Karnataka

Belgaum

CC/223/2014

Vijay B Mane - Complainant(s)

Versus

The Managering Director Syndicate Bank, - Opp.Party(s)

In Person

09 Mar 2015

ORDER

(Order dictated by Shri. V.S. Gotakhindi, Member)

ORDER

          The complainant has filed the complaint u/s. 12 of the C.P. Act, against the O.Ps. alleging deficiency in family health insurance service.

          2) The 3^rd O.P. in the version has justified the repudiation of claim contending that the complainant had suppressed material fact and denied the allegations made contenting that the claim is false and frivolous and there is no cause of action. Further contented that the complainant is not entitle for claim amount as prayed but after transpired examination by the O.P.No.4 the complainant is entitle for Rs.33,216/- only. The O.P.2 also filed objection that he is only an introducer between complainant and O.P. No.3 and the liability to be answered is the O.P.3 only etc.,

3) O.Ps. 1 and 4 have remained exparte, inspite of service of the notice.

          4) The complainant and the Divisional officer of the 3^rd O.P. and also Senior Branch Manger O.P.2 have filed their affidavits and certain documents are produced.

          5) We have heard the learned counsel for the complainant and 2 & 3 O.Ps. and have perused the records.

6) Now the point for our consideration is that, whether the complainant has proved any deficiency in service on the part of the O.Ps. and that the complainant is entitled to the reliefs sought?

7) Finding on the point is in Affirmative, for the following reasons.

REASONS

          8) There is no dispute that the complainant had taken Synd Arogya family health care policy of the O.P.No.3 for the period 15/3/2012 to 14/3/2013. The terms and conditions thereof are not in dispute.

          9) The complainant Inperson appeared and claims that on 15/3/2012 the complainant has purchased the policy from Employee of O.P.2 for face value of Rs.3,00,000/- and produced a cheque for premium amount to O.P.2 and later same was converted in D.D. and the O.P.2 assured that the same will be forwarded through O.P.1. It is further alleged that after two months complainant found that the renewal premium policy papers has not been signed to O.P.3 after due enquiry to the O.P.3 the same was revealed so it was cancelled. The O.P.3 issued a new policy number to the complainant. The complainant in the month July 2013 admitted his wife in the Hospital for delivery and she delivery pre matured baby and baby was NICU for 15 to 20 days. The complainant submitted claim to O.P.3 through O.P.4 duly claim form was filled on 2/10/2013. The complainant claimed Rs.83,367/- but the O.P.3 rejected the claim stating that there is a break up in the policy. The complainant continuously followed by submitting required documents to O.P. No.3 but the O.P.3 did not respondent and no action was taken. The complainant on 20/2/2014 issued letter to the O.P. asking suitable remedy but there was no communication of whatsoever and the O.P. refused to resolved the complainant issued. The complainant prayed to direct the O.P. claiming Rs.83,367/- and Rs.10,000/- as mental agony and also prayed to direct the O.Ps. to apologize for the inconvenience.

          10) Grievance of the complainant is that, he submitted claim to the O.Ps. alongwith the bills but the O.P.3 has not settled the claim inspite of several requests.

          11) The 3^rd O.P. Insurance Company has denied contended that as the complainant’s wife had suffering and taking treatment in the Hospital and policy was in alive and the complainant is not entitled for the claim as prayed in the complaint and there is no cause of action to file the complaint the O.P.3 contended that they have submitted the bills to O.P.4 submitted by the complainant for the settle of the claim and the O.P.4 verified and after checking the same with regard to genuineness and authenticity and same are under payable terms and conditions of the policy. The O.P.3 submitted that out of total bill of Rs.41,032/- under the terms and conditions of the policy the complainant is entitled for 30 days free hospitalization expenses and as the complainant wife was hospitalized from 20/7/2013 the expenses after 20/6/2013 are only payable. The O.p.3 in his objection has given a table stating that the amount mentioned along with particulars in the table are not payable to the complainant and as per the terms and conditions the complainant is entitle for net claim of Rs.33,216/- only and not Rs.83,367/- which is expensive and unreasonable without any evidence and proof and prayed to dismiss the complaint with cost.

