DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Atul Nahar s/o Sh.N.K. Nahar, #3137, Sector 40-D, Chandigarh.

              ---Complainant

Vs

[1]  The Manager, TATA AIG General Insurance Co. Ltd., SCO No. 232-234, Sector 34-A, Chandigarh.

[2] TATA AIG General Insurance Co. Ltd., Simran Centre, 2^nd Floor, 30-H Parsi Panchayat Road, Andheri (E) Mumbai – 400069.

[3]  The AIG General Insurance Co. Ltd., Regd. Office: Peninsula Corporate Park, Nicholas Piramal Tower, 9^th Floor, G.K. Marg, Lower Parel, Mumbai – 400013.

---- Opposite Parties

BEFORE:    SH. LAKSHMAN SHARMA             PRESIDENT

MRS.MADHU MUTNEJA               MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. G.D. Gupta, Counsel for Complainant.

Sh. Rajneesh Malhotra, Counsel for Opposite Parties.

PER MADHU MUTNEJA, MEMBER

1.        The lis between the parties is with regard to non-payment of complete insurance claim by the Opposite Parties as per the claim made by the Complainant.  

          Briefly stated, the Complainant had obtained two Policies from Opposite Parties No. 2 and 3 vide Insurance Policy No. MRP 25000051982 known as TATA AIG Maha Raksha Personal Injury Policy effective from 10.6.2008 to 09.06.2009 (for brevity hereinafter referred to as “MRP Policy”) and Policy bearing No. HCP 250000013636 valid from 28.06.2008 to 27.06.2009 (for brevity hereinafter referred to as “HCP Policy”). Both the policies covered personal accident cover, injuries and hospitalization, besides reimbursement of medical expenses. 

          The Complainant has stated that no policy terms and conditions of either of the policies were supplied to him. The Complainant has also stated that he even got the HCP Policy renewed for another year. Due to an unfortunate event, the Complainant had a sudden accidental fall, while playing cricket in the College ground. He suffered a fracture of the right knee joint for which treatment was given to him at Dr. Bhatia’s Bone and Joint Care Clinic, Sector 37-D, Chandigarh. (Medical treatment & expenses documents are Annexure C-3 to C-11). The Complainant remained confined to bed from 13.9.2008 to 10.11.2008. He submitted his claim form along with detailed medical expenses bill for Rs.7575/-, duly verified by the treating Orthopedician with the Opposite Parties on 6.2.2009 (Annexure C/12 to C/12-A). 

          The Complainant has further stated that as per MRP Policy, he was entitled to a claim of Rs.18,000/- + domiciliary hospitalization @ Rs.15,00/- per day for 58 days for which he remained confined to bed i.e. Rs.1,12,575/-. The Complainant has also stated that he was also eligible for accidental benefit for injuries @ Rs.4000/- per day as In-Hospital Indemnity for accident + Rs.15,000/- as accident Medical Expenses Reimbursement and other compensatory allowance under the HCP Policy. However, no amount of compensation has been paid by the Opposite Parties despite of the fact that the premium had been charged from him.

          The Complainant has stated that he has lodged his claim with Opposite Party No.3 and provided all desired documents to Opposite Party No.2 (entire correspondence at Annexure C-14 to C-18). However, Opposite Parties have only paid a sum of Rs.3500/-, which is also after a lot of reminders. This according to the Complainant is a misuse of the policy and insurance contract of good faith.   

          The Complainant has thus filed the present complaint with the allegation that the Opposite Parties are liable to pay a compensation of Rs.1,12,575/- + Rs.19,500/- to him along with interest, compensation and cost of litigation. The Complainant has thus prayed for a total amount of Rs.2,37,075/- to be paid by the Opposite Parties.

2.        Notice of the complaint was sent to Opposite Parties seeking their version of the case.

3.        The Opposite Parties in their joint reply have taken the preliminary objection that an amount of Rs.3500/- has already been paid to the Complainant as full and final settlement under MRP Policy. The MRP Policy does not provide cover for expenditure incurred towards medical expenses. However, as per terms of HCP Policy, under which no claim has reportedly been filed by the insured, the Opposite Parties are willing to pay a sum of Rs.11,150/- towards In-Hospital Indemnity and accidental medical expenses.

          On merits, Opposite Parties have submitted that the MRP Policy was valid from 10.6.2008 to 9.6.2009 and provided for payment under Plan 3 Level 1 (maximum permissible claim) as given in the schedule of the insurance policy. But the Complainant has placed on record previous MRP Policy Schedule under Plan 3 with Level 4 benefits. It has been submitted by the Opposite Parties that initially the Complainant had applied for Plan 3 Level 4 Policy, but later he called the call center of the Opposite Parties on 9.7.2008 and requested for downgrading of the policy, resulting in reduction of premium payable and reduction in insurance policy from Level 4 to Level 1. As per the request of the Complainant, the MRP Policy was accordingly down graded to Plan 3 with Level 1 benefits. (CD attached by way of proof at Annexure A-2). The HCP Policy was however valid for Level 3 payment (maximum permissible claim). But, no claim under this Policy was ever registered by the Complainant. Opposite Parties have stated that they are willing to release the amount due under this policy to the Complainant, subject to fulfillment of the requirements of claim. In reply to the allegations of non-receipt of terms & conditions of the Policy, the Opposite Parties have submitted that the terms & conditions of the Policy was sent to the Complainant, along with the insurance policy. No prudent man would get the insurance policy renewed if the terms and conditions were not being supplied.

