Date of filing: 27.01.2017

                                                               Date of Disposal:30.01.2023

 BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

                               BENGALURU – 560 027.

DATED THIS THE 30^th DAY OF JANUARY, 2023

CONSUMER COMPLAINT NO.135/2017

PRESENT:

SRI.RAJU K.S,

SMT.REKHA SAYANNAVAR,:MEMBER

Mukesh Daga @ Mukesh Kumar Jain,

S/o Mohan Lal,

Aged about 35 years,

Residing at No.59,

Bangalore-560 003. ……COMPLAINANT

Rep by Sri.S.A.H.Razvi, Advocate.

Universal Sompo General Insurance Company Limited,

First Floor, Plot No.EL-94,

KLS Tower,

TTC Industrial Area,

MIDC Mahape, Navi Mumbai-400 710,

Rep by its Director. ……  OPPOSITE PARTY-1

Universal Sompo General Insurance Company Limited,

No.217/A, 3^rd Floor, KVV Samrat,

Opposite sails factory

Rep by Branch Manager.……  OPPOSITE PARTY-2

Rep by Sri.B.C.Shivanne Gowda, Advocate

//JUDGEMENT//

BY SRI.SHIVARAMA K, PRESIDENT

The complainant has filed this complaint under Section-12 of Consumer Protection Act, 1986 seeking for a direction to the opposite party No.1 & 2 to reimburse a sum of Rs.4,90,000/- with interest at the rate of 18% p.a. from the date of claim till realization and such other reliefs as this commission deems fit in the circumstances of the case.

2. It is not in dispute that the opposite parties had issued Health Insurance Policy in favour of the Jain International Trade Organization, wherein Mukesh Daga is a primary member in it and his family members were also covered under the Arogya Rakshan and accordingly Mukesh Daga had submitted the proposal form and based on the proposal form the opposite parties had issued the policy.  Further, it is not in dispute that the complainant sought compensation of Rs.4,90,000/- and one Mukesh Daga had submitted the claim form to opposite parties on 16.05.2016 stating that his mother underwent for bilateral total knee replacement surgery on 23.04.2016 and for that he has incurred sum of Rs.4,90,000/- and sought for reimbursement of the expenses incurred towards treatment.  Further, it is not in dispute it is mentioned in the claim closure letter dt.21.07.2016 that since there was discrepancy in valid ID proof of proposer as per policy record and the complainant did not produce the required documents, the opposite party had closed the claim of the complainant.

3. It is the further case of the complainant that the complainant’s mother underwent bilateral total knee replacement surgery on 23.04.2016.  Further, the complainant had sent all the ID proof documents to the opposite parties, but the opposite parties without any valid reason had informed the complainant through letter dt.21.07.2016 that there was discrepancy in the ID proof.  Further, the date of birth of her was on 01.03.1956 and as on 02.03.2016 she had attained 61 years.  Hence, the ground to reject the claim was on a flimsy ground.  Further, the complainant had issued notice to the opposite party calling upon to reimburse the claim and in spite of notice been received the opposite parties did not pay the amount.   

4. It is the further case of the opposite parties that even though reminders were issued to the complainant one after another to submit the proper proof, the complainant did not produce it and due to non-production of the required documents to prove the identity of the proposer, the claim has not been honoured.  Further, since there is discrepancy in the age of the mother of the complainant while mentioning in the proposal form, the claim has not been honoured.  Hence, the complainant has played a fraud by creating the identity card in order to make unlawful gain and sought to reject the claim. 

5. To prove the case, the complainant has filed affidavit in the form of his evidence in chief and had produced documents.   The Senior Executive of opposite parties has filed his affidavit in the form of his evidence in chief and had produced documents. 

         6. The points that would arise for consideration are as under:

i) Whether there is deficiency of service on the part of the opposite parties ?

   ii) Whether the complainant is entitle for the 

    compensation as sought ?

    iii) What order ?

  7.   Our findings on the aforesaid points are as follows:

Point No.1 :  In affirmative

Point No.2 :  Partly in affirmative

Point No.3 :  As per the final order for the following;

REASONS

8.POINT NO.1:- The complainant and the Senior Executive of opposite parties have reiterated the fact stated in their respective pleadings, in the affidavits filed in the form of their evidence in chief.  Document No.3 is the Claim Closure Letter dt.21.07.2016.  In which it is stated that there is discrepancy in valid ID proof as per the policy record.  The opposite parties have produced Xerox copy of the proposal form dt.11.05.2015 before taking the health insurance policy from the opposite party.  In which the name of primary member is shown as Mukesh Daga.  Further, the opposite party has produced the Xerox copy of the claim form submitted by the complainant on 16.05.2016 in which the name of the insured is mentioned as Mukesh Daga.  In the Xerox copy of 1^st page of pass book relates to the claimant herein is mentioned as Mukesh Kumar Jain.  In the Xerox copy of the Aadhar Card produced relates to the complainant it is shown as Mukesh Kumar Jain and in the driving licence relates to the complainant it is mentioned as Mukesh Kumar Jain.  In the policy ID card issued by the opposite party, the name of the insured is mentioned as Mukesh Daga.  Further, in the Xerox copy of the election ID card produced by the opposite parties relates to the complainant, his name is shown as Mukesh Daga. 

