Tamil Nadu
North Chennai
CC/07/2018
A.Swaminathan - Complainant(s)
Versus
Medi Assisf Insurance TPA Pvt.Ltd, National Insurance Company Ltd Rep by its Manager , The Secretary - Opp.Party(s)
M.Aaaruseela Sudhakar
24 Nov 2023
ORDER
Complaint presented on :03.01.2018 Date of disposal :24.11.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,
CHENNAI (NORTH)
@ 2ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 600 003.
PRESENT: THIRU. G. VINOBHA, M.A., B.L. : PRESIDENT
TMT. KAVITHA KANNAN, M.E., : MEMBER-I
THIRU V. RAMAMURTHY, B.A., B.L., PGDLA : MEMBER-II
C.C. No.07/2018
DATED THIS FRIDAY THE 24th DAY OF NOVEMBER 2023
A.Swaminathan
Plot No.2A, Vijayalakshmi Nagar Ext,
(Behind Aavudayar Kovil)
Nanmangalam,
Chennai-600 129 .. Complainant.
..Vs..
1.Medi Assist Insurance TPA Pvt Ltd
(Formerly known as Medi Assist India TPA Pvt Ltd)
Rep by its Manager
2nd Floor,RWD Atlantis Building,
24, Nelson Manickam Road,
Metha Nagar, Aminijikarai, Chennai-600 029
2.National Insurance Company Ltd.
Rep by its Manager
190,Anna Salai,Greams Road,
Chennai-600 006,Tamil Nadu
Also at
Division –III,2nd Floor,35/17
Gandhi Nagar, First Main Road,
Adyar,Chennai-600 020
3.The secretary
Bar Council of Tamilnadu&Pudhucherry
High Court Campus Chennai-600 104
... Opposite parties.
Counsel for the complainant : M/s.M.Aaaruseela Sudhakar and other
Counsel for opposite party 1 : Srinivasan Ramalingam
Counsel for opposite party 2 :Sankaranarayanan
Counsel for opposite party 3 :Lesi Saravanan
ORDER
THIRU. G. VINOBHA, M.A., B.L., PRESIDENT
This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986R/W Rule 5 prays to directing the Opposite party 1 and 2 to pay the sum of Rs.72,548/- along with 12% interest being the amount due under the claim lodged by the complainant till the realization and to pay sum of Rs.3,00,000 towards mental agony and cost of this complaint.
1.THE COMPLAINT IN BRIEF:
The complainant states that he is practicing in the Madras High Court during June 2016 he came across the letter dated 24.06.2017 issued by the Bar Council of Tamilnadu and Pudhucherry 3rd opposite herein invited applications from the interested advocates for joining the Floater Group Mediclaim policy of the 2nd opposite party, by its sister concern the 1st opposite party. The complainant had approached the representatives of the 1st opposite party and clarified with the issue that his wife is going to deliver the child in the month of August and applicability of policy for the maternity treatment for which the representatives of the 1st opposite party assured that the policy will come into effect from 28.07.2017. Hence the maternity treatment expected to undergo in the month of August and its claim surely covers under the policy. On their assurance the complainant accepted to pay premium to the policy that the policy will immediately come into effect from 28.07.2017 and the same will cover that treatment as an expected in August 2017. The complainant submits that he had submitted his application on 29.06.2017 along with the demand draft for sum of Rs.11,600/- drawn on central Bank of India, Chennai Main in DD No.250454 dated 29.06.2017. Subsequent to that he had continuously followed for the details of policy but the same was answered that as it is a group insurance hence it will take some time for issuance of physical card but he can make his claim from 28.07.2017. The complainant submits that his wife on 18th August 2017 undergone maternity treatment and delivered the male baby at Cloudnine Hospital kids clinic India pvt ltd at No.54 Vijayaraghava Road, Opp.Hyatt Regency T.Nagar Chennai-600 017. Immediately the complainant contacted the representatives through their mobile number furnished in the brochure to claim insurance amount and for making payment to the Hospital for which the representatives replied that the insurance identity card was not ready and it is in process as it is group claim and advised to settle the bill and thereafter apply the same to the insurance for reimbursement and the same will be settled. Hence the complainant himself paid the entire hospital bill of Rs.72,548/- Subsequent to that the complainant continuously followed with the opposite parties for the mediclaim reimbursement. Complainant received a mediclaim card (In MA-ID No.5032062788) from the 1st opposite party stating that the mediclaim policy will come into effect from 24.08.2017 to 23.08.2018. The opposite parties received sum of Rs.11,600/- on 29.06.2017 as a premium amount with false promise that the policy will come into effect from 28.07.2017 and the benefit will be given to the complainant’s wife for the expected maternity treatment but after receipt of the premium, the 1st and 2nd opposite parties purposely delayed in issuing policy with an intention to cheat and defraud the genuine claim. But the complainant till date neither received the insurance claim or the premium amount nor the reply from the opposite parties. Further the opposite parties also promised to issue the photo identity card for the policy within 30 days but the same was not followed by the opposite parties as the complainant had paid premium on 29.06.2017 and based on which the identity card ought have been issued on or before 29.07.2017. The act of the opposite parties are highly arbitrary and unreasonable and with a clear intention to deny the bonafide claim of the complainant which is nothing but negligent in service and unfair trade practice and not acted in accordance with fair and proper manner. The complainant quantifies the damages caused to him because of mental agony a sum of Rs.3,00,000/- the 3rd opposite party is included as formal party, at who is behest the 1st and 2nd opposite party floated at Group Mediclaim Policy. No request is prayed againstt the 3rd opposite party. Hence this complaint.
