Hon’ble Mr. Sudip Niyogi, President
The Complainant filed this case u/s 12 of the Consumer Protection Act, 1986 seeking several reliefs against the Ops. His contention in short is that he joined OP No.1 Company as Business Development Manager in OP No.2 Company formerly known as Birla Sun Life Insurance in 2009 under OP No.1 at their Branch Office at Cooch Behar. He obtained Health Insurance Policy of the Company for himself, his wife, daughter and parents by paying required premium. Two instalments of such premium amounting to Rs.2,493/- i.e. 4,986/- in total was deducted from his salary in the month of January and February, 2017. The OP No.3 and 4 jointly issued Health Card to him for his Policy No.51-16-00051-00-00 of Birla Sun Life Insurance Co. Ltd. The Policy End date of his Health Card was 11.12.17. During subsistence of the said Policy, his father fell ill and was admitted to Dr. P.K. Saha Hospital Pvt. Ltd. at Cooch Behar on 14.09.17. As the said hospital was not enlisted in the network of the Family Health Plan Insurance TPA Limited (OP No.4), following their advice, he got his father admitted to Anandaloke Hospital & Neurosciences Centre, Siliguri on 15.09.17 and remained there upto 26.09.17. He is entitled to cashless benefit at the said Centre in connection with the treatment of his father. The admission of his father to the said hospital was also informed to OP No.4 by the Complainant and he was assured over telephone and through SMS to take guarantee of payment of cost of treatment of his father as a valid Policy holder. On behalf of OP No.4, one Dr. Sweta Gupta sent an authorization letter to the said Anandaloke Hospital & Neurosciences Centre, Siliguri on 20.09.17 vide Memo No.FHPL-PA-FT-02 dated 20.09.17 being PA No.784249/1 taking responsibility of treatment and guarantee of payment of treatment cost. On 26.09.17, at the time of discharge of his father from the said hospital, a bill of Rs.1,74,340/- inclusive of all charges as treatment cost etc. was issued by the said hospital. The Complainant contacted OP No.4 for such payment and he was assured that payment would be made in a shortwhile. As till the evening, the payment was not made to the hospital by OP No.4, nor they contacted or responded to the Complainant. At this, finding no other alternative, Complainant somehow collected money from his friends and various sources and deposited the said amount to the hospital and got released his father. The aforesaid conduct of the Ops, according to the Complainant, put him in huge mental pressure and agony. It is alleged that there is deficiency in service and unfair trade practice on the part of the Ops. So, Complainant filed this case against Ops claiming several relief(s) as mentioned in the petition of complaint including litigation cost and compensation.
The OP No.1, 2 and 3 contested this case. The OP No.4 did not turn up and the case was heard exparte against them. The OP No.1 and 2 jointly filed their written version, while OP No.3 filed another denying all the allegations made against them by the Complainant. However, in their written version, all of them claimed that Complainant had played fraud by deliberately and willfully suppressing the fact that he had been terminated from his employment for his misconduct on 26.07.17 and as such, all the benefits of his employment ceased to extinguish from that day itself. So, in case of termination from his employment, he is not entitled to avail of the facilities including insurance coverage. So, they prayed for dismissal of the instant complaint.
POINTS FOR CONSIDERATION
- Is the instant case is maintainable?
- Is there any deficiency in service or unfair trade practice on the part of the Ops?
3.Is the Complainant is entitled to get any relief?
- To what other relief, if any, Complainant is entitled?
DECISION WITH REASONS
Point No.1.
We have gone through the materials on record and the documents made as Annexures by the parties. The Complainant filed the instant complaint against Ops alleging deficiency in service and unfair trade practice on the part of the Ops for alleged violation of the terms and conditions of the Health Insurance Policy of the Complainant. It is found that this Forum has both territorial and pecuniary jurisdiction to entertain the instant complaint. So, this point is decided in favour of the Complainant.
Point No.2.
