State Consumer Disputes Redressal Commission
National Insurance Co. Ltd. vs Prem Singh & Another on 20 December, 2013
1st Addl. Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No.242 of 2010
Date of institution:18.02.2010
Date of decision : 20.12.2013
National Insurance Company Ltd., Regional Office, SCO Nos.332-334,
Sector 34-A, Chandigarh through its duly constituted Attorney.
.....Appellant
Versus
1. Prem Singh aged 53 years, son of Late Shri Jawala Ram, resident of
Village Lohgarh Fidde, P.O.Laudi Majra, Tehsil & District Ropar.
2. Med Save Health Care Limited, SCO no.121-123, Second Floor,
Sector 34-A, Chandigarh.
.....Respondents
First Appeal against the order dated 4.1.2010
passed by the District Consumer Disputes
Redressal Forum, Ropar.
Before:-
Shri Piare Lal Garg, Presiding Member
Shri Vinod Kumar Gupta, Member Argued By:-
For the appellant : Sh. R.C.Gupta, Advocate For respondent no.1: Sh. Pankaj Sikka, Advocate alongwith Sh. Prem Singh, in person For respondent no.2: None VINOD KUMAR GUPTA, MEMBER This is an appeal filed by the appellant/OP no.2 (hereinafter called 'the appellant') under Section 15 of the consumer protection act against the order dated 04.01.2010 of the District Consumer Disputes Redressal Forum, Ropar (hereinafter called the 'District Forum') vide which the complaint of the complainant/respondent no.1 (hereinafter called as 'respondent no.1') was allowed by the District Forum.
2. Brief facts of the case are that Sh. Prem Singh-respondent no.1 filed a complaint under the act against the appellant/respondent No.2 making the averments that he purchased a health care policy from respondent no.2/OP no.1(hereinafter called as 'respondent no.2') Med First Appeal No.242 of 2010 2 save health care under Bhai Ganaiya Sehat Sewa Scheme through appellant no.1 on 1.10.2008 vide policy no.400104/46/08/85/00000096 and identity card no.90112371300020Z was issued and the expiry date of the policy was 30.09.2009. The annual premium of the policy was Rs.2242/-. The appellants were liable to reimburse any amount spent by the policy holder for his treatment during the validity of the policy. It was pleaded that in the month of April, 2009 respondent no.1 fell sick and was shifted to Civil Hospital, Ropar from where he was referred to PGI, Chandigarh where he remained admitted on 29.04.2009 to 9.5.2009. It was further pleaded that in the course of his admission in the said institute respondent no.1 spent a sum of Rs.15,000/- for his treatment. The respondent no.1 lodged a claim on 8.6.2009 accompanied by requisite documents including medical bills to respondent no.2 who asked him to wait for call but the appellant and respondent No.2 have not settled his claim despite services of notice dated 1.9.2009 by the respondent no.1 which shows the deficiency in service on the part of the appellant and respondent No.2. The complaint was filed by the respondent no.1 seeking directions to the appellant & respondent No.2 to pay Rs.15,000/- i.e. the amount of treatment as per the policy and to pay Rs.20,000/- as compensation on account of mental and physical suffering alongwith interest @18% per annum from 8.6.2009 till its realisation.
3. Upon notice, appellant and respondent No.2 filed joint written version in the form of affidavit of Sh. Surinder Kumar Goel, Deputy Manager of appellant by taking preliminary objections that the complaint of the respondent no.1 is not maintainable in the present forum. Respondent no.1 has no locus standi to file the complaint. The respondent no.1 is estopped by his own act and conduct to file the present complaint. Respondent No.1 has not come to the Forum with clean hands. The complaint is false and frivolous. It was also admitted that the Govt. of First Appeal No.242 of 2010 3 Punjab, Ministry of Cooperative Society floated the scheme for medical benefits of the members of cooperative society under the scheme of Bhai Ganaiya Sehat Sewa Scheme. Under the said scheme, appellant got insured the respondent no.1 with certain terms and conditions of the policy contained in booklet supplied to him alongwith policy. It was further submitted that the respondent No.1 secured insurance policy for himself and his family members including his mother Channo Devi whose age has been mentioned in the enrolment form as 71 years but in voter identity card her age was shown as 81 years. It was further submitted that a person above 75 years of age was not covered under the policy and due to said discrepancy, card of the respondent no.1 issued by appellant was blocked, as such, neither cashless treatment under the policy nor reimbursement of amount spent by the respondent No.1 is permissible. All other allegations were denied and it was pleaded that there is no deficiency in service on the part of the appellant and prayed for dismissal of the complaint.
