IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 14th day of December, 2011.
Present : Sri. Jacob Stephen (President).
Sri. N. Premkumar (Member)
C.C. No. 177/2008 (Filed on 29.11.2008)
Between:
Sunitha Susan George,
Ayrookuzhiyil,
Puthencauvu, Chengannur,
Alappuzha District.
(By Adv. V.R. Soji)
Addl. 2. Geetha Anne George,
D/o. Susan George, residing at
Pulinthitta, RSPO, Thiruvalla.
Addl.3. Reetha Elizabeth George,
D/o. Susan George, residing at
Kaipallil Malil, Mavelikara.
Addl.4. Preetha Acha George,
D/o. Susan George, residing at
Ayrookuzhiyil House, Puthencauv,
Chengannoor. …. Complainants.
(By Adv. V.R. Soji)
And:
1. Oriental Insurance Company Ltd.,
Represented by its Branch Manager.
Thiruvalla.
(By Adv. Thomas Puthukulam)
2. K.G. Ramesh,
Development Officer,
The Oriental Insurance Company Ltd.,
Thiruvalla.
(By Adv. P.D. Varghese) …. Opposite parties.
ORDER
Sri. Jacob Stephen (President):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The complainant’s case as per the complaint is as follows: The complainant and her mother Susan George are medi-claim policy holders of the first opposite party from 2000 onwards for ` 25,000. The said policy was taken through the second opposite party who is the Development Officer of the first opposite party. The said policy was renewed regularly through the second opposite party by giving cheques for the premium amount. At the time of taking the policy, the premium amount was ` 1,023 and at a subsequent renewal, the policy amount was enhanced to ` 50,000 from ` 25,000 by handing over the cheque covering the insurance premium amount. In the year 2003, the second opposite party gave a Health Card and informed that this card would be used for any purpose in connection with the medi-claim and also intimated that the policy number of the medi-claim is 489.
3. While so, in the year 2006, the complainant’s mother Susan George was admitted at the Medical Trust Hospital, Ernakulam for the treatment of diabetic and an expense of ` 50,811 was incurred for the treatment. The said treatment was intimated to the second opposite party and he collected all the medical bills, discharge summary and other relevant documents for the re-imbursement as per the insurance contract with the first opposite party. After one month, when the complainant contacted with the second opposite party, he assured speedy disposal of the claim within one week. On one occasion, the complainant called him to know about the status of the claim, he told that “a bunch of cheques from the office was misplaced and the complainant need not have to bother about it and the re-imbursement of claim will be given to the complainant at the earliest”. Meanwhile, the second opposite party accepted the cheques from the complainant for the renewal of the policy for the year 2007-2008. Again the complainant contacted the second opposite party for the claim amount and he informed that it is under process at head office. Subsequently, the complainant went to the office of the first opposite party and enquired about the matter. They replied that they are not interested to deal with the policies which the second opposite party was in charge. This shocked the complainant and on seeing the gross latches from the part of the opposite parties, the complainant sent a letter dated 25.10.2007 to the Regional Manager of the first opposite party’s office at Ernakulam who informed that they have already called for the details of the claim from the opposite parties. But no action was taken by the customer service of the opposite parties.
4. While so, the complainant’s mother was again admitted and treated in Medical Trust Hospital, Ernakulam from 26.11.2007 till her death on 13.12.2007. Again the complainant sent a registered letter to the Deputy Manager of the first opposite party’s office at Ernakulam on 22.01.2008. They informed that the complainant’s claim was rejected on the ground of absence of valid policy vide their letter dated 11.03.2008. But the complainant without any default paid the insurance premium by cheques from 2000 onwards and the said cheques were accepted by the second opposite party who is the Development Officer and an authorized person of the first opposite party who have still continuing in the same post. The complainant contacted the second opposite party, but he evaded from specific reply. While so, the second opposite party returned 2 cheques which were entrusted to him for the renewal of the medi-claim for the period 2006-07 and 2007-08 with a covering letter by post. When the complainant submitted her first claim in the year 2006, the first opposite party was duty bound to inform that there was no insurance coverage to the complainant and her mother. If that be done so, the future complications could have been avoided. This incident shows the deficiency in service of the first opposite party. The non-renewal of the medi-claim policy happened due to the negligence of the second opposite party and the returning of the premium cheques clearly proves the unfair trade practice and deficiency in service of the second opposite party. Everything happened due to the irresponsibility of the second opposite party who is an employee of the first opposite party and hence the first opposite party is vicariously liable to the complainant for the same.
5. Hence this complaint for the re-imbursement of the complainant’s claim amount of ` 50,811 for the year 2006 with 12% interest from the date of submitting the claim and the payment of an amount of ` 50,000 for the medical expenses incurred in the year 2007 along with compensation of ` 50,000 and cost of this proceedings.
