PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding deficiency in service and unfair trade practice, on the part of Opposite Party by not paying the health check up claim of the wife of the Complainant, arbitrary increasing the premium, etc. as alleged by the Complainant.
The Complainant states that he alongwith his wife, had taken a mediclaim policy from the Opposite Party since 1996. The sum insured was Rs.1,00,000/- for him and Rs.20,000/- for his wife for the period from 23/03/96 to 22/03/1997. The premium was Rs.1,654/-. In the year 1999-2000 the sum insured for the Complainant was Rs.1,50,000/- and for his wife the sum insured was Rs.1,00,000/- The premium also increased to Rs.3,459/- from Rs.1,654/-.
2) The Complainant further states that he had sent a letter to the Opposite Party No.1 dtd.12/03/2008 enclosing a cheque of premium for the mediclaim policy for 2008-2009 and asking about the unilateral increase in the premium amount and about the medical checkup.
3) The Complainant also sent a letter dtd.19/07/08 to the Opposite Party asking to reimburse the bill of Rs.2,200/- and Rs.2,500/- of health checkup of the Complainant and his wife respectively.
4) The Complainant further states that he received a cheque of Rs.1,500/- on 09/01/2009 against his claim of Rs.2,200/- as health checkup claim. However, he did not receive the amount claimed against his wife’s health checkup claim of Rs.2,500/-. Therefore, the Opposite Party was immediately informed in this respect vide letter dtd.10/01/09. A reminder was also sent vide letter dtd.06/03/2009.
5) On 08/03/2009, the Opposite Party sent a letter in which Opposite Party No.1 asked the Complainant to contact for further continuation on the policy and its premium. However, the bonus accrued column was missing in this letter. In the previous year, this Bonus amount accumulated was Rs.72,500/- and Rs.35,000/- for the Complainant and his wife respectively. The Complainant states that he immediately contacted on telephone to Ms.Madhawani (Opposite Party No.1’s representative) but she did not respond.
6) The Complainant further states that the renewal copy of the policy for the period from 22/03/09 to 22/03/10 was given to him on 14/04/09. The Complainant alleges that the attitude of the Opposite Party has been unprofessional, mindset is arrogant and tyrannical. This caused mental strain to him and his family. Suddenly he and his family were facing discontinuation of their policies. Therefore, he finally prayed for -
a) Compensation for mental agony - Rs.1,07,500/-.
b) Compensation for late reimbursement of health - Rs.5,000/- checkup claim.
c) Compensation for non receipt of health checkup - Rs.5,000/- of Mrs.Alimchandani.
d) Compensation for expenses towards Court attendance Rs.5,000/-.
e) Compensation for legal consultations - Rs.15,000/-.
7) The complaint was admitted and a show cause notice was served on the Opposite Parties. They appeared through their advocate and filed the written statement wherein they denied the allegations made by the Complainant and specifically stated that the Complainant has availed the services of the Opposite Parties and obtained Mediclaim Policy No.141600/48/96/90277 since 1996 for himself and his wife. They further averred that the increase in the rate of premium depends on the various factors and they operate as per the guidelines of IRDA. They further admitted that the explanation had been given by Opposite Party No.2 to the complaint in respect of increase in the rate of premium and about health checkup claim.
8) The Opposite Parties further admitted that the Complainant had lodged his claim of Rs.2,200/- with them for medical expenses incurred for complainant’s health checkup and a claim of Rs.2,500/- for his wife’s health checkup expenses. However, the claim of the Complainant for Rs.1,500/- being 1 % of the sum insured was piad by the Opposite Party. The Claim of the Complainant’s wife for Rs.2,500/- was passed being 1 % of sum insured and was paid by cheque dtd.13/10/2008. This cheque was dispatched on 28/01/09. It was revalidated as per the request of the Complainant and dispatched.
9) The Opposite Parties further stated that the notice of renewal of mediclaim policy was showing nil cumulative Bonus. This was a clerical error and was rectified in the policy. They denied that there is any deficiency in service on their part. They further asserted that the Complainant has suppressed the material facts of the case and misrepresented the facts. There is no cause of action against them and hence, the complaint be dismissed.
10) The Complainant filed affidavit of evidence in support of his complaint. He also filled written argument. Opposite Parties also filed their written argument. We heard the Complainant in person and the Ld.Advocate for the Opposite Parties. We also perused the above mentioned documents & documents attached to the complaint. Our findings are as follows -
11) As admitted by the Opposite Parties they are the service provider to the Complainant, as the Complainant has availed the services of the Opposite Parties by purchasing the mediclaim policy since 1996. As such, the Complainant is a consumer within the meaning of Section 2(1)(d) of the Consumer Protection Act. In the year 1999-2000 the insured amount was increased to 1,50,000/- for the Complainant and Rs.1,00,000/- for his wife. The premium was also increased to Rs.3,459 from Rs.1,654/-.
