DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA(PUNJAB)<br /> <br /> C.C. No. 64 of 7.3.2007<br /> Decided on : 17.7.2007 <br /> <br /> 1. Raman Mahajan W/o Sh. Satish Kumar Mahajan S/o Sh. Gian Chand Mahajan.<br /> 2. Satish Kumar Mahajan S/o Sh. Gian Chand Mahajan, both Residents of H. No. 13282-A, Street No. 4, Sarabha Nagar, Bathinda <br /> ...... Complainants<br /> <br /> Versus. <br /> <br /> 1. United India Insurance Company Limited, 34, Neelam Bata Road, Faridabad-121001 through its Branch Manager.<br /> 2. United India Insurance Company Ltd., Divisional Office, The Mall, Bathinda through its Divisional Manager.<br /> 3. Shivam Global Apparels Pvt. Ltd., Plot No. 74, Sector 27-A, Mathura Road, Faridabad through its Managing Director/Authorised Signatory.<br /> ...... Opposite parties<br /> <br /> Complaint under section 12 of the Consumer Protection Act, 1986<br /> <br /> QUORUM:<br /> <br /> Sh.Lakhbir Singh, President<br /> Sh. Hira Lal Kumar, Member<br /> Dr. Phulinder Preet, Member<br /> <br /> For the complainants : Sh. Raman Khattar, Advocate<br /> For the opposite parties : Sh. Sunder Gupta, counsel for opposite parties No.1&2<br /> Opposite party No. 3 exparte <br /> <br /> O R D E R.<br /> <br /> LAKHBIR SINGH, PRESIDENT:- <br /> 1. Sumit Mahajan was an employee of opposite party No.3 which had obtained Group Mediclaim Policy for its employees vide policy No. 222800/48/04/01815 effective from 25.2.2005 to 24.2.2006. It had purchased Group Personal Accident Policy as well for its employees vide policy No. 222800/42/04/00316 for Rs.1,00,000/- for each employee effective from 26.2.2005 to 25.2.2006 from opposite party No.1 which has its branches all over India including the one at Bathinda. Sumit Mahajan had met with an accident on 3.7.2005 near Badarpur while he was driving his Motorcylce. He had received injury on his head and was admitted in Inder Prastha Apollo Hospital, New Delhi on the same day for treatment where he died on 17.7.2005. He was son of the complainant. They (complainants) incurred Rs.4,26,268.68 as expenses for the treatment of his son in the hospital during the period from 3.7.2005 to 17.7.2005. Intimation regarding the accident was given to opposite party No.1 which had deputed S/Sh. V.J. Nathan and D.K. Saxena as Investigators. All the documents were collected by them for settlement of the claim. Complainants have completed all the formalities. Requests were made by them to the opposite parties to settle their claim, but to no effect. They have learnt that opposite parties No. 1 & 2 have settled the mediclaim of the deceased for a meagre of amount Rs.50,000/- against medical bills of Rs. 4,26,268.68. They have further come to know that opposite party No.1 had issued cheque No. 640075 dated 25.4.2006 for Rs. 50,000/- in favour of opposite party No.3. They assert that this act of opposite party No.1 is illegal and against the terms and conditions of the policy as opposite party No.1 has issued mediclaim policy in the specific names of the employees of opposite party No.3. It is further added by them that they have come to know that opposite party No.3 has returned the cheque to opposite party No. 1 with request that it be issued in the name of father of the deceased in his A/c No. 10002690338 of State Bank of Patiala at Bathinda. According to them, mediclaim of the deceased should have been settled as per medical bills and cheque should have been issued in their names and not in the name of opposite party No.3. Personal accident claim has not been settled till date. They have undergone mental tension, agony and harassment due to the adamant attitude of the opposite parties. They allege gross deficiency in service on their part. In these circumstances, complaint under section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as the Act) has been preferred seeking direction from this Forum to the opposite parties to pay Rs. 4,26,268.68 under mediclaim policy as per medical bills alongwith benefits under table 1 to 4 of the policy; Rs. 1,00,000/- under personal accident policy; Rs. 50,000/- for mental tension, agony and harassment and RS. 10,000/- as litigation expenses. They further claim interest on the aforementioned amounts from the date of accident till realization.