JUDGEMENT

          Complainant by filing this complaint has submitted that complainant is covered by the Group Mediclaim Policy issued by the op no.1 New India Assurance Co. Ltd. in the name of the op no.2 as principal insured and issued policy certificates to the complainants and sum insured of the said Mediclaim is Rs. 35,000/- and the policy certificates were issued on 01.07.2000 and expired on 30.06.2001 vide Policy No. 48-30162 being Sl. No. 0179343/200000104057 and during the validity f the said policy the complainant no.1 admitted in Dish Eye Hospital for his cataract operation on 14.05.2002 and his patient Id was 639762.  The policy required yearly renewal and the second renewal was done on 14.06.2002 coverage of which was expiring on 18.06.2003 and during the period of the renewed policy complainant no. 2 admitted in Divine Nursing Home on 19.11.2002 under Dr. P.S. Mukherjee as an indoor patient whose bed No. 528 and she was discharged on 24.11.2002.  In the same year on 17.12.2002 complainant no.1 admitted with acute chest pain the same nursing home under the same doctor as mentioned above at bed No. 106 and after 3 days he was shifted to general ward under bed No. 505 for proper diagnosis and doctors concerned considered that as a case of acute coronary syndrome, complainant was discharged on 24.12.2002 and the complainant for the above said treatment cost submitted claim on 06.08.2002, 02.01.2003, 20.01.2003 respectively against the policy No. 48-30162 and 510402/48/01/17784.  But the settlement of claim had not been done by the op so complainant sent letter through registered post with A/D on 29.07.2003 to the Divisional Manager of the New India Assurance Co. Ltd. for the settlement of their claims personally went to the office on 10.12.2003.  Further letter was submitted on 10.08.2006 requesting them to settle the claim as early as possible.

          Thereafter complainants visited several times in the branch office of the op no.1 on 17.04.2003 stating that they have had no concern to any disbursement of claim in favour of the policy holders and it was also stated that the matter is outside the scope and limitation of op no.2 and for that they should be discharged.  Subsequently that the litigation is pending before the Hon’ble Kolkata High Court and for which it cannot be disposed of.  But fact remains that op did not dispose of the matter for which complainant appeared before the Forum for releasing of medicalim amount of Rs. 49,304/- with 9% interest and compensation etc.

          Whereas op no.2 P.M. System & Financial Services Pvt. Ltd. submitted that no doubt they acted an agent of op no.1 till 23.12.2001 and after 23.12.2001 op no.2) is not acting as agent of op no. 1 and as such there is no question of settlement of dispute of the policy in between the complainant and op no.1.  Op No.2 further submitted that as no specific relief has been prayed for against op no.2 the case against op no.2 should be dismissed and further submitted that the allegation of the complainant in para nos. 13, 14, 15, 16, 17 & 18 are completely denied because since 23.12.2001 op has not been acting as agent with the op no.1 and in the circumstances the present complaint should be dismissed against the op no.2.

          On the other hand Insurance Company by filing written statement submitted that this complaint is not maintainable and further submitted that complainant submitted and admitted that he was admitted on 19.11.2002 for distinct separate diseases and that repeatedly on 17.12.2002 and complainant no.1 was further admitted allegedly in the hospital and was discharged on 24.12.2002 and thereafter a long gap of 3 years all on a sudden complainants allegedly submitted letter dated 10.08.2006 for settlement of claim and that on 07.12.2006 complainant resorted to the office of the Insurance Ombudsman, Kolkata for necessary arbitration and op no.1 appeared and filed a self contained note dated 22.02.2007 and it was submitted that mediclaim policy was issued in favour of M/s. P.M. System & Financial Services Pvt. Ltd. as per MOU signed between the principle insured and the insurer and Smt Krishna Banerjee is a certificate holder under the said Group Mediclaim Policy.  Initially the insured M/s P.M. System & Financial Services Pvt. Ltd. was allowed a Group discount of 40% on the basis of estimated 30,000 projected members during the policy period and in case the insured fails to complete the target of 30,000 members, the group discount will be reduced depending on the actual number of members covered under the Group Mediclaim Policy during the relevant period.  But the insured could not achieve the target of 30,000 members and also due to adverse claims experience, insurer have raised a claim for recovery of balance premium amounting to Rs. 76,56,757/- from the insured op no.2 which was duly received by the said P.M. System & Financial Services Pvt. Ltd. on 24.12.2002 but insurer did not receive the requisite premium from the insurer to regularize the policy vis-à-vis settlement of pending claims and the act itself is a violation of section 64VB of the Insurance Act by the insured P.M. System & Financial Services Pvt. Ltd.  Fact remains after 2001 it has no legal validity of the same and as per law if premium is not paid then the policy shall be treated as invalid and considering all the above fact, the present complaint should be dismissed as it is not maintainable.

