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

1)        By this complaint the Complainant has prayed that the Opposite Party No.1 be directed to restore the original status of the policy to individual mediclaim since Opposite Party has changed the status of the policy from Individual Policy to Janta Policy without the consent of the Complainant.  The Complainant has further prayed that the Opposite Parties be directed to reimburse the expenditure of Rs.42,624/- with interest @ 18% p.a. from the date of submitting the claim till the date of payment.  It is prayed that the Opposite Parties be directed to pay compensation of Rs.1,00,000/- for the inconvenience and mental agony suffered by the Complainant and cost of Rs.20,000/- towards this complaint. 

2)        According to the Complainant, she is an Advocate by profession. The complaint is filed for wrongly repudiating her mediclaim by changing the status of policy from Individual Policy to Janta Policy by Opposite Party No.1. It is alleged that the Complainant and her family members were originally insured with United India Insurance Co. Ltd. from 25/03/1997 to 24/03/2005.  In the year 2005 they transferred the said policy to the Opposite Party with all existing benefits and no claim bonus by paying all the premiums well in advance. It is submitted that thereafter the said mediclaim policy was renewed every year regularly.  The Opposite Party No.1 issued policy marked at Exh.‘A’ for the period 25/03/2010 to 24/03/2011 under which the Opposite Parties repudiated the claim lodged by the Complainant. 

3)        According to the Complainant, she was admitted on 15/02/2011 in Kokilaben Dhirubhai Ambani, Andheri (W), Mumbai, for her surgery of Hysterectomy as it was sudden and necessary in view of the opinion of three doctors.  It is submitted that after admitting in the said hospital the Complainant had informed to the Opposite Party No.2 about her surgery by fax alongwith all the details.  The Complainant underwent successful surgery on 16/02/2011 and she was hospitalized for 5 days and was discharged on 22/02/2011.  The Complainant thereafter, about 15 days submitted her claim alongwith all necessary documents of Rs.65,124/- including hospitalization charges, Rs.58,185/- and other expenses like medical tests, medicines.  It is alleged that however, an amount of Rs.22,500/- was only sanctioned by the Opposite Parties and remaining claim was disallowed. It is the case of the Complainant that the Opposite Parties had deprived her legitimate and legal claim to which she is entitled for.  It is submitted that till the filing of the complaint the Complainant did not receive original policy for the year 2011-12 for which the Complainant and her family members had already paid premium by cheque and the said amount was debited to their account. It is submitted that this is the deficiency in service of the Opposite Parties.  It is submitted that the reply given by the Opposite Party No.1 regarding the correspondence made by the husband of the Complainant that their policy was converted to Janta Policy shows the malafied intention of the Opposite Party No.1 under which the Opposite Party No.1 snatched the legal rights of full claim of the Complainant and her family members.  The copy of the reply given by the Opposite Party No.1 through Ombudsman is at Exh.‘C’.  It is submitted that the Opposite Party No.1 without the consent of the Complainant and her family members change the nature of the policy.  The Complainant therefore, sent notice on 18/12/2011 to the Opposite Party Nos. 1 & 2.  The copy of the said notice and acknowledgements of it are at Exh.‘D’ & ‘E’. It is submitted that the amount actually spend by the Complainant ought to have been paid by the Opposite Parties.  By not paying the said amount to the Complainant by the Opposite Parties amounts to deficiency in service.  The Complainant has therefore, prayed to grant the reliefs as mentioned in para 1 of this order.

