Punjab

Moga

CC/16/64

Deepak Maini - Complainant(s)

Versus

Kotak Mahindra life Insurance Company limited - Opp.Party(s)

Rajesh Kumar Dua

28 Jun 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

                                                                                                                                                            C.C. No. 64 of 2016

                                                                                                                                               Instituted on: 04.02.2016

                                                           Decided on: 28.06.2016

 

Deepak Maini son of Ram Partap, aged 44 years, resident of Gali Bagichi Golchian, Near Turi Bazar, Ferozepur now resident of Anand Avenue, Ferozepur City. M. No. 98141-75371.

                                                                             ……….   Complainant 

Versus

 

1.       Kotak Mahindra Life Insurance Company Ltd., Branch G.T.road, Moga, through its Branch Manager.

 

2.       National Insurance Co. Ltd., 3, Middleton Street, Kolkata, through its Authorized Signatory.

 

                                                                           ………. Opposite Parties

 

 

Complaint under Section 12 of the Consumer Protection Act, 1986.

 

 

 

Quorum:   Sh. Ajit Aggarwal, President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

Present:       Sh. Rajesh Kumar Dua, Advocate Cl. for the complainant.

                   Sh. Gurmeet Singh Dhaliwal, Advocate Cl. for the opposite party no.1.

                   Sh. Pawan Kumar Sharma, Advocate Cl. for opposite party no.2.

 

 

ORDER :

(Per Ajit Aggarwal, President)

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986  (hereinafter referred to as the 'Act') against Kotak Mahindra Life Insurance Company Ltd., Branch G.T.road, Moga, through its Branch Manager and others (hereinafter referred to as the opposite party) for directing them to sanction genuine medical claim of Rs. 22,833/- alongwith interest @ 18% p.a. from the date of filing of claim till actual realization. Further opposite parties may be directed to pay Rs. 50,000/- as compensation on account of mental harassment, pain and agony and Rs. 11,000/- as litigation expenses to the complainant.

2.                Briefly stated the facts of the case are that the complainant was employee as Senior Sales Manager, Level-4 of Kotak Mahindra Life Insurance Company and joined said insurance on 29.05.2010 at Branch Office Moga. At the time of joining of said insurance company, opposite party no.1 covered complainant and his family members under Group Medical Policy and premium amount was deducted by opposite party no.1 from the salary of complainant every month and sum assured of said policy was Rs. 3.5 lacs. On 23.09.2013, the complainant gave notice of 30 days with regard to his resignation from job to the opposite party no.1 and opposite party no.1 kept resignation of the complainant with them. On 25.09.2013, when the complainant was leaving his office, then unfortunately he slipped at the door of office of opposite party no.1 and he received hip fracture and he was brought at GGS Medical College and Hospital, Faridkot by his colleagues and he remained admitted in the said hospital from 25.09.2013 and discharged on 28.09.2013 and during said period he was operated upon his hip and implants were inserted by doctors. The complainant spent an amount of Rs. 22,833/- on his treatment. After cure from his fracture, complainant immediately filed claim before opposite party no.1, who suggested complainant to send original documents and bills to employee settlement/Medical office at Mumbai and accordingly complainant sent all original documents with bills to said office who further send the same to opposite party no.2 for settlement. But the claim of the complainant was not settled by opposite parties despite repeated requests made by complainant. The complainant earlier filed similar complaint which was dismissed as withdrawn with permission to file the same on same cause of action. The act and conduct of opposite parties amounts to deficiency in service and unfair trade practice, for which, the opposite parties are liable to pay compensation to the complainant. Hence this complaint.

3.                Upon notice, opposite parties appeared through their counsel and filed their separate written replies.

                   Opposite party no.1 filed written reply taking certain preliminary objections that the present complaint is not maintainable qua answering opposite party. There is no proper allegation in the complaint to show that any act attributed on the part of answering opposite party amounts to any deficiency of service or negligence; that this Forum does not have the jurisdiction to entertain the complaint qua the opposite parties solely on the ground that the dispute in question is not covered under the Consumer Protection Act, 1986. The alleged dispute between the complainant and opposite party company does not fall under the CPA, 1986 on the sole ground that the definition of Consumer doesn't cover the present complainant. The dispute in question is a dispute between the complainant and the other opposite parties and the same is not a dispute pertaining to Consumer Protection Act qua the opposite parties. Neither any service has been provided nor have any goods been sold by the answering opposite parties company. The relationship between the two i.e. the complainant and the opposite parties is more or less than that of the employer and the employee which cannot be covered under the preview of this Act. Further submitted that the in the instant case there is not even a dispute regarding a contract of Personal Service between the complainant and the opposite party company. Even if that had been the case the complainant could have approached the Civil Court for adjudication of the matter. A contract of personal service cannot be in any manner be enforced vide such a complaint, hence complainant cannot go beyond the law of the land and seek a relief which he is not entitled to in any manner whatsoever under the provisions of CPA. Further submitted that the complainant raised his resignation on 23^rd of September 2013 giving 30 days notice period. The complainant came to the office of opposite party company on 25^th September, but thereafter he never joined or reported for duty inspite of the fact that he was admittedly discharged from the hospital. As per the policy terms the claim has to be submitted within 30 days from the discharged from the hospital, but in the instant case, the complainant neither joined the office of the company nor submitted the claim. It was only on 8^th November, 2013 he submitted the claim which was almost one month from the date of expiry of the period of submitting the claim, hence is not entitled to any amount whatsoever. Further submitted that the complainant has sought relief on the basis of allegations which are not supported by any documentary evidence to substantiate the same. Therefore, the complaint does not deserve any consideration by this Forum and merits dismissed at the threshold; that this Forum has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of the answering opposite party. In the present case, the opposite parties have strictly acted as per the terms and conditions of the policy contract. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. The Forum cannot pass any order in contravention to the terms and conditions of the policy contract; that there is no deficiency in service rendered by the answering opposite parties in the present case and the answering opposite parties is not a necessary or a proper party to the present dispute, accordingly present complaint ought to be dismissed against the answering opposite parties. In Parawise reply submitted that the contents of preliminary objections and submission shall be treated as part and parcel in response to the respective paras and anything contrary thereto or inconsistent therewith are wrong, hence denied.

4.                Opposite party no.2 filed written reply taking certain preliminary objections that the complaint is not maintainable; that the complainant is not consumer of opposite party no.2; that the complainant has not locus standi to file the present complaint against opposite party no.2; that the complainant has no cause of action against the answering opposite party no.2; that the complainant has not filed any medical insurance policy or any other document in connection with the alleged policy to reveal any liability of the answering opposite party no.2. Thus, the answering opposite party no.2 is not liable to pay any claim. However, the answering opposite party no.2 reserves its right to file the amended written statement on later stage as and when some new material facts comes to the light and knowledge of the answering opposite party no.2; that the opposite party no.2 never received the claim form and other documents as stated by the complainant. The alleged claim form is false and frivolous. The answering opposite party no.2 has no concern with the same; that the opposite party no.2 has no business relations or tie up with the opposite party no.1/Kotak Mahindra Life Insurance Co. Ltd. As they have not filed any document; that there is no deficiency in service on the part of opposite party no.2 as the complainant is not the consumer of opposite party no.2. Thus, the complaint may kindly be dismissed on this score; that the answering opposite party no.2 has been impleaded falsely. Thus, the name of answering opposite party may kindly be struck off; that the complaint is not within time. Thus, the complaint may kindly be dismissed on this score. On merits, the all other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.

5.                In order to prove the case, complainant Deepak Maini tendered in evidence his duly sworn affidavit Ex. C-1 and copies of documents Ex. C-2 to Ex. C-13  and closed the evidence. 

6.                In rebuttal, the opposite party no.1 tendered in evidence duly sworn affidavit of Sh. Shouvik Sen, Chief Manager, Kotak Mahindra Old Mutual Life Insurance Co. Ltd. Ex. OP-1/1 and copies of documents Ex. OP-1/2 to Ex. OP-1/5 and closed the evidence. Whereas, opposite party no.2 tendered in evidence duly sworn affidavit of Sh. Kamaljit Singh, Divisional Manager, National Insurance Company Ex. OP-2/1 and closed the evidence.

7.                We have heard the learned counsel for the parties and have carefully gone through the record placed on file.

8.                Ld. Counsel for the complainant argued that the complainant was employee of OP-1, he joined the service on 29.05.2010 at Moga branch of Op-1, OP-1 covered the complainant and his family members under Group Medical policy for Sum of Rs.3,50,000/- and premium of this policy was deducted by OP-1 from the salary of the complainant every month. On 23.09.2013 the complainant gave notice of 30 days with regard to his resignation from job to OP-1. On 25.09.2013 complainant was leaving office of OP-1, he slipped at the door of the office and received hip injuries and brought to GGS Medical College and Hospital, Faridkot by his colleagues and he remained admitted in hospital from 25.09.2013 to 28.09.2013 where he was operated upon his hip and implants were inserted by the doctors, he spent Rs.22,833/- on his treatment, after curing from the injuries, the complainant immediately filed claim with OP-1 and at their instructions he sent original documents and bills to employee settlement/Medical office of OP-1 at Mumbai. Complainant sent original documents to the Ops who further sent to OP-2 for settlement but till date the claim of the complainant is not settled by the OPs despite repeated request. The act and conduct of the Ops amounts to deficiency in service and unfair trade practice on their part on which they are liable to pay compensation to complainant. In his support the complainant produced copy of claim form as Ex C-2, discharged summary Ex C-7, hospital bills Ex C-8 and full and final settlement issued by OP-1 as Ex C-10, which shows deduction of amount as medical insurance premium. The complainant prayed that OPs may be directed to pay his Medical claim along with compensation and litigation expenses.

9.                To controvert the arguments of the Complainant, Ld. Counsel for the OP-1 argued that the present complaint is not maintainable against them, there is no proper allegation in the complaint to show that any act attributed on the part of OP-1 amounts to deficiency in service and negligence which gives any cause of action to file this complaint. This Forum has no jurisdiction to try and hear this complaint as the dispute between the parties is not covered under the Consumer Protection Act. The dispute in question is dispute between the complainant and OPs and the same is not dispute of Consumer Services neither any service has been provided nor any goods sold by OP-1 to complainant. The present dispute between the parties is not between the company and the customer. The relationship between the complainant and OP-1 more or less than that of the employer and the employee which cannot be covered under the preview of this Act. In the instant case, there is no dispute regarding a contract of Personal service between the complainant and the OP-1. He should have been approached to the Civil Court for the adjudication of the matter. However, the complainant raised his resignation on 23.09.2013 giving 30 days notice period. The complainant comes to the office of OP-1 on 25.09.2013 but thereafter he never joined or reported for duty and he admittedly discharged from hospital. As per the terms and conditions of the policy the claim has to be submitted within 30 days from the discharge from the hospital but in the instant case the complainant neither joined the office of the company nor submitted his claim within this period. It was only on 08.11.2013, he submitted the claim which was much later from the date of the expiry of one month period for submitting the claim. He is not entitled to any amount whatsoever. The Hon’ble Forum may be pleased to dismiss the present complaint against OP-1. The complaint deserves to be dismissed on this count alone. The allegations of the Complainant are not supported by any documentary evidence. The complainant has failed to demonstrate any deficiency in service on the part of OP-1. The OP-1 has strictly acted as per terms and conditions of the policy. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. There is no deficiency in service rendered by OP-1 in the present complaint and OP-1 is not necessary or a proper party to present dispute. The present complaint may be dismissed against OP-1. The complaint being false, frivolous and vexatious is liable to be dismissed U/s 26 of the Consumer Protection Act.

10.              The Counsel for OP-2 argued that the present complaint is not maintainable. The complainant is not consumer of OP-2, he has no locus standi to file the present complaint against OP-2. The complainant has not file any medical insurance policy or any other document in connection with the alleged policy to reveal any liability of OP-2. OP-2 is not liable to pay any claim. OP-2 never received claim form or other documents as stated by complainant. The claim form produced by complainant is false, OP-2 has no concern with the same. There is no tie up or business relation of OP-2 with the OP-1 as they have not filed any document.  They never issued any group insurance policy for the employees of OP-1. Even OP-1 also have not filed any document regarding the issuance of insurance policy by OP-2. There is no deficiency in service on the part of the OPs as complainant is not consumer of OP-2. The complaint may be dismissed only on this score. The OP-2 is impleaded falsely. The present complaint may be dismissed with cost.