12) The Complainant in his complaint in para 4 has alleged - “As there was a continuous arbitrary increase in yearly premium rates, I wrote to the company vide my letter dtd.23/03/08 seeking explanation for increase in rates but the Opposite Party did not respond.” In this regard we perused the Exhibit-‘C’ to the complaint. This letter is addressed to the Opposite Party but date appearing on that letter is 12/03/2008 which is written in handwriting. On perusal of this letter it reveals that the Complainant has enclosed a cheque in which figure is Rs.10,648/- (handwritten). However, the typed amount of Rs.5,805/- has been cancelled. There is no signature of the Complainant on this correction. In the subject of the letter (caption), it is written as “ Renewal notice 2007-2008 and in the 1st paragraph it is stated that mediclaim policy from 22/03/08 to 22/03/09 by canceling 22/03/07 to 22/03/08. In the second paragraph, the Complainant has requested the Opposite Party to inform as to how his premium amount was unilaterally increased. The Complainant also requested the Opposite Party about the date as to when he could avail his & his wife’s medical checkup claim. It is not seen from the letter as to when this letter was received by the Opposite Party. However, perusal of Exhibit-‘D1’ shows a remark on this letter as follows –
“with reference to the above, the premium rates have been changed from Aug., 2007, on the basis of the age not on the basis of the claim ratio. However, since no claim has been lodged, in the above policy, you would be entitled to a Cumulative Bonus of 5 % of the sum insured every year to a maximum of 50 %. Assuring of best services at all times, as far the medical checkups, which can be availed once every 4 years to maximum limit of 1 % of sum insured. Sorry for delay.”
It appears that this remark (reply) is given by Opposite Party No.1. This is also corroborated by the Opposite Party in the written statement also.
13) The Complainant has also attached the xerox copy of a letter dated 26/05/2008 with U.P.C. but there is no proof to show whether this letter has been received by the Opposite Party.
14) Exhibit-‘E’ a letter dtd.19/07/08 issued by the Complainant to the Opposite Party No.1 shows that the Complainant has sent his health checkup claim for Rs.2,200/- for his health checkup and claim of Rs.2,500/- for the health checkup of his wife and requested Opposite Party No.1 to reimburse the amount (total Rs.4,700/-) Here also the typed date is 19/07/2008 then by handwriting it is changed as 30/07/08. Date 19 has not been cancelled. There is no proof to show that this letter was received by the Opposite Party. However, a letter dtd.11/11/2008 which is a reminder of earlier letter, was sent under certificate of posting on 15/11/2008 (Exhibit-‘F’).
15) A xerox copy of a Cheque No.76888 dtd.13/12/2008 is attached (Exhibit-‘G’) to the complaint. This cheque was received by the complainant on 09/01/2009 as per the complaint. The Opposite Party has not denied this averment.
16) Regarding the claim of the wife of the Complainant for Rs.2,500/- the claim for Rs.1,000/- (1 % of the insured amount) was sanctioned by the Opposite Party but the cheque was dispatched by them on 28/01/09. It was revalidated and again dispatched on 27/04/2009. This cheque was dated 13/10/08 as per the contention of the Opposite Party themselves in para 8 of the written statement. That shows that they have received the claim before 13/10/08 but they dispatched the same cheque on 28/01/09 i.e. after 3 and half months. This is an inordinate delay in dispatching the claim of the Complainant’s wife. Again it was revalidated and sent on 27/04/2009 i.e. again after 3 months. Therefore, in reimbursing this claim the Opposite Parties have shown tremendous negligence.
17) So far as the other allegation of the Complainant regarding the missing accrued bonus of Rs.1,07,500/- in the letter for renewal of policy for the period from 2009 to 2010 is concerned, this letter is only to remind the Complainant that his policy is expiring on 22/03/2009 and he should contact the Opposite Parties. In this letter only the Opposite Parties have mentioned the details of Policy No.11130034/07/11/000085 59 for the period from 23/03/08 to 22/03/09. Actually this is not a documents called as mediclaim policy. It is a letter in which the particulars of the above policy are given but the bonus accrued was not given. The Opposite Parties in their written statement have categorically admitted that it was a clerical mistake and when the policy for the period from 23/03/09 to 22/03/2010 was issued to the Complainant (Exhibit –‘N’) it reflected the Cumulative Bonus as Rs.50,000/-, Rs.25,000/- and Rs.40,000/-. This document was issued on 01/04/2009. Therefore, the perusal of documents mentioned at Exhibit-‘M’ page 22 and bonus amount accrued is reflected in the policy documents. Therefore, it can be said that the Opposite Parties are deficient in service, in this respect.
18) Taking into consideration these two aspects of this complaint there is certainly a deficiency in service on the part of Opposite Parties in delaying the health checkup claim of Rs.1,000/- in respect of the wife of the Complainant only. However, the prayer of the Complainant is exorbitant and is not rational. Therefore, we pass the following order -
O R D E R
i. Complaint No.130/2009 is partly allowed.
ii. The Opposite Party No.1 & 2 are directed to pay jointly and/or severally Rs.3,000/- (Rs.Three Thousand Only) to
Mrs.Shobha Rajan Alimchandani for delaying in reimbursing her health checkup claim of Rs.1,000/-(Rs.One
Thousand Only).
iii.Opposite Party No.1 & 2 are also directed to pay jointly and/or severally Rs.2,000/-(Rs.Two Thousand Only) to
the Complainant towards the cost of this complaint.
iv.Opposite Party No.1 & 2 are also directed to comply with this order jointly and/or severally within 30 days
from the date of receipt of this order.
v. Certified copies of this order be furnished to the parties.
