KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.

APPEAL NO.233/12

JUDGMENT DATED : 31/10/2012

PRESENT:

SMT. A. RADHA                                               :  MEMBER

SHRI. K. CHANDRADAS NADAR                  :  JUDICIAL MEMBER

1.     Sunitha Susan George,

Ayrookuzhiyil, Puthencavu,

Chegannoor, Alappuzha 689123

2.     Geetha Annee George,

Pulinthitta, RSPO,

Thiruvalla, Pathanamthitta 689 111.

3.     Reetha Elizabeth George,

Kaipallil Malil, Mavelikara,

Alappuzha – 690 101

4.     Preetha Acha George,

Ayroorkuzhiyil, Puthencauvu,

          Chenganor,

Alappuzha, 689 123.                                 :  APPELLANTS

                          (Rep. by Sri. Adv. P. Santhoshkumar)

                                    Vs

1.        The Oriental Insurance Company Ltd.

Rep. by The Bank Manager, Thiruvalla,

Pathanamthitta – 689 101

                 (R1 rep. by Sri.  Advs.B. Ravikumar) 

2.        Sri. K.G. Ramesh,

Development Officer,

Oriental Insurance Company Ltd.

Thiruvalla, Pathanamthitta                       :  RESPONDENTS

                   (R2  rep. by Sri.  Advs.G.S. Kalkura) 

JUDGMENT

          Feeling aggrieved by the dismissal order in CC No.177/2008 on the file of CDRF, Pathanamthitta the appellant/complainant came up in this appeal.

          2.      The case of the complainant is that the complainant and her mother were medi-claim policy holders from 2000 onwards with the opposite party. The medi-claim policy was renewed regularly through the 2^nd opposite party giving cheques for the premium amount. On subsequent renewal, the policy amount was enhanced to Rs.50,000/- and in 2003 the 2^nd opposite party gave a health card and intimated that the policy number of the medi-claim is 489. It is the definite case of the complainant that the complainant’s mother fell ill and admitted in Medical Trust Hospital and incurred medical expenses amounting  to Rs.50,811/-. The treatment details were informed to the 2^nd opposite party and he assured speedy disposal of the claim within one week. While contacting the 2^nd opposite party the insured was informed that the claim was under process. When the complainant approached the 1^st opposite party/1^st respondent it is informed that no action was taken by the customer service of the opposite parties regarding the claim. Again on 26.11.07 the complainant’s mother was admitted in the hospital and succumbed to death on 13.12.07. The complainant was informed of the rejection of his claim in reply to his letter to the Deputy Manager of the 1^st opposite party. The allegation of the complainant is that he was regularly paying the premium and premium was paid by cheque to the 2^nd opposite party and the claim ought to have  honored by the 1^st opposite party. In the meantime the 2^nd opposite party returned two cheques which were entrusted for renewal of the medi-claim policy for the period from 2006-2007 and 2007-2008. The non-renewal of the medi-claim policy was happened due to the negligence of the 2^nd opposite party who was the Development Officer of the 1^st opposite party. All the time the complainant was entrusting the cheques for renewal of the medi-claim policy with the 2^nd opposite party. Due to the negligence of the 2^nd opposite party who is an employee of the 1^st opposite party, the 1^st opposite party is liable for the act of the employee. The vicarious liability of the employer cannot be shred out by the 1^st opposite party. The complaint is filed for re-imbursement of the claim amount of Rs.50,811/- for the year 2006 with 12% interest and also for Rs.50,000/- for the medical expenses incurred in the year 2007 along with compensation of Rs.50,000/- and cost.

3.   Though the complaint was allowed as an exparte order on the basis of the proof affidavit and documents of the complainant, the opposite parties approached this Commission in Appeal No.274/10
and this Commission allowed to contest the matter and remanded the case.