2. WRITTEN VERSION OF OPPOSITE PARTIES 1&2 IN BRIEF:
The opposite parties states that the claim of the complainant towards hospital bills for surgical delivery of his male baby on 18.08.2017 by his wife at Hospital (Cloudnine Kids Clinic India Pvt.Ltd, Chennai-17) cannot be admitted under the Group Mediclaim Insurance Policy No.500300501710000290 as issued to the insured, the claim does not fall within the period of insurance covered by the policy that is to say from 18.00 hours 24.08.2017 to midnight of 23.08.2018. This opposite party hereby specifically and firmly contends that only on 24.08.2017, the premium amount of Rs.34,32,142/- was sent by the Secretary The Bar Council of Tamilnadu and Puducherry who are the 3rd opposite party herein to the divisional office no.3 of the 2nd opposite party by way of a Cheque bearing No.038974 dated 24.08.2017 for covering 239 beneficiaries (Advocates in SI.No.1-239 batch 1, as per list furnished by the Secretary the bar council of tamilnadu and puducherry) under the floater group mediclaim policy and immediately on receipt of such premium cheque this opposite party has duly issued a floater Group Mediclaim Policy for a period of 1 year commencing from 18.00 hours on 24.08.2017 to midnight of 23.08.2018 and that the name of the complainant figures as SI.No.1 in the list of such 239 beneficiary advocates as furnished by 3rd opposite party enclosed to their letter dated 24.08.2017 where under the said premium cheque was also enclosed by them. The opposite party hereby specifically and strongly contends that no policy can be issued by this opposite party unless and until premium amount is paid in advance as mandatorily required under section 64VB of Insurance Act 1938, under the proposed Group Mediclaim Policy towards the amount of premium payable by that member or the amounts collected upto a point of time and kept in the hands of the 3rd opposite party from its enrolled advocates opting for cover under such proposed group mediclaim policy cannot be construed as premium paid to this opposite party unless and until such premium amount is actually paid to this opposite party so as to enable this opposite party to issue such a group mediclaim policy and to assume risks under the policy from the date on which premium has been paid to this opposite party. This opposite party hereby contends strongly that the insured under the floater group mediclaim policy as issued by this opposite party is only the 3rd opposite party.
