DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Complaint No. CC/15/78 of 20.4.2015

                                      Decided on:        19.10.2015

Gulbir Singh Anand, Roll No.6114, PPO No.11774, resident of House No.155 New Mehar Singh Colony Tripuri, Patiala.   

                                                                   …………...Complainant

                                      Versus

1. Indian Overseas Bank a body corporate duly constituted under the Banking Companies (Acquisition and Transfer of Undertaking)Act,1970 having its Central Office at 762,Anna Salai, Chennai.
2. Indian Overseas Bank through its Manager, Tripuri Branch, Tripuri Town, Patiala(Punjab).
3. E-Meditech (TPA) Services Limited, SCO No.56, First Floor, Sector 30-C,Chandigarh.
4. M/s. Universal Sompo General Insurance Co.Ltd., SCO No.72, First Floor, Swastik Vihar, Sector 5, MDC,Panchkula.

                                                                   …………….Ops

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh.D.R.Arora, President

                                      Smt.Neelam Gupta, Member

                                      Smt.Sonia Bansal,Member                               

Present:

For the complainant:     Sh.Preet Grewal, Advocate proxy counsel of

                                      Sh.Gaurav Bansal,Advocate.

For Op No.3:                 Ex-parte.

For Op no.4:                Sh.Amit Gupta,Advocate.            

