PER SHRI. S.B.DHUMAL - HON’BLE PRESIDENT :
1) In brief consumer dispute is as under –
In the year 2000-03 the Complainant had taken Mediclaim Policy from the Opposite Party for himself and his wife Smt. Kanchan Ben Shah. In the aforesaid Mediclaim Policy sum assured was given Rs.2 Lacs each. From the year 2002, the Complainant renewed the said policy from year to year without any break. Till date the Complainant has not submitted any claim to the Opposite Party under the Mediclaim Policy and therefore, the Complainant is entitled to ‘No Claim Bonus’.
2) It is the grievance of the Complainant that from the year 2007-08, the Opposite Party did not offer any accumulated bonus to the Complainant and had illegally and unjustifiably withheld the same with an ulterior purpose. The Complainant made no default in remitting the premium to the Opposite Party. The Complainant has given statement showing details of the policy renewed since 2002 which are as follows -
YEAR |
MEDICLAIM policy for self & Spouse |
PREMIUM |
CLAIM, IF ANY |
2002-03 |
300000.00
300000.00 |
11,389.00 |
No claim. Bonus shown is Rs.30,000/- each. |
2003-04 |
300000.00
300000.00 |
12,072.00 |
No claim. Bonus Rs.45,000/- each |
2004-05 |
300000.00
300000.00 |
12,417.00 |
No claim. Bonus Rs.60,000/- each |
2005-06 |
300000.00
300000.00 |
13,490.00 |
No claim. Bonus Rs.75,000/- each |
2006-07 |
300000.00
300000.00 |
13,490.00 |
No claim. Bonus Rs.90,000/- each |
2007-08 |
450000.00
450000.00 |
27,784.00 |
No claim. But no Bonus shown |
2008-09 |
450000.00
450000.00 |
36,508.00 |
No claim. But no Bonus shown |
3) It is the case of the Complainant that Opposite Party has exorbitantly increased premium from the year 2007-08 and deleted accumulated bonus. With a view to avoid discontinuity of policy, the Complainant paid premium at exorbitant rate as demanded by the Opposite Party. The Complainant by his letter dtd.04/06/08 asked Opposite Party to explain undue rises in the Mediclaim premium. Premium for the period from 12/04/08 to 11/04/09 was raised by Opposite Party to all time high of Rs.36,508/- with no benefit of accumulated bonus. For the year 2009-2010, the Opposite Party did not forward any note about the premium to be paid by the Complainant. Therefore, the Complainant himself approached Opposite Party and handed over cheque dtd.06/04/09 for sum of Rs.13,490/- as a renewal premium. Opposite Party by their letter dtd.16/04/09 gave evasive reply but did not solve the problem. Opposite Party asked the Complainant to pay difference amount within 3 days to avoid any administration inconvenience. The Complainant was depressed as Opposite Party caused injustice to the Complainant. On 24/04/09, the Complainant forwarded a letter to the Chairman of Opposite Party. In reply to the letter, Chief Manager of the Opposite Party vide letter dtd.24/04/09 informed the Complainant that the subject matter was referred to the concerned authority and requested the Complainant to wait till decision is received. Thereafter, the Complainant on 25/05/09 again wrote a letter to the Chief Manager of Opposite Party to issue policy for the year 2009-2010 as the same was not forwarded to the Complainant inspite of payment of Rs.13,490/-. However, till date the Complainant has not received either the policy or the refund of said amount of Rs.13,490/- from the Opposite Party .
4) Regional Manager of Opposite Party vide letter dtd.15/06/2009 informed the Complainant that as per the decision taken by M.C.D.O.4 vide their letter dtd.16/04/09 was examined and they concurred with the said decision. The Complainant’s file was treated as ‘closed’ and he was advised to approach the Insurance Ombudsman. On 12/06/09, the Complainant sent notice to the Opposite Party through advocate. Opposite Party has not sent reply to the said notice. According to the Complainant, he is entitled to be reimbursed by the Opposite Party in respect of the extra money collected by the Opposite Party during the aforesaid period of the insurance policy. It is submitted by the Complainant that Sr. Citizen like Complainant and his wife, was covered under the policy taken, cannot be shunted off at the whims and fancies of the Opposite Party. It is submitted that it was never disclosed by the Insurance Agent of Opposite Party pre-existing ailment or heart ailment above 1.5 Lacs is excluded from the policies. Depriving insured person from accumulated bonus is unjustified and it amounts to deficiency in service on the part of Opposite Party. Therefore, the Complainant has filed this complaint.