9. It is the contention of the learned counsel for the complainant that Mukesh Daga is also known as Mukesh Kumar Jain.  According to the opposite parties as stated in the affidavit filed in the form of his evidence in chief that the voter ID card reveals that his name as Mukesh and in another ID card the name is shown as Mukesh Daga. But both identity card having same EPIC No.STZ3917549.  No doubt in the Aadhar the name of the complainant is shown as Mukesh Kumar Jain.  In the Xerox copy of the election ID card dt.24.01.2013 the name is mentioned as Mukesh and father name is shown as Mohanlal and in another election ID card dt.24.01.2013 the name of the complainant is mentioned as Mukesh Daga.  We feel since in both cards it appears that father name is one and the same and photos in both election ID cards appears to be same and it is not the case of the opposite parties that the person shown in two election ID cards are different persons and there are two sons to Mohanlal by name Mukesh or Mukesh Daga, further, the Epic number shown in the election ID card is similar, we feel there is no merit in the contention of the learned counsel for the opposite parties that the complainant had created election card to have a wrongful gain.  The other ground urged in respect of the claim is that there is discrepancy in patient age as per hospital document and policy record.  In the discharge summary issued on 05.05.2016 the age of the patient is shown as 61 years.  In the proposal form given at the time of taking the policy the age of the patient was shown as 59 years as on 11.05.2015.  Further, the date of birth is mentioned as 01.03.1956.  Therefore, we feel there is no wrong in mentioning the age as 61 years as on 05.05.2016.  Hence, there is no merit in the contention of the learned counsel for the opposite parties in repudiating the claim. 

10. The other ground taken in the repudiation letter that discrepancy found in the name in voter ID.  I feel already stated above that since the voter ID produced belongs to the complainant, it cannot be said that it is a created one. Hence, there is no merit in the contention.  Therefore, we feel the opposite parties ought to have closed the claim of the complainant.  Hence, there is deficiency on the part of the opposite parties in not honouring the claim.  Accordingly, we answer this point in affirmative.

11.POINT No.2:-The complainant claimed a sum of Rs.4,90,000/-.  The complainant has produced Xerox copy of the inpatient bill dt.05.05.2016, in which the amount paid is shown as Rs.4,90,000/-.  The opposite parties did not dispute the genuineness of the medical bills.  Hence, the complainant is entitle for the claim of Rs.4,90,000/-.  Further, the complainant claimed interest at the rate of 18% p.a.  We feel the rate of interest is highly an exorbitant one.  The complainant is entitled for interest at the rate of 9% p.a. from the date of claim.  We feel the complainant is entitled for interest from the date of claim closure letter i.e., 21.07.2016.  Further, the complainant claims a sum of Rs.1,00,000/- as damages for deficiency in service.  We feel the complainant is entitle for a sum of Rs.20,000/- towards damages and mental agony sustained.  Further, the complainant is entitle for a sum of Rs.10,000/- towards litigation cost.  Accordingly, we answer this point partly in affirmative.

12.POINT NO.3:- In view of the discussion made above, we proceed to pass the following;

The complaint is allowed in part.

The opposite party No.1 & 2 are directed to pay a sum of Rs.4,90,000/- to the complainant with interest at the rate of 9% p.a. from 21.07.2016 till realization and a sum of Rs.20,000/- towards damages and mental agony and a sum of Rs.10,000/- towards litigation cost. 

The opposite party No.1 & 2 shall comply the order within 30 days. In case, the opposite party No.1 & 2 fail to comply the order within the said period, the above said amount of Rs.30,000/- carries interest at the rate of 9% p.a. from the date of order till realization.

Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.

Applications pending, if any, stand disposed of in terms of the aforesaid judgment.

  (Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 30^th day of January, 2023)                                            

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA. K)    
•  

//ANNEXURE//

Witness examined for the complainants side:

Sri.Mukesh Daga @ Mukesh Kumar Jain, the complainant has filed his affidavit.

Documents marked for the complainant side:

1. The policy dt.25.05.2015.
2. Copy of proposal form.
3. Copy of Hospital bills, reports, Discharge summary, amount paid receipt.
4. Copies voter ID. Aadhar Card, Bank pass book, Pan card, Central Bank of India Bank endorsement.
5. Copy of letter sent through email by the opposite party dt.21.07.2016.
6. Copy of notice.
7. Postal receipt and acknowledgment. 

Witness examined for the opposite party side: 

Sri.Ramesh P, Senior Executive of opposite parties Insurance Company has filed his affidavit.

Documents marked for the Opposite Party side:

1. Proposal Form.
2. Health Insurance Claim Form.
3. Claim Closure Letter dt.21.07.2016.
4. Bank Pass book.
5. Aadhar Card of Mukesh Kumar Jain and his father.
6. DL Copy.
7. Voter ID and Mukesh and Kanchan No.STZ3917549 and STZ3917762.
8. Voter ID No.STZ3917549 belongs to Mukesh Daga.

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA. K)    
•