State Consumer Disputes Redressal Commission
Royal Sunderam Alliance Insurance Co ... vs Anish Ahamed Kazi & Ors on 16 September, 2011
BEFORE THE HON'BLE STATE CONSUMER DISPUTES REDRESSAL
BEFORE THE
HON'BLE STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, MAHARASHTRA, MUMBAI
First Appeal
No. A/10/1312
(Arisen out
of Order Dated 19/10/2010 in Case No. 252/07 of District
Mumbai(Suburban))
1. BRANCH MANAGER,
ROYAL SUNDERAM ALLIANCE INSURANCE CO LTD
DELPHI BUILDING C- WING SECOND
FLOOR HIRANANDANI
BUSINESS PARK POWAI MUMBAI 76
MUMBAI
MAHARASHTRA
2. THE GENERAL MANAGER
ROYAL SUNDERAM ALLIANCE INSURANCE CO LTD.
CORPORATE CLAIMS DEPARTMENT
SUNDARAM
TOWERS, 45 &
46
WHITES ROADS CHENNAI 600 014
...........Appellant(s)
Versus
1. ANISH AHAMED KAZI
M/S ANISHAENGG WORKS OFF AND WORKSHOP AISHA ENGG
WORKS SHRIRAM INDUSTRIAL ESTATE BAIL BAZAR KURLA WEST
MUMBAI
MUMBAI
MAHARASHTRA
2. THE BRANCH MANAGER,,STANDERD CHARTEREED BANK,
MEZZAINE FLOOR,462 PHONEIX CENTRE,PHONEIX MILL
COMPOUND,S.B.MARG, LOWER PAREL,MUMBAI-13
3. THE GENERAL MANAGER (H.O.) STANDARD CHARTERED
BANK
MEGRATH
ROAD, BANGALORE-560025
...........Respondent(s)
BEFORE:
Hon'ble Mr. S.R. Khanzode
PRESIDING MEMBER
Hon'ble Mr. Narendra Kawde MEMBER
PRESENT:
Mr.A S VIDYARTHI , Advocate for the Appellant
Mr.S.M.Chauhan-Advocate
for respondent no.1
Mr.S.Hussain -Advocate for
respondent nos.2 & 3
ORDER
Per Mr.S.R.Khanzode, Honble Presiding Judicial Member.
This appeal takes an exception to an order dated 19/10/2010 passed in consumer complaint no.252/2007, Mr.Anis Ahmad Kazi v/s. Branch Manager, Royal Sundaram Alliance Insurance Co.Ltd. and others, passed by Additional District Consumer Disputes Redressal Forum, Mumbai Suburban, Bandra (forum in short). It is a case about alleged repudiation of the mediclaim by Royal Sundaram Alliance Insurance Co.Ltd. (herein after referred as Insurance company). The consumer complaint was filed against the Branch Manager of the Insurance company at HiranandaniBusinessPark, Powai, Mumbai and the General Manager of the Insurance Company of Corporate Claim department at Head quarter at Chennai. Forum accepted the contention of the complainant and directed the appellants/original opponent nos.1&2 to pay jointly and severally `3 lakhs to the respondent/complainant along with compensation of `5000/- and cost of `5000/-. Feeling aggrieved thereby, original opponent nos.1 & 2 preferred this appeal. It may be mentioned that original opponent no.3 i.e. Branch Manager, Standard Chartered Bank, Phonix centre, Lower Parel, Mumbai stood discharged from the liability, since no order is passed against it fastening any liability.
Undisputed facts are that respondent/complainant Mr.Anis Ahmed Kazi (herein after referred as the complainant) held two credit cards issued by Standard Chartered Bank. When it was informed about mediclaim facility made available by the Insurance company to the card holders/customers of Standard Chartered Bank, he preferred to avail said benefit and, accordingly, had taken Health Shield Premiere insurance policy from the Insurance company. Said insurance cover is alive when on 06/07/2006 the complainant suffered heart ailment and for that purpose initially was admitted at Ashirwad Heart Hospital at Ghatkopar, Mumbai and, thereafter, for further treatment, admitted at Asian Heart Institute and Research Centre, BKC, Mumbai during the period 11/07/2006 to 27/07/2006. Thereafter, he raised an insurance claim on the above referred Health Shield Premiere Insurance policy to the extent of `3,39,075/-. Said claim stood repudiated by the Insurance company referring to the exclusion clause, particularly, mentioning that it relates to pre-existing ailment. It is also held that said ailment was not disclosed to the Insurance company while taking the policy. Feeling aggrieved thereby, consumer complaint was filed on 19/05/2007.
Heard Mr.A.S.Vidyarthi-Advocate for the appellant, Mr.S.M.Chauhan-Advocate for respondent no.1 and Mr.S.Hussain Advocate for respondent nos.2 & 3.
This appeal is admitted and heard forthwith with consent of parties. At the outset it may be mentioned that respondents/ original opponent nos.3 & 4 i.e. respectively Branch Manager & General Manager of Standard Chartered Bank by no stretch of imagination could be the service providers in respect of the mediclaim in question. Even the Standard Chartered Bank itself is not a service provider in this context and, therefore, forum rightly did not pass any order vis--vis dismissed the complaint as against opponent nos.3 & 4.