5) The Complainant has requested to direct Opposite Party to refund excess payment taken from the Complainant for the year 2007-08, 2008-09 i.e. Rs.37,312/-. Further he has requested to direct Opposite Party to renew Complainant’s Mediclaim Policy for the year 2009-2010 at early premium of Rs.13,490/- and to benefits of accumulated bonus to the Complainant and his wife. The Complainant has claimed compensation of Rs.50,000/- for the mental agony, harassment and inconvenience and prayed for cost of this proceeding.
6) Opposite Party has filed written statement and thereby resisted claim of the Complainant contending interalia that the allegations made in the complaint are false and the Complainant is not entitled for relief claimed. Therefore, complaint deserves to be dismissed.
7) Opposite Party has admitted that the Complainant had taken Mediclaim Policy for himself and for his wife from the Opposite Party in the year 2002-03. Sum assured under the said policy was Rs.2 Lacs each. The Opposite Party has not disputed the fact that from time to time the said policy was renewed by the Complainant without any break. Till filing of the complaint the Complainant did not make claim under the policy. Therefore, cumulative bonus was recorded in the name of Complainant and his wife. According to the Opposite Party, in the year 2007-08, as per new scheme approved by IRDA new policy was issued to the Complainant. Earlier scheme was discontinued. Concept of cumulative bonus was abolished and in lieu of cumulative bonus sum assured was enhanced from Rs.3 Lacs to Rs.4,50,000/- each, despite the advanced age of the Complainants and without charging any additional premium. The Complainant accepted aforesaid policy for the period 2007-08 and paid increased premium of Rs.27,784/-. The Complainant was fully aware of difference of early premium paid by him. Subsequently for the year 2008-09, the Complainant on payment of premium of Rs.36,508/- renewed mediclaim policy. Cumulative bonus was not shown in the policy issued from the year 2007 onwards. The Complainant is well aware of the aforesaid facts even though he has unnecessarily filed this complaint against Opposite Party which is Public Sector Company.
8) According to the Opposite Party, the Complainant was always at liberty to have change the Underwriters but inspite of introduction of new policy the Complainant paid enhanced premium and obtained Mediclaim Policy for the year 2007-08 and 2008-09. The Opposite Party has denied allegations that they have increased the premium exorbitantly. The Complainant had made grievance by letter dtd.04/06/08 which was addressed to the Chairman of the Opposite Party. Regional Manager of the Opposite Party has looked into the grievance of the Complainant and vide his letter dtd.15/06/09 informed Divisional Office that decision was correct.
9) It is submitted that Public Sector cannot create a soft glove treatment for one type of customers, but have to follow uniform principles as set out by the Company and also as per guidelines of IRDA. Premium was increased as per the guidelines of the IRDA. For renewal of the policy alongwith letter dtd.06/04/09 the Complainant submitted a cheque of Rs.13,490/- as a premium. As per the contract of insurance, premium was not completely paid and it was accordingly informed to the Complainant. While calculating the rate of a premium the Opposite Party has taken into consideration various factors such as, additional risk, etc and guidelines of IRDA. There is no deficiency in service on the part of Opposite Party. The Complainant has made false allegations against the Opposite Party. The Complainant is not entitled to refund of premium or any other relief claimed against Opposite Party and therefore, complaint is liable to be dismissed with cost.
10) Opposite Party has filed affidavit of evidence of Laiju Marar and produced photo copies of the insurance policy issued to the Complainant and copies of the correspondence to the Complainant. We heard oral submission of Ld.Advocate A.M.Nathani for the Complainant and Ld.Advocate Priscilla Samuel for the Opposite Party and complaint was closed for the order.
11) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Party ?
Findings : No
Point No.2 : Whether the Complainant is entitled for any relief from Opposite Party as prayed for ?
