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State Consumer Disputes Redressal Commission

Manipal Cigna Health Ins.Co.Ltd vs Shankarbhai Dhirubhai Patel on 8 April, 2022

    A-2021/697                                                   A-2021/714


     Details         DD   MM     YY             Details         DD    MM         YY
Date of Judgment     08   04    2022       Date of Judgment     08    04        2022
  Date of filling    08   12    2021         Date of filling    08    12        2021
    Duration          -   04      -            Duration          -    04          -


            IN THE CONSUMER DISPUTES REDRESSAL COMMISSION
                       GUJARAT STATE, AHMEDABAD

                APPEAL NO. 2021/697 with Appeal No. 2021/714
                              Court No. 1


        Appeal No. 2021/697

        Manipal Cigna Health Ins. Co. Ltd.,
        (Formally known as Cigna TTK Health Insurance Company Limited)
        401/402, Raheja titanium, western express Highway,
        Goregaon (East), Mumbai - 400063                   ....Appellant
                            Vs

         1. Shankarbhai Dhirubhai Patel,
         233/1 Udachiya Fadiya, Ambheta,
         Ta. Chilkhi, Dist. Navsari.

         2. Samarjeet Alakhnarayan Mishra,
         C/O Jay Bherunath kirana, Gayatri nagar,
         Nr. Macchi market, saribujrang, Ta. Gandevi
         Dist. Navsari.                                    ...Respondents

           Appeal No. 2021/714

        Manipal Cigna Health Ins. Co. Ltd.,
        (Formally known as Cigna TTK Health Insurance Company Limited)
        401/402, Raheja titanium, western express Highway,
        Goregaon (East), Mumbai - 400063                   ....Appellant
                            Vs

         1. Shankarbhai Dhirubhai Patel,
         233/1 Udachiya Fadiya, Ambheta,
         Ta. Chilkhi, Dist. Navsari.

         2. Samarjeet Alakhnarayan Mishra,
         C/O Jay Bherunath kirana, Gayatri nagar,
         Nr. Macchi market, saribujrang, Ta. Gandevi
         Dist. Navsari.                                        ...Respondents

           APPERANCE : Mr. R.P. Raval for the appellant.


    M.B.Desai                       A-21-697,A-21-714                      Page 1 of 6
       Coram : Hon'ble Mr. Justice V. P. Patel, President
              Mr. I. D. Patel, Judicial Member

Smt. A. C. Raval, Member Order: (By Smt. A. C. Raval, Member)

1. Appellant has filed these two appeals under section 41 of the Consumer Protection Act 1986, being aggrieved and filling dissatisfied with the common judgment and order dated 6.10.2021 Passed in Consumer Complaint No. 60/2020 & Complaint No. 61/2020, by the Consumer Disputes Redressal Commission, Navsari.

2. Heard ld. Advocate Mr. A. D. Solanki for Mr. R. P. Raval for the appellant. Though the notice duly served to the respondents, they have not chosen to appear before this Commission.

2.1 The appellant is original opponent and respondent is original complainant before the District Commission. Herein after the appellant and respondent will be referred as per their original status.

Facts of the case of the complainant :

3. The complainant has taken Mediclaim policy known as " Pro Health Product" from opponent, bearing policy no. PROHLR980128302 for time duration 29.08.2018 to 28.08.2019, for the sum insured Rs. 4,50,000/-. By this policy complainant and his wife Ushaben S. Patel were insured.

3.1 Due to stomach pain, vomiting and urinary issues, wife of the complainant admitted in Metas Adventist Hospital- Surat as an indoor patient on 16.11.2018 and discharged on 29.11.2018. The hospital raised the bill for Rs. 3,36,711.25/-. Again she was admitted in hospital on 6.12.2018 and discharged on 8.12.2018. The expenditure occurred in time of Rs. 2,29,896.40/- .

3.2 The complainant first of fill up the claim form and sent with the required documents to the opponent insurance company for Rs.

3,36,711/-. The claim was rejected on 28.12.2018. Hence, the complainant preferred Consumer Complaint No. 60/2020 before the ld. District Commission, Navsari which was partly allowed hence, opponent preferred appeal no. 697/2021 before this State Commission.

3.3 The complainant raised another claim before the insurance company for Rs. 2,29,897/- which was not answered by the insurance company for a longer time. Hence the complainant filed consumer complaint no. 61/2020 before the Ld. District Commission, Navsari. Which was partly allowed by common order passed in the CC No.60/2020 against the order in CC no. 61/2020 opponent preferred appeal no. 714/2021 before this State Commission.

Order Under Challenge :

4. The Ld. District Commission has partly allowed the complaint and opponents were directed to pay Rs. 3,36,711/- in C.C. no. 60/2020 and Rs. 2,29,897/- in C.C. no. 61/2020 along with 7% interest from the date of filing of the complaint till the date of realization within 30 days from the date of order. It is further ordered that opponent shall pay Rs. 5000/- towards cost of hardship and mental agony.

