This complaint coming up before us for hearing on 30-04-15 in the presence of Sri N.Venkateswarlu, Advocate for complainant and Sri G.Erukala Reddy, Advocate for opposite parties,  upon perusing the material on record, after hearing both sides and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao, President:-

          The complainant filed this complaint U/s.12 of the Consumer Protection Act seeking a direction to the opposite parties to indemnify claim of its three  employees to the extent of  Rs.84,944/-; Rs.5,244/-  ( being interest  from 11-07-14 to 20-12-14); Rs.10,000/- as compensation and Rs.5,000/- towards costs.  

2.      In nutshell the complaint averments are these:

The complainant made proposal covering mediclaim insurance for  its employees and their family members  for the year 2014 – 2015 and called for quotations from five insurance companies by  its letter dated 13-03-14 incorporating its terms and  conditions.  The 1^st opposite party in response to the above letter quoted Rs.6,46,670/- as premium  agreeing to the  terms and conditions mentioned in the letter dated 13-03-2014.  The complainant paid Rs.6,46,670/- on 28-03-14 by way of cheque drawn in favour of the 1^st opposite party of Axis Bank.  The 1^st opposite party accepted the cheque on 28-03-14 and issued insurance policy bearing NO.560700/46/14/8500000025 on 27-05-14.  During the continuance  of the policy the complainant preferred claim in respect of its employees namely K.Nagaraju, J.Ravi Kumar and Smt.P.Rama Devi for  Rs.38,080/-, Rs.18,672/- and Rs.33,192/- respectively.  The 1^st opposite party repudiated claim on untenable grounds. The 1^st opposite party have not disputed the condition of no exclusions and waiting period.   The above act on the part of the 1^st opposite party is utter violation of agreed terms of contract of coverage stipulated in the letter dated 13-03-14.  The 1^st opposite party having received the premium subsequently cannot impose conditions unilaterally. There was no proper response from the opposite parties to complainant’s demands and notice. The said conduct of the opposite parties amounted to deficiency in service.  The complaint is liable to indemnify the above mediclaim together with compensation.  The complaint therefore may be allowed.          

3.      The contention of the opposite parties in brief is thus:

The complaint is not maintainable either in law or on facts.  The complainant did not come under the purview of consumer and as such there is no consumer dispute.  The opposite parties gave a suitable reply on        20-10-14.  The opposite parties while issuing policy mentioned special conditions.  Even after receipt of the policy the complainant had fifteen days period to cancel the said policy which is not suitable for its employees. As per those conditions only the opposite parties have repudiated three claims made by the complainant on behalf of its employees.    As the complainant accepted and remained silence after receipt of the policy it can be implied that the complainant had accepted the policy conditions.  The opposite parties did not commit any act amounting to deficiency in service as it acted as per conditions mentioned in the policy.  The complaint therefore may be dismissed.     

4.       Exs.A-1 to A-10 on behalf of complainant and Exs.B1 on behalf of the opposite parties were marked.

5.  Now the points that arose for consideration in this case are these:

1.       Whether the complainant is a consumer?

2.       Whether there is triable consumer dispute?

3.       Whether the opposite parties committed deficiency in service?

4.       Whether the complainant is entitled for compensation and if so to what

          amount?

5.       To what relief?

6.    Admitted facts in this case are these: 

a).  The complainant on 13-03-14 called quotations from insurance   

       companies including the opposite parties for obtaining mediclaim policy for its employees. (Ex.A-2).   

b).  The opposite parties quoted the premium as Rs.6,46,670/- inclusive of service tax (Ex.A-3). 

c).  The opposite parties issued mediclaim insurance policy issued to the complainant on 27-05-14 covering the  period from 01-04-14 to    31-03-15.  (Ex.A-1).                 

       d).   The complainant submitted claim on behalf of its three employees

              and they were repudiated.  (Exs. A-4 to A-6). 

       e).   Exchange of notices between the complainant and opposite parties

              (Ex.A-7 to A-9).   

7.      POINT Nos.1&2:- The opposite parties issued Ex.A-1 policy covering employees of complainant and their families for consideration.  Therefore the complainant is a consumer under the purview of the Consumer Protection Act.  The dispute is with regard to applicability of terms and conditions prescribed and accepted.  Thus there is a triable consumer dispute.  We therefore hold that the complainant is a consumer and there is a triable consumer dispute between the insured and insurer.  We therefore answer this point infavour of the complainant.  

8.      POINT NO.3:- In Ex.A-2 the complainant mentioned certain terms conditions while inviting quotations from the insurance companies including the opposite parties to quote their premium.  The opposite parties in their Ex.A-3 quotation referred to Ex-A2. The relevant portion in Ex-A2 is extracted for better appreciation.