<br /> 2. Opposite parties No. 1 & 2 filed reply of the complaint taking legal objections that this Forum has got no jurisdiction to entertain and try the complaint as no part of cause of action has accrued within the territorial jurisdiction of this Forum; there is no privity of contract between them and the complainants as neither any premium was deposited by them with them nor Sumit Mahajan was employee of opposite party No.3 on the date of accident; Sumit Mahajan had left the job on 6.5.2005 as per investigation report and as per letter of opposite party No. 3 dated 22.7.2006. Hence, there was no insurable interest of opposite party No.3 in the deceased at the time of accident being unnamed group personal accident policy issued by them to opposite party No.3; Policy was issued to opposite party No.3 for unnamed employees covering risk of group personal accident for a sum of Rs. 1,00,000/- and mediclaim policy for a sum of Rs. 50,000/- to each employee on the rolls of opposite party No. 3. So whosoever is on the rolls and on duty with opposite party No. 3 on the date of accident was covered in Group Personal Accident Policy and Group Mediclaim Policy and any employee who had left the job of opposite party No.3, was not covered; Neither deceased nor complainants are the consumers qua them as deceased had left the job of opposite party No.3 and Claim of the complainants has been repudiated after thorough investigation; This Forum has got no jurisdiction to entertain and try the complaint; amount of compensation is highly excessive and exorbitant. If this Forum comes to the conclusion that they are liable to pay any compensation, then liability to pay compensation under group personal accident policy is limited upto Rs. 1,00,000/- only and mediclaim policy is limited upto Rs. 50,000/- only; complaint is bad for non-joinder of necessary parties i.e M/s. Med Save Health Care Limited which is third party claim Administrator for medi-claims and complaint is false and frivolous. On merits, they admit that opposite party No.3 had obtained Group Mediclaim Policy for its employees vide policy No. 222800/42/04/00316 effective from 26.2.2005 to 25.2.2006 from opposite party No.1. Group Personal Accident Policy and Mediclaim Policy were for unnamed employees. There was no employee/employer relationship on the date of accident. They admit that Sh. Vijay Nathan Top Professional was deputed to investigate the claim who had submitted report dated 27.3.2006. Sh. D.K. Saxena was deputed to survey/investigate the claim of the complainants and he had submitted his report on 24.7.2006. After receipt of the reports, it was found that deceased had left the job of the insured on 6.5.2005. Injuries were received in the accident on 3.7.2005. Sumit Mahajan had died on 17.7.2005. Hence, he was not having any insurable interest. Firstly, a cheque for Rs. 50,000/- was issued by Med Save Health Care Limited which is third party claim Administrator for mediclaim settlement on their behalf and cheque of Rs. 50,000/- was sent to opposite party No.3. Opposite party No.3 had returned the cheque to them stating that deceased had left his job on 6.5.2005. Then, opposite party No.1 came to know that deceased had left the job before the date of accident. Thereafter, claim was repudiated as per policy terms and conditions of opposite party No.1. They deny that policy was issued in the name of specific employees of opposite party No.3. They further deny that they are liable to pay the amount as per medical bills. Remaining averments in the complaint stand denied. <br /> 3. Registered A.D post notice was issued to opposite party No.3 on 14.3.2007. Till 16.4.2007 neither registered cover nor A.D was received back. More than 30 days had elapsed. In these circumstances, opposite party No.3 was deemed to have been duly served. No-one came present on its behalf. Accordingly, it was proceeded against exparte. <br /> 4. In support of their allegations, complainants have tendered into evidence affidavit (Ex.C.1) of Sh. Satish Kumar Mahajan, complainant No. 2, photocopy of claimant's statement (Ex.C.2), photocopy of Group Personal Accident Policy (Ex.C.3), photocopy of Group Mediclaim Policy (Ex.C.4), photocopy of bill dated 17.7.2005 (Ex.C.5), photocopy of investigation report (Ex.C.6), photocopy of claim process sheet (Ex.C.7) and photocopy of Doctor Report dated 7.4.2006 (Ex.C.8).