Date of Filing:13.09.2007<br /> Date of Order:11.02.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> Dated: 11 TH DAY OF FEBRUARY 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> COMPLAINT NO: 1918 OF 2007<br /> <br /> <br /> Messrs Bible Society of India,<br /> (A Society constituted under the <br /> Societies Registration Act)<br /> ‘LOGOS’ # 206, M.G. Road, <br /> Bangalore 560 001,<br /> Represented by its General Secretary<br /> Dr. B.R. Pramanik. Complainant<br /> <br /> V/S<br /> 1. The Managing Director,<br /> Messers Cholamandalam MS <br /> General Insurance Company Ltd.,<br /> II Floor: Dare House,<br /> # 2, NSC Bose Road,<br /> Chennai-600 001.<br /> <br /> 2. The Managing Director,<br /> Messers Paramount Health<br /> Services Pvt Ltd., FF-1: Business Point,<br /> # 137, Brigade Road, <br /> Bangalore-560 095. Opposite Party<br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed by under Section 12 of the Consumer Protection Act, 1986.<br /> The brief facts of the case are that, the complainant is a non-profitable organization. Opposite party No.1 is one of the leading general Insurance Companies. Opposite party No.1 had assigned a representative company by name M/s Paramount Health Services Pvt Ltd., as its administrator at Bangalore. Complainant availed Group Comprehensive Health Policy for its employees and their respective spouses from the opposite party towards premium amount of Rs.14,89,556/-. The validity of the policy was for a period of one year from 01/06/2005 to 31/05/2006. Opposite party had undertaken to indemnify all the 300 odd staff members of the complainant along with their respective spouses for health related medical claims. Customer Id: CD 765339 was allotted to the complainant by the opposite party No.1 on acceptance of the policy. The complainant further availed an additional coverage on the health policy for the spouses of directors. Towards the said coverage the complainant paid an additional premium of Rs.1,72,164/- to the opposite party No.1 and get a further health coverage of Rs.5,00,000/-. The earlier coverage being for Rs.5,00,000/-. Thus the complainant has paid a total sum of Rs.16,61,720/- towards the premium amount to the opposite party No.1 for the policy. On receipt of the additional premium opposite party No.1 issued an endorsement on 21/09/2005. The claim requests were put up by the complainant to opposite party No.1 through its administrator. On various dates prior to January-2006 and all of which were promptly settled by opposite party No.1. It is the case of the complainant that ever since January-2006 opposite party No.1 has refused to settle further claim. 20 claim requests as detailed below totally amounts to Rs.6,39,588/- are pending. The name of the 20 claimants and the amount claimed are mentioned in detail in para 10 of the complaint. All the claims are within the validity period of the policy. The said claims are still pending. Opposite party No.1 issued a renewal policy notice to the complainant on 10/04/2006. Complainant has sent many reminders to the opposite party No.1. Opposite party No.1 forwarded an untenable and whimsical letter to the complainant stating its arbitrary decision to cancel the endorsement and also sought recovery of excess claim amount of Rs.3,44,608/- paid to late Mrs. Aruna Pramanik. In the said letter opposite party No.1 states that endorsement was issued due to a mistake on its part and is willing to refund the additional premium collected. Opposite party No.1 has not clarified the reasons with 13 other claim reasons. Aggrieved by the reprehensible attitude of the opposite party in settling the claim, the complainant got issued legal notice. The inability of the opposite party in settling the claim amounts to gross professional delinquency and deficiency in service on its part. Therefore, the complainant prayed that opposite party No.1 be directed to settle the claim amount of complainant to the tune of Rs.6,39,588/- with interest and opposite party No.1 be directed to pay compensation of Rs.1,00,000/- and costs.