Punjab

Rupnagar

CC/15/10

Arvind Rattan - Complainant(s)

Versus

ICICI Bank & Others - Opp.Party(s)

Sh. Narinder Parshar, Adv

28 May 2015

ORDER

ORDER

                                      MRS. NEENA SANDHU, PRESIDENT

                   Sh. Arvind Rattan has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘the O.Ps.’) praying for the following reliefs:-

i)       To reimburse the amount of Rs.79,074/-,

ii)      To pay Rs.30,000/- as compensation for the harassment caused to him,

iii)     To pay Rs.15,000/- as litigation expenses

 

iv)     To pay interest on the above said amounts @ 18% P.A. from the date of filing of the complaint till realization.

 

2.                 In brief, the case of the complainant is that he had worked with the ICICI Bank since 21.01.2005 and lastly, remained posted at ICICI Bank, Branch Near Petrol Pump, Railway Road, Nangal Township, Tehsil Nangal, District Rupnagar(Pb.) and resigned on 10.08.2013 as a Senior Office under employee No.125489. He and his dependents were covered under the Group Medical Insurance Policy No. 4016/68796664/01/000 being employee of the institution of the O.Ps. On 03.08.2013, his wife was admitted in a hospital and was discharged therefrom on 18.08.2013. He had paid Rs.79,074/- to the said hospital and he was entitled to get reimbursement of the said amount Rs.79,074/- under the medical insurance policy got issued by the O.P. bank. He had sent entire medical bills, through email, to the concerned branch of the O.P. bank for making reimbursement of the amount of Rs.79,074/- on 05.09.2013, but the said amount was not reimbursed despite numerous requests and representations made by him, personally as well as through emails, and receipt of legal notice issued by him, in that regard. The concerned officials had been putting off the matter, on one pretext or the other and lastly, they have flatly refused to make reimbursement of any amount of medical bills to him, saying that he had resigned from the bank on 10.08.2013.  The policy in question was issued by the opposite parties, since the time of his employment with the bank and the original policy is with the O.P. bank, who had never disclosed any terms and conditions of the said policy to him. The aforesaid acts and conduct of the O.Ps. is illegal, unconstitutional and highly condemnable in the eyes of law and amounts to deficiency in service and adoption of unfair trade practice on their part, due to which,   he has suffered a great mental agony, physical harassment & financial loss. Hence, this complaint. 

 

3.                 On being put to notice, the O.Ps. No.1 & 3 filed a joint written statement, taking preliminary objections; that the complaint is not maintainable before this Forum as the complainant is not ‘consumer’ as defined in the Act and the claim lodged by the complainant does not fall under the terms & conditions of the policy in question, because at the time of discharge from the hospital, the complainant was not the employee of the answering O.Ps., as such, no claim is payable to him; that the complainant has not approached this Forum with clean hands, as he has not only concealed the material facts from this case, but has also twisted & distorted the same, as per his own convenience, to mislead the Forum and has filed the instant complaint on wrong & false facts, which deserves outright dismissal; that the complaint has been filed with ulterior motive and malafide intention, just to cause harassment & prejudice to the answering O.Ps. and to gain undue advantage & unjustified money from them, therefore, the same deserves to be dismissed in limini and that this Forum has no territorial jurisdiction to try & decide this complaint. On merits, it is stated that the answering O.Ps. had obtained a Group Medical Insurance policy for its working employees from the O.P. No. 2 and the claim, if any, was admissible, subject to the terms & conditions of the policy. The policy in question being a Group Insurance policy, there was no occasion for issuance of a separate policy for each of the employees. However, all the terms & conditions of the said policy are within the knowledge of the complainant, as he had already availed benefit under the said policy on two occasions, which fact clearly falsifies his averment that he was not having knowledge about the policy terms & conditions. It is admitted that the complainant lodged the claim with answering O.P.  However the concerned department of the answering O.P. informed the complainant through e mail dated 10.09.2013 that his claim is not payable because as per the terms and conditions of the policy, the admission date and the discharge date must be prior to employee’s last working day in the organization, whereas in the present case, the wife of the complainant was admitted in the hospital on 03.08.2013 and was discharged on 19.08.2013 and the complainant had left the organization on 10.08.2013. Since at the time of discharge of her wife from the hospital, the complainant was not employee of the answering O.Ps., as such, no claim was payable, and the medical documents, in original, were returned to him. All other allegations made in the complaint have also been denied and it is further stated that in case of liability, if any, under the policy, the same is of the insurer i.e. O.P. No.2 and a prayer has been made that the complaint against the answering O.Ps. be dismissed with costs.