6. Since opposite parties are exparte, this complaint was allowed on the basis of the proof affidavit of the complainant and the documents marked for the complainant as Exts. A1 to A10.
7. Being aggrieved by the order of this Forum, opposite parties preferred an Appeal before the Hon’ble Consumer Disputes Redressal Commission, Thiruvananthapuram by Appeal No. 274/2010. After hearing the Appeal, Hon’ble CDRC set aside the order of this Forum and the matter is remanded for fresh disposal on merits after permitting the opposite parties to file version and contest the matter.
8. On receiving the Lower Court Records and the order of the Hon’ble CDRC, this Forum issued notices to both parties and accordingly both parties appeared before this Forum and on appearance, the first and second opposite parties filed their versions separately.
9. The main contentions in the version of the first opposite party is as follows: According to the first opposite party, since the mother of the complainant is no more, the complainant ought to have been filed by all the legal heirs of the deceased. But this complaint is filed only by one person and hence this complaint is not maintainable for the non-joinder of necessary parties in the party array. Further, the first opposite party contended that the complainant or her mother had no valid medi-claim policy at the relevant time. Medi-claim policies are issued for a period of one year and there is no provision for automatic coverage for infinite period or for a period beyond one year from renewal. The complainant’s policy was expired on 16.03.2006 and thereafter there was no valid policy in the name of the complainant or her mother. After 16.03.2006, no renewal application is ever filed by the complainant before the first opposite party. Hence it can be seen that there is no valid policy at the relevant time. With the above contentions, first opposite party prays for the dismissal of the complainant with their cost as they have not committed any deficiency of service against the complainant.
10. The main contentions in the version of the second opposite party is as follows: According to the second opposite party, the complainant had availed a medi-claim policy for a period from 14.11.2000 to 13.11.2001 covering the complainant for ` 15,000 and covering her mother for ` 25,000. The policy was availed not as per the advice of the second opposite party. It is admitted that, being the neighbours, the complainant made enquiries to the second opposite party about the details of the medi claim policies and the second opposite party had given the required information about the policy. The second opposite party did not take any initiative to issue the policy to the complainant. It is also admitted that the complainant used to entrust papers for submitting at the first opposite party’s office and the second opposite party did so, being a neighbour of the complainant. The complainant’s policy was renewed upto 16.03.2006. Thereafter the policy was not renewed by the complainant in due time. On 09.05.2006, the complainant entrusted a cheque to the second opposite party for renewing the complainant’s policy. But on verification, it was revealed that immediate prior policy was already expired on 16.03.2006. Since the policy was expired, the complainant has to submit the medical certificate and other connected records for the renewal of the policy. This matter was properly intimated to the complainant. But the complainant did not collect the cheque from the second opposite party or submitted the required documents. Thereafter, the complainant entrusted another cheque on 01.08.2007, drawn by a stranger for the renewal of the policy. Since the complainant did not produc the required medical certificate, the second opposite party returned these cheques to the complainant and she had accepted the same. The statement that the second opposite party contacted the complainant for the renewal of the policy is not correct. It is the complaint, who being a bank employee, entrusted the papers for submitting at the first opposite party’s office. The complainant did not submit the treatment records of the mother of the complainant for submitting before the first opposite party’s office. After the expiry of the last policy, the complainant’s dealing was with the office of the first opposite party. The second opposite party is not aware of the averments and allegations contained in para 6 to 9 of the complaint. The non-renewal of the policy was not due to the latches on the part of the second opposite party. The complainant had not produced the required medical certificate for the renewal of the policy. The second opposite party is in no way responsible for the loss, if any, sustained by the complainant. The second opposite party used to hand over the papers entrusted by the complainant to the first opposite party’s office. No deficiency in service can be attributed against the part of the second opposite party. With the above contentions, second opposite party also prays for the dismissal of the complaint with his cost.
11. On the basis of the version of the first opposite party, legal heirs of the deceased Susan George were impleaded as additional complainants 2 to 4.
12. On the basis of the averments of the parties, the only point to be considered is whether this complaint can be allowed or not?
13. The evidence of this complaint consists of the oral deposition of PW1, DWs. 1 and 2 and Exts. A1 to A13 and B1 and B1(a). After closure of evidence, both sides filed arguments notes and they were heard.