<br /> 2. Notice was issued to opposite parties. Opposite party No.1 appeared through Advocate and presented defense version. The opposite party No.2 remained absent though served with notice. The opposite party No.1 submitted in the defense version that the opposite party No.1 had issued Group Health Insurance Policy for a period from 01/06/2005 to 31/05/2006 and the complainant had paid premium of Rs.14,89,556/-. The policy covers the risk of employees of the complainant with their spouses being covered as dependents. The liability of the opposite party under the policy is subject to the terms and conditions of the policy. The opposite party had also admitted that complainant sought for coverage of additional persons under the policy and paid additional premium of Rs.1,72,164/-. On receipt of the additional premium opposite party issued an endorsement which is in attachment of the main policy. It is submitted that totally 21 persons are covered and were shown as employees of the complainant. 8 persons among 21 persons were not employees but were dependent spouses. The complainant did not correct the discrepancy even after receipt of the endorsement. In case of Mrs. B.K. Pramanik and his spouse the sum assured is Rs.5,00,000/-. Claims were paid to the extent of Rs.8,44,608/-, as such opposite party wrote a letter calling for refund of Rs.3,44,608/- being the excess claim. It is submitted that with regard to the list of pending claims stated at para 10 of the complaint, a sum of Rs.3,02,147/- is towards the claims pertainin g to Mrs. Aruna Pramanik, and remaining 13 pertains to others for a sum of Rs.3,37,441/-. It is submitted that in all a sum of Rs.8,44,6-8/- is paid to complainant on account of Mrs. Aruna Pramanik, of which Rs.3,44,607/- is paid in excess. The pending claims of Mrs. Aruna Pramanik mentioned in the list at Para No.10 are inadmissible, as the cover under the policy is limited to Rs.5,00,000/-. With regard to other claims which works to Rs.3,37,441/-, this has to adjusted in the amount excess paid that is Rs.3,44,608/-, in such an event the complainant would be liable to pay a sum of Rs.7,167/- to the opposite party. The opposite party submitted that there is no deficiency of service. Opposite party is not liable to pay Rs.6,39,588/- with interest. It is submitted by the opposite party that the present case requires elaborate evidence and detailed trial and as such cannot be adjudicated before this Forum in a summary trial. It has to be tried in a competent Civil Court. For all these reasons stated above, the opposite party has prayed to dismiss the complaint.<br /> 3. Affidavit evidences are filed. Arguments are heard.<br /> 4. The points for consideration are:-<br /> 1. “Whether the complainant has proved deficiency in <br /> service on the part of the opposite party?”<br /> <br /> 2. “Whether the complainant is entitled to the <br /> claim amount?” <br /> <br /> REASONS<br /> <br /> 5. It is an admitted case of the parties that, the opposite party had issued Group Health Insurance Policy. It is also an admitted fact that the complainant had paid Rs.14,89,556/- for taking the Group Insurance Policy. The said policy covers the risk of complainant’s employees and their spouses. It is also an admitted fact that the complainant has paid additional premium of Rs.1,72,164/- for that the opposite party had issued an endorsement which is attachment to the main policy. It is the case of the opposite party that in respect of Mrs. Aruna Pramanik W/o B.K. Pramanik, she is not entitled to the claim of Rs.10,00,000/-, but the opposite party has paid claim to the extent of Rs.8,44,608/- as such opposite party wrote a letter calling for refund of Rs.3,44,608/- being the excess claim. It is the case of the complainant that the opposite party settled the claim of Mrs. Aruna Pramanik for Rs.7,06,791/-. The learned Advocate for the complainant submitted that the opposite party has not produced any evidence or proof or documents to show that in respect of Mrs. Aruna Pramanik an amount of Rs.8,44,608/- was paid by the opposite party. In the absence of any proof of payment the statement made by the complainant that an amount of Rs.7,06,691/- was received in respect of Mrs. Aruna Pramanik’s policy requires to be accepted. It is an admitted case of the opposite party that claims in respect of 13 persons/employees has been adjusted towards the excess amount paid to Mrs. Aruna Pramanik. This adjustment is wholly illegal, without