Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 432.
Instituted on : 11.09.2018.
Decided on : 15.09.2020.
Hari Mohan s/o sh. Shyam Lal R/o H.No.258 Ward No.35 Aggarsain Colony, Rohtak.
………..Complainant.
Vs.
- Star Health & Allied Insurance Co. Ltd., Narayana Complex, Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak through its Branch Manager.
- Star Health & Allied Insurance Company Ltd., New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
Present: Sh. Parveen Solanki, Advocate for complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant got joint health insurance from the respondents for his all four family members vide policy No.P/211128/01/2018/000033 from opposite party company and has deposited the insurance premium vide cheque no.799752 amounting to Rs.15287/-. That Smt. Kavita wife of complainant fell ill due to high sugar level and remained under treatment at Apex Plus Hospital, Rohtak in unconscious condition and an amount of Rs.19000/- was spent on her treatment when she was admitted in hospital i.e. 11.05.2018 to 15.05.2018 and about Rs.70000/- on tests and medicines. The complainant has submitted all the relevant documents to respondent and applied for insurance claim vide claim No.CLI/2019/211128/0069876 but the complainant was shocked to know that the cheque of premium was dishonored and the policy of the complainant was cancelled. Whereas as per account statement of the complainant, the said cheque was never dishonored and the complainant was never intimated about dishonor of cheque prior to filing the claim. There is no fault on the part of complainant rather it is the fault on the part of opposite parties. Complainant requested the opposite parties to reconsider the claim but they refused to accede the genuine request of the complainant. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the claim amount of Rs.100000/- alongwith interest, compensation and litigation expenses to the complainant as explained in the relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties in their reply has submitted that an application form for issuance of Family Health Optima Insurance Plan was received in the office of opposite party and accordingly the policy bearing no.P/2/111/28/01/2018/0000/33 was issued to the complainant. It is submitted that complainant issued cheque no.799752 but the same was not encashed and the same was in the knowledge of the complainant. The complainant knowing the factum not bothered to submit the premium amount with answering respondent and now wants benefits of the policy coverage. Hence on the receipt of the claim, answering respondent were not able to process claim of the complaint, due to non-compliance of 64VB. It is the complainant to prove that he had paid the premium amount. No amount has been paid by the complainant qua the policy in question and hence the complainant is not entitled for any reimbursement. Opposite party further submitted that even if this Hon’ble Forum comes to the conclusion that the claim of the complainant needs to be allowed and if the opposite party is held liable to pay the claim of the complainant, the liability of the opponent as per terms and conditions shall be limited to Rs.27826/-(on receipt of premium amount of Rs.15287/-). All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C7 and has closed his evidence on dated 14.05.2019. On the other hand, Ld. counsel for the opposite parties has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R8 and closed his evidence on dated 01.10.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case, lots of documents have been presented by the opposite parties to prove this case. In support of their case, opposite party has also relied upon the Revision Petition No.207 of 2016 of Hon’ble National Commission, New Delhi titled as Sagir Alam Vs. HDFC ERGO. We have perused all the relevant document placed on record by both the parties. The main contention of the complainant is that whether the insurance company has presented the cheque of the premium issued by the complainant before the bank at any time till date. On the other hand, perusal of the record shows that the respondent company has placed on record so many documents i.e. insurance policy, terms and conditions of the policy, claim form, repudiation letter, calculation sheet showing the liability of the company and discharge summary but they failed to place on record any document to show that they have presented the cheque regarding the premium before the bank. On the other hand, complainant has placed on record the account statement and other documents to show that there was a sufficient amount in his account for payment of premium on the date of issuance of cheque and thereafter upto 01.03.2018. As per the documents Ex.C5 & Ex.C6, it is established that the cheque was never presented by the insurance company because any amount has not been deducted from the account of complainant regarding dishonor of cheque. Moreover on the mail dated 21.08.2018, it has been submitted by the complainant to the insurance company that he had provided the account statement to the insurance company and it is very much clear from the perusal of the account statement that the cheque has not been presented by the insurance company for the clearance in the bank and this fact has been confirmed by the concerned bank i.e. Punjab National Bank.
6. On the other hand, the law cited above by ld. Counsel for the opposite parties i.e. Sagir Alam(Supra) is not supported to the opposite parties because in this authority, the cheque has been presented and the same was dishonored and there was no liability of the insurer to pay any amount. But in the present case the facts are different as the cheque was never presented before the bank. Moreover the policy was issued for the period 28.12.2017 to 27.12.2018 and the complainant issued the cheque dated 22.12.2017 and the same was collected by the insurance company and the advance premium receipt has been issued in the name of complainant. Thereafter, the wife of complainant namely Smt. Kavita was got admitted in the Apex Plus Hospital on 11.05.2018 and after receiving the information, the respondent insurance company started the process of claim of the complainant. During the process of claim, it was came into the notice of the insurance company that premium has not been received in the above mentioned policy No.P/211128/01/2018/000033. Thereafter, they endorsed the same vide Endorsement schedule in the policy on dated 08.06.2018 that the policy has been cancelled due to cheque dishonor but to prove this fact, the respondent insurance company has not placed on record any document that the cheque has been presented by the insurance company for clearance. Moreover, the endorsement dated 08.06.2018 itself shows that the same is afterthought of the insurance company. As such, there is deficiency in service on the part of opposite parties and the complainant is entitled for the claim amount. But the complainant has failed to place on record any bill regarding the expenditure on the treatment of his wife. On the other hand, we have perused the documents Ex.R5 and Ex.R7 which shows that there is a liability upon the insurance company to pay an amount of Rs.27826/-. Moreover, this fact has been mentioned in the written statement in para no.10 filed by the opposite parties that if the opposite party is held liable to pay the claim of the complainant, the liability of the opponent as per terms and conditions shall be limited to Rs.27826/-(on receipt of premium amount of Rs.15287/-).
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay Rs.12539/-(Rupees twelve thousand five hundred and thirty nine only) i.e. after deduction of premium amount of Rs.15287/- from the claim amount of Rs.27826/-. The amount shall be paid alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 11.09.2018 till its realization and shall also pay Rs.10000/-(Rupees ten thousand only) on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
15.09.2020.
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Nagender Singh Kadian, President
………………………………..
Renu Chaudhary, Member.