14. The Point: The complainant’s allegation is that the complainants are the legal heirs of the deceased Susan George and the first complainant and deceased Susan George were medi claim policy holders of the first opposite party from 2000 onwards. The said policy was renewed regularly through the second opposite party who is the Development Officer of the first opposite party. For the renewal, the first complainant used to give cheque for the premium and the relevant documents to the second opposite party. During this period, the second opposite party informed the complainant’s policy number as 489 and also given the health card and the complainant had also enhanced the policy coverage to ` 50,000 from the original coverage of ` 25,000. While so, the complainant’s mother was admitted at Medical Trust Hospital, Ernakulam for the treatment of diabetic during the year 2006 and incurred an expense of ` 50,811 for the treatment. Thereafter the complainant submitted the claim for the re-imbursement of the said treatment expenses. Since the re-imbursement was delayed, the complainant contacted the first opposite party on several occasions and at last she approached the first opposite party and later she sent a letter to the Regional Manager requesting him to take necessary steps for the re-imbursement of the treatment expenses. Thereafter she was intimated that her claim was rejected for want of valid policy as her policy was not renewed after 16.03.2006. Though she had renewed her policy regularly through the second opposite party, the rejection of the claim is illegal. The non-renewal of a policy was solely due to the negligence of the second opposite party. Because of the above said acts of the opposite parties, the complainant sustained mental agony and financial loss. The second opposite party is an employee of the first opposite party and hence the first opposite party is vicariously liable to the complainant.
15. In order to prove the case of the complainant, the first complainant filed a proof affidavit along with certain documents. On the basis of the proof affidavit, the first complainant was examined as PW1 and the documents produced were marked as Exts. A1 to A13. Ext.A1 is the photocopy of the letter-dated 25.10.2007 sent by the complainant to the Regional Manager of opposite parties. Ext.A2 is the copy of the reply letter from Customer Service. Ext.A3 is the photocopy of the letter sent by the complainant to the Deputy Manager on 22.01.2008. Ext.A4 is the reply letter from Deputy Manager dated 11.03.2008. Ext.A5 is the postal receipt of Ext.A3. Ext.A6 is the envelope addressed to the complainant by the second opposite party. Ext.A7 is the covering letter sent by the second opposite party. Ext.A8 series are the 2 cheques issued in favour of the Oriental Insurance Company dated 1.08.2007 and 9.05.2006 respectively. Ext.A9 is the medical bills for the treatment of the complainant’s mother during 2007. Ext.A10 is the 2 Health Cards issued by the Oriental Insurance Company in favour of the complainant and her mother. Ext. A11 is the individual mediclaim policy schedule of the opposite parties. Ext. A12 is the Development Officer Code of the second opposite party. Ext. A13 is the duties and obligations of Development Officers.
16. On the other hand, the first opposite party’s contention is that no valid policy existed at the relevant time. The medi claim policies are issued for a period of maximum one year each and there is no provision for automatic renewal. The last renewal of the complainant’s policy was on 17.03.2005 and it expired on 16.03.2006. Thereafter the policy was not renewed or no renewal application is ever filed by the complainant’s. After few months of the expiry of the policy, she sent a cheque belonging to someone else through a stranger. Once the policy is lapsed, a new policy will always be issued as a fresh policy and not as a continuity of the expired policy. The officers concerned had specifically stated to the person who brought the cheque that since there is no valid policy in existence, the party needs to come in person and also asked to produce the medical and other records required for issuing new policy which was not done. In the next year also, another cheque was sent in the same manner through some one, the requirements were repeated to him and finally upon no response, the cheques were sent back to her. In the absence of a valid policy at the relevant date, the first opposite party is not liable to pay anything to the complainant and thus they have not committed any deficiency in service.
17. In order to prove the contentions of the first opposite party, an authorized officer of the first opposite party filed proof affidavit and one document. On the basis of the proof affidavit, he was examined as DW1 and the documents were marked as Exts. B1 and B1(a). Ext. B1 is the terms and conditions of medi claim policy and Ext. B1(a) is the relevant portion in page No.11 of Ext.B1 under the heading renewal of policy.
18. The second opposite party’s contention is also similar to that of the first opposite party’s contentions. According to the second opposite party, the complainant had valid medi claim policy from 14.11.2001 to 13.11.2002, 27.11.2002 to 26.11.2004, 20.02.2004 to 19.02.2005 and from 17.03.2005 to 16.03.2006. Thereafter the policy was not renewed. While so on 09.05.2006, the complainant entrusted a cheque to him for entrusting at the first opposite party’s office for renewal of the policy. On verification, it was found that the policy was already expired on 16.03.2006. Since the policy was expired, the complainant has to submit medical certificate and other relevant documents for the renewal of the policy and it was also intimated to the complainant. But she had not complied the direction of the second opposite party. Thereafter, another cheque was also given to the second opposite party on 01.08.2007. Since the complainant did not produce the required medical certificate, the second opposite party returned the said cheques and she had accepted the same. The complainant has also not collected any records of the mother of the complainant. The non-renewal of the policy was due to the latches from the part of the complainant and hence the second opposite party argued that he is not liable to the complainant.
