State Consumer Disputes Redressal Commission
Anil Agrawal vs Divisional Manager on 16 July, 2012
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION
PANDRI, RAIPUR
Appeal No.FA/12/126
Instituted on 09.03.12
Anil Agrawal, S/o: Late Shri R.B.Agrawal,
R/o: 67/5, Nehru Nagar (West), Bhilai,
Dist. DURG (C.G.) ... Appellant.
Vs.
Divisional Manager,
The New India Insurance Co. Ltd.,
Divisional Office, 1st Floor, Thakkar Chamber,
G.E.Road, Power House, Bhilai,
Tah. & Dist. DURG (C.G.) ... Respondent.
PRESENT: -
HON'BLE JUSTICE SHRI S.C. VYAS, PRESIDENT
HON'BLE SHRI V.K. PATIL, MEMBER
COUNSEL FOR THE PARTIES: -
Shri R.K. Bhawnani, for appellant.
Shri P.K. Paul, for respondent.
ORDER
Dated:16/07/2012 PER: - HON'BLE JUSTICE SHRI S. C. VYAS, PRESIDENT This appeal is directed against order dated 13.02.2012, passed by District Consumer Disputes Redressal Forum, Durg (hereinafter called "District Forum" for short) in complaint case No.238/2011, whereby the complaint of the appellant herein against the respondent / insurance company alleging deficiency in service and claiming Rs.1,10,000/- from the respondent has been dismissed.
2. Indisputably, the appellant herein Anil Agrawal is a retired employ of the respondent / insurance company. At the time of retirement in the year 2004 he was a member of Group Mediclaim // 2 // Policy for Staff and was having mediclaim insurance cover to the extent of Rs.2,00,000/- for himself, Rs.2,00,000/- for his wife and Rs.1,10,000/- each for his two sons and was paying premium of that policy @ Rs.6,894/- till the year 2009.
3. The case of the complainant / appellant before District Forum was that in the year 2010 he decided to get the insurance coverage enhanced and proposed for insurance coverage of Rs.3,10,000/- for himself, Rs.3,10,000/- for his wife and Rs.1,10,000/- each for his two sons and accordingly submitted Form, Annexure A-1 dated 30.03.10 before the insurance company. The proposal was accepted by the respondent / insurance company and accordingly complainant / appellant deposited enhanced premium of Rs.10,040/- against receipt dated 31.03.10, Annexure A-2. No other document was issued by the respondent / insurance company in respect of the enhanced coverage of mediclaim insurance. It has further been contended that in the month of December 2010, the appellant herein fell ill and hospitalized in Max Healthcare Super Speciality Hospital, New Delhi for coronary artery disease with ACS, hypertension and type 2 diabetes mellitus on 02.12.10. He was to undergo coronary angioplasty and was discharged from the Hospital on 06.12.10, vide discharge summary Annexure A-3. He was to spent Rs.7,13,947/- on his hospitalization and treatment, so he preferred a claim before the respondent / insurance company for // 3 // payment of Rs.3,10,000/- under the insurance coverage which he was enjoying, but the respondent / insurance company has settled the claim only up to Rs.2,00,000/- and paid that amount. The insurance company denied to pay the remaining amount of claim and thus committed deficiency in service, so he filed complaint before the District Forum, alleging this act of the insurance company as deficiency in service and claiming Rs.1,10,000/- from the insurance company and interest on that amount @ 18% p.a. and also Rs.1,00,000/- as compensation for agony suffered by him.
4. The averments made by the complainant in the complaint, were denied by the insurance company in the written version and it has been specifically averred that the insurance cover, which was available to the complainant was under mediclaim policy under welfare scheme of the insurance company and the mediclaim policy was issued as per the terms and conditions of the welfare scheme formulated by the insurance company. It has been specifically averred that under the welfare scheme and under the provisions of Staff Mediclaim Policy, present and past employees of the insurance company were enjoying mediclaim insurance cover, but the option for enhancement of cover was available to a past employee only at the time of retirement or leaving the job. Thereafter, he was not having any option to enhance the mediclaim insurance cover. It has further been averred that the // 4 // mediclaim insurance cover of the complainant was only to the extent of Rs.2,00,000/-, which was opted by him at the time of his retirement and was continuing even on the date when the claim was submitted by him for reimbursement. In the meantime, the cover was neither enhanced nor could be enhanced, as per the policy of the respondent / insurance company. Thus, the allegation of deficiency in service and the liability of payment of Rs.1,10,000/- has been denied.
5. Learned District Forum vide the impugned order has agreed with the defence taken by the insurance company and dismissed the complainant.
6. We have heard arguments advanced by both parties and perused the record of the District Forum.
7. Learned counsel for the appellant has drawn our attention towards document Annexure A-1 and submitted that by this document the complainant / appellant had made proposal for the enhanced mediclaim insurance cover for himself and for his wife from Rs.2,00,000/- to Rs.3,10,000/-. He has further submitted that the proposal was accepted by the insurance company and that is why the enhanced premium of Rs.10,400/-, deposited by the appellant, was accepted and receipt, Annexure A-2, was issued. It has been pointed // 5 // out by him that in this receipt in the column of 'Particulars' it has clearly been stated that the amount which was deposited by the complainant was for mediclaim premium for the period 2010-11 (Retired / SVRS employees). He submitted that this receipt bears signature of Authorized Signatory of the respondent / insurance company and therefore it is sufficient to demonstrate that the proposal of the complainant was accepted by the insurance company and insurance cover was enhanced.