Admittedly, the Complainant was an employee of OP No.1 and 2 and admittedly he had Family Health Insurance Policy of OP No.3 and was issued Health Card under the scheme. The OP No. 4 is the Family Health Plan Insurance TPA Ltd. in accordance with the Agreement between the OP No.3 and OP No.4.
It is also found that the father of the Complainant, who was also covered with the said Insurance Policy of the Complainant was ill and admitted to Dr. P.K. Saha Hospital Pvt. Ltd. at Cooch Behar on 14.09.17 and subsequently, he was shifted to Anandaloke Hospital & Neurosciences Centre, Siliguri as the said hospital was in the hospital net work of OP No.4 and in the said hospital, the father of the Complainant had been admitted from 15.09.17 to 26.09.17. The OP No.4 was duly intimated about the illness of the father of the Complainant and also subsequent admission to the said hospital at Siliguri. It is the contentions of the Complainant that all along OP No.4 assured him of payment of medical expenses for the treatment of his father, but on 26.09.17, when the father of the Complainant was discharged, the said hospital authority raised a bill of Rs. 1,74,340/- for the cost of treatment etc. At that time, it is alleged, OP No. 4 declined to make payment. As a result, Complainant had to face immense difficulties and somehow procuring money from his acquaintances, made payment of the bill to the hospital authority. So, the Complainant alleged that there was deficiency in service and unfair trade practice on the part of the Ops. During argument before this Forum and also in their written argument, on behalf of the Complainant, it was emphasized that OP No.4 all through assured the Complainant for making payment of the treatment cost of his father but subsequently they declined, resulting in immense suffering of the Complainant.
On the other hand, the contentions of OP No.1,2 and 3 is that the Complainant is not at all entitled to any benefit under said Health Scheme as at the relevant time, the Complainant was not an employee of the Ops. According to OP No.1, 2 and 3, the Complainant was terminated from his job for his misconduct on 26.07.17 and as such, all benefits of his employment ceased to exist from that day, but suppressing the fact, Complainant filed the instant case. Nowhere in the petition of complainant, evidence and written argument, Complainant has mentioned this fact, rather, there is also no denial of the said contention of Ops about the termination of the Complainant from the job.
In this connection, Ld. Advocate for OP No.1,2 and 3 drew our attention to the guidelines of Group Insurance Policies of Insurance Regulatory and Development Authority and also the Service Level Agreement between Aditya Birla Health Insurance Co. Ltd. and Family Health Plan Insurance TPA Ltd.
In the said guidelines dated 14.07.2005, it has been specifically mentioned in paragraph A- 4 that “ insurance will, however cease, as soon as a member leaves the group except where it is agreed in advance to continue the benefit even after the member leaves the group, such as in case of an employee who retires.”
Admittedly, there is no question of retirement by the Complainant as he was terminated from his Co. before relevant time i.e. the treatment of his father. There is also no agreement in advance to continue the benefit in favour of the Complainant even after his termination.
Annexure “D” filed by the Complainant which contains the terms and conditions of the Health Card (Point No.8) also supports the contention of the Ops.
Therefore, Complainant has lost his right to claim the treatment cost of his father under the Insurance Policy after his termination from his Co. The OP No.4 gives health services to an insurer following the agreement with OP No.3. But, as the services of the Complainant was terminated, the contention of subsequent assurances of making payment by OP No.4 cannot change the actual scenario in the status of the Complainant with regard to his employer.
Not only that, it is also not found that the Complainant had intimated his status of having no longer any employment with his employer.
Therefore, we are of the opinion that the allegation of deficiency in service and unfair trade practice does not hold water. So, this issue is decided against Complainant.
Point No.3 and 4
In view of our observations with regard to Point No.2, Complainant is not entitled to any relief as sought for. That being so, we hold that the instant complaint is liable to be dismissed.
Hence,
It is ordered
That the instant case be and the same is dismissed on contest. No order as to cost.
Let plain copy of this Order be supplied to the parties concerned by hand/by Post forthwith, free of cost for information & necessary action, if any. The copy of the Final Order also available in the official website: www.confonet.nic.in.
Dictated and corrected by me.