3. WRITTEN VERSION OF 3rd OPPOSITE PARTY IN BRIEF:
It is submitted that the 2nd Opposite Party came forward to provide Floater Group Mediclaim Policy to the advocates practicing in the State of Tamilnadu and Puducherry for the period of one year from the date of its actual commencement with certain terms and conditions. Accordingly, the Bar council of Tamilnadu and Puducherry has issued notice vide ROC.No.2375 of 2017 dated 24.06.2017 to all the Bar/Advocates Associations informing the advocates, who are practicing in various courts to avail the opportunity and requested to join in the Floater Group Mediclaim Policy. In the Notice vide ROC.No.2375 of 2017 dated 24.06.2017 issued by the Bar Council it has been clearly mentioned that the policy is likely to commence from 28.07.2017 and the actual commencement of the policy will be intimated after receipt of the applications from the members of the Bar all over Tamilnadu along with annexure of premium chart given by the 2nd opposite party. Since the Bar Council has received only 232 applications from the advocates the final cut off date was not fixed by the 2nd opposite party. It is subimitted that thereafter the Bar council has issued another Notice vide R.O.C.No.5548 of 2017 dated 11.08.2017 to all the Bar/Advocates Associations intimating that the filled up application forms from the interested advocates for joining the Floater Group Mediclaim Policy along with demand draft shall be reached on or before 31.08.2018 and further intimated that the date of application for joining the said policy will not be extended further. Thereafter on 24.08.2017 the Bar Council has sent the list of 239 beneficiaries along with a cheque for a sum of Rs.34,32,142/- vide ROC.No.5548 of 2017 dated 11.08.2017 to all the Bar/Advocates Associations intimating that the filled up application forms from the interested advocates for joing the Floater Group Mediclaim along with demand draft shall be reached on or before 31.08.2018 and further intimated that the date of application for joining the said policy will not be extended further. Thereafter on 24.08.2017 the bar council has sent the list of 239 beneficiaries along with a cheque for a sum of Rs.34,32,142/- vide ROC.No.5780 of 2017 dated 24.08.2017 to the 2nd opposite party. After receipt of payment from the Bar council the 2nd opposite party has launched the Floater Group Mediclaim policy covering the period from 24.08.2017 to midnight of 23.08.2018. The 3rd opposite party has not given any promise to the complainant for the actual commencement of the policy. Only after joining of more than 200 persons the Bar council has sent list of advocates along with the cheque to the 2nd opposite party and accordingly they have commenced the policy. It is submitted that the complainant very well knows about the policy and at the time of submitting his application the policy was not commenced. Therefore the complaint is not maintainable before this Forum.
4. POINTS FOR CONSIDERATION:
1. Whether there is any deficiency in service and unfair trade practice and negligence on the part of the opposite party as alleged in the complaint?
2. Whether the complainant is entitled to the reliefs prayed in the complaint. If, so to what extent?
The complainant had filed proof affidavit, written arguments and documents Ex.A1 to Ex.A10 were marked on his side.The opposite parties had filed proof affidavit, written arguments and documents Ex.B1 to B4 were marked by the 3rdopposite party and Ex.B5 to B7 documents were marked by 2nd opposite party
Point No.1:-
The complainant had approached the representatives of the 1st opposite party and clarified with the issue that his wife is going to deliver the child in the month of August and applicability of policy for the maternity treatment for which the representatives of the 1st opposite party assured that the policy will come into effect from 28.07.2017. Hence the maternity treatment expected to undergo in the month of August and its claim surely covers under the policy. On their assurance the complainant accepted to pay premium to the policy that the policy will immediately come into effect from 28.07.2017 and the same will cover that treatment as an expected in August 2017. The complainant submits that he had submitted his application on 29.06.2017 along with the demand draft for sum of Rs.11,600/- drawn on central Bank of India, Chennai Main in DD No.250454 dated 29.06.2017. Subsequent to that he had continuously followed for the details of policy but the same was answered that as it is a group insurance hence it will take some time for issuance of physical card but he can make his claim from 28.07.2017. The complainant submits that his wife on 18th August 2017 undergone maternity treatment and delivered the male baby at Cloudnine Hospital kids clinic India pvt ltd at No.54 Vijayaraghava Road, Opp.Hyatt Regency T.Nagar Chennai-600 017. Immediately the complainant contacted the representatives through their mobile number furnished in the brochure to claim insurance amount and for making payment to the Hospital. The complainant paid Rs.72,548 to the hospital and then claimed reimbursement of the amount from opposite parties 1 and 2. Complainant received a mediclaim card (In MA-ID No.5032062788) from the 1st opposite party stating that the mediclaim policy will come into effect from 24.08.2017 to 23.08.2018. The opposite parties received sum of Rs.11,600/- on 29.06.2017 as a premium amount with false promise that the policy will come into effect from 28.07.2017 and the benefit will be given to the complainant’s wife for the expected maternity treatment but after receipt of the premium, the 1st and 2nd opposite parties purposely delayed in issuing policy with an intention to cheat and defraud the genuine claim. But the complainant till date neither received the insurance claim or the premium amount nor the reply from the opposite parties and hence the complainant contended that the opposite parties 1 and 2 committed deficiency in service and unfair trade practice.
