Delhi

East Delhi

CC/01/2011

BRIJESH KR. SHARMA - Complainant(s)

Versus

INSTENT HEALTH CARE - Opp.Party(s)

07 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 01/11

 

Brijesh Kumar Sharma

C-4/175, Yamuna Vihar

Delhi – 110 053                                                                              ….Complainant

Vs.

1. Manager

Instant Healthcare Private Limited

1107, New Delhi House

Barakhamba road, Connaught Place

New Delhi – 110 001

 

2. Legal Manager/CEO

Bharti Axa General Insurance Co. Ltd.

1107, New Delhi House

Barakhamba road, Connaught Place

New Delhi – 110 001                                                                    ….Opponents

 

 

Date of Institution: 08.02.2011

Judgment Reserved for : 07.07.2017

Judgment Passed on : 07.07.2017

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Ms. Harpreet Kaur Charya (Member)

 

JUDGEMENT

The complainant Shri Brijesh Kumar Sharma has filed a complaint against the Manager, Instant Healthcare Private Limited, 1107, New Delhi House, Barakhamba road, Connaught Place, New Delhi–1(OP-1) and Legal Manager/CEO, Bharti Axa General Insurance Co. Ltd., 1107, New Delhi House, Barakhamba road, Connaught Place, New Delhi –1 (OP-2), alleging deficiency in services and unfair trade practice and monopoly.

2.        The facts in brief are that on 30.09.2009, the complainant was approached by Shri Krishan Kumar, the agent of OP-1, for taking the mediclaim policy for his family.  The complainant issued a cheque of Rs. 3,114/-, dated 30.09.2009, as premium.  It was assured to the complainant that the copy of policy would be sent within 15 days.  The agent had issued a provisional receipt bearing stamp of OP-1.  However, the complainant did not receive the copy of mediclaim policy till December 2009.  On inquiry, the official of OP-1 informed that the complainant would receive the policy in the month of January 2010.  It is further stated that in the last week of January 2010, the complainant received the copy of mediclaim policy vide policy number Q0005928, mentioning period of coverage from 1.1.2010 to 31.12.2010.  The wife of the complainant was detected with Breast Cancer and consequently required a surgery, which was planned on 20.12.2010 in Pushpanjali Crosslay Hospital, where the cashless facility was denied as OP-1 had not processed the claim of the complainant.  The expenses of the treatment were Rs. 61,499/-.  The complainant filed the claim with OP-1 and submitted all the relevant documents for reimbursement of medical expenses.  The claim was neither processed nor the policy was renewed.  Hence, the complainant filed the present complaint praying for direction to OP to pay a sum of Rs. 61,499/- towards the medical expenses incurred in the hospital with interest                 @ 24% p.a., renew the policy in question without any break, Rs. 25,000/- towards damages for harassment, tension and agony and Rs. 10,000/- towards cost of the present complaint.

3.        OPs were duly served and were proceeded ex-parte on 14.06.2011 and an order/judgment dated 21.10.2011 was passed by this Forum allowing the complaint of the complainant.  However, the said order was set aside by Hon’ble State Commission in FA No. 821/12 subject to the payment of cost of Rs. 20,000/-, payable to the complainant.  Thereafter, the WS was filed by   OP-2 and complainant filed  rejoinder to the WS. 

In the WS, OP-2 have denied their liability and have submitted that there was no deficiency in service on their part.  They have stated that the complainant cannot claim independent rights than what OP-1 had under the contract of insurance, as the Insurance Policy was a contract only between  OP-1 and OP-2.  It was further submitted that as per contract, it was the duty of OP-1 to inform its members and return the premium.

           Complainant and OP-2 have led their evidence by way of affidavit.  The complainant have examined himself and have relied on Annexure C1 to Annexure C7, which are: original receipt (Annex. C-1), original copy of the policy (Annex. C-2), copy of discharge summary (Annex. C-3), copies of the hospital bills (Annex. C-4), medical treatment documents and                   reports (Annex. C-5), copy of letter to the TPA (Annex. C-6) and copy of the receiving (Annex. C-7).

           OP-2 has examined Ms. Shivali Sharma, Legal Officer, Bharti Axa General Insurance Co. who is relying on policy condition as Ex. R2W1/A, letter to OP-1 dated 30.03.2010 as Ex. R2W1/B and copy of bank advice as               Ex. R2W1/C.

4.         We have heard the Ld. Counsel for the parties and have also gone through the written arguments submitted by them.  The complainant has reiterated the facts of the complaint and have argued that his claim was neither processed nor the policy was renewed by OP-1.  The main arguments of counsel for the complainant was that the plea taken by OP-2 in its WS was irrelevant, as OP-1 had taken the premium of medical insurance and mediclaim policy was issued by OP-2, and the complainant was not informed regarding the cancellation/dispute of the policy either by OP-1 or OP-2.  It was further argued that OP-2 has admitted that complainant was not informed about the cancellation of policy by OP-2 and OP-1 was vicariously liable for  OP-1. 

            Counsel for OP-2 has also placed on record the written arguments and judgments and submitted that there was no deficiency on their part.  They have submitted that they had an agreement with OP-1, to whom they had issued a group mediclaim insurance policy, providing cover to members and complainant was one of the member in that group insurance.  OP-2 has also placed on record the policy conditions, exhibited as Ex. R2W1/A, clause XVIII, which deals with cancellation/termination of the policy, where the notice to the “insured” was to be given.

It was further argued by the counsel for OP-2 that they had written to OP-1 vide letter dated 30.03.2010 that OP-1 shall inform members/customers accordingly.

Counsel for OP-2 stated that OP-2 had duly returned the balance  premium to OP-1 and has exhibited transfer of premium receipt as       Ex.R2W1/C.  Counsel for OP-2 was relying on judgements of Hon’ble National Commission titled as “Ashok Jain Vs. OIC; 2012 CPJ 150 (NC)” where it was held that the notice to the “insured” was sufficient in case of group health insurance policy.

5.         As OP-1 has been proceeded ex-parte, averments made by the complainant and OP-2 against OP-1 remains uncontroverted.  The fact that the complainant was not informed about the cancellation of the policy by OPs and even OP-1 failed to return the premium, amounts to deficiency in service and unfair trade practiceq.  Perusal of policy terms and conditions as well as Ex.R2W1/B-letter written to OP-1 reveals that OP-2 had informed OP-1 only and not to the complainant.    

6.        However, the complainant cannot be made to suffer because of the mutual arrangement between OP-1 and OP-2.  Hence, the complainant is fully entitled for the reimbursement of medical expenses. We direct OP-1 to pay Rs. 61,499/- alongwith interest @ 9% p.a. from the date of filing the complaint as OP-1 retained the returned premium and further did not inform the complainant making the complainant believe that he was covered under the policy. 

           As far as OP-2 is concerned, they had informed OP-1, but they being the insurer had all the details of the member, also had moral responsibility to inform the members.  Thus, they are directed to pay Rs. 10,000/- as compensation, which will act as a deterrent to the practice followed by OP-2, for not informing the members in case of termination/cancellation of group policy. 

           We further award Rs. 10,000/- as compensation in favour of the complainant, to be paid by OP-1 as he left the complainant without insurance cover and enjoyed the premium. 

            This order be complied within a period of 30 days.

           Copy of the order be supplied to the parties as per rules.

File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                                  (HARPREET KAUR CHARYA)

Member                                                                                Member                 

 

(SUKHDEV SINGH)

President