J U D G E M E N T

The case of the complainant in brief is as follows:

            The husband of the complainant was a member of Mediclaim Policy with his spouse having MIN Nos. 11902062 & 11902063 respectively from the year 2003, but unfortunately the policies were discontinued from, the 2013. The husband of the complainant prayed for renewal of the said policies and in response to memo. No. PER/ITB & Med.HOP/GC-2014 dated 03=4.3.2014 Mediclaim – 2014 for Renewal under SAIL Medical Scheme – 2014 made payment of Renewal Premium by demand draft in favour of SAIL for Rs. 15,494=00. Subsequently the husband of the complainant submitted the filled in prescribed application with the demand draft along with photo

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ID card of his husband and his spouse with photographs of both and one cancelled cheque as directed before the SAIL Growth Works Authority along with other insured persons on 11.4.2014. Thereafter all the insured persons received the Brochure with Cashless Cards in between, the complainant enquired before the SAIL Growth Works Authority for getting Renewal Certificate or letter in respect of the Mediclaim Policies in the name of the husband of the complainant and his spouse. The concerned official of SAIL stated that all the documents has been completed and asked to enquire before the E-Meditek (TPA) Services Ltd at Asansol for getting Brochure and Cashless Cards. The husband of the complainant had been suffering with Cancer Rectum with LOPD with Septicemia with Renal failure and he was admitted in H.L.G. Charitable Hospital & Research Institute Pvt. Ltd., Asansol pm 03.5.2014 and died on 04.5.2014 after undergoing series of chemotherapy. The complainant endeavourer to submit Mediclaim bills in connection with medical cost incurred for the treatment of her spouse at the TPA but they refused to accept the same on the ground that they had no information from the SAIL Authority in regard renewal of Mediclaim policies in respect of the employee or his spouse. Being a widow of the ex-employee, the complainant had to run severally before the SAIL Growth Works Authority and also before the TPA at Asansol but in vain. Even e-mail sent to SAIL Mediclaim Authority on 28.11.2014 to that effect which yielded no result. The SAIL authority neither accepted nor rejected Renewal of Mediclaim for the year 2014 and the demand draft in respect of the Renewal Premium was not also refunded rendering the widow insured person in quandary. In response to Circular No. PERSAIL/ITB & Med/Ren/Mediclaim dated 31.12.2014 issued by SAIL Authority by Internet, the complainant endeavoured to effect payment of Renewal premium in respect of SAIL Mediclaim Policy extended up to 31^st March 2015 through SBI collect as directed in the circular but it is found that no data was displayed in the computer screen online in respect of the MIN number of the complainant or of the employee/insured person. Either the OP-1 and/or the OP-2 are found negligent in service to renew the policies despite realizing the premium amounts and it is a great deficiency in service from the part of the OP-1&2. Due to utter negligent in service from the part of the OP-1&2 the ex-employee and his spouse were deprived of getting the benefit of social security scheme of SAIL, despite effecting payment of premium in due time as directed by the OP-2 in their letter. Under the above circumstances the complainant prays for relief as under:

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1. To allow the complainant to treat the policy of the complainant to continue without any break,
2. The OP may kindly be directed to pay to the complainant the amount as stated below:

1. to refund the premium amount paid for renewal of Mediclaim policy for 2014 Rs. 15m494=00 with interest @18% p.a.
2. compensation for loss, harassment, mental agony Rs. 1,00,000=00,
3. payment towards conveyance charges Rs. 5,000=00,
4. litigation cost Rs. 10,000=00.

It has been found from the record that after admission of the complaint summons were issued against the OP-1, 2&3. Despite proper service of notices the OP-1&2 have not appeared before this ld. Forum by filing written version to contest the case. So the case is heard ex parte against the OP-1&2.