8. Learned counsel for the appellant has further drawn our attention towards documents, which have been filed by the appellant before us at the appellate stage, as evidence on behalf of the appellant. The first such document is a letter of the insurance company addressed to the appellant in which information under Right to Information Act, as demanded by the complainant / appellant, was provided to him. He has submitted that in this letter, it has been specifically stated by the insurance company that no policy was sent to an individual employee and the coverage, premium etc. was as per the sum insured opted by the retired employee at the time of retirement. He has further submitted that the insurance company has stated that since there was no change in premium / loading from 2007 to 2010, no information was sent separately. Second letter received by the complainant from the insurance company has also been referred by learned counsel for // 6 // the appellant and it has been submitted that in this letter it has been informed by the insurance company that the premium rates were not revised since 2004-05 under group staff mediclaim policy and the chart for calculation of mediclaim premium for retired employees for the year 2006-07 and 2009-10 was also sent by the insurance company to the appellant / complainant. However, that chart has not been filed by the appellant before us. At the place of that chart, a letter written by the appellant to the insurance company has been filed, in which it has been stated that as to how much amount was deposited by the appellant as premium of his group mediclaim insurance policy in different years and then information was sought as to what was the sum insured for each and every year and the detailed premium computation worksheet.
9. He has also drawn our attention towards Insurance Regulatory and Development Authority (Protection of Policyholders' Interests) Regulations 2002 and submitted that as per regulation 4 sub-clause (4), 'it was necessary for the insurer to record the information obtained orally or in writing from the proposer and to confirm it within a period of 15 days thereof with the proposer and incorporate the information in its cover note or policy. The onus of proof shall rest with the insurer in respect of any information not so recorded, where the insurer claims that the proposer suppressed any material information or provided // 7 // misleading or false information on any matter material to the grant of a cover'. Our attention has also been drawn towards regulation 10, which is in respect of 'Policyholders' Servicing' and it has been submitted that it was the duty of the insurer to respond to the communication within 10 days of the receipt, in all matters. And in this regulation, it has been highlighted that 'in issuance of an endorsement under the policy; noting a change of interest or sum assured or perils insured, financial interest of a bank and other interests', were inter alia a matter regarding which this regulation applies. On the basis of these documents, learned counsel for the appellant submitted that under the regulations framed by IRDA, it was the duty of the respondent / insurance company to note the proposal of the insured for enhancement and to provide correct information to him. It has also been submitted that as the proposal was made and enhanced premium was accepted, therefore it should be presumed that the cover was extended from Rs.2,00,000/- to Rs.3,10,000/-, as no separate policy document was ever issued in respect of such insurance cover.
10. To counter these arguments, learned counsel for the respondent has drawn our attentions towards the provisions of Reference Book for Personnel Administration of the New India Assurance Co. Ltd., Section-V and submitted that the respondent Company has framed // 8 // Employees Welfare Scheme under this reference book, and provisions for retired employees have been made under chapter 'Medical Benefits for Retired Employees'. He has drawn our attention towards that separate chapter and submitted that under this policy the mediclaim insurance cover under the Group Mediclaim Policy is an optional scheme. It has been submitted that for the employees who were retired, such option was to be exercised before retirement. It has been provided that the entire premium, less group discount shall be borne by the retired employee. It has again been reiterated that as mentioned in sub-clause (2) of the policy, retiring employees were required to exercise option for coverage before retirement. The employees may opt for higher sum insured and any sum insured subject to maximum of Rs.3 lacs but it will be one-time option and can't be changed subsequently. It has also been specified that premium for the remaining period of the policy year in which the employee retires was to be recovered on retirement. From April 1, immediately following the retirement, coverage shall be under the sum insured opted for, provided entire annual premium is paid by the concerned retired employee before the commencement of every policy year. He submitted that in the letters, which were written by the insurance company to the complainant in respect of his application under Right to Information Act, also it was clarified that the coverage and premium etc. were as per the sum insured opted by the retired employee at the // 9 // time of retirement and as he was covered for sum assured of Rs.2,00,000/- since his retirement, so that coverage was continuing.
11. We have taken into consideration all the aforesaid arguments advanced by both parties and are of the view that the appeal filed by the appellant is devoid of any merits and is liable to be dismissed.
