Ex-P A R T E   O R D E R

PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        The Complainant Company has claimed Rs.6,26,322/- alongwith 12% interest from the Opposite Party and such other reliefs deemed fit and proper against the Opposite Party.

 2)        According to the Complainant, it had taken a Group Mediclaim Policy form the Opposite Party dtd.07/04/2005 for the period from 08/04/2005 to 07/04/2006 covering 654 employees their spouse and childrens for floater sum insured.  The said policy was subsequently revised to include the parent of the employees and additional staff members on payment of additional premium w.e.f.25/08/2005.  It is alleged that the Complainant has paid necessary premium payable as agreed by the Opposite Party.  It is contended that however, there were lapses/deficiency in service on the part of the Opposite Party and the services offered were not at all satisfactory. There was considerable delay in settling the claims of the covered employees which was wholly unprofessional on the part of the Opposite Party.  According to the Complainant the policy which was obtained was a Group Insurance Policy.  The net amount payable was only in respect of total number of employees and their family members covered and that joining of new employees in the backdrop of some of the existing employees leaving the organization should not warrant payment of additional premium amount so long as the total number of employees to be covered at a given point of time does not exceed the coverable limit.  Despite the aforesaid position the Opposite Party claimed the additional amount towards premium in respect of the new employee to be covered in the month of Sept., 2005 till Feb., 2006.  The said fact was brought to the notice of the Opposite Party during the intervening period and claimed consequential refund due to the Complainant from the Opposite Party.  The Complainant has addressed various letters to the Opposite Party dtd.08/03/06, 09/03/06, 26/04/06, 28/04/06, 20/09/06 and also informed the date of the employees joining and leaving of the organization with some of the letters referred above.  According to the Complainant, the representative of the Complainant had also meetings discussions with Mr. R. Sunder, Sr. Divisional Manager of the Opposite Party who had agreed that he had received said correspondence and data from the Complainant.  According to the Complainant, after calculating the exact position regarding the entitlement of the beneficiaries under the Group Insurance Policy obtained from the Opposite Party, it was observed that the Opposite Party had charged an excess amount of Rs.6,26,322/-. It is submitted that the Opposite Party instead of refunding the said amount had informed that they have done revised calculation and the refund works out to Rs.3 to 4 Lacs and not Rs.6,26,322/-.  According to the Complainant, thereafter, the Opposite Party again by letter dtd.15/05/06 at page 39 of the documents filed with the complaint informed that they had erroneously intimated that the refund amount would be around Rs.3 Lacs and the said mistake was on account of their building not having electricity and the correct amount refundable provisionally works out to Rs.1,48,129/- as per the enclosed worksheet.            

 3)        According to the Complainant, the said calculation done by the Opposite Party was totally wrong and erroneous on the basis of the calculations done by the Opposite Party. The refund amount payable by the Opposite Party worked out to Rs.1,51,063.35.  Accordingly, the Complainant without prejudice agreed for refund of the said amount which was agreed by the Opposite Party and the said fact was recorded by the Complainant vide its letter dtd.20/09/06 which is at page 37 alongwith complaint.  It is alleged that despite repeated requests and legal notices the Opposite Party did not pay the said amount.  According to the Complainant the said act on the part of Opposite Party in not calculating the premium amount properly and charging excess amount to the Complainant is nothing but deficiency of service as a result of which an excess amount was claimed from the Complainant and non refunding the excess amount which has been paid by the Complainant is also deficiency of service.  It is therefore, submitted that the Opposite Party be directed to refund the excess amount received from the Complainant towards the Group Insurance Policy obtained from it by the Complainant amounting to Rs.6,26,322/-.

 4)        The Opposite Party though served with notice did not appear, the matter therefore, proceeded ex-parte against the Opposite Party.  The Complainant has filed affidavit of Yug Samrat, the Company Secretary and G.M., Legal and written submissions.  We heard the Ld.Advocate Shri. S.P. Dhulapkar, for the Complainant.  He made submission that the claim made by the Complainant goes unchallenged and therefore, the Opposite Party be directed to pay/refund an amount of Rs.6,26,322/- alongwith interest @ 12% p.a. and cost of this proceeding.

 5)        We have gone through the documents placed on record. From the premium receipt placed at page no.7 alongwith complaint issued by the Opposite Party, it appears that the Opposite Party agreed to cover Group Mediclaim of 1654 employees with their spouse & children working with the Complainant and the sum assured was Rs.9,25,50,000/-.  The Complainant had paid premium and service tax to the Opposite Party for that purpose of Rs.18,10,300/- vide receipt dtd.07/04/2005. The Complainant has produced various letters addressed to the Opposite Party. In the letter dtd.20/09/2006 addressed to the Opposite Party by Rupa Randive, Manager H.R. it is stated that the Complainant Company agreed without prejudicing their rights to accept the refund amount of Rs.1,51,063.35.  However, from the documents placed on the record by the Complainant at page 39 alongwith complaint it appears that by letter dtd.15/05/06 the Opposite Party had informed to the Complainant that the refund allowable provisionally works out to Rs1,48,129/- as per the enclosed sheet. The Complainant in the complaint as well as the correspondence placed on the record has though alleged that they are entitled for Rs.6,26,322/- from Opposite Party, but it appears that the Complainant has not placed on record the worksheet or data showing as to how the Complainant is entitled for the refund of Rs.6,26,322/- as claimed.  We therefore, hold that as the Opposite Party by its letter dtd.15/05/06 on the basis of the work sheet enclosed with the said letter had informed the Complainant that the refund allowable to the Complainant works out to Rs.1,48,129/- is liable to be paid by the Opposite Party to the Complainant can be accepted.  In the said letter the Opposite Party had informed to the Complainant that it had referred the mater to the regional office for their confirmation and shall revert back in this regard shortly.  It appears that till filing of the complaint, for about 2 years nothing has been informed to the Complainant by the Opposite Party and the provisional refund worked out by the Opposite Party was also not paid to the Complainant.  The Opposite Party remained absent in the present proceeding and therefore, we hold that whatever agreed and assured by the Opposite Party in their letter dtd.15/05/06 at page 39 is required to be accepted while granting the claim in favour of the Complainant. Thus, in our view, there is deficiency in service on the part of the Opposite Party as regards charging excess premium. We therefore, hold that the Complainant is entitled for the amount of Rs.1,48,129/- towards refund from the Opposite Party  alongwith interest @ 6% p.a. from 15/05/06 till the actual payment. The Complainant is entitled for cost of Rs.3,000/- from the Opposite Party. In the result we pass the following order - 

O R D E R

i.                 Complaint No.48/2008 is partly allowed against Opposite Party.

ii.              Opposite Party is directed to policy Rs.1,48,129/-(Rs. One Lac Forty Eight Thousand One Hundred Twenty Nine Only) to the Complainant alongwith interest @ 6% p.a. from 15/05/2006 till actual payment.

iii.              The Opposite Party is directed to pay Rs.3,000/- (Rs. Three Thousand Only) towards the cost of this proceeding to the Complainant.  

iv.             The Opposite Party is directed to comply with the above order within one month from the date of service of this order.  

v.              Certified copies of this order be furnished to the parties.