As far as repudiation of the mediclaim is concerned, it may be mentioned here that it is the insurance company which offered Health Shied Premiere insurance policy to the complainant. Said Insurance company is not a party before us. Consumer complaint is not filed against it. Referring to the definition of person as well as the phrase deficiency respectively embodied in section 2(1)(m) and 2(1)(g) of the Consumer Protection Act, 1986 (the Act for brevity), it is the Insurance company which is a service provider as far as Health Shield Premiere Insurance policy from which disputed mediclaim arose. Said Insurance company is a separate and distinct juridic person than its officials or employees, namely, Branch Manager or General Manager.
Under the circumstances, no deficiency in service as against these officials or employees could be alleged. There are no personal allegations against these officials (who are described by their respective position but not naming any individual) to fasten any liability in terms of deficiency in service. Therefore to hold these officials/employees guilty of deficiency in service is per se erroneous and forum did not consider these aspects at all, even though as per their written version the opponents categorically denied their liability, and arrived at a wrong conclusion.
Undoubtedly, since it is a case based upon insurance policy, its terms are to be construed strictly and on its own the Consumer Fora cannot substitute anything as a part of insurance policy. In this background, we refer to the insurance policy in question, the documents which are relied by both the parties and, particularly, the following statement in the policy regarding pre-existing disease.
Pre Existing Disease Pre Existing Disease shall mean any disease, illness, medical condition, injury for treatment of which claim is made under this policy, which existed prior to the Commencement Date of the Policy, or is found by the insurer, to be of such nature that ought to have existed or begun to set in, prior to Commencement Date of the Policy, whether or not the Insured Person was aware of such disease, illness, medical condition or injury.
(underlining provided) The other document which is relied by both the parties is the Discharge Summary issued by Asian Heart Institute. Said Discharge Summary was issued after the hospitalization of the complainant against which this insurance claim arose. In the said Discharge Summary, History of present illness and Past history is mentioned as under:-
History of Present Illness:
58 yrs old male patient was admitted at Ashirwad hospital on 06/07/206 with c/o left hand pain chest pain with sweating. H/o DOE-Gr-II was diagnosed to have Acute ASMI.
Patient is discharged today 11/07/06. Patient is advised CAG. Patient came to AHI for the same. No h/o any other complaints P/h/o PVD-Grafting done (no details present).
Past History :
Hypertension Since 1-2 yrs Previous Procedures/Operations Abdominal surgery Aortoilac Bypass Surgery in 1994 TURBT done 2000 Operated Inguinal Hernia orchidectomy It is tried to be argued on behalf of respondent/original complainant that since in a certificate of insurance, pre-existing disease of insured person refer to Hypertension only therefore, Ischemic heart disease to which he has undergone the treatment at Ashirwad Heart hospital and Asian Heart Institute is not the one which will come under the exclusion clause. We find this submission is without any substance and is contrary to the material on record. We already have made a reference to the Discharge Summary of Asian Heart Institute, particularly, about Past History. It reflects that the complainant had suffered from heart disease and even had undergone surgical treatment in the year 1994 and TURBT in the year 2000. Therefore, it is not that he was not aware of suffering from heart disease relating to the illness for which the insurance claim is made. The investigation report of A.K.Bajaj-insurance investigator, copy of which is also on record further refers to the fact as to how he tried to collect the information relating by the Asian Heart Institute but how the said material is tried to be suppressed from him. Therefore, referring to the clause relating to the pre-existing disease of the insurance policy, supra, clearly it will fall under the Exclusion clause, viz, EXCLUSIONS The company shall not be liable under this policy for any claim in connection with or in respect of:
1. a) Pre Existing Disease and any disease illness, medica condition, injury, which is a complication of a Pre Existing Disease.
b) Any heart, kidney and circulatory disorders in respect of Insured Persons suffering from pre-existing Hypertension, Diabetes.
These diseases shall however be covered after 5 years of consecutive insurance from the Commencement Date of the cover with us under this Health Shield Premiere Policy.
Under the circumstances, repudiation/denial of the insurance claim by the Insurance company cannot be faulted with. Thus, no deficiency in service on that count against the Insurance company can be inferred.
For the reasons stated above, we find forum erred itself in reaching to the conclusion about alleged deficiency in service on the part of the Insurance company and, particularly, holding that appellants/original opponent nos.1 & 2 are responsible to pay the compensation of `3 lakhs. We hold accordingly and pass the following order:-
ORDER Appeal is allowed.
Impugned order dated 19/10/2010 is set aside and in the result, consumer complaint no.252/2007 stands dismissed.
In the given circumstances both the parties to bear their own costs.
Pronounced on 16th September, 2011.
[Hon'ble Mr. S.R. Khanzode] PRESIDING MEMBER [Hon'ble Mr. Narendra Kawde] MEMBER Ms.