Argument of the Appellant/Opponent :

5. Learned Advocate for the appellant/opponent argued that the impugned order passed by the Learned District Commission is illegal, unjust, improper, devoid merits and contrary to the provisions of law and the settled principles of law. That there was no deficiency of service. That the order passed by the Learned District Commission is not sustainable at law as the same seems to be passed just in a routine manner and is required to be set aside. Specifically it is further argued that the Learned District Commission has awarded the amount of compensation more than sum insured. He has requested to allow the appeal.

5.1 Ld. Advocates for the respondents/ original complainant has argued that the impugned judgment & order is legal, valid and correct in eye of law. The learned District Commission has appreciated documentary evidence in proper perspective. He requested to dismiss the appeal.

Merits of the case:

6. Merits of the case: One of the argument by the insurance company in the appeal memo at ground 28 and 29 are as under:

"28. That the total liability of an insurer cannot go beyond the stipulated sum insured under the policy. In the present case, the Ld. District Commission had passed joint order in CC No. 60/20 and 61/20 fastening total liability under both the complaints to the tune of Rs. 5.66 Lacs. However, the total sum insured opted by the complainant at the time of purchasing the policy was only Rs. 4.5 lakhs. Hence, it is humbly submitted that under no circumstances the company's total liability can go beyond the agreed sum insured under the policy.

29. That the award amount for both the cases is Rs. 3,36,711 + 2,29,897 = Rs. 5,66,608/-. The sum insured was Rs. 4,50,000/-. Hence, there is a difference of Rs. 5,66,608/- - 4,50,000/- = 1,16,608/-."

Further the appellant has given a summary details of the policy in appeal memo at page 5 in para 5. The summary reads as under:

        Policy No.       PROHLR980128302
        Product          ProHealth-Protect
        Proposer         Shankarbhai D. Patel
        Insured          Shankarbhai D. Patel (Self) Ushaben S. Patel (Wife)
        Policy Period    29-8-2018 to 28-8-2019
        Sum Insured      Rs. 4,50,000/-
        Policy Status    Terminated

7. The above referred amount can be summarized as follows.

The amount awarded by the Ld. District Commission in CC No. 60/20 = Rs. 3,36,711/-

        in CC No. 61/20 =        Rs. 2,29,897/-
        total amount awarded     Rs. 5,66,708/-
        -amount insured          Rs. 4,50,000/-

        The excess award is Rs. 1,16,608/-.
M.B.Desai                          A-21-697,A-21-714                        Page 4 of 6

8. The insurance company is liable to pay the amount as sum insured is Rs. 4,50,000/- thus, claimant is entitled to get only Rs. 4,50,000/- and not the total awarded amount i.e. Rs. 5,66,608/-.

9. We have considered the facts of the complaint, grounds stated in memo of appeal, reasons stated in judgment and order passed by the Ld. District Commission, documentary evidence produced on record, argument advanced by both the parties and facts and circumstances of the case. The Ld. District Commission has awarded higher amount then the sum insured amount. Therefore, the judgment and order passed by the Ld. District Commission is required to be modified to the extent. Therefore, in the interest of justice following final common order is passed.

ORDER

1. The Appeal No. 697/2021 and Appeal No. 714/2021 is hereby partly allowed.

2. Order dated 6.10.2021 passed by the Learned District Commission Navsari in Consumer complaint No. 60/21 is hereby confirmed and order in Consumer complaint No. 61/21 is hereby modified to the extent that the original complainant Shankarbhai D. Patel is entitled to get Rs. 1,13,289/- (One Lakh Thirteen Thousand Two Hundred and Eighty Nine only), instead of Rs. 2,29,897/-(Two Lakh Twenty Nine Thousand Eight Hundred and Ninety Seven only) (Not more than sum insured). The rest of the order passed by the Learned District Commission is hereby confirmed.

3. No order as to costs.

4. Copy of the order to be kept in appeal No. 714/2021.

5. Office is directed to verify the amount deposited by the appellant in Appeal No. 697/2021 & 714/2021 or C.M.A No. 348/2021 & 347/2021 if found deposited, refund the same with interest, if any, accrued on the deposit to the appellant by issuing A/c, payee cheque in the name of the appellant. The A/c. payee cheque may M.B.Desai A-21-697,A-21-714 Page 5 of 6 be handed over to the attending advocate after following due procedure and verification.

6. Registry is directed to send a certified copy this order to the parties as well as intimate to the ld. District Commission Navsari through E-mail in PDF format.

Pronounced in the open Court today on 8th April, 2022.

[Justice V. P. Patel] President [Mr. I. D. Patel] Judicial Member [Smt. A. C. Raval] Member M.B.Desai A-21-697,A-21-714 Page 6 of 6