                                         ORDER

D.R.ARORA, PRESIDENT

1. The complainant is retired employee of the Indian Overseas Bank i.e. Op no.1. He retired on 30.11.2011.The complainant is a subscriber of Indian Overseas Bank, Retired Employees Medical Assistance Scheme known as REMAS, which was meant to provide the financial assistance to the retired employees so as to cover their medical expenses, the number of the policy issued in this regard being 2816/52396325/01/000.The scheme was introduced w.e.f.1.7.2012 vide circular dated 26.7.2012 and the same covered the employees and their spouse for the sum insured of Rs.1,50,000/-. The complainant had become a member of the mediclaim policy floated by Op no.4 at the instance of Ops no.1&2 having made the payment of the premium of Rs.11,650/-.
2. The complainant  had a knees problem and under the advice of the doctors he had undergone the surgery for the replacement of the knees in the Fortis Hospital SAS Nagar (Mohali). He was admitted in the said hospital on 16.2.2014 and was discharged on 23.2.2014.After replacement of both the knees the said hospital charged a sum of Rs.3,22,162/-.The complainant raised a claim of Rs.1,50,000/- under the mediclaim policy through the said hospital. The hospital had sent the claim under the REMAS scheme but Op no.3 namely E-Meditech (TPA) Services Ltd. repudiated the claim of the complainant on the flimsy grounds vide its letter dated 29.4.2014. The said grounds were not disclosed to the complainant at the time of the issuance of the policy and therefore, the repudiation of the claim of the complainant by Op no.3 on behalf of Op no.4 is said to be a deficiency of service as also an unfair trade practice, which resulted into harassment and mental agony experienced by the complainant. Accordingly the complainant brought this complaint against the Ops under Section 12 of the Consumer Protection Act,1986 ( for short the Act) for a direction to the Ops to pay him Rs.1,50,000/- with interest @ 24% per annum from the date of the lodging of the claim; to award him Rs.50,000/- by way of compensation on account of the harassment and the mental agony experienced by the complainant and to award Rs.11000/- towards the costs of the litigation.
3. The cognizance of the complaint was taken against the Ops No.3&4.Op no.3 despite service failed to come present and was accordingly proceeded against exparte. Op no.4 on appearance filed its written version. It is admitted by the Op that Op no.1, the employer of the complainant, had obtained Group Health Insurance Policy No.2816/52396325/01/000, covering its employees for the period 1.7.2013 to 30.6.2014 subject to the terms and conditions of the policy.
4. The complainant had intimated one claim upon the said policy, which was registered at No.100041408048.The complainant remained admitted in the hospital for the treatment of osteoarthritis both knees from 16.2.2014 to 23.2.2014 having presented himself with complaint of pain in both knees associated with  difficulty in walking and climbing stairs. He was diagnosed with osteoarthritis both knees and  was managed with bilateral knee replacement on 17.2.2014.There is three years waiting period for osteoarthritis. The policy inception date was 1.7.2013. Therefore, under basic coverage exclusions (2), the claim was repudiated as the same does not fall within the purview of the policy. The claim was repudiated vide letter dated 29.4.2014. Thus, there was no deficiency of service on the part of the Op. Ultimately, it was prayed to dismiss the complaint.
5. In support of his complaint, the complainant produced in evidence Ex.CA, his sworn affidavit alongwith documents Exs.C1 to C16 and his counsel closed the evidence.
6. On the other hand, on behalf of the Op, it’s counsel tendered in evidence Ex.OPA, the sworn affidavit of Sh.Piyush Shanker,Assistant General Manager, legal of the Op at Mumbai alongwith documents Exs.OP1 to OP7 and closed its evidence.
7. The complainant filed the written arguments. We have examined the same, heard the proxy counsel for the complainant, the learned counsel for the Op and gone through the record on the file.
8. Ex.C8 is the letter dated April 29^th,2014, written by Op no.3 to the complainant on the subject: Medical under 2816/52396325/01/000 and interalia informed the complainant, “ We invite your attention to the following exclusions in the policy: 1) Basic coverage. Exclusions( 2)-The waiting period for the ailments of Joint Replacement due to degenerative conditions and Age related osteoarthritis and osteoporosis is 3 years under the policy. The  said terms and  conditions duly highlighted are attached herewith  for your ready reference. In view of the foregoing , we regret our inability to consider the claim lodged by you. Should you believe that we have over looked any material facts or circumstances, or should you wish to present an alternative interpretation of any relevant policy provisions, please draw the same to our attention for our further consideration”
9. It was submitted by Sh.Preet Grewal, the learned proxy  counsel for the complainant that it is the positive plea taken up by the complainant that the very grounds on the basis of which the claim of the complainant was repudiated by Op no.3 vide letter dated 29.4.2014 were never conveyed to the complainant at the time of the  issuance of the policy under REMAS. The complainant was simply issued the ID card  Ex.C3. Nowhere, in the written version, filed by the Op the said plea  taken up by the complainant has been refuted by way of specifically alleging that the terms and conditions were supplied by Op no.4 either to the employer of the complainant or the complainant directly. Ex.OP6, is the Group Health Insurance Policy schedule in respect of policy No.2816/52396325/01/000.The name of the proposer has been recorded as Indian Overseas Bank. The period of insurance has been recorded as 1.7.2013 to 30.6.2014.On first page of the policy schedule, it is recorded that the policy is subject to the following special condition(s) and those conditions given on page no.2 have been recorded as: 1) Premium payable under this policy shall be payable in advance.2) Subject to otherwise terms and conditions of Group Health Insurance Policy of Universal Sompo General Insurance Co.Ltd. , 3) After inception of the policy, No midterm inclusion of any dependants of the primary insured, other than newly married spouse, new born child, new joinees’ and their dependents shall be allowed. There is no reference of the other terms and conditions of Group Health Insurance Policy of Universal Sompo General Insurance Company Ltd. to be attached to the policy schedule. Therefore, it was for the Op to  have lead the evidence that the terms and conditions which have now been produced alongwith the policy schedule by the Op and which were said to be attached with the repudiation letter Ex.OP1, were supplied to the proposer namely Indian Overseas Bank or the insured. In the case of the citation First Appeal No. 19 of 2014 Indian Overseas Bank Vs. Sh.N.R.Chauhan and others , decided on 3.3.2014 by the Hon’ble State Consumer Disputes Redressal Commission, U.T.Chandigarh, it was observed in para no.15: “The core question, which falls for consideration, is, as to whether, respondent No.1/complainant was supplied the terms and conditions, under which, the claim was not tenable leading to repudiation vide letter dated 20.12.2012.No doubt, Cards (Annexure-2) were supplied by Opposite Party no.2/Respondent No.2 and the same contained a stipulation that “use of this is governed by the terms and conditions of the Policy you hold, it is not transferable”. Clearly respondent No.1/complainant subscribed to the Scheme on the basis of the Circular dated 26.7.2012 and the same did not contain any condition, under which, the claim was not tenable. The circular explained salient features of the Group Health Insurance Scheme and the scope of Coverage, which are extracted hereunder:

“The salient features of the Group Health Insurance scheme are as under:

• Treatments in the hospitals/nursing homes in India are covered.
• Limit per family shall be Rs.1,50,000/- covering self and spouse on family floater basis.
• Members will be benefited out of cash less facility for their hospitalization claims subject to 20% of co payment clause.

Add on benefits

• Pre existing diseases will be covered.
• Waiver of exclusion of waiting period of 30 days.
• Waiver of exclusion of first year.
• Policy covers the age band of 50-90 years.
• Coverage of death due to accident of retiree (not spouse) for Rs.2 lacs.

Xxxxxxxx

1.  COVERAGE:

Those who have retired from services of Bank on superannuation.

                   The scheme will also cover the following staff retiring after

                 completion of 50 years of age and not gainfully employed.

