State Consumer Disputes Redressal Commission
Vax Asssurance And Solution (P) Ltd vs Govindbhai Patel on 30 September, 2023
Details DD MM YY
Date of disposal 30 09 2023
Date of filing 19 05 2022
Duration 11 04 01
BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION
GUJARAT STATE AHMEDABAD.
COURT NO: 03
APPEAL NO. 336 of 2022
Vax Assurance & Solutions (P) Ltd.
B/208, Wall Street-2, Nr. Gujarat College,
Ellisbridge, Ahmedabad-6. ...Appellant
V.s
1. Govindbhai Patel
2. Mrs. Kapilaben G. Patel
At Po. Gabat. Ta. Bayad,
Dist. Sabarkantha-383325. ...Respondent
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BEFORE: Mr. I. D. Patel, Judicial Member
APPERANCE: Mr. M. K. Dudhiya, Ld. Adv. for the appellant,
Mr. R. U. Nahar, Ld. Adv. for the respondent.
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ORDER BY Mr. I. D. PATEL, JUDICIAL MEMBER.
JUDGMENT
1. The appellant/original complainant has preferred this fist appeal as per the provision of Section 15 of the Consumer Protection Act, 1986 against the impugned order passed by the Ld. District Consumer Disputes Redressal Commission, Ahmedabad (City) (for short Ld. District Commission) in complaint no.589/2019 dated 08.03.2022 on the grounds stated in the appeal memo. The appellant is the original opponent whereas the respondents are original complainant. Therefore, for the sake of convenience parties are referred to by their original nomenclature/status.
2. It is the case of the complainant before the Ld. District Forum that the complainant had paid premium of Rs.15,165/- to the opponent for the policy of Rs.1,00,000/- for the period of 06.01.2018 to Akshay A/336/2022 Page 1 of 6 05.01.2019 vide cheque of State Bank of India dated 25.12.2017. It is further the case of the complainant that thereafter the complainant no.2 Kapilaben G. Patel admitted in the Trisha Multi Specialty Hospital on 22.08.2018 for knee replacement operation and spent Rs.1,57,253/- and thereafter the complainant lodged the claim with the insurance company as well as opponent but, since the insurance company has not issued any policy in favour of the complainant, insurance company had not paid any amount to the complainant therefore, the complainant filed the complaint against the appellant for deficiency in service committed by the opponent and claimed Rs.1,00,000/- with 15% from the date of repudiation i.e. 25.08.2018 till its realization.
3. That though the notice of the complaint duly served upon the opponent Vax Assurance & Solution Pvt. Ltd., the opponent has not appeared before the Ld. District Commission and also has not filed any written statement against the complaint and therefore, Ld. District Commission proceeded matter ex-parte against the appellant/original opponent.
4. After hearing the Ld. Adv. for the parties and after the perusing the material on record, Ld. District Commission, Ahmedabad (City) has partly allowed the complaint and directed the opponent to pay to the complainant Rs.1,00,000/- at 7% interest from the date of filing of the complaint within 30 days and Rs.3,000/- for mental agony and Rs.2,000/- for litigation cost. Being aggrieved and dissatisfied with the order passed by the Ld. District Commission, Ahmedabad (City), original opponent/appellant has filed the present appeal on the grounds stated in the appeal.
5. I have heard Ld. Adv. Mr. M. K. Dhudhiya on behalf of the appellant/original opponent insurance company and Ld. Adv. Mr. R. U. Nahar respondent/original complainant.
6. That the Ld. Adv. Mr. M. K. Dhudhiya has submitted that the impugned order passed by the Ld. District Commission directing the appellant to pay Rs.1,00,000/- to the complainant is not just Akshay A/336/2022 Page 2 of 6 and proper. He has also submitted that the Ld. District Commission has not considered terms and conditions of the insurance policy issued by the oriental insurance company in favour of the complainant for the period 31.08.2008 to 30.08.2019. That the Ld. Adv. has also submitted that it is an admitted fact that though the appellant has received the premium from the complainant for issuance of the policy from 06.01.2018 to 05.01.2019. The oriental insurance company has not issued any policy in favour of the complainant and therefore, the insurance company had not paid any amount of medical reimbursement to the complainant. Therefore, the complainant filed the complaint against the appellant but he has also submitted that as per the terms and conditions of the insurance policy for the period of 31.08.2018 to 30.08.2019 page 26, the sum insured of the policy is Rs.1,00,000/- and as per discharge summary of the Trisha Multi Specialty Hospital page 28, complainant had admitted for the operation of the right side total knee replacement and as per the terms and conditions, the complainant is entitled to get 60% of the sum insured which comes to Rs.60,000/- and out of the said amount Rs.10,110/- proportional premium for the insurance policy requires to be deducted the said amount which is paid by the appellant on behalf of the complainant therefore, as per the submission of Ld. Adv. M. K. Dudhiya, the complainant is entitled to get Rs.49,890/- from the appellant/original opponent and accordingly, the impugned order is required to be modified and appeal may be allowed.