          “The employees of our Bank The Guntur District Co-Op. Central Bank Ltd., are covered under Group Mediclaim over the past several years.  The policy at present is going to expire on 31-03-14.  In this connection, we request you to give your quotation for premium amount as per the details mentioned below:

          1).  No. of employees                :        226

          2).  Total No. of members                   :        641 (226 Employees

                                                              + 415 family members)

          3).  Floater policy (Employee + Spouse+2 Dependent

               Children)

          4).  Should be a continuous policy and not a new policy.

          5).  All pre existing diseases shall be covered and Maternity

                facility also shall be covered.

          6).  Sum insured – Rs.1,00,000/- (under floater). 

          7).  Cashless facility should be provided

          8).  No sub limits. 

          9). No exclusions (eg.1^st year, 2^nd year etc.) and waiting period.

We request you to please communicate your quotation (inclusive of all taxes) by 22-03-2014”

9.      The opposite parties issued policy on 27-05-14 covering period from 01-04-14 to 31-03-15.  The relevant terms mentioned in Ex.A-1 by the opposite parties in their insurance policy mentioned are here under:

  “Total sum insured (in words):  Rupees two crore twenty six lakh only

Risk Covered:  Group Mediclaim policy covering no of employees 226+415 family members i.e., employee +spouse+ 2 dependant children.    

Location : Floater policy (As per schedule attached)

Special peril :  As pr terms and conditions of tailor made group Mediclaim policy

Special Exclusion:  As pr terms and conditions of tailor made group Mediclaim policy

Subject to clause:  1).  Cashless facility:  This policy is extended to provide cash less facility (though – M/s.Medi Assist India Pvt Ltd subject otherwise to the terms conditions, exclusions and limitation of the policy

Special Excess:  Endt.No.1(b) insured person including spouse and dependant children end No.2(a) pre-existing disease  exclusion waiaver for all insured persons including their dependents. 

Special Conditions :  No sub-limits :- subject to treatment for cataract to 30% of SI or 30,000/- whichever is lower this policy extends maternity expenses limited to Rs.15,000/-  for normal and Rs.30,000/- for caesarean and also awaiting period of 9 months from the date of cover is applicable and also expenses  incurred in connection with voluntary medical termination of pregnancy during the first 1 2 weeks from the date of conception are not covered” 

10.    The question now before this Forum is whether the opposite parties can prescribe its conditions without mentioning them in their Ex.A-3 acceptance letter.  The learned counsel for the opposite parties relied on clause 5.8 of Ex.B-1 i.e., mediclaim insurance policy (individual). For better appreciation clause 5.8 is extracted below: 

          The policy may be renewed by mutual consent.  The Company shall not however be bound to give notice that it is due for renewal and the Company may at any time cancel this policy by sending the Insured 30 (thirty) days notice by Registered Letter at Insured’s last known address and in such even the company shall refund to the insured a prorate premium for unexpired period of insurance The company shall however, remain liable for any claim which arise prior to the date of cancellation the insured may at any time cancel this policy and in such even the company shall allow refund of premium at Company’s short period rate only (table given here below) provided no claim has occurred up to the date of cancellation.

The opposite parties in their acceptance letter (Ex-A3) did not specify their terms and conditions before accepting the premium and issuing policy. The opposite parties issued policy belatedly. As opposite parties accepted the premium one can safely conclude that they agreed to the terms and conditions imposed by the complainant. The opposite parties can not unilaterally impose conditions after accepting the premium. The opposite parties can not approbate and reprobate. The opposite parties imposing their terms while issuing policy with out mentioning them in their acceptance letter in our considered opinion amounted to unfair trade practice and it comes under the purview of deficiency in service.  The opposite parties therefore have to indemnify the complainant in a sum of Rs84944/-in respect of mediclaim of its employees together with interest. We therefore answer this point against the opposite parties.    

11.    POINT NO.3:- The complainant claimed Rs10,000/- as compensation. The complainant being an institution is answerable to its employees. The attitude of the opposite parties in repudiating claims of its employees could have caused annoyance to the complainant. Under those circumstances awarding Rs5000/- as damages will meet ends of justice. For the above discussion we answer this point accordingly.

12. POINT NO.4:-  In the result the complainant is partly allowed as indicated below:
    1. The opposite parties are directed to pay Rs.84,944/- (Rupees eighty four thousand nine hundred and forty four) together with interest @ 9% p.a. from 01-08-2014 till realization to the complainant. 

2. The opposite parties are directed to pay a sum of Rs.5,000/- (Rupees five thousand) as compensation to the complainant.   

3. The opposite parties are directed to pay a sum of Rs.2,000/- (Rupees two thousand) as costs to the complainant.  

4. The above order shall be complied within a period of six weeks from the date of receipt of the copy of this order. 

          Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 06^th day of May, 2015.

MEMBER                                  MEMBER                                PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite parties: 

                                                                                                                         PRESIDENT

NB:   The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.