• Those who have been allowed to retire from bank service on medical grounds
• Those who have taken voluntary retirement from Bank’s service in terms of the provisions of Indian Overseas Bank (Officers’) Service Regulations,1979 and who are not gainfully employed.
• Those who have taken voluntary retirement from bank’s service in terms of the provisions of IOB Employees Pension Regulaions,1995.
• Those who have retired under VRS,2000 scheme

Spouses of those retired, employees mentioned above if they are not gainfully employed”.

10. Incidentally the said citation  namely Indian Overseas Bank Vs. Sh.N.R.Chauhan (supra) pertains to the Op itself as  Op no.4 in our case was the insurer in the case of the citation and the claim was also lodged by retired employee of Indian Overseas Bank and circular dated 26.7.2012 referred to in the said citation has been placed on record by the complainant as Ex.C1 and the same does not contain the very terms and conditions on the basis of which the claim of the complainant was repudiated by Op no.3.
11. In the case of the citation Indian Overseas Bank Vs. Sh.N.R.Chauhan,(Supra) the Hon’ble State Commission (U.T.)Chandigarh observed: “In the absence of any such condition, the complainant was under a bonafide belief that treatment of knee replacement which his wife undertook, was fully covered. It was the bounden duty of appellant/Opposite Party No.1, which took the Insurance Policy for the benefit of its Retired Employees, to make the complainant aware of those conditions of the Policy, which were contrary to the provisions of the Circular dated 26.7.2012. The appellant/Opposite party No.1, failed to do so, despite the fact that such conditions, contrary to the Circular, were supplied to it, by Opposite Party No.3. In  M/s Modern Insulators Ltd. Vs. Oriental Insurance Co.Ltd.,1(2000) CPJ 1(SC), the principle of law, laid down , was to the effect, that it is the fundamental principle of Insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew. The insured has a duty to disclose all the facts, and similarly it was the duty of the Insurance Company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applied to both equally. It was, thus, the duty of  Opposite Party No.1 to disclose all the facts and circumstances, relating to the insurance cover, to the complainant to which the Insurance Policy was supplied by Opposite party No.3.It was also required of Opposite Party No.1, to apprise the complainant of the benefits of insurance, exclusion clauses, contained therein, and the warranties referred to, in the same. It was, under these circumstances, the utmost duty of Opposite Party No.1 to supply the Insurance Policy and the terms and conditions thereof, to the complainant, so as to enable him(complainant) to go through the same and understand the clauses contained therein. In United India Insurance Co. Ltd. & Anr. Vs. S.M.S. Tele Communications & Anr.III(2009) CPJ 246(NC), it was observed that being aware of the existence of the policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. Under these circumstances, the claim of respondent No.1/complainant was wrongly repudiated and the same clearly happened due to deficiency on the part of the appellant/Opposite Party No.1. In the instant case, respondent No.1/complainant subscribed to the Policy, in question, by paying subscription fee of Rs.15750/- , on the basis of Circular dated 26.7.2012 and it was, therefore, incumbent upon the appellant/Opposite Party No.1 to make the respondent No.1/complainant aware of the terms and conditions by supplying a copy thereof to him. The complainant protested repudiation of claim, vide his letter dated 11.1.2013 addressed to the appellant/Opposite Party no.1, interalia , pleading that under the highlighted benefits of Circular dated 26.7.2012, declining of claim was ridiculous, evasive. Apparently, the appellant/Opposite party No.1, was deficient in rendering service.”
12. In the light of the citation Indian Overseas Bank Vs. Sh.N.R.Chauhan, (Supra) rendered by the Hon’ble State Commission U.T.Chandigarh, it can safely be held that the repudiation of the claim of the complainant made by Op no.3, is violative of the principles of natural justice and therefore, we can not up hold the same.
13. Now coming to the entitlement of the complainant in the matter of the reimbursement of the claim, the complainant has produced in evidence Ex.C1, the bill dated 23.2.2014 issued by the Fortis Hospital, Mohali, in the name of the complainant in a sum of Rs.3,52,162/- out of which Rs.30,000/- were reduced by way of rebate and thus as claimed in the complaint, the complainant spent Rs.3,22,162/-.Under the mediclaim policy, the complainant is entitled to the reimbursement of the insured amount of Rs.1,50,000/-.We therefore, accept the complaint and direct  Op no.4, to make the payment of the same with interest @9% per annum from the date of the repudiation i.e.29.4.2014 till final payment. In view of the facts and circumstances of the case, the complaint is accepted with costs assessed at Rs.7500/-. The complainant is also awarded compensation in a sum of Rs.10,000/- on account of the harassment and the mental agony experienced by the complainant on account of the deficiency of service on the part of the Op. The order be complied by the Op within one month on receipt of the certified copy of the order.

Pronounced

Dated:19.10.2015

                   Sonia Bansal                Neelam Gupta                        D.R.Arora

          Member                        Member                                  President