5. Both the parties produced the evidence in support of their contentions.
6. Learned District Forum after hearing the learned counsel for the parties and going through the record, accepted the complaint and directed the appellant to pay to respondent no.1 a sum of Rs.15,000/- i.e. the amount spent by the respondent No.1 on his treatment, alongwith interest @9% p.a. from the date of discharge from the hospital i.e.9.5.2009, till date of payment, with further direction to pay him a sum of Rs.1,000/-, on account of costs of filing of instant complaint, within a period of 2 months, from the date of receipt of copy of this order.
7. Aggrieved by the impugned order dated 04.01.2010, the appellant has come up in the appeal.
First Appeal No.242 of 2010 4
8. The appeal was filed by the appellant on the ground that the order passed by the District Forum is illegal and erroneous, the respondent No.1 lodged a claim with the respondent No.2 but his claim was not settled, District Forum has further erred in holding that the voters list is not a conclusive proof until it is corroborated by some documentary evidence. District Forum has further erred in holding that there was no misrepresentation on the part of the respondent No.1. District Forum further held that the non-settlement of the claim of the respondent No.1 was not justifiable and it amounted to deficiency in service. The respondent No.1 was not entitled to any claim, neither cashless nor reimbursement, in as much as his card was blocked due to the misrepresentation. The order passed by the District Forum is totally illegal and erroneous and is liable to be set-aside and prayed for dismissal of the complaint with costs.
9. We have gone through the pleadings of the parties, grounds of appeal, perused the record of the learned District Forum and heard the arguments of the counsel for the parties.
10. The only question for consideration before us is whether the appellants were justified in blocking the identity card? The appellant has placed on record the detail of member Charno Devi under Policy No.400104/46/08/85/00000096 in which the age of Charno Devi is shown as 71 years (20.10.1937) Ex.R-5 and also produced Ex.R-6 i.e. Voter Card issued by the Election Commission in which her age was mentioned as 81 years vide Election Card No.185/GR9210721. No doubt in both the documents the age of Charno Devi was mentioned differently.
11. Before the acceptance of Date of Birth mentioned in the member enrolment form under Bhai Ghanhya Sehat Sewa Scheme, no objection was raised regarding the age of Charno Devi by the appellant First Appeal No.242 of 2010 5 and even till the lodging of the claim by the respondent No.1, no query was raised by the appellant regarding the age of Charno Devi mentioned in the member enrolment form.
12. We have also gone through Service Level Agreement entered on 2nd day of May 2008 between National Insurance Company Ltd. (insurer) and The Bhai Ghanhya Trust and Condition No. 7.1.10 relates to the issuance of the identity card after the acceptance of enrolment form submitted by the insured, which is reproduced:-
"7.1.10 The Insurer shall underwrite the Beneficiaries in accordance with the terms of the Policy. The Enrollment Forms underwritten and verified by the Insurer shall also be attested and stamped by the Insurer before being forwarded to the TPA for issuance of the I.D. Cards. The Insurer shall be fully and exclusively responsible for any fault/ mistake in underwriting of the Beneficiaries, with respect to any deviation from the definition of the word "Family", permissible age limit, premium computed for that Family, timely collection of premium from the Beneficiaries and shall solely bear the consequent financial or other losses, if any."
