MRS. NEENA SANDHU, MEMBER

1.         This is an appeal filed by the appellant/OP against the order, dated 12.8.2009 passed by District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as District Forum only) in complaint case No. 217 of 2009 vide which, it allowed the complaint and directed the OP to pay Rs.48,480/- to the complainant alongwith Rs.25,000/- as compensation and Rs.5,000/- as litigation costs, within 30 days, failing which, the OP was to be liable to pay the same, alongwith penal interest @12% p.a. since the filing of the complaint i.e. 13.2.2009, till its actual payment to the complainant. 

2.         Briefly stated, the facts of the case, are that the complainants were issued Medi-claim Policy operative from 6.10.2004 to 5.10.2005 by the OP after they were medically examined by the doctor. It was stated that the complainants further got renewed the policy from 6.10.2005 to 5.10.2006 and paid the required premium. It was stated that on the expiry of the said policy, the complainants again got renewed the same from 6.10.2006 to 5.10.2007 vide No. 110301/48/06/20/414 and paid the requisite premium to the OP. The OP received the premium amount from the complainants from time to time and gave bonus to them.  It was further stated that the OP granted the cumulative bonus to the complainants in 2006-07 for the policies upto Rs.20,000/- each and Rs.40,000/- each for the policy of 2008-09. It means that the complainants were taking the policies in continuity. It was further stated that during the existence of the policy, complainant No.2 suffered Left Breast Carcinoma and was advised surgery. Complainant No.1 intimated the OP for passing the claim, as complainant No.2 was hospitalized in PGI, Chandigarh and necessary expenses were required to be met for her operation/surgery. The OP without going into the merits of the case, repudiated the claim of the complainants. It was further stated that complainant No.2, was hospitalized in PGI from 12.6.2007 to 16.6.2007 and the first Chemotheraphy was done on 3.9.2007. The second chemotheraphy was done on 15.10.2007 and the third was done on 13.11.2007. It was further stated that the treatment was still continuing. It was further stated that complainant No.1 deposited the bills amounting to Rs.48,480/- with the OP, but it passed the claim to the tune of Rs.16,000/-. The complainants refused to encash the cheque of Rs.16,000/- as the claim settled by the OP was for a very meagre amount. It was further stated that the complainants further purchased policy for one year from 6.10.2007 to 5.10.2008 but when the policy was received, it was found that it covered the risk from 31.12.2007 to 31.12.2008. The complainants on receipt of the policy, requested the OP to correct the dates of same but to no avail. The complainants also wrote a letter to the office of the OP on 10.1.2008 but to no avail. It was further stated that the complainants had not signed the proposal form.  The complainants requested the OP several times to pass their claim, as per the original bills, but it failed to do so. It was further stated that the abovesaid act of the OP amounted to deficiency, in service. Hence, the complaint was filed.

3.         Reply was filed by the OP, wherein, it was admitted that the medi-claim policies were issued to the complainants, on the basis of information, furnished by them to it. It was stated that the complainants were granted the cumulative bonus as per the Rules and Regulations framed by the OP, and, in accordance with their entitlement from time to time. It was further stated that the complainants concealed the material facts and misled the OP. The OP had engaged the specialized services of M/s Family Health Plan Limited, New Delhi, who are the third party administrators, being duly registered, with the Insurance Regulatory and Development Authority of India, which submitted their specialized report to the OP on the basis of which, the claim was dealt with keeping in view the other merits. It was further stated that the claim of the complainants above Rs.16,000/- was rightly repudiated. It was further stated that the complainants were offered Rs.16,000/- on the basis of expert opinion of the family health plan doctors. The said offer was made after due application of mind and considering all the facts and circumstances of the case, but the complainants with a malicious mind, declined to accept that amount as they wanted to grab more money from the OP, which they were not entitled to. It was further stated that the complainants were given the policy of insurance, as and when, they paid the premium in advance. It was further stated that once the previous policy had lapsed, it was incumbent upon the complainants, to get the same renewed, either in advance or within the stipulated time.  It was further stated that the complainants approached the OP on 31.12.2007 itself and paid the premium, as a result whereof the policy was issued from that date. All other allegations, levelled by the complainant, in the complaint, were denied. It was further stated that there was no deficiency, in service, on the part of the OP.

4.         The parties led evidence, in support of their case.

5.       The learned District Forum allowed the complaint, in the manner, referred to, in the opening para of the judgment.  

6.            Aggrieved by the order, passed by the learned District Forum, the appellant/OP filed an appeal. 

7.         We have heard Sh.D.K.Dogra, Advocate for the appellant/OP, Sh.R.D.Gupta, Advocate for respondents/complainants alongwith respondent No.1 in person and, have perused the record, carefully.

8.         The learned Counsel for the appellant/OP, submitted that the complainants took a medi-claim policy for the first time from 6.10.2004 to 5.10.2005 and the same was renewed from 6.10.2005 to 5.10.2006. Thereafter, it was again renewed for the third time from 6.10.2006 to 5.10.2007. It was further stated that the abovesaid policy could not be renewed again for the 4^th time because of non-payment of the premium by the complainant. Thereafter the complainants paid the premium and fresh policy from 31.12.2007 to 30.12.2008 was issued to them. It was further stated that, during this period, complainant No.2 suffered left breast Carcinoma and she lodged a claim for an amount of Rs.48,480/- but the OPs settled the claim for Rs.16,237/- because the expenses incurred by the complainant on the treatment, for the period from 6.10.2007 to 30.10.2007 were not payable by the OP as there was no policy during this period. Due to non-payment of the premium, on the due date, the earlier policy for the fourth time, could not be renewed from 6.10.2007 to 5.10.2008 and a fresh policy from 31.12.2007 to 30.12.2008 was issued to the complainants after receiving the premium. It was further stated that though the full and final payment of Rs.16,237/- as assessed by the expert doctors of M/s Family Health Plan was offered to the complainants, yet they refused to accept the same. It was further stated that the learned District Forum erred in allowing Rs.25,000/- as compensation, whereas it was proved on file that there was no  deficiency, in service, on the part of OPs.

9.         The learned Counsel for the respondents /complainants submitted that medi-claim policy was taken by the complainants from the OPs w.e.f. 6.10.2004 to 5.10.2005, which was subsequently renewed further upto the year 2009.  It was further submitted that the OP also granted cumulative bonus to the complainants upto Rs.20,000/- each for the policy of 2006-2007 and Rs.40,000/- each for the policy of 2008-2009. It was further stated that once the OP granted a cumulative bonus to the complainants, it meant that policy was in continuity. It was further submitted that complainant No.2 was hospitalized in PGI, Chandigarh from 12.6.2007 to 16.6.2007 as she was suffering from Cancer and first chemotherapy was done on 3.9.2007, second on 15.10.2007 and third on 13.11.2007. It was further stated that the treatment was still going on. It was further stated that they submitted the medical bills to the OPs for Rs.48,880/- for reimbursement, but it only passed the claim just for Rs.16,000/-, which complainant No.1 refused to accept because she was entitled to the full amount, as the policy taken by them w.e.f. 6.10.2004 to 5.10.2005 was renewed by the OP upto the year 2009.  It was further submitted that the policy, which had expired on 5.10.2007, was again renewed on 31.12.2007 by getting the due premium from them. Once the OPs renewed the policy may be from a different date, even then it had no adverse effect on the right of the complainants.

10.       After giving our thoughtful consideration, to the rival contentions advanced by the Counsel for the parties, and, on going through evidence on record, we are of the considered opinion that the appeal is liable to be dismissed for the reasons to be recorded hereinafter. On perusal of Annexure X, the policy issued by the OP for the period from 31.12.2007 to 30.12.2008, it has come to our notice that on the reverse of the same, the date of proposal and declaration is mentioned as 5.10.2004. It means that the OP issued this policy, in continuation of the earlier policies, taken by the complainants w.e.f. 6.10.2004. Not only this, the OP also granted cumulative bonus to the complainant of Rs.20,000/- each in respect of the policy for 2006-2007 and Rs.40,000/- each, in respect of the policy for 2008-2009. Grant of cumulative bonus, aforesaid, is indicative of the fact that last medi-claim policy was issued to the complainants, in continuation of the previous policies. The gap of a few months, after the expiry of previous policy on 5.10.2007 and issuance of a new medi-claim policy w.e.f. 31.12.2007 was condoned by the OP. The District Forum was, thus, right in holding that the complainants were entitled to the full amount of the claim submitted by them. The order of the District Forum, does not suffer from illegality and deserves to be upheld.

11.       In view of the above discussion, the appeal filed by the OP is dismissed, being devoid of merit, and the order passed by the learned District Forum is upheld. The parties are left to bear their own costs.

12.            Copies of this order be sent to the parties, free of charge. 

Pronounced.                                                                        

20^th May, 2011.                   

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