7. Per contra, Ld. Adv. R. U. Nahar on behalf of the original complainant support the impugned order passed by the Ld. District Commission and submitted that the Ld. District Commission has rightly directed the appellant to pay Rs.1,00,000/- with interest and therefore, there is no illegality in the impugned order hence, he has urged to dismiss the appeal filed by the appellant.
Akshay A/336/2022 Page 3 of 68. I have considered the argument advanced by the Ld. Adv. of the parties and also gone through the impugned order as well as documentary evidence in question produced by the appellant.
9. That it is admitted that the complainant paid Rs.15,165/- vide cheque of the State Bank of India dated 25.12.2017 to the appellant's Vax Assurance And Solution (Pvt.) Ltd. for issuance of the insurance policy for the period of 06.01.2018 to 05.01.2019. that the appellant in turn sent the premium to the insurance company for issuance of policy in favour of the complainant but somehow it appears that the insurance company has not issued any policy in favour of the complainant's family member for the period of 06.01.2018 to 05.01.2019. that it also appears that as on 22.08.2018, the complainant's wife Kapilaben G. Patel admitted in Trisha Multi Specialty Hospital as discharge card page 28 for the operation of Right side total knee replacement and for the said treatment, the complainants spent Rs.1,57,253/- as per the medical bill page 29-30. That the complainant lodged the claim with the insurance company but since there was no policy in force on the date of operation i.e. 22.08.2018 in favour of the complainant and his wife, insurance company has not paid any amount to the complainant.
10. That though the complainant paid the amount of insurance Rs.15,165/- to the appellant for issuance of the policy in favour of the complainant, the policy was not issued in favour of the complainant for the period in question and therefore, the appellant is responsible or liable to pay the amount of medical reimbursement of the Kapilaben G. Patel but looking to the policy issued insurance company for the period of 31.08.2018 to 30.08.2019 which is after the date of operation page 26 as per the terms and conditions of the said policy, the complainant who had admitted in the Trisha Multi Specialty Hospital for the operation of knee joint replacement is only entitled to get 60% of sum insured of Rs.1,00,000/- which comes to Rs.60,000/-. Furthermore, the Akshay A/336/2022 Page 4 of 6 appellant had paid the premium for the policy commencing from 31.08.2018 to 30.08.2019 therefore, the pro rata amount of premium which comes to Rs.10,110/- requires to be deducted from the entitlement amount of the claim i.e. from Rs.60,000/- which comes to Rs.49,890/-. So, as the terms and conditions of the insurance policy, the complainant is entitled to get Rs.49,890/- from the appellant however, the Ld. District Commission has directed appellant to pay Rs.1,00,000/- to the complainant which is against the terms and conditions of the insurance policy therefore, the impugned order passed by the Ld. District Commission directing appellant to pay Rs.1,00,000/- to the complainant requires to be modified and accordingly appeal requires to be partly allowed in terms of the following final order.
ORDER
1. Appeal no.336/2022 filed by appellant is hereby partly allowed.
2. Impugned order passed by the Ld. District Commission, Ahmedabad (City) in complaint no.589/2019 directing appellant to pay Rs.1,00,000/- (Rupees One Lacs) to the complainant is hereby modified and appellant/original opponent is hereby directed to pay Rs.49,890/- (Rupees Forty Nine Thousand Eight Hundred Ninety) at the rate of 7% interest from the date of filing of the complaint and rest of the order passed by the Ld. District Commission is hereby confirmed.
3. No order as to cost.
4. Registry is directed to verify the amount deposited by the applicant in appeal no.336/2022 and if found deposited, refund the same with interest, if any, accrued there on the deposit to the appellant by RTGS after following due procedure and verification. For this purpose the appellant has to file an application with details to the account branch of this commission.
Akshay A/336/2022 Page 5 of 65. Registry is hereby instructed to send a copy of this order in PDF format by E-mail to Ld. District Forum, Ahmedabad (City) for taking necessary action.
6. Office is directed to forward a free of cost certified copy of this judgment and order to the respective parties.
Pronounced in the open Court today on 30th September, 2023.
[I. D. Patel] Judicial Member.
Akshay A/336/2022 Page 6 of 6