Findings : No
Reasons :-
Point No.1 & 2 :- According to the Complainant, for the first time in the year 2000 he had obtained Mediclaim Policy for himself and for his wife from the Opposite Party in which the sum assured was Rs.2 Lacs each. The Complainant has not produced Mediclaim Policies which he had taken in the year 2000-01 and 2001-02. Opposite Party has submitted that for the first time the Complainant obtained Mediclaim Policy for himself and for his wife in the year 2002-03. Alongwith complaint the Complainant has produced copies of Mediclaim Policies. It appears from the Mediclaim Policy which was issued to the Complainant for the period from 12/04/2002 to 11/04/2003, previous policy year is stated as 2002. From the documentary evidence on record, it is clear that even from 2002-03 the Complainant has renewed mediclaim policies regularly without any break. From 2002-2003 to 2006-07, sum assured given to the Complainant was Rs.3 Lacs and to his wife was Rs.3 Lacs. For year 2002-03 premium was Rs.11,389/- and cumulative bonus was recorded Rs.30,000/- each. In the year 2003-04, sum assured remained same but premium was increased to Rs.12,072/-. Amount of cumulative bonus was also increased form Rs.30,000/- to Rs.45,000/-. In 2004 to 2005, sum assured and premium was same the cumulative bonus was increased from Rs.45,000/- to Rs.60,000/-. 2005-06, sum assured was same but premium was increased to Rs.13,490/-. Cumulative bonus was recorded Rs.75,000/- for each. For the year 2006-07 sum assured was Rs.3,00,000/- each. Premium remained the same but amount of cumulative bonus was increased fromRs.75,000/- to Rs.90,000/-. For the year 2007-08 sum assured was increased from Rs.3 Lacs to 4,50,000/- each and premium was increased from Rs.13,490/- to Rs.27,784/-. In the policy for the period 12/04/2007 to 11/04/2007 cumulative bonus is not recorded. This policy is different than earlier policy, subsequent policy which is for the period from 12/04/2008 to 11/04/2009. There is also no mention of cumulative bonus. Premium is stated as Rs.36,508/-. Last two policies are different from earlier policies. The Complainant has paid enhanced premium of Rs.27,784/- for the policy of 2007-08 and premium of Rs.36,508/- for the policy of the year 2008-09. Ld.Advocate for the Complainant has submitted that by letter dtd.04/06/08, the Complainant asked explanation to Opposite Party regarding undue increase in the premium but there was no reply from the Opposite Party. From the year 2007 the Opposite Party has discontinued cumulative bonus. The Opposite Party has changed terms and conditions of the policy to the detriment of Complainant without prior notice and without consent of the Complainant. It is submitted that the Complainant has taken Mediclaim Policies from the Opposite Party with the assumption that at old age the Mediclaim Policy would take care of him and the Complainant would be at peace at the time of health crises. However, the Opposite Party exorbitantly increased the premium, discontinued cumulative bonus facility and limited liability of expenses heart ailment etc. to Rs.1.5 Lacs only and it amounts to deficiency in service on the part of Opposite Party. According to the Complainant’s Advocate, renewal of policy means a repetition of original policy. In support of his contention, Ld.Advocate relied upon the decision of Hon’ble Supreme Court in Biman Krishna Bose V/s. United India Insurance Co. Ltd. & Ans., reported in (2001) 6 Supreme Court Cases 477. The Complainant’s advocate further relied upon another decision of the Hon’ble Supreme Court, reported in (2008) 10 Supreme Court Cases 404, in which it is held ‘where a renewal is based on mutual consent, there is no automatic renewal – However, a mediclaim policy issued by a PSU insurer where a senior citizen is involved would stand on a somewhat different footing.’
Ld.Advocate for the Opposite Party has submitted that aforesaid decisions relied upon by the Complainants are not applicable to the present case as facts of the present case are altogether different. It is submitted that according to the Complainant, from the year 2002-03 in a mediclaim policy issued to the Complainant and Complainant’s wife sum assured was Rs.3 Lacs each. Initially in the year 2002-03 premium was Rs.11,389/- subsequently it was increased to Rs.12,072/- then to Rs.12,417/- then Rs.13,490/-. In the year 2007-08, premium was increased to Rs.27,784/- and in a subsequent year 2008-089 it was increased to Rs.36,508/-. It is submitted that as per the guidelines of IRDA, Opposite Party took decision and introduced different mediclaim policy which was accepted by the Complainant on payment of increased premium in the year 2007-08 and 2008-09. It is submitted that in a new policy concept of cumulative bonus is abolished. However, in order to compensate insured who had earned cumulative bonus prior to introduction of new policy, proportionate sum assured was increased without charging extra premium. In the instant case 2006-07 the sum assured given to the Complainant was Rs.3 Lacs and to the Complainant’s was Rs.3 Lacs. After introduction of new policy sum assured given to the Complainant in the policy of year 2007-08 is Rs.4,50,000/- and to the Complainant’s wife is Rs.4,50,000/-. The Opposite Party has not charged anything for the increase in the sum assured. Therefore, is cannot be said that terms and conditions of new policy introduced by the Opposite Party are against interest of the Insured. It is vehemently submitted that IRDA is a Regularity Authority and Opposite Party is under obligation to follow-up guidelines of the IRDA. New mediclaim policy was introduced as per the guidelines of IRDA. It is submitted that the Complainant accepted terms and conditions of new policy and paid premium of new policy for 2 years. If the Complainant had any grievance regarding change in terms and conditions of the policy, the Complainant was at liberty to change Underwriters. Instead of changing Insurance Company the Complainant accepted 2 policies for the year 2007-08 and 2008-09. Thereafter, for the subsequent year the Complainant had applied for renewal of policy but he had forwarded inadequate premium of only Rs.13,490/- by cheque. As complete premium was not paid by the Complainant, Opposite Party could not renew mediclaim policy for subsequent year and there is no deficiency in service of Opposite Party. It is submitted on behalf of Opposite Party that the Complainant is not entitled to claim refund of alleged excess premium paid by the Complainant during the period 2007-08 and 2008-09. Further as the Complainant has not paid full premium for the year 2009-10. The Complainant is not entitled to seek directions for renewal of terms and conditions of policies. It is submitted that insurance policy/mediclaim policy is a contract between the parties. The Consumer Forum has no jurisdiction to modify terms and conditions of the policy. Therefore, the Complainant is not entitled any relief claimed and the complaint deserves to be dismissed with cost.