            The case has contested by the OP-3 by filing written version denying the entire allegations made by the complainant in his petition of complaint. The OP-3 has stated that the complaint is not maintainable against this OP as in the entire complaint there is no relief sought against this OP. This OP further stated that the complaint is not maintainable for non-joinder of necessary parties because the complainant had not made national Insurance Company Limited as a party. This OP is only the agent of the Insurance Company and can process the claims and the Insurance Company will make the payment only on the fulfillment of the terms and conditions of the Insurance Company. The premium is also charged by the Insurance Company. Therefore National Insurance Company is a necessary party. Moreover, as per the recent judgment of the Hon’ble National Commission it has been specifically held that no suit is maintainable against TPA without impleading the Insurance Company in the case of “HDFC Bank Ltd Versus Vir Bhan Sharma” Revision Petition No. 213 of 2013, decided on 03.3.2014. Further it was held by the Hon’ble Supreme Court of India in case titled as Prem Nath Motors Vs. Anurag Mittal reported in AIR 2009 SC 567 wherein it was held that Section 230 of the Contract Act categorically makes it clear that an agent is not liable for the acts of a disclosed principal. This OP further stated that it has no pecuniary/financial interest in any of the claims whatsoever as such we only recommend the cases to Insurance Company and the final call is of Insurance Company to reimburse the claims

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of the insured or not. It has also stated that this OP had received no information from SAIL corporate in respect of renewal of Mediclaim policy of the complainant, hence no claim arises against this OP and there is no deficiency in service on the part of this OP. The OP-3 has prayed for dismissal of the complaint with heavy cost.

-: Decision with reasons :-

On going through the statements of the complainant and the OP-3 it is seen that the complainant’s husband was an ex-employee of SAIL and had a Mediclaim policy bearing no. 11902062 & 119002063 for himself and spouse since 2003 which was discontinued in 2013 and renewed on 2014 for payment of due premium amounting to Rs. 15,494=00. But no information was received for the said renewal from the OP-1&2. The complainant’s husband who was a patient of cancer was treated at H.L.G. Memorial Charitable Hospital & Research Institute Pvt. Ltd., Asansol on 03.4.4014 and died on 04.5.2014 after undergoing series of Chemotherapy.  Due to non-receipt of cashless cards from the Ops or any valid certificate of policy, the same would not be utilized. The complainant’s attempt for renewal of the Mediclaim policy in the year 2015 was also not accepted as no data was displayed in the computer screen of OP-3. OP-3 has stated that the complainant has no claim against the OP-3. Moreover, the case suffers from non-joinder of necessary parties as National Insurance Company Ltd. has not been made a party to this case. During argument the complainant submits documents like renewal fees of acceptance of the policy of the complainant by hand confirming renewal of the policy with effect from 01.01.2015 on payment of Rs. 484=00. On further scrutiny it is also seen that the complainant’s Mediclaim policy was not computerized by OP-1&2 resulting such sufferings of the complainant which is deficiency in service on the part of the OP-1&2. But so far complainant’s prayer is concerned it is seen that the complainant has claimed refund of the premium paid for the year 2014 along with renewal of the policy for the year 2015 which is vice versa. The complainant’s harassment due to non-entry in the computer of the policy in the year 2014 by OP-1&2 has caused sufferings to the complainant and non-encashment of medical bills or avail the facility of cashless card. But as the same is not concerned with the claim of the complainant, we are not going to highlight in this case. But had it been entered in proper way the complainant being not to suffer for policy benefit or for

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renewal of the same. The renewal of the policy is also admitted by the OP-1&2 as evinced from the renewal premium receipt of the complainant for the year 2015 for three months which is not even today computerized. In such a situation the complaint succeeds in part. Hence, it is

O r d e r e d

that the complaint is allowed in part on contest  ex parte against the OP-1&2 and dismissed on contest against the OP-3. The OP-1&2 is directed to make necessary entry for the renewal of the policy and sent renewal intimation of the Mediclaim policy to the complainant and other facilities as per terms and condition of the Mediclaim policy within 45 days from the date of passing of this judgment. The OP-1&2 are also directed to pay Rs. 10,000=00 as compensation for harassment and mental pain along with litigation cost of Rs. 2,000=00 to the complainant within 45 days from the date of passing of this judgment, in default, the complainant will be at liberty to put the entire decree into execution as per provisions of law.

            Let a copy of this judgment be supplied to the parties free of charge.

                (Asoke Kumar Mandal)        

             Dictated and corrected by me.                                                  President      

                                                                                                          DCDRF, Burdwan

                    (Durga Sankar Das)

                            Member

                     DCDRF, Burdwan

                                                      (Silpi Majumder)                           (Durga Sankar Das)

                                                             Member                                             Member

                                                     DCDRF, Burdwan                            DCDRF, Burdwan