4.  The main contention raised by the opposite parties was that there is no valid medi-claim policy for the complainant or her mother during the relevant period. The medi-claim policies are issued for a period of one year and there is no provision for automatic coverage. The policy of the complainant expired as on 16.03.2006 and there is no valid policy thereafter. No renewal application was filed nor the premium remitted to the 1^st opposite party. It is not disputed that the complainant and her mother were having policy for the previous years. But the policy had to be renewed from 16.03.06. It is also contended that the complainant renewed the policy as on 09.05.06 for which cheque was entrusted with the 2^nd opposite party for renewal of the policy. As the policy had already expired on 16.03.06 the complainant had to submit medical certificate and other records for the renewal of the policy. Even after sending communications the complainant entrusted another cheque on 1.08.07 for renewal of policy without the required medical certificate. The 2^nd opposite party returned the cheques to the complainant.  It is also contended that the non-submission of the medical records for renewal of the policy, the 1^st opposite party is in no way responsible for the lapse of policy. It is also admitted that the 2^nd opposite party used to hand over the documents entrusted by the complainant to the 1^st opposite party being the neighbour of the complainant. No deficiency in service can be attributed on the part of 1^st and 2^nd opposite parties for the non-renewal of the policy in due time.

        5. The oral evidence adduced by PW1 and DWs1 and 2 Exts.A1 to A13 and B1 and B1 (a) were marked in evidence.

       6.  The argument put forth by the counsel for the appellant is that he entrusted the cheque for renewal of policy with the 2^nd opposite party sufficiently early and it is the negligent act of the 2^nd opposite party who is an employee of the 1^st opposite party caused the breakup of policy. The cheques given to the opposite party were marked in evidence as Ext.A8 series. The cheques were dated 9.5.06 and 1.8.07 the policy expired on 16.3.06. The non-renewal of policy was not informed to the complainant by the 2^nd opposite party until the claim form submitted to the 1^st opposite party. It was presumed that a valid policy was prevalent on the basis of cheque dated 9.5.06 which was returned only on 8.5.07. The complainant was under the impression that the policy was renewed automatically as early from 2001 to 2008 through the 2^nd opposite party. The complainant produced the health cards (Ext.A10) issued by the Oriental Insurance Company infavour of the complainant and her mother. As the two cheques issued infavour of the 1^st opposite party had already been  handed over the 2^nd opposite party, the appellant/complainant relied on the 2^nd opposite party’s words.  The 1^st opposite party is liable for re-imbursement of the claim amount under the medi-claim.

7.      The counsel for the respondents vehemently opposed the existence of the valid policy at the relevant time. The medi-claim policies are issued for one year only and there is no provision for automatic renewal. The last renewal of the complainant’s policy was on 17.03.2005 and it expired on 16.03.06. Thereafter no renewal took place. Once the policy lapsed, new policy has to be issued as a fresh policy. There is no continuity for the medi-claim policy. If there is a break up of a policy the party has to submit with medical records in order to join a fresh policy. In this case, the complainant had not produced any medical records for issuance of the fresh policy.  Hence the respondents are not liable to entertain the claim of the complainant.

8.      Heard both sides and on going through the documents we find that she had issued cheques dated 9/5/06 and 1/8/07 with a lapse of 54 days and there is no valid policy for the complainant. No evidence is on record to show that there had  a valid policy during 2006-2007. The non-renewal of the policy was due to the latches on the part of the complainant alone. The expiry of the policy was evident by Ext.A11 and the cheques handed over  to the 2^nd opposite party were marked as Ext.A8 series. The issuance of the cheque itself had a lapse of 54 days. Further the non-production of medical certificate also goes against the complainant. It is also to be pointed out that the cheques were not encashed nor credited in favour of the 1^st respondent. On that ground also the 1^st respondent is not liable for the entertainment of the claim amount under medi-claim policy. We find that there is no bonafides on the part of the appellant and the complaint is liable to be dismissed and no deficiency can be attributed on the part of the respondents.

          In the result, appeal is dismissed and hence the complaint is also dismissed. We have no hesitation to uphold the order passed by the Forum below.

Office is directed to send a copy of this order to the Lower Forum with the LCR.

                                    A. RADHA      ;  MEMBER

               K. CHANDRADAS NADAR  :  JUDICIAL MEMBER

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