District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.034/2020.
Date of Institution: 14.01.2020.
Date of Order: 13.12.2022.
Satish Kumar Lamba S/o Shri Govind Ram Lamba R/o H.No. 1766, Sector-16, Kheri Kalan, Faridabad, Tehsil and District Faridabad (Haryana)
…….Complainant……..
Versus
1. United India Insurance Co.Ltd., D.O. 11, SCO NO. 177-178, Sector-8C, Chandigarh, through its Regional Manager.
2. Divisional Manager, United India Insurance Co. Ltd. SCO 106, Commercial Complex, Green Channel Road, Sector-16, Faridabad.
3. Syndicate Bank Faridabad(Code-BKA -9210009000821(4) Agent as D.O. (921000) of Syndicate Bank Faridabad Mobile NO. 9811581912, Neelam Bata Road, Faridabad.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. T.C.Sharma, counsel for the complainant.
Sh. N.K.Garg, counsel for opposite parties Nos.1 & 2.
Sh. Anup Kumar, counsel for Opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant obtained a Synd Argogya (Group Health Insurance Scheme) – 2011 UIN NO. INDA/NL-HLT/UII/P-H/V.I/13-14 vide policy No. 2221002815P101013889 in continuation of his previous as recent policy which was mediclaim Insurance Policy of the complainant alongwith his family members, issued by the opposite party No.1 on 28.02.2019 for a sum Rs.5,00,000/- after receiving the premium of Rs.11,141/- from the complainant, covering the risk w.e.f. 24.2.2019 to 28.02.2020. The complainant was account holder of Syndicate Bank, a scheme launched by the United India Insurance Co. for making members of policy who were account holders of Syndicate Bank, so as per the scheme of opposite party No.1, being account holder of Syndicate Bank, the Syndicate Bank issued a Arogya policy to the complainant vide policy No. 110300/48/10/14/00001147 on 24.02.2011 which was mediclaim policy covering the risk of all family members of the complainant namely Veena Lamba-wife, which was continuously renewed without any break after depositing the premium amount. Firstly on 23.10.2016 the complainant was admitted in Metro Hospital, Faridabad for his treatment and whatsoever expenses incurred upon his treatment, paid by the opposite parties without raising any objection. Opposite parties had also issued Separated Arogya policies through Syndicate Bank to all sons of the complainant like as Rajiv Lamba, Rishu Lamba and Sai Lamba, thereafter the complainant saw that that date of birth in the policies of Rajiv Lamba, Rishu Lamba and Sai Lamba were incorrect as the date of birth of all the members was same except the year, the said act and conduct of negligency was done on the part of the opposite party No.1, then on the request made by the complainant, their date of birth were changed by the Faridabad, Sector-16, branch office of opposite party O.1 and corrected the date of birth of the said all policies. Again the complainant was admitted due to suffering from disease as indoor patient in the same hospital i.e. Metro Heat Institute at Faridabad, for his treatment on dated 5.6.2019 and remained admitted till 18.06.2019 and discharged on 18.06.2019 and the said hospital issued the bill of Rs.2,50,000/- but the opposite parties did not pay the said amount of Rs.2,50,000/- approximately reasons the date of birth of the complainant was not correct, so the said amount of Rs.2,50,000/- which was occurred on the treatment of the complainant had to pay by the complainant from his own pocket. Immediately thereafter his client made a request to Head Office-opposite party No.1 in writing on 7.7.2019 for correcting his date of birth as well as the date of birth of his wife Veena Lamba but the opposite party No.1 did not pay ear, thereafter the opposite party No.1 was requested by the complainant through email dated 6.8.2019 & 19.08.2019 and otherwise, for which neither the opposite party No.1 responded the correspondence did by the complainant, nor corrected the date of birth of the complainant including his wife. The complainant paid a visit in person in the branch office situated at Sector-16, Faridabad as the Sub Divisional office of the opposite party No.1, but no fruitful result came out by saying the officials that they never received any record from Head office Chandigarh. The complainant sent legal notice dated 17.09.2019 to the opposite party but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) release the payment of Rs.2,50,000/- (i.e the amount duly spent by the complainant on account of his treatment) alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately, on the basis of mediclaim policy.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 5500 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the present complaint was not maintainable in the eyes of law as the complainant had bytrailed and violated the basic principle of insurance i.e. “Atmost good faith” in procuring the policy in question. Further the policy in question was that the same could only be procure upto the age of 65 years but the complainant taking benefit of the principle of good faith as per own version initially procure the policy in the year 2011 by showing his age as 63 years whereas he was that of 65 years. He further procured the policy by showing his date of birth as 24.2.1950 but this factum of concealment of his date of birth came to the notice of TPA/answering opposite party only on submitting request by the complainant of cashless facility through Metro heart Institute at Faridabad while admitting in the hospital on 5.6.2019 and after perusal of the documents and quarry raised by TPA in processing the cashless facility against his claim. It came to the notice that complainant concealed his date of birth and did not disclose the actual date of birth while procuring the policy in question. On coming into notice this fraudulent act the complainant himself withdrawn this process of cashless facility and kept mum further to cover-up this hospitalization claim within the policy knowingly and intentionally made attempt by writing letter initially letter dated 7.7.2019 to the answering opposite party requesting to change the date of birth without assigning any reason regarding i.e. reason of writing of wrong date in the policy and even for this no allegation of negligence as claimed in the complaint had been leveled against the answering opposite party and clearly mentioned “while going through policy we had observed that date of birth of Satish Lamba and Veena Lamba were not mentioned correct. Thus, conduct of complainant clearly shows that since inception he was having due knowledge that he had been succeeded in procuring policy to take benefit of old disease in old age by showing his wrong date of birth as prima facie even on that date he was not eligible to procure the policy. Furthermore the insurance premium was differ and was being charges according to age. The version of petitioner that he had taken claim in the year 2016 dos not entitled him and even did not make legible to take further benefit when his fraudulent act came to notice. Thus the act and conduct of the complainant in legal terms was a fraud upon the Hon’ble forum as well as upon the answering opposite party. Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No..3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that the claim amount (if any) was to be paid only by the opposite party No.1 but in no case by the answering opposite party and therefore the present complaint be dismissed on this ground alone. It was submitted that the answering opposite party was into banking sector and was required to only render banking services and not insurance services. Bare perusal of documents as filed by the complainant nowhere revealed that the answering opposite party owes any liability to pay the said amount as claimed by the complainant. It was nowhere mentioned in the documents as filed by the complainant that the answering opposite party should pay the amount to the complainant upon hospitalization. The complainant had made communication dated 18.06.2019 United India Insurance Co. Ltd. for the reimbursement of his claim which clearly revealed that the liability (if any) was of the opposite party No.1. The policy had been issued by the opposite party No.1. Receipts had also been issued by opposite party No.1 and all the communication with regard to the present claim had also been made with the opposite parties Nos.1 & 2 which made it crystal clear that the answering opposite party had no role in the present claim/policy. On 30.10.2019 revealed that United India Insurance Co. Ltd. rejected the claim that date of birth of the complainant was not correct, It was submitted that the said communication made between United India Insurance Co. Ltd., i.e opposite parties Nos.1 & 2 and complaint clearly reveals that the contract was only between the complainant and the opposite party No.1 in which the answering opposite party had no say either to pass the claim or reject it, moreover the answering opposite party had not issued any policy or receipt and therefore the answering opposite party could not be made liable and therefore the present complaint be dismissed against the answering opposite party. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– United India Insurance Company Ltd. & Ors. with the prayer to: a) release the payment of Rs.2,50,000/- (i.e the amount duly spent by the complainant on account of his treatment) alongwith interest @ 18% p.a. from the date of its due till realization of whole amount immediately, on the basis of mediclaim policy. b)pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 5500 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Satish Kumar Lamba, Ex.C-1 – Bills summary, Ex.C-2 – Discharge Summary, Ex.C-3 & 4– final Bills, Ex.C-5 to 20– Final Bill break up, Ex.C-21 to 26 – Payment receipts, Ex.C-27 7 28 – receipts, Ex.C-29 – Retail invoice, Ex.C-30 – Cash Credit Memo, Ex.C-31 to 33– receipts, Ex.C-34 – GST invoice, Ex.C-35 to 37 – receipts, Ex.C-38 – GST Invoice, Ex.C-39 - Cash/Credit Memo,, Ex.C-40 & 41 – GST invoice, Ex.C-42 receipt, Ex.C-43 to 45– GST Invoice, Ex.C-46 – receipt, Ex.C-47 & 48– GST invoice, Ex.C-49 – receipt, Ex.C-50 – GST invoice, Ex.C-51 – receipt, Ex.C-52 – GST invoice, Ex.C-53 – insurance policy, Ex.54 – Endorsement schedule, Ex.C-55 – insurance policy, Ex.C-56 - letter sent by the complainant to United India Insurance Co. Ltd. regarding change of date of birth, Ex.C-57 & 58 – Aadhar card, Ex.C-59 & 60 – PAN Card, Ex.C-61 – Identity card, Ex.C-62 – Admission form,, Ex.C-63 & 64 – Select policy NO. for Further Details… & Wait, Ex.C-65 – email dated August 19,2019, Ex.C-66 – email dated August 6,2019.
On the other hand counsel for the opposite parties Nos.1 & 2 strongly
agitated and opposed. As per the evidence of the opposite parties,
Ex.RW1/A – affidavit of Dinesh Kumar, A.O. M/s. United India Insurance Company, Sector-16, Faridabad. Ex.r-1 – email dated June 13,2019,, Ex.R-2 – Request for cashless hospitalization for medical insurance policy, Ex.R-3 – letter dated June 06.2019, Ex.R-4 – letter regarding cashless query for patient name Satish Kumar Lamba, Ex.R-5 – note, Ex.R-6 - Adhaar card, Ex.R-7 – insurance policy valid from 24.02.2019 to 23.02.2020.
As per evidence of opposite party No.3, Ex.RW3/A – affidavit of Dhani Ram, Branch Manager/Authorized person-cum-power of attorney holder-cum-Principal Officer of Syndicate Bank (Canara Bank), Neelam Bataa Road, NIT, Faridabad,
7. The complainant has got the insurance policy through opposite party No.3 who is the bank has issued the policy in favour of the complainant. It was the duty of opposite party No.3 to verify the age of the complainant. At the time of claim opposite parties Nos.1 & 2 can not agitate on the ground of age. Once the opposite parties have accepted the premium of the policy and the policy was issued in favour of the complainant. Now opposite party can not deny for the claim as per the IRDA.
8. Moreover, when the insured is 65 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite parties to get the complainant immediately examined before issuing the policy as per IRDA guidelines. As per insurance policy alongwith terms and conditions vide ex.R-7 in page 15 it has been mentioned that “ AGE LIMIT: 3 MONTHS TO 65 YEARS & RENEWAL UPTO 80 years.
9. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties, jointly & severally, are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a from the date of filing of complaint till its realization. The opposite parties, jointly & severally, will also pay Rs.2200/- as compensation on account of mental tension, agony and harassment and Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 13.12.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