4)        The Opposite Party Nos.1 filed its written statement.  The Opposite Party Nos. 2 & 3 remained absent though served.  The complaint therefore, proceeded ex-parte against the Opposite Party Nos.2 & 3. The Opposite Party No.1 contested the claim by contending that the Complainant’s husband had availed the service of the Opposite Party No.1 and taken insurance policy namely the Hospitalization and Domiciliary Benefit Policy/Janta Mediclaim Policy for himself and his wife and two daughters and one son. It is contended that there is no deficiency of service rendered by the Opposite Party Nos.1 & 2. It is contended that the Complainant lodged her claim of Rs.65,124/- with the Opposite Party No.1 but after due scrutiny as per the terms and conditions of the policy the said claim of the Complainant was partly sanctioned for Rs.22,500/- as per Janta Mediclaim Policy.  It is contended that the changes in the policy status from Individual Mediclaim Policy to Janta Policy were as per the proposal of the Complainant and the Complainant had paid premium accordingly for the said Janta Policy.  According to the Opposite Parties the Complainant being legal professional should have raised objection to change of status of her policy at the time of payment of premium and also on receipt of insurance policy, which she has failed to do clearly indicates her consent for the change of policy status.  It is the case of the Opposite Parties that the claim of the Complainant was rightly partly sanctioned and given intimation of part sanctioned claim in writing to the Complainant.  It is contended that whatever is stated by the Complainant is with malafied intention and the same cannot be treated as deficiency of service.  The Opposite Parties denied all the allegations and the claim in Toto on the ground that it is false and frivolous. It is prayed that the complaint is required to be dismissed and the Complainant did not suffer any mental torture, harassment as claimed in the complaint. 

5)        The Complainant has filed affidavit of evidence. The Opposite Party No.1 affidavit of evidence of Shri. Sushim Dhakate, Sr. Divisional Manager of the Opposite Party. Both the parties have filed their written arguments.  We heard the oral argument of Complainant in person and Smt. Kalpana Trivedi, Ld.Advocate for the Opposite Party No.1.  We have perused the documents field on record.  

6)        While considering the claim made in the complaint it is undisputed that earlier the Complainant and her family members had obtained the insurance policy from United India Insurance Co. Ltd. for the period 25/03/1997 to 24/03/2005 and later on the said policy was transferred to Opposite Party.  The Complainant has also produced the copies of the policies issued by United India Insurance Co. Ltd. showing that initial policy was issued for the period 25/03/1997 to 24/03/1998 and it was continued upto to 25/03/2004 to 25/03/2005 by the said Company.  The Complainant has also produced the copy of the insurance policy issued by the Opposite Party from 25/03/2005 to 24/03/2006.  The earlier policy was issued by United India Insurance Co. Ltd. was styled as “Mediclaim Insurance Policy”.  Thereafter the Opposite Party issued the policies styled as “Mediclaim Insurance Policy (01/09/1996).”  Under both the policies referred above the Insurance Company agreed to the Insured that in the event of any claim becoming admissible under this scheme, the Company will pay to the Insured person the amount of such expenses as would fall under different heads mentioned in the policy which are reasonable and necessarily incurred thereof by or on behalf of such Insured person, but not exceeding the some insured in aggregate in any one period of insurance stated in the schedule hereto.  Thus, from the terms of the policy which the Complainant had earlier obtained from the United India Insurance Co. Ltd. as well as which was continued by the Opposite Party, it appears that there was no any restriction of any amount as contended by the Opposite Party.  The Opposite Party has though contended that as per Janta Mediclaim Policy Hysterectomy operation is caped at Rs.22,500/- and that much amount is liable to be paid by the Opposite Parties is not proved by the Opposite Parties by filing the terms and conditions of Janta Mediclaim Policy.  The Complainant has therefore, rightly alleged that the Opposite Party has changed the status of the policy without any intimation or notice to the Insured amounts to breach of trust on the part of the Opposite Parties.  The contention raised by the Opposite Party No.1 that the Complainant should have raised the objection to change of status of her policy at the time of payment of premium and also on receipt of insurance policy and it clearly gives indication of consent for the change of policy status in our view cannot be accepted. The said contention raised by the Opposite Party is devoid of merits in view of the observations of the Hon’ble Supreme Court in the case of Bimal Krishna Bose V/s. United India Insurance Co. Ltd., reported in III (2001) CPJ 10 (SC) wherein it is held that –

                 “A renewal of insurance policy means repetition of the original policy.  When renewed, the policy is extended and the renewed policy in the identical terms from a different date of its expiration comes into force.  In common parlance, by renewal, the old policy is revived and it is sort of a substitution of obligations under the old policy unless such policy provides otherwise.  It may be that on renewal, a new contract comes into being, but the said contract is on the same terms and conditions as of the original policy.”