19. In order to prove the contentions of the second opposite party, he had filed a proof affidavit and on the basis of the proof affidavit he was examined as DW2.
20. On the basis of the contentions and arguments of the parties, we have perused the entire materials on record. The complainant’s argument is that she had regularly renewed her policy from 2001 to 2008 through the second opposite party by giving cheque for the premium amount. But her first claim submitted in the year 2006 was not allowed by the opposite parties by saying that she had no valid policy. According to the opposite parties, the last policy of the complainant was expired on 16.03.2006. It is also evidenced from Ext. A11. The complainant’s argument is that she had given cheques to the second opposite party for the renewal of her policy. The cheques given to the second opposite party is marked in evidence as Ext. A8 series. But the dates of the cheques are 09.05.2006 and 01.08.2006. As per Ext. A11, her policy was expired on 16.03.2006 and the cheque for the renewal of the policy is dated as 09.05.2006. So the issuance of the cheque as claimed by the complainant, if admitted for argument sake, there is an interval of 54 days from the date of expiry of the policy and the date of the cheque. So it is very clear that during this period (54 days) there is no valid policy. Further the complainant’s specific allegation is that her claim in the year 2006 was not allowed by the opposite parties. But she had purposely suppressed her date of claim and her period of treatment in respect of the said claim. The willful suppression of the relevant dates by the complainant indicates that she is well aware of the fact that she had no valid policy from 16.03.2006 onwards. Further if it is presumed that if there was a valid policy on the basis of the cheque dated 09.05.2006, that policy will expire on 08.05.2007. If it is so, the next cheque is issued on 01.08.2007 which means there is an interval of about 82 days. Thus it is clear that the cheques issued were not corresponding to the date of expiry of the policy. As per Ext. B1(a) policy conditions, in the case of expiry of the policy, no automatic renewal will take place even if the payment is made after the expiry of the policy, either by cash or by cheque. So it is clear that the complainant had no valid policy at the relevant time. From the above circumstances, it is clear that this complaint is without bonafides and the complainant approached this Forum with unclean hands. Thus, the above said factual suppression in respect of relevant facts by the complainant compelled this Forum to accept the contentions of the opposite parties as real and genuine. In the circumstances, we could not find any deficiency of service from the part of the opposite parties. Therefore, this complaint is not allowable and is liable to be dismissed.
21. In the result, this complaint is dismissed. No costs.
Declared in the Open Forum on this the 14th day of December, 2011.
(Sd/-)
Jacob Stephen,
(President)
Sri. N. Premkumar (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Sunitha Susan George. (After remand)
Exhibits marked on the side of the complainant:
A1 : Photocopy of the letter dated 25.10.2007 sent by the complainant to the
Regional Manager, Oriental Insurance Company Ltd., Ernakulam.
A2 : Photocopy of the reply letter dated 06.11.2007 issued by the Deputy
Manager, Oriental Insurance Company Ltd., Regional Office, Ernakulam to the complainant.
A3 : Photocopy of the letter dated 22.01.2008 sent by the complainant to the
Deputy Manager, Oriental Insurance Company Ltd., Regional Office, Ernakulam.
A4 : Reply letter dated 11.03.2008 issued by the Deputy Manager, Oriental
Insurance Company Ltd., Regional Office, Ernakulam to the complainant.
A5 : Postal receipt.
A6 : Envelope.
A7 : Covering letter.
A8 (series): Returned cheques (2 in number).
A9 : Medical bills for the year 2007 of Rs.31,995-58.
A10 : Health Cards (2 Nos.)
A11 : Individual mediclaim policy schedule of the opposite parties. (After remand)
A12 : Development Officer Code of the second opposite party. (After remand)
A13 : Duties and obligations of Development Officers. (After remand)
Witness examined on the side of the opposite parties:
DW1 : Punnoose. K.K. (After remand)
DW2 : K.G. Ramesh. (After remand)
Exhibits marked on the side of the opposite parties:
B1 : Terms and conditions of medi claim policy. (After remand)
B1(a) : Relevant portion in page No.11 of Ext.B1. (After remand)
(By Order)
(Sd/-)
Senior Superintendent.
Copy to:- (1) Sunitha Susan George, Ayrookuzhiyil, Puthencauvu, Chengannur,
Alappuzha District.
(2) Branch Manager, Oriental Insurance Company Ltd., Thiruvalla.
(3) K.G. Ramesh, Development Officer, Oriental Insurance Company Ltd.,
Thiruvalla.
(4) The Stock File.