          12) The O.P.2 on the other hand filed objection and contended that he is not at all the introducer he is only acting was a conduit to accept the premium amount in form of D.D. and cheque in the name of insurance company from the customer for their convenience only. This O.P. at para No.7 contended that the duty of the bank to submit the proposal for the Arogya policy on behalf of United India Insurance Company the sole description of the insurance company whether to accept or reject. This O.P. further submits that the complainant has to act according to terms and conditions of the policy and the complainant cannot hold this O.P. No.2 responsible for deficiency of service and it is the O.P.3 insurance company to settle the claim or reject the claim. At para No.13 of objection of O.p.2 submitted that the insurance company agreed to settle the claim of the complainant for Rs.15,000/- being 5% of the amount insured and same was intimated by the insurance company to this O.P. etc.,

          13) Now the point for consideration after perusing the documents and after going through objection filed by the O.P.2 & 3 and according to the terms and conditions of the policy after going through the same at clause No.1.3 additional cover at sub clause-e-Maternity benefit and baby care under the heading maternity expenses benefit it has stated that treatment in the hospital / Nursing home arising from or traceable to pregnancy child birth including normal cesarean section. Waiting period is 9 months ii) Baby care means expenses related to treatment given to the new born baby in the hospital as an inpatient for maximum period of 90 days from the date of its birth. The re-imbursement in baby care will be limited to actual expenses subject to maximum of 5 % of sum assured of obtained in mediclaim section. After 90 days from the date of birth the baby will have to be covered under policy on payment of additional premium. The another point to be considered is that the O.P.3 has already sent a cheque in the name of the complainant to extend of Rs.33,216/- and same is revealed in the savings bank of the complainant.  The complainant under protest has filed this complaint claiming the amount as prayed in the complaint. Moreover, the O.P.3 admits that the total bill under the claim as per their calculation is Rs.41,032/- but the O.p.3 deducted Rs.8,860/- stating that they are not entitle for this amount. At the time of argument the O.P.3 fail to submit as to why the complainant is only entitle for Rs.33,216/- but submitted that we are only liable to pay this amount only and not more than this. There was no proper explanation given or argument putforth by O.p.3 as to why the claim of the complainant was rejected for the amount claim be the complainant i.e., Rs.83,367/- only the argument was we entitle to pay Rs.33,216/- only. Moreover the O.P.2 in his para No.13 has statedthat the O.P.3 has wrote a letter stating that they are only entitle for Rs.15,000/- only as 5% of insured amount. This itself goes to show that O.P.3 is not at all clear as to what amount they are entitle to pay to the complainant as per the policy. Hence the O.P.3 has utterly fail to explain and argue on the said point. Coming to the liability of O.P.2 is that as per the objection and after going through the documents their part is only to collect the premium and pay to the O.P.3 company is proved. Hence O.P.2 is not liable to answer the claim of the complaint. The O.P.1 is also not entitled to answer the claim of the complainant as he is only the head office of the O.P.2 is branch.

          14) The O.P.No.4 though placed exparte is necessary party to answer the claim of the complainant as there is correspondence of letter between the complainant and between O.P.3 and this O.P. Moreover the important point to be considered is that the O.P.3 through whom and to whom the claim form is forwarded by the complainant and the O.P.3 has already paid a part of claim amount made by the complainant. Considering the facts, evidence documents and argument putforth by the complainant and O.Ps. the complainant has proved deficiency of service on the part of the O.P.

          15) Accordingly, following order:

ORDER

          The complaint is partly allowed.

O.P. No. 3 is hereby directed to pay a sum of Rs.83,367/- to the complainant towards the hospitalization expenses with interest at the rate of 9% P.A. from the date of claim till, realization of the entire amount.

          Further the O.P. No.3 is hereby directed to pay a compensation of Rs.3,000/- to the complainant for mental agony and inconvenience caused.

So, also O.P. No.3 is hereby directed to pay a sum of Rs.2,000/- to the complainant towards costs of the proceedings.

Order shall be complied within two months from the date of the order.

          Member                         Member                         President.

gm*