But the opposite parties 1 and 2 contended that the claim of the complainant towards hospital bills for surgical delivery of his male baby on 18.08.2017 by his wife at Hospital (Cloudnine Kids Clinic India Pvt.Ltd, Chennai-17) cannot be admitted under the Group Mediclaim Insurance Policy No.500300501710000290 as issued to the insured, the claim does not fall within the period of insurance covered by the policy that is to say from 18.00 hours 24.08.2017 to midnight of 23.08.2018. This opposite party hereby specifically and firmly contends that only on 24.08.2017, the premium amount of Rs.34,32,142/- was sent by the Secretary The Bar Council of Tamilnadu and Puducherry who are the 3rd opposite party herein to the divisional office no.3 of the 2nd opposite party by way of a Cheque bearing No.038974 dated 24.08.2017 for covering 239 beneficiaries (Advocates in SI.No.1-239 batch 1, as per list furnished by the Secretary the bar council of tamilnadu and puducherry) under the floater group mediclaim policy and immediately on receipt of such premium cheque this opposite party has duly issued a floater Group Mediclaim Policy for a period of 1 year commencing from 18.00 hours on 24.08.2017 to midnight of 23.08.2018 and further contended that the insured is only 3rd opposite party and no insurance cover can be legitimately given prior to 24.08.2017 and further contended that as per section 64VB of insurance act 1938 no policy can be issued by the opposite party until premium amount is paid in advance which is mandatory requirement and hence contended that the delivery of male baby by the wife of the complainant is much before commencement of policy and hence it is not covered under the insurance policy and therefore denied deficiency in service.
The 3rd opposite party contended that the Bar council of Tamilnadu and Puducherry has issued notice vide ROC.No.2375 of 2017 dated 24.06.2017 to all the Bar/Advocates Associations informing the advocates, who are practicing in various courts to avail the opportunity and requested to join in the Floater Group Mediclaim Policy and further stated that in the notification dated 24.06.2017 it has been clearly stated that the policy is likely to commence from 28.07.2017 and the actually commencement of the policy will be intimated only after receipt of applications from the members all over Tamilnadu and since the required number of applications from 239 beneficiaries along with premium amount was received by the 3rd opposite party thereafter only on 28.08.2017 the cheque amount of Rs.3432142/- was sent to the 2nd opposite party and accordingly policy was issued from 24.08.2017 to midnight of 23.08.2018 and the complainant was well aware of the fact that at the time of submitting his application the policy was not commenced and hence contended that the complainant claim does not fell during the policy period.
It is found from Ex.A1 notification issued by the Bar council that the policy is likely to commence 28.07.2017 and actual commencement of policy will be intimated after receipt of applications from members all over tamilnadu and it is further found from Ex.A1 that the policy period is for 1 year covering the birth of first two child and it is further stated that photo id card will issued within 30 days Ex.A2 is a copy of application form submitted by the complainant on 29.06.2017 along with a demand draft for Rs.11,600/- and it is found from Ex.A3 the wife of the complainant delivered a male baby on 18.08.2017 at Cloudnine Hospital Ex.A4 are bills issued by the said hospital Ex.A5 is a copy of insurance identity card issued by the 1st opposite party to the complainant and his wife and it is found in Ex.A5 and Ex.B5 that the policy period is from 24.08.2017 to 23.08.2018. Though it is found from the list of beneficiaries in Ex.B5 that the complainant has paid the premium amount by demand draft on 29.06.2017 it is found from Ex.B6 that the 3rd opposite party has paid the total premium amount of Rs.3432142/- covering 239 beneficiaries only on 24.08.2017 and hence as per section 64VB insurance act 1938 the 2nd opposite party has issued the policy after receipt of premium amount from 24.08.2017 which is not deficiency in service or unfair trade practice on the part of opposite parties 1 and 2. The 3rd opposite party also cannot be held liable since under Ex.A1 notification only a tentative commencement date from 28.07.2017 is announced by the 3rd opposite party and no actual date of commencement of policy was assured by the opposite parties 1 to 3 and therefore there is no force in the contention of the complainant that the opposite parties received e premium amount by promising that the benefit will be given on or before 20.07.2017. The re is no document filed by the complainant to prove any such promise or assurance was given by the opposite parties 1 and 2. Since the alleged policy is a group mediclaim policy the 3rd opposite party has paid the total premium amount