PER SUBHASH CHANDRA

1.      This revision petition under section 21 (B) of the Consumer Protection Act, 1986 (in short, the “Act’) assails the order dated 08.02.2017 in Appeal No. 543 of 2016 of the State Consumer Disputes Redressal Commission, Chhattisgarh, Raipur (in short, the ‘State Commission’) arising from the order dated 22.06.2016 of the District Consumer Disputes Redressal Forum, Durg (in short, the ‘District Forum’) in Consumer Complaint no. 14/335 of 2014.

2.     Heard the learned counsel for the parties and perused the record. In the interest of justice, the delay of 100 days in preferring the revision petition is condoned.

3.      The brief facts of the case according to the petitioner are that respondent no. 1 who is retired personnel of the Steel Authority of India had purchased an insurance policy from the petitioner under the Group Mediclaim Scheme 2012 from respondent no. 2/ United Insurance Co. Ltd. for the period 01.01.2012 to 31.12.2012 and another insurance policy from the petitioner for the period from 01.01.2013 to 31.12.2013. On 25.12.2012 the respondent was admitted to Breach Candy Hospital, Mumbai on 25.12.2012 where he remained admitted till 03.01.2013 and was diagnosed with cancer. A claim for Rs 11,52,672/- was submitted on 18.02.2013 which was returned on 22.02.2013 with the endorsement that the same be submitted to the TPA of the company. The papers were submitted to the TPA on 23.10.2013 through the MD, India Healthcare Services TPA Pvt. Ltd., Pune. However, the claim was not paid as there was a delay of 303 days in submission. The repudiation was complained against before the District Forum which awarded Rs 4,00,000/- within one month failing which with interest @ 12% p.a. till the date of payment along with Rs 1,00,000/- and Rs 5,000/- towards harassment and mental agony and litigation respectively. Aggrieved by this order, appeals were filed by the petitioner and respondents 2 and 3 before the State Commission in separate First Appeals. The State Commission allowed the appeal partly and while retaining the award of Rs 4,00,000/- with a reduced interest rate of 9% set aside the order of compensation of Rs 1,00,000/-to be paid jointly and severally by respondents 2 and 3. This order is impugned before us.

4.      The petitioner has challenged the State Commission’s order on the ground that the claim had been submitted after 303 days and that the District Forum had erred in entertaining the compliant on the ground that the policy was not in force till 01.01.2013 whereas the respondent had been admitted in the hospital on 25.12.2012, i.e., prior to the policy coming into force. Per contra, respondent argued that the policy was a Group Mediclaim Scheme and that the admission in hospital was at a time when there was a valid policy in force. 

5.     We have heard the learned counsel for the parties and carefully considered the material on the record.

6.      The District Forum’s findings in its order are as below:

11.     At the time of the aforesaid renewal, there having not made the insurance policy by the United India Insurance, there had been got done it through the Bajaj Allianz General Insurance Company. Since the complainant was a retired officer of the Bhilai Steel Plant and there had been gone done the Group Mediclaim Insurance for the retired employee, therefore as there had been expire the policy of 2012 on 31.12.2012 there had been got done the insurance for the next session from the non-applicant no.3 Bajaj Allianz Insurance Company, which was being a Group Mediclaim Policy.

12.     From the aforesaid facts it is clear that, when the complainant had been admitted in the Hospital, then he was insured under the Group Insurance by the non-applicants number 1 and 2 and the day when he had been discharged, on that day the insurance policy was renewed in regard to being insured by the non-applicant no.3 Bajaj Allianz Insurance Company.

17.     Looking to the circumstances of the case we conclude only this that, both the insurance companies are responsible jointly and severally for making the payment of insurance amount to the complainant. Complainant also made this plea that, by the Bhilai Steel Plan in perspective of the claim of complainant having disclosed the factual position having assumed bonafide to the reason of delay there had been filed the case for making consideration sympathetically on the claim, which being beyond their jurisdiction due to this reason there had been given the advice by the E Meditec to submit it before the T P A then the document had been submitted before the MD India T P A Limited, in regard to which the complainant  made the plea that there should had been assumed bonafide to the aforesaid reasons of delay.

