BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

MAHARANA PARTAP BUS TERMINAL, 5TH FLOOR,

ISBT, KASHMERE GATE: DELHI-110006

No. DF(Central)/2015/                                                        Dated:

Complaint Case No.14 of 2013                        

Minakshi Rajawat

A-74, 3^rd Floor, Street No. 6,

West Vinod Nagar

DELHI                                                                                      Complainant

Versus

The Manager Cholamandalam MS GIC Ltd.

No. 81, Pusa Road, Metro Pillar,

Plot NO. 6, First Floor (Opp. HP Petrol Pump)

New Delhi – 110 005.                                                

The Chairman Cholomandalam MS GIC Ltd.,

2^nd Floor, “DARE HOUSE”

No. 2, NSC Bose Road,

CHENNAI – 600 001

The Manager Cholamandalam GIC Ltd.

7^th Floor, Tower A, No. 5, DLF Phase – III,

DLF Cyber City,

GURGAON                                                                   Opposite Parties

ORDER

Complaint under  Sec.12 of the CPA 1986 as amended upto date

Per Sh. Rakesh Kapoor, President

          The complainant was a member of Group Health Insurance policy which was purchased from the OPs on 5.11.2011.  She was admitted in G.K. Surgical and Maternity Clinic for the delivery and was discharged on 17.12.2011.  It is alleged by the complainant that she had made an enquiry before getting admitted and was informed that the insurance policy covered the expenses incurred during the delivery.  After discharged she had lodged a claim with the Ops which not paid .  Hence, the complaint.

          The OPs have contested the complaint and have filed a written statement they have denied any deficiency on their part and have claimed that the complaint is liable to be dismissed.  The OPs have contested the complaint on merit Para 2, 2.2, 2.3, 4 and 5.1 of the reply on merits is relevant and is reproduced as under:-

1. That in reply to Para 2 it is submitted that the Opposite Parties have issued a Group Health Insurance Policy No. 2825/00002789/000/02 to M/s Accretive Health for the period 17.6.2011 to 16.6.2012 with respect to the employees of M/s Accretive Health.  The complainant has filed no evidence of her being an employee of M/s Accretive Health.  In the absence of any such evidence, the Opposite Parties say that the complainant is not a consumer and has no privity of contract with Opposite parties and cannot maintain a complaint under the CP Act. 1986.
   1. It is wrong for the complainant to say that at the time of execution of insurance policy.  She was categorically informed by the representative of respondent that the policy obtained by complainant shall cover maternity claim also.  It is submitted that the insurance policy was not executed in favour of the complainant but in favour of M/s Accretive Health.  It is wrong for the complainant to say that being so counselled she had opted to use the policy. It was not her option, but that of the Insured Policy holder to include employees for the sums insured as fixed by the employer.
   2. The insurance policy issued by the opposite parties is a Group Health Policy issued to the Insured for their employees only, the Opposite Parties have specified each and every terms, conditions, exclusions and limitations of the policy in the Memoranda attached to and forming part of the policy.  It was for the Insured employer to have provided to all its employees failing within the scope of coverage all the terms conditions exclusions and limitations advising them to comply the requirements needed for the approval of any claim submitted by their covered employees.  
2. That in reply to para 4 it is submitted that the insurance policy was obtained by Insured policy holder nearly six months prior to the complainant being admitted for delivery.  The terms of cover had been settled thus long back and would not get changed at the stage of her admission to the hospital.  Her calim would be subject to the terms conditions exclusions and limitations of the policy issued to the Insured Policy holder.
   1. The Opposite Parties had repudiated the claim by their letter dated 7.1.2012 as the General Exclusion clause C-23 excludes the claims arising due to Pregnancy.  Childbirth and their consequences, including changes in chronic conditions a result of pregnancy. The claim therefore is outside the scope of cover granted by the policy.  The reason for repudiation given in letter dated 7.1.2002 were reproduced in the opposite parties letter dated 9.11.2012 which is filed by complainant at pgs. 35 and 36 of the complaint.  This is confirmed in para 8 of complainants legal notice at page 33 of the complaint.

We have heard the arguments advanced at Bar and have perused the record.

The parties have placed the record guidelines issued by IRDA vide its Circular dated 14.7.2005.  Para 6 of the guidelines under the head Group Insurance Administration reads as under:-

6.Where an employer buys a group insurance policy as a service benefit for its employees and pays the premium in full or in part, the employer may be treated as the policyholder with the employees being treated as the beneficiaries.  In such cases, the employer may issue confirmation of insurance protection to individual employees with clear reference to the group insurance policy and the benefits secured thereby.  In respect of such group policies, the claims of individual persons insured thereunder may be processed through the employer.

          The perusal of aforesaid para makes amply clear that in the case of a employer buying a group insurance policy the employer is treated as the policy holder and the employee as the beneficiaries.  It is the duty of the employer to issue confirmation regarding insurance to the individuals employees and to apprise them of the benefit secured thereby.  A perusal of the W.S/evidence filed on record by the OPs makes on amply clear that the group insurance policy purchased by the employer of the complainant did not covered expenses incurred on pregnancy/child birth.  There was an exclusion clauses C-23 in the group insurance policy according to which the expenses were not payable in respect of pregnancy/child birth.  The complainant ought to have known about the terms and conditions of the policy purchased by the employer of which she was the beneficiaries.  We therefore, find no deficiency on the part of the OPs and we hold that they were justified in repudiating the complaint lodged by the complainant.  We find no merit in this complaint.  The same is hereby dismissed.

          Copy of the order be made available to the parties as per rule.  File be consigned to record room.

          Announced in open sitting of the Forum on.....................

               (S N SHUKLA)                                  (RAKESH KAPOOR)

                    MEMBER                                            PRESIDENT