by collecting from 239 beneficiaries and paid by way of cheque on 24.08.2017 to the 2nd opposite party and accordingly policy was issued from 24.08.2017 which cannot be alleged as delay in issuing policy by the opposite parties has alleged by the complainant. Though the complainant alleged that he received the insurance identity card only on 18.09.2017 there is no proof for the same. Ex.A6 is legal notice issued by the complainant for which the 1st opposite party has send Ex.A8 reply mail it is found from Ex.B3 that the cheque issued by the 3rd opposite party was realized the 2nd opposite party only on 29.08.2017. There is no force in the contention of the complainant that the opposite parties has not mentioned in any document that the policy will come in to effect only after payment of premium by the 3rd opposite party to the 2nd opposite party for the reason that there is no commitment made by the opposite parties in any of the notifications issued by them mentioning the actual date of commencement of policy and they have only given a tentative likely commencement date in the notification and further stated that the policy will be issued only after receiving application for members all over tamilnadu and hence as prudent person the complainant ought to have enquired and verified the actual date of commencement of policy and then ought to have submitted the application along with premium amount which is a lapse on the part of complainant for which he cannot blame the opposite parties by stating that they have issued policy belatedly in order to cheat the complainant. Similarly there is no force in the contention of the complainant that no where in any document filed by the 3rd opposite party that the policy will commence only after joining of more than 200 members for the reason that it has been already stated in Ex.A1 notification that the policy will commence only after receipt of applications from members of bar all over tamilnadu which imply that the policy will commence after receipt of application from more than 200 persons. Hence from the perusal of the documents filed by both the parties and their averments it is found that the claim in respect of wife of complainant occurred on 18.08.2017 which is 6 days prior to the commencement of policy on 24.08.2017 and hence the said claim is not covered under the policy and hence the complainant is not entitled to claim Rs.72548 from opposite parties 1&2 as the claim was out of policy period and it is further found that the complainant failed to prove deficiency in service and unfair trade practice on the part of opposite parties. Point No.1 is answered accordingly.
Point No.2:
Based on the findings given to the PointNo.1,since there is no negligence and deficiency in service and unfair trade practice on the part of opposite parties, hence the complainant is not entitled for Rs.72548 /- with interest as claimed in the complaint and also not entitled for compensation as claimed in the complaint. Point No.2 is answered accordingly.
In the result the complaint is dismissed. No Cost
Dictated by President to the Steno-Typist taken down, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 24th November 2023
MEMBER I MEMBER – II PRESIDENT
LIST OF DOCUMENTS FILED BY THE COMPLAINANT:
Ex.A1 | 24.06.2017 | Circular&Notice published by the 3rd opposite party in ROC.No.2375 of 2017 along with the brochure issued by the 1st and 2nd opposite parties |
Ex.A2 | 29.06.2017 | Copy of the complainant’s application for enrollment under group mediclaim policy |
Ex.A3 | 21.08.2017 | Complainant’s wife discharge summary |
Ex.A4 | 24.08.2017 | Bill issued by cloudnine Hospital for the treatment undergone by the complainant’s wife |
Ex.A5 | 24.08.2017 | Complainant’s received insurance identity card from the 1st opposite party on 18.09.2017 |
Ex.A6 | 25.09.2017 | Complainant’s notice to the 2nd and 3rd opposite parties with acknowledgement card |
Ex.A7 | 20.10.2017 | Complainant’s notice to the 1st opposite parties with acknowledgement card |
Ex.A8 | 21.10.2017 | 1st opposite party’s Email reply to the complainant for receipt of the complaint. |
Ex.A9 | June,2017 | Photo showing 1st and 2nd opposite parties canvassing in the Bar council campus |
Ex.A10 | 27.07.2018 | Brochure issued by the 3rd opposite party |
LIST OF DOCUMENTS FILED BY THE 3rd OPPOSITE PARTY:
Ex.B1 | 29.06.2017 | Application from A.Swaminathan |
Ex.B2 | 14.07.2017 | Amount Deposited to Bank |
Ex.B3 | 24.08.2017 | Amount sent to National Insurance Company |
Ex.B4 | 24.08.2018 | Insurance Period from 24.08.2017 to 23.08.2018 |
LIST OF DOCUMENTS FILED BY THE 1&2 OPPOSITE PARTIES
Ex.B5 | 24.08.2017 | Group mediclaim policy (floater) issued by chennai divisional office No.III |
Ex.B6 | 24.08.2017 | Letter from secretary bar council to 2nd opposite party |
Ex.B7 | 29.08.2017 | Collection Receipt issued by Chennai DO |
MEMBER – I MEMBER – II PRESIDENT
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