O R D E R
(By Sri S. Bhaskararao, Member on behalf of the Bench)
1. The complainant sought an amount of Rs. 1,00,000/- towards Mediclaim policy from opposite party and also Rs. 50,000/- towards compensation for mental stress and agony.
2. The allegations in the complaint in brief are that opposite party bank sponsored mediclaim insurance policy exclusively for Andhra Bank to his credit card holders to meet any unanticipated medical expenses. The main document of the scheme is proposal form which contains terms and conditions set out therein. Since 10 years he has been renewing mediclaim policy and at the time of taking policy about 10 years ago he has not given any written consent to be abide by subsequent changes in terms and conditions. Since his wife was not having good health she was included as insured person in mediclaim policy and it was renewed up to 31.03.2010. As existing policy holder he is renewing the same since 11 years and his name was also included for a sum of Rs. 1,00,000/- assured sum along with his wife in the proposal for the years 2010-2011.
3 According to him the subsequent changes in the policy form are not applicable to him and as such he is entitled to become policy holder in the subsequent proposal form which is from 31.03.2010 to 31.03.2011 and it was received at Kakinada when he was at Chennai. In the said policy the opposite party accepted his wife only as insured person for Rs. 1,00,000/- and did not accept his name and it is his main grievance. Any changes effected in the terms and conditions since the year 2007 are not applicable to him. He met with an accident on 02.09.2010 and had treatment in Frotis Malar Hospital from 02.09.2010 to 20.09.2010. He submitted claim along with pre authorization letter, discharge certificate and other documents for an amount of Rs. 5,80,000/- and addressed a letter to the opposite party to consider his claim for the running year 31.03.2011 and requested to pay Rs.1,00,000/- towards medical expenses. As no reply was received he addressed two letters for which received reply with untenable allegations and subsequently also issued lawyer’s notice for which a reply was issued denying his claim. Thus he approached this Forum.
4 The claim of the complainant is resisted by opposite party who filed its written version denying the material allegations in the complaint and further according to them they issued a medi group insurance policy for Andhra Bank Credit card holders 10 years ago in the name of the complainant’s wife. But the complainant is not entitled to renew to be the age of 80 years and policy covers entry of fresh person upto age of 65 years and complainant is well aware of the same and renewed the policy from time to time. It is also their case the complainant applied for inclusion of his wife in the policy for the first time during the renewal time 31.03.2010 and filled up the proposal form and added his name along with his wife name on 19.03.2010. The proposal is to be sent on or before 15.03.2010 being the last date of renewal of every year. The proposal of the complainant as insured was not accepted by them as the age of the complainant on the date of proposal i.e. 19.03.2010 itself is 76 years and as can be seen from the proposal form itself the insurance cover is available for the age group of 3 months to 65 years and further existing the policy holders will be considered to renew upto 80 years. Hence the inclusion of complainant’s name in the policy for year 2010 -2011 is not considered. At no point of time they received a consideration towards risk to the complainant and the insurance coverage is extended to the insured person whose name is appearing on the policy and the complainant is not entitled to mention his name and claim the amount. Thus disputing the claim of the complainant they sought dismissal of the complaint.
5 Now the points for determination are:
- Whether there is any deficiency of service on the part of opposite parties in not honouring the claim of the complainant?
- If so, whether the complainant is entitled for the amount as sought by him?
6. Point No.1: To buttress his contention the complainant furnished his chief affidavit and exhibited Ex.A1 & Ex.A2 renewal copies of the mediclaim policy, Ex.A3 & Ex.A4 office copies of letters sent by complainant to the opposite parties, Ex.A5 is office copy of lawyer’s notice issued by the complainant, Ex.A6 reply notice issued by opposite party and Ex.A7 copy of proposal form along with terms and conditions.
7 As against this evidence the Administrative Officer of 1st opposite party furnished his chief affidavit re-iterating the allegations in the written version and no exhibits are marked on their side.
8 As seen from the rival contention it is manifest the opposite party is disputing the claim of the complainant on the ground that for the first time he sought to include his name as one of the policy holders for the years 2010 -2011. In this regard the contention of the complainant is that since 11 years he has been renewing policy and the terms and conditions which were applicable at the time of his obtaining first policy can’t be change subsequently and as such he is entitled to include his name in the policy for the year 2010-2011.
9 The opposite party resisted the claim of the complainant mainly on the ground at the time of proposing his name for the first time during the year 2010-2011 he is 76 years and as per the terms and conditions the persons between the age group of 3 months to 65 years are only eligible and their policies can be renewed upto the age of 80 years.
10 Admittedly in the case on hand when the complainant proposed his name during the year 2010 -2011 he was 76 years old. Admittedly during the earlier years he was obtaining policy in the name of his wife only. It is well settled law that any terms and conditions between the parties should be agreed upon by both of them and when a proposal made it is for the opposite party to accept it or reject it as rightly claim by them. The complainant can’t force the opposite party to accept his name in the proposal form submitted during the year 2010-2011. The opposite party as rightly pointed out by them got right to change the terms and conditions for the subsequent years and the policy holders obtain fresh policy from year to year. Thus in these circumstances as the complainant for the first time sought to add his name in the proposal form during the year 2010-2011 at the age of 76 years it can’t be accept. Hence this point is answered against the complainant and in favour of the opposite party.
11 Point No.2: In view of the finding rendered under point No.1, the complainant is not entitled for any amount. Hence this point is answered accordingly.
12. In the result, the complaint is dismissed in the circumstances without costs.
Dictation taken by the Steno, transcribed by her, corrected and pronounced by us, in open Forum, this the 20th day of March, 2015.
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MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For complainant:
PW1: Sri Maddimsetti Narasimhan Rao [complainant]
For opposite parties:
RW1: Sri Nati Nageswararao, Administrative Officer, M/s. New India
Assurance Co. Ltd., Kakinada
DOCUMENTS MARKED
For complainant:-
Ex.A1 Renewal copy of the mediclaim policy
Ex.A2 Renewal copy of the mediclaim policy
Ex.A3 Office copy of letter sent by complainant to the opposite parties
Ex.A4 Office copy of letter sent by complainant to the opposite parties
Ex.A5 Office copy of lawyer’s notice issued by the complainant to the opposite parties
Ex.A6 Reply notice issued by opposite party
Ex.A7 Copy of proposal form along with terms and conditions.
For opposite parties:- NIL
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MEMBER PRESIDENT