19.     Undisputedly the aforesaid police was of Floater Type and there was insured a sum of Rs.2,00,000/- under the aforesaid policy and there was Rs.2,00,000/- in regard to spouse, thus the complainant is assumed as entitled for attainment of total Rs.4,00,000/- in regard to the aforesaid policy.

7.      The State Commission in its order dated 12.08.2016 states as under:

18.     Claim format which has been filled on behalf of the complainant, that is Annexure A 8 (Exhibit P 8) wherein there is mentioned the complainant remaining admit from dated 25.12.2012 to 03.01.2013 and it is stated there being known the knowledge of the disease on dated 06.12.2012 and the treatment had been completed on dated 13.01.2013 and there on there is remaining the mention of Dr Sultan A Pradha. Annexure A 11 (1) is the e mail made/ sent by the complainant on dated 20.09.2013. Through the perusal of these documents it appears that, previously by the complainant there had been submitted the claim before the non-applicant number 3 Bajaj Allianz General Insurance Company Limited, which had been returned to him. Thereafter there had been submitted the claim before the non-applicant no.1 and 2 United India Insurance Company Limited and the reason of delay which has been shown that is fully satisfactory.

19.     On behalf of the complainant there has been submitted the guideline of IRD Annexure A – 4, (Exhibit P 4) wherein it is mentioned that:

“The insurers’ decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policy holders losing confidence in the insurance industry, giving rise to excessive litigation.

Therefore, it is advised that all insurers needs to develop a sound mechanism of their own to handle such claims with utmost care and caution. It is also advised that the insurers must not repudiate such claims unless and until the reasons of delay are specifically ascertained, recorded and the insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time”.

20.     In the aforesaid circumstances whereas the complainant was inflicted/ affected by the Cancer Disease and by him previously there had been submitted the claim before the non-applicant no.3 Bajaj Allianz General Insurance Company Limited which had been returned back, then the complainant submitted the claim before the non-applicants number 1 and 2 United India Insurance Company Limited. In such a situation, in perspective of the guideline of IRDA and the citation of Madras Port Trust vs Hymanshu International by its Proprietor V Venkatgiri (Dead) by LRs (Supra), it was the duty of the non-applicants number 1 and 2 United India Insurance Company limited that there should had been made the consideration generously on the claim and in such a situation only on the ground of delay of 303 days there may not to be denied/ dismissed the claim.

8.      It is evident that the respondent no 1 was covered under a Group Mediclaim Insurance Policy which was taken by the Steel Authority of India for the benefit of its employees/ex-employees with the objective of providing assistance for medical coverage in case of need. The respondent was covered under a policy of Group Mediclaim for the year 2012 by respondent no 2/United Insurance Co. Ltd. and thereafter by another policy of the petitioner. The order of the District Forum, which has been upheld by the State Court, awards the respondent a claim of Rs 4,00,000/- to be paid jointly and severally by the petitioner and respondent no 2 with interest which has been reduced from 12% awarded by the District Forum to 9% by the State Commission. There is no dispute regarding the admission and treatment of the respondent no 1 in the hospital from 25.12.2012 to 03.01.2013. In view of the fact that respondents had entered into arrangements to provide to employees/ex-employees of the Steel Authority of India, of which the respondent was admittedly was a former employee, the scheme of medical insurance of both petitioner and respondent no 2 was to provide insurance cover for treatment to the respondent. Merely because the date of hospitalization straddled the period during which one scheme lapsed and the other commenced, he cannot be denied the benefit under the policy that commenced subsequently. The District Forum, in allowing the complaint, has rightly awarded the insurance coverage with compensation to the respondent no 1. The State Commission has also upheld the order with the modification that the compensation of Rs 1,00,000/- be deleted and the rate of interest be 9%. The orders are concurrent in their findings on facts and cannot be faulted. There is therefore no reason for the orders to be interfered with. The deletion of the award of compensation cannot be faulted with since the award includes compensation @ 12% by the District Forum and therefore compensation with interest for a singular deficiency cannot be justified. The rate of compensation @ 9% is also a justified award considering that even the Hon’ble Supreme Court has of late been ordering payment of compensation in cases of deficiency in service at this rate of interest. The order of the State Commission therefore does not warrant any interference.   

9.      In addition, it is apparent from the records that the petitioner has challenged the impugned order on the very same grounds which were raised before the District Forum as well as the State Commission in appeal. The concurrent findings on facts of these two foras are based on opportunity to the parties and documents on record. The present revision petition is therefore an attempt by the petitioner to urge this Commission to re-assess, re-appreciate the evidence which cannot be done in revisional jurisdiction. Learned counsel for the petitioner has failed to show that the findings in the impugned order are perverse.       

10.    This Commission, in exercise of its revisional jurisdiction, is not required to re-assess and re-appreciate the evidence on record when the findings of the lower fora are concurrent on facts. It can interfere with the concurrent findings of the fora below only on the grounds that the findings are either perverse or that the fora below have acted without jurisdiction. Findings can be concluded to be perverse only when they are based on either evidence that have not been produced or based on conjecture or surmises i.e., evidence which are either not part of the record or when material evidence on record is not considered. The power of this Commission to review under section 21 of the Act is therefore, limited to cases where some prima facie error appears in the impugned order. Different interpretation of same sets of facts has been held to be not permissible by the Hon’ble Supreme Court.

11.   The Hon’ble Supreme Court in Rubi (Chandra) Dutta (2011) 11 SCC 269 dated 18.03.2011 has held that:

“23. Also, it is to be noted that the revisional powers of the National Commission are derived from Section 21 (b) of the Act, under which the said power can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view than what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the Courts below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. In this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21 (b) of the Act has been transgressed. It was not a case where such a view could have been taken by setting aside the concurrent findings of two Fora.”

12.    Reiterating this principle, the Hon’ble Supreme Court in Lourdes Society Snehanjali Girls Hostel and Ors. vs H & R Johnson (India) Ltd., and Ors.  (2016) 8 SCC 286 dated 02.08.2016 held:

“17. The National Commission has to exercise the jurisdiction vested in it only if the State Commission or the District Forum has either failed to exercise their jurisdiction or exercised when the same was not vested in them or exceeded their jurisdiction by acting illegally or with material irregularity. In the instant case, the National Commission has certainly exceeded its jurisdiction by setting aside the concurrent finding of fact recorded in the order passed by the State Commission which is based upon valid and cogent reasons.”

13.   The Hon’ble Supreme Court in its judgment dated 05.04.2019 in the case of T Ramalingeswara Rao (Dead) Through LRs & Ors. Vs. N Madhava Rao and Ors., Civil Appeal No. 3408 of 2019 dated 05.04.2019 held as under:

“12. When the two Courts below have recorded concurrent findings of fact against the Plaintiffs, which are based on appreciation of facts and evidence, in our view, such findings being concurrent in nature are binding on the High court. It is only when such findings are found to be against any provision of law or against the pleading or evidence or are found to be perverse, a case for interference may call for by the High Court in its second appellate jurisdiction.”

14.    The foras below have pronounced orders which are detailed and have dealt with all the contentions of the petitioner which have been raised before me in this revision petition. It is also seen that the orders of these fora are based on evidence on record.  In view of the settled proposition of law that where two interpretations of evidence are possible, concurrent findings based on evidence have to be accepted and such findings cannot be substituted in revisional jurisdiction, this petition is liable to fail.

15.   We, therefore, find no illegality or infirmity or perversity in the impugned order warranting any interference of this Commission. The present revision petition is, therefore, found to be without merits and is accordingly dismissed. Pending IAs, if any, stand disposed of with this order.