                                                        Decision with reasons

          In this particular case practically after hearing the Ld. Lawyers of both the parties and also considering the complaint and written version, it is clear that op no.2 M/s P.M. System & Financial Services Pvt. Ltd. has admitted in his written statement that since 23.12.2001 he is not acting as agent of the op no.1 the Insurance Company.  From the defence of the op, it is also proved that as per MoU in between the op nos. 1 & 2, op no.2 did not deposit huge amount of premium as insured for which several litigation is pending before the Hon’ble Kolkata High Court and fact remains Hon’ble High Court of Kolkata restrained all the financial agents to renew or to take any premium from any subscriber in respect of such Mediclaim policy or any other accidental policy and considering the order of Hon’ble Kolkata High Court, it is clear that op no.2 had no right to renew or to collect any premium from any subscriber after 1999 and that order was passed by Hon’ble Justice P.C. Ghosh in CAN No. 2179/2004 and op no.2 has admitted that he has not renew any policy after 23.12.2011.

          But after overall evaluation of the present complaint, it is found that complainant has prayed for disbursement of mediclaim amount of Rs. 49,304/- for the period from 19.11.2002 to 24.11.2002 and 17.12.2002 to 24.12.2002 and all those claims were submitted as alleged by the complainant on 06.08.2002, 02.01.2003 and 20.01.2003.  No doubt op no.2 is shown as insured for the period 18.06.2011 to 17.06.2012.  But complainant claimed that complainant was treated in between the period 19.11.2002 to 24.11.2002 and 17.12.2002 to 24.12.2002.  But the Mediclaim Policy and risk coverage period was for 18.06.2001 to 17.06.2002.  So, the claim of the complainant on the basis of Policy No. 4851040214140 is not covered the risk of reimbursement of medical expenses incurred at hospital.  But no doubt op no.2 the M/s P.M. System & Financial Services Pvt. Ltd. submitted in their written version that they never act as agent of the op no.1 in this regard w.e.f. 23.12.2001.  If that is the fact then it is clear that the Policy No. 510402/48/01/17784 for the period from 14.06.2012 to 18.06.2013 is not a valid Insurance Policy in view of the fact that op no.2 did not renew that policy as insured for covering the risk of the Group Mediclaim Policy and it is admitted by the op no.2 and op no.1 Insurance Company has submitted that the said policy was collected by giving some false statement by the op no.2 and it is invalid in view of the Provision 64VB of the Insurance Act and it is mandatory provision of law if any Insurance Policy is issued but subsequently premium is found not made by insured in that case even after issuance of the policy, the policy shall be treated as void from its date of inception and in view of the provision of law and findings we are convinced to hold that the complainant’s claim on the basis of the Policy No. 510402/48/01/17784 being Sl No. 050200210044062 shown as renewal is completely a void document and op no.2 has admitted that he did not renew and he never acted as agent of op no.2.

          So, it is clear that insurance policy as issued in the name of M/s P.M. System & Financial Services Pvt. Ltd. is a void document.  So, on the basis of the void document, complainant cannot claim any benefit of Mediclaim disbursement.  When insured himself admitted that he did not renew the said Mediclaim Insurance Policy for covering the risk of the members then it is clear that this policy somehow or otherwise was collected but no premium was paid by the op no.2 and op no.2 has admitted that after 31.12.2001 he never continued this business with the op.

          Truth is that after 2002 op no.1 had no legal capacity to collect any premium from any person for a mediclaim policy or any other policies as per order of Hon’ble Kolkata High Court.  In the light of the above observation, we are convinced to hold that complainant has no legal right to claim any disbursement on medical expenses as member of Group Mediclaim Insurance Policy alleged to have purchased by the op no.2 as insured.

          Moreover it is also proved that the claim was of the year 2002-03 for the medical treatment cost for the period from 19.11.2002 to 24.11.2002 and 17.12.2002 to 24.12.2002.  But admittedly during that period there was no valid insurance policy.  But complainant produced a void document the insurance policy as discussed above but complainant has no legal right to claim it as it is void policy and op has also admitted that he did not renew the said policy after 31.12.2001.

          Moreover complainant submitted all claim on 02.01.2003 and op did not consider the same reported the matter to the insured op no.2 and thereafter op no.2 or op no.1 did not take any step and after long 3 years they submitted one complaint before the Insurance Ombudsman in the year 2006 that was also rejected.  Thereafter complainant was sitting idle and the present complaint was filed on 07.10.2013 after lapse of 7 years.  So, initially the entire complaint is barred by limitation and at the time of filing the complaint no application u/s 24A of C.P. Act 1986 was filed for condonation of delay.  So, admittedly the complaint is also barred by limitation and at the same time complainant is not a insured under the op as per Insurance Policy being No. 510402/48/01/17784, being Sl. No. 05200210044062 dated 14.06.2002 for covering the risk period up to 18.06.2003.

          In the result, the complaint fails as the complainant is not a consumer under the op no.2 or op no.1 for which this complaint fails.

          Hence, it is

                                                             ORDERED

          That the complaint be and the same is dismissed on contest without any cost against the ops.