                Considering the aforesaid observation of the Hon’ble Supreme Court and as pointed in the policies issued by United India Insurance Co. Ltd. and later on continued from 25/03/2005 by the Opposite Party as referred above and the Opposite Party did not file any consent letter of the Complainant or her husband for the change in the policy status and the terms and conditions of the earlier policies we hold that the Opposite Parties have acted arbitrarily and tried to modify the terms and conditions of the earlier polices issued to the Complainant’s husband and to the family members of the Complainant whose names are stated in the policy documents.  We therefore, hold that as regards the claim made in para 2 of the prayer clause in the complaint needs to be granted in favour of the Complainant as the Opposite Parties had indulged in unfair trade practices by way of issuing Janta Policy and under the garb of that policy curtailed the rights of the Complainant which were available to the Complainant and her insured family members under the old policies.

7)        The Complainant has incurred an expenditure for her treatment at Kokilaben Dhirubhai Ambani Hospital to the tune of Rs.58,185/- is not disputed by the Opposite Parties.  The Complainant has also produced the bill issued by the said hospital.  The Complainant has also produced the bills of miscellaneous expenditure which she had incurred to the tune of Rs.6,939/-.  In our view the Opposite Parties therefore ought to have allowed the claim lodged by the Complainant of Rs.65,124/-.  The Opposite Parties failed to comply their obligation which they agreed initially under the policy and the same was not continued as held by the Hon’ble Supreme Court in the aforesaid case, the Opposite Party Nos.1 & 2 are therefore, guilty of deficiency in service by restricting the claim to the tune of Rs.22,500/- only in favour of the Complainant. We thus, hold that the Opposite Party Nos. 1 & 2 are liable to reimburse the remaining amount of Rs.42,624/- in favour of the Complainant with interest @ 9% p.a. from the date of lodging the claim i.e. 16/02/2011 till realization of the said payment in favour of the Complainant.  The Complainant has claimed compensation for mental agony and inconvenience suffered by her to the tune of Rs.1,00,000/- and cost of Rs.20,000/- towards this complaint.  In our view the said claims made by the Complainant are exorbitant.  An amount of Rs.10,000/- towards the compensation for inconvenience and mental agony suffered by the Complainant if granted would be justified and cost of Rs.5,000/- would be just and proper.  The claim made against the Opposite Party No.3 in our view that he being the Agent of the Opposite Party No.1 is not justifiable as he is not any way personally liable for the claim made in the complaint and therefore, the claim made against Opposite Party No.3 is rejected. In the result the following order needs to be passed -

O R D E R

i.        Complaint No.226/2012 is partly allowed against the Opposite Party Nos.1 & 2.

ii.       The Opposite Party No.1 is directed to renew the policy in favour of the Complainant, Complainant’s husband and other insured

         members of her family whose names are mentioned in the policy with the original terms and conditions as per the insurance 

         coverage first incepted i.e. on 24/03/2005 vide Policy No.110600/48/04/82772 styled as “Hospitalization & Domiciliary

         Hospitalization Benefit Policy (Individual Mediclaim)” within 2 months of this order.

iii.     The Opposite Party Nos.1 & 2 are directed to pay Rs.42,624/- (Rs. Forty Two Thousand Six Hundred Twenty Four Only) with

         interest @ 9% p.a. from 16/02/2011 till the realization of the said amount and Rs.10,000/- (Rs. Ten Thousand Only) towards

        compensation for mental agony and inconvenience caused to the Complainant and Rs.5,000/- (Rs. Five Thousand Only) towards

         this complaint to the Complainant.

iv.     The Opposite Parties are is directed to comply order in para iii of the aforesaid order within one month from the date of service of

         this order.

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