12. The bone of contention of the appellant are two documents, Annexure A-1 and Annexure A-2.
13. So far as document Annexure A-1 is concerned it is a printed form and in the heading it has been clarified that it is enrollment form for revised staff mediclaim policy effective from 01.04.08. Initial columns are regarding name of the employee, place of posting, salary as on 01.04.08, designation, date of confirmation, salary roll No. etc. Under the head employee's signature, the appellant has singed this document and date 30.03.2010 has also been mentioned in this Form. It has been stated that the complainant was wishing to increase sum insured by Rs.2,00,000/- and then in different columns name of the complainant, name of his wife and two sons, relation with the complainant, date of birth, age, residential address, in respect of students their class, name of the institute and thereafter there was a column having heading 'if earning', in which name of the employer // 10 // and earning per month was to be given. In that column figure 3,10,000 was filled against the name of the complainant, figure 3,10,000 against the name of his wife and figure 1,10,000 against the name of Sajal Agrawal and Soyash Agrawal, respectively. Thus, it is clear that the aforesaid figures were filled in the column of name of employer and monthly earning of the persons to be insured. There appears not even a single word on the basis which it can be said that there was any proposal for enhancement of sum insured from Rs.2,00,000/- to Rs.3,10,000/- for the complainant / appellant and for his wife. Nowhere anything about enhancement of sum insured to Rs.3,10,000/- or something else has also been stated in the Form.
14. Apart from it, there is no material on the basis of which it can be said that this Form was ever submitted before the insurance company. There is no endorsement of receipt on this document, nor any signature of any officer or seal impression of the insurance company. There also appears no separate receipt issued by the insurance company. There appears to be a mere statement of the complainant in the form of affidavit to the effect that whatever has been stated in the complaint is true to his knowledge and in the complaint it has been stated in paragraph No.6.4 that he decided to get the insurance coverage enhanced and submitted form dated 30.03.2010, wherein the proposed enhancement was duly detailed. It has again been submitted // 11 // that the enhancement of coverage was duly accepted by the non- applicant / Company.
15. This statement of the complainant which has been stated in the complaint itself is not acceptable. Firstly because it has been denied by the insurance company through its Manager, P.K. Mehta in his affidavit; secondly Annexure A-1 is not a proposal for enhancement of sum insured from Rs.2,00,000/- to Rs.3,10,000/- and thirdly that there is no acknowledgement of submitting this form before the insurance company nor any receipt nor any document to show that proposal for enhancement was accepted by the Insurance Company, has been obtained by the appellant / complainant.
16. If somebody deposits some amount in the Office of the insurance company, as premium of group mediclaim policy, then normally the Office of the insurance company issues receipt. In the present case, there is document Annexure A-2, which is a receipt, which nowhere says that this receipt is in respect of acceptance of proposal of enhancement of the mediclaim insurance cover. The receipt merely shows that it is mediclaim premium for the period 2010-
11. So, if a mediclaim premium was deposited by the appellant for a particular year in the Office of the insurance company and it has been accepted, particularly on 31.03.2010, which is last date of the financial // 12 // year, then by no stretch of imagination it can be said that this deposit was made by the appellant / complainant after acceptance of any proposal for enhancement of mediclaim insurance cover.
17. It is well settled that a contract of insurance is not complete unless there is a proposal and then there is acceptance of that proposal. In the present case, neither the proposal has been proved to have been made before the respondent / insurance company nor there is any material to show that any such proposal was ever accepted by the Insurance Company.
18. Thus, there appears nothing on the basis of which it can be said that the appellant was enjoying enhanced group mediclaim insurance cover under the insurance policy issued by the respondent Company.
19. Apart from it, it was not possible for the insurance company to have enhanced the insurance policy under the policy of the insurance company in respect of coverage under the group mediclaim policy, Annexure D-2, which was filed before the District Forum and whole booklet having heading Reference Book for Personnel Administration filed before us, clearly show that the retired employees, before retirement, were having only one opportunity of exercising option for enhancing the mediclaim coverage, maximum up to Rs.3,00,000/- and // 13 // thereafter there was no opportunity for a retired employee to make proposal for enhancement of mediclaim insurance cover. Admittedly, the complainant retired from the services of the respondent Company when he opted for voluntary retirement long back in the year 2004 and in the document which has been filed by the complainant before us at the appellate stage, as evidence, it has been stated that he has taken SVRS in the year 2004. Thus, he ceased to be a regular serving employee since 2004 and remains retired employee of the respondent / insurance company since 2004, so his right to exercise option for enhancing sum insured had already expired in the year 2004 and thereafter he could not have made any proposal for enhancement of sum insured under group mediclaim insurance cover policy and so also it cannot be said that the coverage was enhanced by the respondent from Rs.2,00,000/- to Rs.3,10,000/- as some extra premium was deposited by the appellant.
20. It is again worth mentioning that in reply to the application moved under Right to Information, the respondent Company had also sent the premium chart for calculation of mediclaim premium for retired employees from the year 2006-07 and 2009-10. That chart which was enclosed with the letter has not been produced by the appellant before us. There is possibility that, the said chart may be containing some information that the amount which was deposited by // 14 // the appellant / complainant vide document Annexure A-2, may be the revised premium payable in that year for the coverage which were available to him under the existing policy.
21. In view of the aforesaid discussion, it is clear that the appeal has no substance and is liable to be dismissed. The same is thus dismissed. No order as to cost.
(Justice S.C.Vyas) (V.K. Patil)
President Member
/07/2012 /07/2012