authority of law. The opposite party cannot in this way adjust the amount legally payable to the 13 employees. The opposite party is bound to pay the claim amount of 13 employees as per the claim submitted. There is no rule or law to make adjustment of excess payment made to third party with the amount legally payable to the employees of the complainant institution. The 13 employees cannot be made to suffer for the mistake committed by the opposite party for excess payment made to Mrs. Aruna Pramanik. If at all there was any excess payment that has to be recovered from Mrs. Aruna Pramanik as per law on proof of excess payment made. The opposite party is not entitled in law to adjust any excess payment with the claim of 13 employees. Therefore, admittedly the claims of 13 employees have not been paid by the opposite party. Therefore, O.P is bound to make the claim of 13 employees as per the claim application. Since the opposite party has clearly admitted that the claims of 13 employees have not been paid. Therefore, opposite party shall be directed to pay the claim amount of 13 employees. It is the case of the opposite party that the collection of premium amount for additional policy was by mistake and the additional policy was repudiated and cancelled. The opposite party submitted that it is ready and willing to refund the premium collected of Rs.1,72,164/-. The complainant submitted that so far the opposite party has not refunded the additional premium amount of Rs.1,72,164/- till today. It is just, fair and reasonable to direct the opposite party to refund additional premium amount to Rs.1,72,164 to the complainant. The defense that excess amount has been paid by the opposite party in respect of Mrs. Aruna Pramanik that question cannot be gone into a summary way in this proceeding. The opposite party will be at liberty to approach Civil Court in case they are able to establish excess payment before the Civil Court they may get the relief of refund. In this summary proceedings without there being proper documents and evidence, it is not possible to determine the excess payments as alleged by the opposite party. However, on the defense version and arguments submitted by the opposite parties, it is clear that the claim in respect of 13 employees have not been paid the total amount payable comes to Rs.3,37,441/- in respect of 13 claims. The opposite parties have also admitted receipt of Rs.1,72,164/- as additional premium amount and they have cancelled the additional policy and submitted that they are ready to refund the premium amount. But so far that amount has not been refunded. Therefore, the opposite party shall be directed to refund additional premium collected from the complainant. With this observation and discussion the matter deserves to be disposed off with the following:-<br /> ORDER<br /> <br /> 6. The complaint is partly allowed. The opposite party No.1 is directed to pay the claim amount of 13 employees as per the list below.<br /> Sl.No. Name of the claimant Amount<br /> 1 Mrs. Ruma Dass Rs.21,245.75<br /> 2 Mr. M Stanley Rs.18,533.00<br /> 3 Mr Richard Khan Rs.16,610.00<br /> 4 Rev. Samson Peters Rs.53,190.00<br /> 5 Mr. Sunit R Pershad Rs.43,171.70<br /> 6 Mrs. Jessy Masih Rs.28,115.00<br /> 7 Mr.P Mathew Rs.28,433.00<br /> 8 Mrs. Suriya Kumari Rs.7,069.00<br /> 9 Mr P.I. Jojesph Rs.7,232.00<br /> 10 Mrs Gladys Longanathan Rs.7,834.00<br /> 11 Mr & Mrs Israel Rs.62,298.00<br /> 12 Mrs Vasantha Lawrence Rs.18,995.00<br /> 13 Mr John S Abraham Rs.24,715.00<br /> TOTAL Rs.3,37,441.45<br /> <br /> 7. The opposite party No.1 is directed to refund Rs.1,72,164/, the additional premium collected from the complainant. The opposite party No.1 is directed to settle the claim and make payment within 30 days from the date of this order. The opposite party No.1 is directed to pay interest on the respective claim amount at 10 % p.a from the date of respective claim application till payment/realization. <br /> 8. The opposite party No.1 is also directed to pay Rs.1,000/- as costs of the present proceedings. <br /> 9. Send the copy of this Order to both the parties free of costs immediately. <br /> 10. Pronounced in the Open Forum on this 11TH DAY OF FEBRUARY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br /> Rhr.,<br />