 

4.                Separate written statement was filed on behalf of the O.P. No. 2, taking preliminary objections; that the present complaint being frivolous & vexatious is liable to be dismissed, as the complainant had not lodged any claim in respect of the alleged treatment taken during the period from 3.8.2013 to 18.8.2013, as such, there was no occasion for the answering O.P. to verify about the genuineness of the claim; that this Forum has got no territorial jurisdiction to try & decide this complaint, as no cause of action had arisen within its jurisdiction because the policy in question was issued from Mumbai, the alleged treatment was taken at the place, outside of the jurisdiction of this Forum & at the time of taking  alleged treatment, the complainant had admittedly resigned from the ICICI bank; that the complainant is not ‘consumer’ of the answering O.P. as defined in the Act; that the complainant has not approached this Forum with clean hands, as he has not only concealed the material facts from this case, but has also twisted & distorted the same, as per his own convenience, to mislead the Forum and has filed the instant complaint on wrong & false facts, which deserves outright dismissal; that the contract of insurance is governed by the policy terms & conditions and the rights/obligations under the same are strictly governed by the policy terms & conditions and no exception or relaxation can be made on the ground of equity; that the complaint is devoid of any material particulars and has been filed with ulterior motive and malafide intention, just to cause harassment & prejudice to the answering O.P. and to gain undue advantage & unjustified money from it, therefore, the same deserves to be dismissed in limini; that the above said preliminary objections got to the very root of the matter, as such, the same need to be considered at the outset, to dismiss the complaint summarily, without going into the merits thereof and that the answering O.P. is entitled to get special cost of Rs.25,000/- from the complainant for unnecessarily dragging it into this uncalled for litigation. On merits, it is stated that the insurance policy in question was issued, subject to its terms & conditions. It is reiterated that

since no claim was lodged with the answering O.P. either by the complainant or through O.Ps. No. 1 & 3, as such, there was no occasion for it to verify the genuineness of the claim. Moreover, as per averments made in the complaint itself, the complainant had resigned the organization on 10.08.2013 and at the time of discharge of her wife from the hospital on 18.8.2013, he was not employee of the O.P. No.1, therefore, no claim is payable. It is stated that there was no occasion for issuance of a separate policy for each of the employees. However, all the terms & conditions of the said policy are within the knowledge of the complainant, as he had already availed benefit under the said policy on two occasions, therefore, the averment made by him that he was not aware  about the terms & conditions of the policy is wrong. All other allegations made in the complaint have also been denied and a prayer has been made that the complaint against the answering O.P. be dismissed with costs.

 

5.                On being called upon to do so, the complainant tendered his duly sworn affidavit, Ex. C1, photocopies of documents Ex.C2 to C6 and closed the evidence. On the other hand, the learned counsel for the O.Ps. tendered affidavit of Ms. Meenu Sharma, Legal Manager,  Ex. OP1, affidavit of Sh. Arshdeep Kumar, Legal Manager,  Ex. OP6, photocopies of documents Ex.OP-2 to O.P. 5 and closed the evidence.

6.                We have heard the learned counsel for the parties and gone through the record of the file carefully.

 

7.                At the outset, the learned counsel for the O.Ps. submitted that this complaint is liable to be dismissed for want of territorial jurisdiction of this Forum, as no cause of action had arisen to the complainant within its jurisdiction, because the policy in question was got issued from Mumbai office of the insurance company and the alleged treatment was also taken outside the jurisdiction of this Forum. In rebuttal, the learned counsel for the complainant submitted that in the year 2013, he was working with the O.P. No.1, from whom he had resigned on 10.8.2013, whose office is situated at Nangal, which falls within the territory of Ropar District, and the claim was also lodged with the said branch of the bank, as such, a part of cause of acting having arisen within the territory of Ropar District, therefore, this Forum has territorial jurisdiction to entertain & adjudicate this case.

                   We find force in the submission made by the learned counsel for the complainant, because in the relevant year i.e. 2013, the complainant was working with the ICICI bank branch, situated at Nangal, District Ropar, and admittedly, he had also lodged the claim regarding reimbursement of the amount in question, which he had spent on the treatment of his wife, with the said branch of the bank, as such, part of cause of action having arisen within the territory of Ropar District, this Forum has territorial jurisdiction to entertain & adjudicate upon the dispute involved in this case, consequently, the objection raised by the learned counsel for the O.Ps. regarding territorial jurisdiction of this Forum is baseless, hence, rejected.

 

8.                          The learned counsel for the complainant submitted that the complainant was the employee of the ICICI Bank since 2005 and he resigned from there on 10.08.2013. The complainant being the employee of the bank, he himself and his dependents were duly covered under the Group Medical Insurance Policy bearing No.4016/68796664/01/000 issued by the O.P. No.2. Due to ill health, his wife was admitted in hospital on 03.08.2013 and was discharged on 18.08.2013. Being a member of the Group Medical Insurance Policy, he was entitled for reimbursement of the amount of Rs.79,074/- which he had incurred on the treatment of his wife. However, the O.Ps, refused to make the reimbursement of the aforesaid amount on the flimsy ground that the complainant has resigned from the bank on 10.08.2013 i.e. prior to the discharge date i.e. 18.08.2013 of his wife from the hospital.  He prayed that the complaint may be allowed and the O.Ps. be directed to reimburse the amount of Rs.79,074/-. They be also directed to pay compensation on account of mental agony and physical harassment along with litigation expenses.         

 

9.                On the contrary, the learned counsel, who appeared on behalf of all the O.Ps., submitted that the complaint is not maintainable as the claim of the complainant does not fall under the terms and conditions of the policy, because as per Group Medical Policy in question, the admission date and discharge date must be prior to the employee’s last working day in the organization. In the present case, the wife of the complainant was got admitted in hospital on 3.8.2013 and was discharged on 18.08.2013. However, the complainant had resigned from the bank on 10.08.2013 i.e. prior to the said discharge date. Therefore, as per terms & conditions of the policy, the O.P. No. 2 is not liable to reimburse the amount incurred by the complainant on the treatment of his wife and the complaint filed against the O.P. No.2 i.e. the insurance company is liable to be dismissed. Even the complaint filed against O.Ps. No. 1 & 3 is also liable to be dismissed, because the reimbursement, if any, was to be made by the insurer i.e. O.P. No. 2 only and not by the said O.Ps.

 

10.              It is a settled law that the parties are bound by the terms and conditions of the insurance policy.  After going through the Group Health Floater Policy Schedule i.e. Ex.OP-3, it is evident that under the head—‘Termination’, it is specifically mentioned that policy will cease to be in effect from the date of termination of relationship with the organization. Admittedly, the complainant had resigned from the ICICI bank, Branch Nangal, District Rupnagar, on 10.08.2013, it means that he ceased to have any relationship with the bank from the said date. Undoubtedly, his wife was discharged from the hospital on 18.8.2013, and on the said date, his relationship with the bank stood terminated. Therefore, as per terms and conditions of the policy, the complainant is not entitled for reimbursement of the amount, as claimed by him, consequently, the complaint is dismissed, being devoid of merit. The parties are left to bear their own costs.

12.              The certified copies of this order be supplied to the parties forthwith, free of cost, as permissible under the rules, and the file be indexed and consigned to the Record Room.

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