As mentioned above in the complaint para no.1, the Complainant has given particulars of mediclaim policy taken by the Complainant for himself and for his wife from the 2002-03 to 2008-09. It appears that initially premium was Rs.11,389/- and in the next year it was increased to Rs.12,072/-. Subsequently it was increased to Rs.12,417/- and then to Rs.13,490/-. Further it was increased to Rs.27,784/- and then to Rs.36,508/-. It appears from the evidence on record, for the first time by letter dtd.06/04/2009, the Complainant made grievance against increases in premium. By letter dtd.16/04/09, Opposite Party informed the Complainant that new product of mediclaim policy is introduced with effect from 15/09/2006, the component of cumulative bonus which were adjusted in terms of enhanced sum assured without charging any premium on that part. As regards increase in premium it was informed that percentage of hike in premium was average, reckoned with various age groups. While calculating premium for particular age band, loss experience in individual age band were analyzed and premium was lodged accordingly. Further it was informed that premium calculated is as per tariff of the Company duly accepted by IRDA. It is grievance of the Complainant that Opposite Party has changed terms and conditions of policy against the interest of the Complainant without notice to the Complainant and or without consent of the Complainant. The Complainant has not produced terms and conditions of earlier policies which are changed by the Opposite Party from 15/09/06. Terms and conditions of new policy are also not produced on record. It admitted fact that in the new policy introduced after 15/09/06, cumulative bonus is abolished. According to the Opposite Party, to compensate the insured who had earned cumulative bonus prior to introduction of new policies, the Opposite Party has enhanced sum assured without charging any premium on that part. In the instant case, it appears that during the period 2006-07, sum assured given to the Complainant and to the Complainant’s wife was Rs.3 Lacs each. After introduction of new policies Opposite Party has enhanced sum assured from Rs.3 Lacs to Rs.4,50,000/- each. For new policy premium was charged Rs.27,784/- and the Complainant while obtaining policy for the year 2007-08 paid enhanced premium. Further for subsequent year the Complainant has paid enhanced premium of Rs.36,508/-. After accepting mediclaim policies for 2 years on payment of enhanced premium the Complainant made grievance to the Opposite Party by his letter dtd.06/04/09 regarding enhancement in premium. The Complainant has obtained new policies for 2 years by accepting terms and conditions of new policies. Thereafter, according to the Complainant, he had sent cheque dtd.06/04/09 of Rs.13,490/- as a premium for renewal of his policy for further period of 2009-10. According to the Opposite Party, the Complainant had sent cheque of inadequate premium so Opposite Party could not issue policy for the aforesaid period. There is no evidence on record to show that aforesaid cheque of Rs.13,490/- was enchased by the Opposite Party. Mediclaim Policy is a contract between the parties. The Consumer Forum has no jurisdiction to modify or alter the terms and conditions of the policy. Considering the evidence on record, we hold that the Complainant has failed to prove deficiency in service on the part of Opposite Party. Therefore, we hold that the Complainant is not entitled to reliefs as claimed. In the result we answer point no.1 & 2 in the negative.
For the reasons discussed above, complaint deserves to be dismissed. Hence, we pass following order -
O R D E R
i.Complaint No.208/2009 is hereby dismissed with no order as to cost.
ii. Certified copies of this order be furnished to the parties.
