ORDER
(Passed this on 24th April, 2017)
Shri Shekhar P. Muley, President.
01. This complaint is against an Insurance company for deficiency in its service in respect of settlement of insurance claim.
02. The complainant is a retired Assistant Manager of the Opposite Party, the New India Assurance Company. He and his family are covered under the Staff Mediclaim Policy of the O.P. during the tenure of his service. After retirement he got the policy revised by paying revised premium to the O.P. however the O.P. did not issue the policy nor its terms and conditions. During subsistence of the policy on 3/8/2012 his married daughter Mrs. Sneha experienced hypertension with high blood pressure and was therefore admitted to the hospital. The complainant intimated to the O.P. and submitted claim form to the O.P. along with medical bills, hospitalization bill to the tune of Rs.- 29,939 on 13/8/2012. The O.P., however, did not settle the claim for considerable time despite several persuasions. This is deficiency in its service and also unfair trade practice. Hence he has claimed Rs.29,939/- with interest along with compensation of Rs. 1 lakh and cost Rs. 25,000/- form the O.P.
03. The O.P. filed its reply and denied having issued policy to the complainant. The said policy was taken for its employees and retired employees from United India Insurance Company. Hence the claim should have been lodged with that company, but that company is not joined to the complaint. Thus the complaint is bad for non joinder of necessary party. It is admitted that the complainant was employee of it and had opted for health group policy. It is denied that the policy with its terms and conditions were not provided. His daughter was admitted to hospital for pregnancy induced hypertension with uncontrolled B.P. proximate cause of hypertension was pregnancy, which is out of scope of the policy for a married daughter. Maternity expenses benefits are optional cover on payment of additional 10% premium to married daughters. Said additional cover was not given to the complainant. For all these reasons the claim was not payable. Denying deficiency in service or unfair trade practice, it is prayed to dismiss the complaint.
04. Heard Ld counsels for both the sides. Perused documents, and notes of argument. Upon considering the same we give our findings for the reasons as under.
FINDINGS AND REASONS
05. The complainant in support of his claim has produced copies of Enrollment Form for revised staff mediclaim policy and premium receipt. These two documents prima facie show the policy was taken from the O.P. and not from the United India Assurance company as alleged by the O.P. Not only that, claim form was also submitted to the O.P. and repudiation letter was also issued by the O.P.
06. Counsel for the O.P. argued that since the complainant was an employee of the O.P. his mediclaim policy was taken from the United India Assurance Company and the O.P. acted merely as a mediator. Therefore it was for the United India Assurance Company to decide the claim. But since it has not been joined the complaint has to be dismissed for non joinder of necessary party. To this argument of O.P. counsel, there is no documentary proof to support his contention. He contended it was for the complainant to produce relevant documents and as he failed to produce the same his complaint is devoid of evidence. We do not agree with this contention for simple reason that the burden to prove the averments made by the O.P. is on it and not on the complainant. The complainant has categorically stated the policy was taken from the O.P. on payment of premium to it and no policy document was given to him. When the complainant has come up with such facts, it is for the O.P. to rebut these facts by placing relevant documents on record. The O.P. could have obtained certificate from Untied India Assurance Company that the policy was given by that company to the complainant. Since no policy document is placed before us by either party, we are unable to ascertain what are the terms and conditions of the policy. In absence of prima facie evidence, it is not possible to accept the theory put forth by the O.P. that the policy was issued by United India Assurance company and not by it. Hence the complaint cannot be said to bad for non joinder of necessary party.
07. It is further argued by the counsel for the O.P. that married daughter is not covered under the policy. He submitted the policy, no doubt, covers insured and his family, but meaning of the word ¨family¨ cannot be stretched to include married daughter. This anomaly is cropped up because the word ¨family¨ has not been defined. Therefore, he submitted, clarification was sought from the Regional Office of the O.P. as to whether maternity benefit cover can be extended to married daughter or daughter in law. From the copy of the circular it appears that certain observations were made and communicated to all branch offices that by virtue of newly introduced provision, married daughters and their families are eligible for inclusion in the policy. However, a note by way of caution is also made that it would not be advisable to extend maternity benefit cover in cases of married daughter or daughter in law of employees sought to be included under the category of non dependent children. But these are only observations made in the meeting of General Managers of the O.P. and it does not appear to be in the nature of terms and conditions of said policy. An advisory clarification was issued not to extend maternity benefit cover to married daughter.
08. In the Enrollment Form for revised mediclaim policy name of Sneha, daughter of the complainant was included and it was also mentioned that she was recently married. So married daughter inclusion under the policy was barred. If she was included in the policy cover she is entitled to policy benefits. According to the counsel for the O.P. maternity benefits are not covered unless 10% additional premium is paid. Further it is argued that under clause 5.15 of the policy also the O.P. is not liable to pay claim since hypertension and B.P. were pregnancy induced problems. The clause on which the O.P. is relying is, in fact, pertaining to policy of United India Assurance company and not of the O.P. Therefore it cannot take aid of some other company policy to repudiate
the claim. Even otherwise the clause 5.15 is about maternity expenses benefit extension, which is an optional cover available on payment of 10% of total basic premium. The complainant says he has availed of this optional cover by paying additional premium. What is material note is that when the claim was made the O.P. sought clarification from its Regional office whether maternity benefit cover could be extended to married daughters. Instead of that the O.P. could have straightway informed him since 10% additional premium was not paid, claim was not payable.
09. It is also to be noted that the O.P. could have taken the decision promptly had it been a case of non payment of additional premium or non coverage of married daughter or non extension of maternity benefit cover. There are letters from the complainant to the O.P. asking for status of the claim which was pending for more than three months. As per the Regulations laid down by the Insurance Regulatory and Development Authority (IRDP) insurance companies are under obligation to decide claims within 30 days and failure amounts to deficiency in their service.
10. At the cost of repetition we may point out from above discussion that if the O.P. is not the insurer of the complainant, why it repudiated his claim. Besides the clause on which the claim was repudiated is of policy of United India Assurance company. The O.P. has taken benefit of exclusion clause of other company policy in repudiating the claim of the complainant also contradicts its case.
11. Having considered rival submissions, we have come to the conclusion that the O.P. has committed deficiency in service by not settling the claim for long and then repudiating the same for wrong reason. The complaint deserves to be allowed, hence the following order.
ORDER
- The complaint is partly allowed.
- The O.P., New India Assurance Company is directed to pay the claim amount Rs.29,939/- (In words Rupees Twenty Nine Thousand & Nine Hundred Thirty Nine only) along with 9% p.a interest from the date of claim to the complainant.
- The O.P. shall also pay compensation of Rs.10,000/- (In words Rupees Ten Thousand only) for mental agony and litigation cost Rs. 5000/- (In words Rupees Five Thousand only) to the complainant.
- The order shall be complied by the O.P. within 30 days from receipt of copy of the judgment.
5. Copy of judgment and order shall be given to
both the parties, free of cost.