11.              We have heard the arguments of both the parties and also gone through the pleadings and evidence led by both the parties. The case of the complainant is that he was in service of OP-1 and during the service the OP-1 cover complainant and his family members under Group Medical Insurance policy and premium of this policy was deducted from the salary of the complainant every month. On 25.09.2013 during his service period he slipped in the office of OP-1 and he had to remain admitted in hospital from 25.09.2013  to 28.09.2013 and operated upon hip. After curing from injuries he filed his medical claim with OPs but till today the OPs have not settled his medical claim despite the repeated request. In reply OP-1 submitted that the complainant is not their consumer. However, they admitted that complainant was their employee and he was covered under group medical insurance policy, he further admitted that on 25.09.2013, he suffered hip injuries and admitted in the hospital, they further admitted that  the complainant submitted his claim form along required documents with them but their only objection is that as per policy the claim form have to be submitted within one month from discharge from hospital but in present case complainant discharged from the hospital on 28.09.2013 and he did not file claim form within one month and file claim after the expiry of that period on 08.11.2013 in violation of the terms and conditions of the policy. Another objection is that the complainant submit his resignation on 23.09.2013 with one month notice and after 25.09.2013 when he got injuries, he never reported in the office of OP-1, even after the discharge from the hospital, therefore, he is not entitled for any claim. OP-2 argued that they have no relation with complainant or OP-1. They never issued any medical insurance policy for the employees of OP-1, they have no tie up or business relation with OP-1. Complainant or OP-1 failed to produce any document showing any relationship with OP-2.

12.              We have thoroughly gone through the file and evidence. The full and final settlement produced by complainant as Ex C-10 and by OP-1 as OP-1/3 clearly shows that the OP-1 deducted medical insurance premium from the salary of the complainant every month which clears that complainant was cover under Group Medical Insurance policy of OP-1. It is admitted case complainant suffered injuries on his hip on 25.09.2013 and remained in hospital up to 28.09.2013 and paid charges for his treatment. The plea of OP-1 is that as per terms and conditions of the policy, he had to submit his claim form within one month from the date of discharge and complainant failed to submit his claim documents in this period. In reply, the Counsel for the complainant argued that in hospital he was operated on his hip and implants were inserted, the doctors advised him to complete bed rest and due to the operation he was unable to move when he became able to move and doctor advised him to work. He immediately filed the claim documents with OP-1 without any delay. Within period as stipulated in the terms of the insurance policy, the 2^nd objection of OP-1 is that after 25.09.2013 i.e. date of incident. The complainant never reported in their office and not rendered his service with OP-1, so he is not entitled for the benefit of group insurance policy with OP-1. It is admitted that on 25.09.2013 when complainant received injuries, he was in the service of OP-1 even he received injuries in the office of OP-1, then they cannot denied the claim on the basis that later on complainant never reported on the job or left the job of OP-1.

13.              From the above discussion, we are of the considered opinion that Complainant is entitled to get his insurance claim under Group Medical insurance policy of OP-1 and by not settling his claim the OP-1 is negligent and these acts of the OP-1 amounts to deficiency in service and trade mal practice on their part. However, complainant as well as OP-1 have not produced any document or insurance policy issued by OP-2 regarding Group Medical Insurance for the employees of OP-1, they did not produce even single document that there is any relation between OP-1 & 2.

14.              We are fully convinced with the evidence, arguments and case law produced by the complainant, hence the present complaint against opposite party no.2 stand dismissed and the present complaint against opposite party no.1 is allowed. The opposite party no.1 ordered to pay the medical claim of complainant for the sum of Rs.22,833/- alongwith interest @ 9% PA from 08.11.2013 when complainant submitted his claim with opposite party no.1 till final realization.  The opposite party no.1 is burdened to pay Rs 5,000/- (Five thousand only) as compensation for mental agony and harassment faced by complainant and Rs.3000/- (Three thousand only) as litigation expenses to the complainant. Opposite party no.1 is directed to comply with the order within one month from the date of receipt of the copy of the order, failing which, complainant shall be entitled to initiate proceedings under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to the record room. 

Announced in Open Forum

Dated: 28.06.2016

 

                        (Bupinder Kaur)                           (Vinod Bala)               (Ajit Aggarwal)

                              Member                                      Member                      President