<br /> 5. On behalf of opposite parties No. 1 & 2 reliance is placed on affidavit (Ex.R.1) of Sh. Gobind Aggarwal, Divisional Manager, photocopy of letter dated 8.9.2006 alongwith postal receipt (Ex.R.2), photocopy of letter dated 22.7.2006 (Ex.R.3), photocopy of full and final receipt dated 9.5.2005 (Ex.R.4), photocopy of Group Personal Accident Policy alongwith terms and conditions (Ex.R.5 & Ex.C.6), photocopy of Group Mediclaim Policy alongwith terms and conditions (Ex.R.7 & Ex.R.8), photocopy of Investigation Report of Sh. D.K. Saxena (Ex.R.9), photocopy of letter dated 116.5.2006 (Ex.R.10),affidavit of Sh. Devinder Kumar Saxena (Ex.R.11) & photocopies of Special Conditions for Group Mediclaim and Group Personal Accident Policies (Ex.R.12 & Ex.R.13)<br /> 6. We have heard the learned counsel for the complainants and opposite parties No.1 & 2 and gone through the record. Apart from this, we have considered written arguments submitted by complainants and opposite parties No. 1 & 2. <br /> 7. First argument pressed into service by Mr. Gupta learned counsel for opposite parties No. 1 & 2 is that this Forum has got no jurisdiction to entertain and try the complaint as no cause of action has accrued within the territorial jurisdiction of this Forum.<br /> 8. Mr. Khattar learned counsel for the complainant vociferously argued that complainants are residing at Bathinda. Sh. Vijay Nathan, Investigator visited them and met them at Bathinda and opposite party No.1 has its Divisional Office/Branch Office at Bathinda. Moreover, columns of personal accident insurance claimant's statement, copy of which is Ex.C.2, were filled in at Bathinda and it was signed by the complainants and witnesses at Bathinda. <br /> 9. We have considered respective arguments. Mere signing of the claimant's statement, copy of which is Ex.C.2, and the visit of Sh. Vijay Nathan, Investigator to Bathinda do not confer jurisdiction upon this Forum at Bathinda. However, from the other aspect of the case that United India Insurance Co. Ltd. has its Divisional Office/Branch Office at Bathinda attract jurisdiction of this Forum to entertain and try this complaint even if no cause of action wholly or partly arose at Bathinda. In this view of the matter, we are fortified by the observations of Hon'ble State Commission, Punjab in First Appeal No. 1384 of 2005 titled as Harinder Singh Vs. M/s. Seasky Cargo & Travers Pvt. Ltd. & another decided on 1.3.2006. Reference can also be made to the observations of the Hon'ble State Commission, Punjab in the cases of Harinder Kumar Hari Vs. New India Assurance Co. Ltd. & Another-II(1998)CPJ-91 and Life Insurance Corporation of India Vs. Kewal Krishan Kampani-I(2007)CPJ-34. Accordingly, we hold that since opposite insurance company has Divisional Office which is opposite party No.2 at Bathinda and complainants are residing within District Bathinda, this Forum has got jurisdiction to entertain and try this complaint.<br /> 10. Mr. Gupta learned counsel for the opposite parties argued that claim of the complainants has already been repudiated by the opposite parties as deceased Sumit Mahajan was not on the rolls of opposite party No. 3 on the day of accident and was not having any insurable interest. For this, he drew our attention to the copy (Ex.R.2) of the repudiation letter dated 8.9.2006 according to which claim has been repudiated as there was no insurable interest with the insured as insured person (employee) had resigned prior to the accident.<br /> 11. Learned counsel for the complainant argued that Sumit Mahajan was employee of opposite party No.3 which had obtained Group Mediclaim Policy and Group Personal Accident Policy for its employees, copies of which are Ex.C.4 & Ex.C.3 respectively. Sumit Mahajan had met with an accident on 3.7.2005 and had died on 17.7.2005 and that complainants incurred Rs. 4,26,268.68 on his treatment vide bill, copy of which is Ex.C.5. Intimation regarding the accident was given to opposite parties No. 1 & 3. Sh. Vijay Nathan was deputed to investigate the matter and he had submitted his report dated 27.3.2006, copy of which is Ex.C.6, holding that claim is genuine. He further argued that after receipt of the report, copy of which is Ex.C.6, cheque for Rs. 50,000/- was sent to opposite party No.3 by Med Save Health Care Limited as is clear from Ex.C.7 & Ex.C.8. It is also evident from Ex.C.8 that claim was found admissible. Opposite party No.3 had returned the cheque to opposite party No.1 with request to issue the same in the name of the father of the complainant. Next contention of the learned counsel for the complainants is that version of opposite parties No. 1 & 2 that insurance company is only liable to employees who are on the rolls of opposite party No.3 is not tenable and documents relating to insurance policies which are Ex.R.5 to Ex.R.8, Ex.R.12 & Ex.R.13 were not supplied to the deceased. Even as per Ex.R.5 & Ex.R.7 employees, who were covered were mentioned as per list and copies of the lists of the employees have not been placed on the file by opposite parties No. 1 & 2. No premium amount has been refunded to the employees who have left the job. <br /> 12. We have considered respective arguments. Admittedly, two polices i.e. mediclaim policy and group personal accident policy for employees of opposite party No. 3 were purchased by opposite party No.3 from opposite party No.1. Group Personal Accident Policy for Rs. 1,00,000/- for each employee was effective from 26.2.2005 to 25.2.2006 and the other policy was valid from 25.2.2005 to 24.2.2006. Complainants in this case were required to stand on their own legs. For the first time they have taken the plea in the written submissions that copies of Ex.R.5 to Ex.R.8, Ex.R.12 & Ex.R.13 were not supplied. No amount of evidence or arguments can be considered if there are no pleadings to that effect. There are no specific averments of the complainants in the complaint to this effect. Hence, submission on behalf of the complainants on this aspect of the matter, is not tenable. Ex.R.5 & Ex.R.7 are copies of the Group Personal Accident and Group Mediclaim Policies respectively. Ex.R.5 reveals that risk covered was regarding 48 persons and Ex.R.7 shows that risk covered was of 62 persons. Complainant did not prove the list of 48 and 62 persons nor did they get the lists produced from opposite parties No. 1 & 2. Ex.R.12 & Ex.R.13 are the copies of the special conditions for Group Mediclaim and Group Personal Accident Policies. According to them the details of the employees covered have to be provided and the covers are for the persons who are employees as per muster roll of the insured. These special conditions also relate to premium adjustment. No-doubt, Sh. V.J Nathan vide his report, copy of which is Ex.C.6, has held the claim of the complainants as genuine and recommended that it be settled as deemed fit. Accordingly, Med Save Health Care Ltd. Sent cheque for Rs. 50,000/- to opposite party No.3 as is evident from Ex.C.7 & Ex.C.8. Cheque was returned by opposite party No.3 vide letter dated 16.5.2006, copy of which is Ex.R.10, saying that cheque be issued in the name of father of the deceased. Opposite party No.1 was further intimated by opposite party No.3 through this letter that deceased Sumit Mahajan had left the job on 6.5.2005. In this manner, opposite party No.1 came to know that deceased had left the job on that date. Accident had taken place on 3.7.2005. He was not on the rolls of the insured on the date of accident as per information received by opposite party No.1 from opposite party No.3. Accordingly, opposite party No.1 deputed Sh. D.K. Saxena to again investigate the claim and he submitted his report, copy of which is Ex.R.9. According to it, Sh. Sumit Mahajan was relieved by opposite party on 7.5.2005. Deceased gave full and final receipt in favour of opposite party No. 3 on 9.5.2005 after receiving Rs. 31,489/- stating that he has left its service of his own accord and sweet will. This is evident from Ex.R.4. Opposite party No.3 also issued letter dated 22.7.2006 to opposite party No.1 intimating that Sh. Sumit Mahajan had resigned of his own accord and that he had left the company w.e.f. 6.5.2005. In these circumstances, claim of the complainants has been rightly repudiated by the insurance company as it stands proved that deceased had left the job of opposite party No. 3 on 6.5.2005 before he had met with an accident. He was not on the rolls of opposite party No.3 and was not having any insurable interest. So far as refund of premium is concerned, it was to be on pro-rata basis only for the persons for whom no claim was lodged in the policy. In this case, claim has been lodged concerning Sh. Sumit Mahajan who left the service of opposite party No.3 on 6.5.2005 or 7.5.2005. Moreover, refund of premium on pro-rata basis can be allowed by the insurance company only for the persons meaning thereby that it can be claimed by the insured. <br /> 13. In the premises written above, repudiation of the claim submitted by the complainants concerning Sh. Sumit Mahajan cannot be said to be arbitrary and illegal. Accordingly, there is no deficiency in service or unfair trade practice on the part of opposite parties No. 1 & 2. Complaint is, therefore, meritless and is dismissed. In the circumstances, parties are left to bear their own costs. Copy of this order be sent to the parties free of cost. File be also consigned. <br /> <br /> <br /> Pronounced (Lakhbir Singh)<br /> 17.7.2007 President<br /> <br /> <br /> (Hira Lal Kumar)<br /> Member<br /> <br /> <br /> (Dr.Phulinder Preet)<br /> Member <br /> <br /> 'bsg' <br /> <br /> <br /> <br />