13. It is also settled law that once the insurance co. accepts the age of the life assured then it has no right to repudiate the insurance claim by alleging her age to be different than that. Hon'ble Calcutta High Court in case "Allianz and Stuttgarter Life Insurance Bank Ltd. V. Hemanta Kumar Dass", AIR 1938 Cal. 641 dealt with the above question and held as under:-
"It is to be borne in mind that this was an insurance by a man who admittedly was, at any rate, at the age of over forty-five years. He himself stated that he was fifty four. Therefore, the transaction came within the category of those proposals which require at the outset the furnishing by the proponents of proof of their age. Noot Behari Das was required to furnish proof of his age. He produced a horoscope. First Appeal No.242 of 2010 6 The horoscope was accepted by the company as being sufficient. Therefore, we may take that the company issued the policy upon the footing that they were insuring the life of a man whose age was fifty four. This is not a case where the proposer says that his age was fifty four and the Company merely accepted that statement at its face value and proceeded to issue a policy on that tooting and subsequently, either shortly afterwards or a long time afterwards, admitted the age as stated in the policy in accordance with the provisions of Clause 9(2) thereof. This was a case where the whole transaction from the very beginning proceeded upon the basis that the company has satisfied themselves that the proposer was of the age of fifty four and then issued the policy accordingly. In my view therefore the admission contained in the endorsement at page 3 of the policy is of such a character that the defendants when the policy matured could not be heard to say that the age of the insured was anything different from what he himself had stated it to be in Februrary 1934. It is not necessary that one should apply in terms of the principle of estoppel, because that is merely a rule of evidence. In my view, this matter goes far deeper than that. The question of the age of the deceased was a definite and determining factor in the transaction from the very outset."
14. The Hon'ble Apex Court in case "P.C. Chacko and another Vs. Chairman, Life Insurance Corporation of India and others", (2008) 1 SCC 321, held that three conditions essential for application of Section 45 of the Insurance Act, 1938 are as under:-
(a) the statement must be on a material matter or must suppress facts which it was material to disclose;First Appeal No.242 of 2010 7
(b) the suppression must be fraudulently made by the policy holder; and
(c) the policy-holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose.
15. This question was also dealt with by this Commission in number of judgments and followed the above law. In case "Balwinder Singh v. The Life Insurance Corporation of India & Anr.", 2010(3) CPR 235, this Commission held in para No. 28 as follows:-
"28. In view of the discussion held above, we hold that once the respondents had accepted the age of Gian Kaur to be 45 years, they have no right to repudiate the insurance claim by alleging her age to be different than that."
16. Respondent No.1 has placed on record the detail of Member vide Policy No.400104/46/08/00000096 and also placed on record OPD Slip Ex.C-3, Discharge and follow-up Card Ex.C-4 and Discharge Summary Ex.C-5. The respondent No.1 has placed on record the bills Ex.C-8 to Ex.C-11. On the other hand, respondent No.2 has placed on record Affidavit of Dr.Rolli Aggarwal, Regional Manager, Med Save Health Care (TPA) Ltd. Ex.R-2 in which she mentioned that Med Save card of the respondent No.1 Mr.Prem Singh vide No.90112371300020Z was blocked due to the age discrepancy of Mrs.Charno Devi-90112371300020G mother of the respondent No.1. Respondent No.2 submitted that at the time of enrolment Mrs.Charno Devi enrolled herself as 71 years Ex.R-5, whereas her age was shown as 81 years in Election Commission Voter ID Card No.PB/06/066/352109 Ex.R-6. According to the policy conditions, the person with age more than 75 years was not covered under the policy. First Appeal No.242 of 2010 8
17. In view of the above preposition of law, it is proved that the appellant has wrongly repudiated the claim of the respondent No.1 on the ground that the age of her mother Smt.Charno Devi was wrongly mentioned in the Enrolment Forum and on this ground, the appellant is not justified as per the settled law and the respondent No.1 is entitled to receive Rs.15,000/- from the appellant amount spent on his treatment.
18. The order passed by the District Forum is legal and valid and there is no ground to interfere with the same. There is no merit in the appeal and the same is dismissed and impugned order passed by the District Forum is affirmed and upheld. No order as to costs.
19. The appellant had deposited an amount of Rs. 8510/- with this Commission at the time of filing of the appeal. This amount of Rs. 8510/- with interest accrued thereon, if any, be remitted by the registry to the respondent No.1 by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellant.
20 Remaining amount shall be paid by the appellant and respondent No.2 to the respondent No.1 within 30 days from the receipt of the copy of the order.
21. The arguments in this appeal were heard on 17.12.2013 and the order was reserved. Now the order be communicated to the parties.
23. The appeal could not be decided within the stipulated timeframe due to heavy pendency of court cases.
(Piare Lal Garg)
Presiding Member
December 20, 2013 (Vinod Kumar Gupta)
Rs/Lata Member