          Opposite Parties have also stated that after the unfortunate accident, the Complainant submitted his bill which was processed as per terms and conditions of the policy and Rs.3500/- was paid. The insured had suffered fracture in the right knee and was hospitalized for one day. The other amounts claimed by the claimant under the policy were not covered and hence, were not payable. The amount payable as per terms and conditions of MRP Policy (Level 1) were in hospital indemnity for sickness with benefit of Rs.500/- per day and 25% of principal sum insured of Rs.12,000/- for Coverage under Fractures Dislocation & Burns. Also, the amount payable under the HCP Policy is Rs.11,150/- which has not still been claimed by the Complainant. Thus according to the Opposite Parties the amount claimed by the Complainant in this complaint is not payable, except the amount of Rs.11,150/- due under HCP Policy as per terms and conditions of the Policy. This claim has not been filed. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.

4.        Parties led evidence in support of their contentions.

5.        During the course of proceedings, the Complainant filed evidence in rebuttal by way of affidavit of Sh. N.K. Nahar (father of the Complainant). Vide this affidavit the Complainant alleged that there was no documentary proof that the MRP Policy had been reduced from Level 4 to Level 1. It has been stated that the voice recorded in the C.D. does not belongs to the father of the Complainant and there has been no request for converting/ reducing the level of policy. It is also stated in the affidavit that as the amount had been debited from the HSBC account of the Complainant, the Bank be asked to provide copies of bank statements for the relevant period to ascertain the details. As the Complainant was unable to procure the said details himself, efforts were made by this Forum to get the details from the Bank. The details were provided by the Bank which have been placed on record along with letter dated 31.10.2012. As per these details for the period 18^th June to 17^th July, 2008, an amount of Rs.6024/- has been received in the account of the Complainant from TATA AIG General Insurance Company.    

6.        We have heard the learned counsels for the Parties and have perused the record.  

7.        The case of the Complainant is that despite obtaining two Policies, referred to above, from the Opposite Parties for medical reimbursement/ hospitalization the due amount has not been paid by the Opposite Parties when the need arose, and claim was filed. The Opposite Parties in reply have submitted that though the Complainant had taken two Policies he has filed claim under one Policy only i.e. MRP Policy while claim under the other policy (HCP Policy) still remains unfiled. The Opposite Parties have also stated that they are willing to make payment if the claim is filed by the Complainant as per the terms and conditions of the Policy.

8.        Against the claim filed by the Complainant for MRP Policy, Opposite Parties have submitted that since the Complainant had got the policy down graded, the full amount claimed has not been paid. Only the amount due as per the downgradation has been given.

9.        When the Complainant objected to this down grading of policy and alleged refund of premium from the Opposite Parties, this Forum sent summons to the HSBC Bank to verify if the amount of refunded premium (with regard to the down grading of policy) had been received in the account of the Complainant or not. As per details provided by the HSBC Bank, it is proved that the amount of Rs.6024/- has been received in the account of the Complainant. Hence it is adequately proved that the Policy has been down graded.

10.       All documents placed on record by the Complainant also show that the Complainant had filed claim before the Opposite Parties for MRP Policy alone and it is only one last letter dated 12.4.2009 (Annexure C-17) wherein both the Policies have been mentioned. The Opposite Parties have already stated that as the claim for HCP Policy has not been filed they are still willing to settle the claim. We also agree with the contention of the Opposite Parties in terms of the documentary evidence available on record that the Complainant has not filed the claim before the Opposite Parties in respect of the HCP policy. The claim papers have not been placed on record. Hence, entitlement of the Complainant for more amount under the MRP Policy is not proved. The Opposite Parties have fairly conceded that Complainant was hospitalized for one day only. In case the Complainant can prove that he was hospitalized for more than one day, he can approach the Opposite Parties for payment under the MRP Policy for the period of hospitalization beyond one day. Opposite Parties should make payment for the period of hospitalization @ Rs.500/- per day in terms of the policy accordingly.     

11.       Keeping in view the foregoings, we dispose off the present complaint. The Complainant is at liberty to approach the Opposite Parties for payment of the hospitalization benefit under the MRP Policy bearing No. MRP 25000051982 in terms of hospitalization beyond one day if he can prove the hospitalization. The Complainant may also file his claim under the HCP Policy bearing No. HCP 250000013636 and take payment as per the willingness shown by the Opposite Parties to make payment in terms of the reply filed. No costs.

12.       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

03^rd December, 2012.                                            

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER