arisen here and lastly that the complaint is not maintainable in the present form and is liable to be dismissed. On merits, the opposite parties controverted all the material averments. However, it is admitted that complainant got the policy renewed for the periods from 22-12-2011 to 21-12-2012, 11-4-2013 to 10-4-2014 and thereafter from 13-5-2014 to 12-5-2015. It is further mentioned that there was break between the policies and policy for the period 13-5-2014 to 12-5-2015 did not cover Ankush Garg son of complainant as he was no longer a dependent member of complainant having attained age more than 21 years. After controverting all other averments, the opposite parties reiterated their stand as taken in legal objections and detailed above. In the end, the opposite parties prayed for dismissal of complaint. Parties were afforded opportunity to produce evidence. In support of his claim, complainant has tendered into evidence documents (Ex.C-1 to Ex. C-29) which included his affidavit dated 10-12-2014 (Ex. C-1), photocopies of DDs (Ex. C-4 & Ex. C-7), photocopies of bills (Ex. C-12 & Ex. C-14) and photocopy of discharge card (Ex. C-13). In order to rebut this evidence, opposite parties have tendered into evidence photocopy of proposal form (Ex. OP-1/1), photocopy of schedule (Ex. OP-1/2), photocopy of policy wording (Ex. OP-1/3), photocopy of claim form (Ex. OP-1/4), photocopies of schedules (Ex. OP-1/5 to Ex. OP-1/7), photocopy of letter dated 18-9-2014 (Ex. OP-1/8), photocopy of first reminder (Ex. OP-1/9), photocopy of closure letter (Ex. OP-1/10) and affidavit dated 8-8-2015 of Deepti Rustogi (Ex. OP-1/11). Learned counsel for the opposite parties have also submitted written submissions. We have heard learned counsel for the parties and gone through the record and written submissions of the opposite parties. Learned counsel for complainant has submitted that it is not disputed that complainant used to obtain policies of the opposite parties from time to time. The complainant also obtained policy for himself and his family members against payment of premium of Rs. 17813/- but against this premium, the opposite parties issued policy in favour of complainant, his wife and daughter only. His son was not covered under this policy., The opposite parties demanded separate premium alongwith ID proof of his son Ankush Garg. The complainant paid separate premium of Rs. 6137/- vide demand draft dated 1-9-2014, copy of which is brought on record as Ex. C-7. Admittedly, the opposite parties have not issued any policy against this premium in favour of Ankush Garg. Therefore this amounts to deficiency in service and unfair trade practice on the part of the opposite parties. It is further submitted by learned counsel for the complainant that complainant submitted medical claim of Rs. 12,354/- alongwith documents. This claim was neither repudiated nor paid till date and as per opposite parties, the complainant failed to submit documents and the claim has been filed. Copy of letter Ex. C-8 and Ex. OP-1/9 shows that complainant was required to submit cancelled cheque copy, original consolidated final bill and original detailed discharge summary. The complainant has deposed on oath that he has submitted all these documents. Copy of consolidated final bill and discharge card are also produced on record as Ex. C-12 & Ex. C-13. The complainant has also produced photocopy of cancelled cheque as Ex. C-11. It proves that all the documents were already submitted. Therefore, the opposite parties have filed the claim of the complainant without any justification. As such, deficiency in service also stands proved for this reason. On the other hand, learned counsel for the opposite parties has submitted that complainant has filed this complaint for two separate reliefs. Therefore the common complaint is not maintainable as both the claimed reliefs are independent and not inter-connected. The complaint is not maintainable for this reason. Moreover, son of the complainant Ankush Garg was major at that time. He was not to be covered under the policy issued in the name of complainant. The opposite parties have refunded the excess amount paid by the complainant. The complainant has alleged that he has paid a sum of Rs. 6137/- vide demand draft but the opposite parties have not received this draft. Even otherwise, mere submission of demand draft would not entitle the complainant for issuance of policy. Some other formalities such as proposal form and declaration were required to be completed by Ankush Garg. He has not completed these formalities. Moreover, complainant cannot claim any relief on behalf of Ankush Garg as he was having remedy to claim his relief. It is further submitted by learned counsel for the opposite parties that qua other relief, the complainant has failed to produce documents despite repeated reminders. As such, the opposite parties were having no option except to file the claim. We have carefully gone through the record and have considered the rival contentions. The complainant has claimed two reliefs in this case. For the sake of convenience, both the claims are being dealt with separately. Firstly prayer of the complainant is for issuance of policy in the name of his son Ankush Garg. Of course, the complainant has pleaded that he has paid a sum of Rs. 6137/- by way of demand draft for getting insurance policy in the name of his son Ankush Garg. Photocopy of demand draft is also produced on record as Ex. C-7 but the stand of the opposite parties is that this demand draft was not received by the opposite parties. The complainant has not produced any documentary evidence to prove that this demand draft has been received and got encashed by the opposite parties. Even otherwise, it is a matter of common knowledge that in order to get insurance policy, some other formalities are also to be completed by the proposed insured i.e. Ankush Garg in this case. He was also required to fill proposal form including declaration. In the absence of it, he was not able to get insurance policy. Therefore, no deficiency can be found on the part of the opposite parties in this regard as the complainant has failed to prove actual receipt of premium by the opposite parties. The second claim of the complainant is regarding Rs. 12,237/-. Categorical stand of the opposite parties is that complainant failed to furnish documents required vide letter Ex. OP-1/9. Of course, the complainant has placed on record copies of discharge certificate and bill submitted by the concerned doctor but still it is not proved that blank signed cheque was also received by the opposite parties. Copies of these bills and certificate have been provided to the opposite parties by the complainant. The blank signed cheque has been received by the learned counsel for the opposite parties in this Forum. Therefore, all the required documents stand supplied to the opposite parties. In these circumstances, the complaint is partly accepted. Opposite parties are directed to settle the claim of the complainant regarding said medical claim, within 45 days from the date of receipt of copy of this order. The parties are left to bear their own costs. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 15-01-2016 (M.P.Singh Pahwa ) President (Sukhwinder Kaur) Member (Jarnail Singh ) Member
| |
