State Consumer Disputes Redressal Commission
National Insurance Company Ltd., vs Hari Singh on 22 October, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
PLOT NO. 1037, SECTOR 37-A DAKSHAN MARG, CHANDIGARH
First Appeal No. 1407 of 2010
Date of institution : 10.08.2010
Date of decision : 22.10.2012
1. National Insurance Company Ltd., Regional Office, SCO No. 332-334, Sector 34-
A, Chandigarh, through its duly constituted Attorney.
2. Med Save Healthcare (TPA) Ltd., SCO No. 121-122-123, second floor, Sector
34-A, Chandigarh.
...Appellants
Versus
1. Hari Singh s/o Bara Singh, resident of village Saunti PO Amloh, District
Fatehgarh Sahib.
...Respondent
2. The Saunti Co-operative Agricultural Service Society Ltd. Saunti Tehsil Amloh,
District Fatehgarh Sahib through its Secretary/President
3. The Deputy Registrar Co-Operative Societies, Fatehgarh Sahib
4. Mukat Hospital & Heart Institute, SCO No. 47-49, Sector 34-A, Chandigarh.
.....Performa Respondent
First Appeal against the order dated 12.07.2010 of
the District Consumer Disputes Redressal Forum,
Fatehgarh Sahib.
Before:-
Sh. Piare Lal Garg, Presiding Member
Sh. Jasbir Singh Gill, Member Present:-
For the appellants : Sh. G.D.Gupta, Advocate
For the respondent No.1 : Sh. Sukhbir Singh, Advocate for
Sh. Nakul Sharma, Advocate
For respondent No. 2&3 : Ex-parte
For respondent No. 4 : Sh. D.K.Singal, Advocate
JASBIR SINGH GILL, MEMBER
This is an appeal filed by OPs No. 1 & 2/appellants (herein after called the appellants) against the order dated 12.7.2010 passed by the District Consumer Disputes Redressal Forum, Fatehgarh Sahib (hereinafter called as "District Forum") by which the complaint of respondent no. 1 was allowed.
First Appeal No. 1407 of 2010 2
2. The brief facts of the case are that the respondent No. 1 was member of the Saunti Co-op. Agricultural Service Society Ltd., Saunti. Respondent No. 1 was covered under the Bhai Ghanhya Sehat Sewa Scheme bearing policy No. 400104/46/08/85/00000096 valid for 1.10.2008 to 30.9.2009. Identity card number was 90102220700064 Z, SO Code number was issued to the respondent no. 1 by the appellants. The respondent No.1 was got admitted in Mukat Hospital and Heart Institute, Chandigarh for treatment on 2.6.2009and was discharged on 10.6.2009.
3. As per policy of the insurance the treatment was cashless as the said hospital was on the panel of the appellants. As per the terms & conditions of the policy the expenditure of the treatment was to be paid by the appellant to the hospital. Inspite of the fact that the identity card was shown to the authorities of the hospital, an amount of Rs. 1,50,000/- was got deposited on different dates by the hospital authorities from respondent No. 1. Respondent No. 1 approached the appellants for the payment of claim but the same was not paid by the appellants on the vague ground that correct age of Bhajan Kaur was not disclosed by respondent No. 1 at the time of filling the proposal form to take the insurance policy. The complaint was filed alleging that there was deficiency in service and it was unfair trade practice on the part of the appellants with the prayer that the appellants may be directed to refund the amount of Rs. 1.50 lacs which was paid by respondent No. 1 alongwith other expenses and Rs. 20,000/- may be awarded as compensation.
4. After notice, the appellants appeared and replied by stating that Insurance Company had issued group medical insurance policy under Bhai Ghanhya Sehat Sewa Scheme for the period of 1.10.2008 to 30.9.2009 covering the members and employees as well as other family members of cooperative societies. The policy covered the risk of treatment of all medical/surgical diseases, requiring minimum 24 hours hospitalization up to an expenditure of Rs. 2 lacs per year per family. As per policy only treatment from network hospital/nursing home empanelled by the insurer was payable. Respondent No. 1 alongwith his family members was insured under the policy. Third Party Administrator (TPA) had considered the claim and found that the claim was not payable as the insured had declared the age of his wife Smt. Bhajan Kaur as 53 years at the time of enrolment. But later on vide her voter card ID No. BSL 207619 it was revealed that she First Appeal No. 1407 of 2010 3 was 59 years old. Respondent No. 1 had intentionally given wrong age in order to pay less premium. This was violation of terms and conditions of the policy. Therefore the card of the respondent No. 1 was cancelled alongwith family members due to age discrepancy of Bhajan Kaur. Information regarding this was given vide letters No. 228 and 288 dated 14.5.2009 and 14.7.2009 respectively.
5. Respondent No. 3 replied by taking preliminary objections that the complaint was not maintainable, complaint was false, frivolous and vexatious, District Forum has no jurisdiction to try and decide the complaint. On merits, it was pleaded that member/beneficiary had been clearly informed regarding financial and legal liabilities, if any, arising consequent to the operationalization of the scheme or the policy, shall rest exclusively and unconditionally with the TPA & the Insurance Company i.e. the appellants and respondent No. 3 was not responsible in any manner. The role of the Trust was/is only confined to the passing of the premium paid by the members to the insurer on their behalf.
6. Reply of the OP No. 6 (not arrayed as a party in the appeal) is on the same footings as of respondent No. 3. It was stated that role of the Trust was only confined to the appointment of insurer and passing on the premium paid by the members to the insurer on their behalf. The member had given his/her undertaking on the enrollment form which was supplied to him/her that he/she had read and understood all the terms and conditions of the Scheme and undertook to abide by all such terms and conditions, which were contained in the service level agreement executed between the Trust and the insurer on behalf of the beneficiaries by respondent No.3.
7. Respondent no. 4 replied by taking preliminary objections that the complaint was not maintainable qua the answering respondent, District Forum had no territorial jurisdiction to try and decide the complaint. On merits, it was admitted that respondent No. 1 was admitted in the hospital and it was clarified that the treatment was to be given cashless only if respondent No. 4 received authorization from the appellant. It was pleaded that the answering respondent was on the panel of the appellant-Trust but the treatment amount was charged as the I.D. card of respondent No. 1 was cancelled, as such, respondent No. 1 was not entitled for cashless treatment.
8. Parties filed their respective evidence by way of affidavits and documents. First Appeal No. 1407 of 2010 4
9. Learned District Forum, after going through the pleadings of the parties and evidence on record, allowed the complaint and ordered the opposite party No. 1 to 3(the appellants) to pay respondent No. 1 Rs. 1.50 lacs as insurance amount within one month after receiving the copy of the order.
10. Hence the appeal.
11. 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 learned counsel for the parties.
12. The only question for consideration before us is whether the appellants were justified in cancelling the identity card?
13. The appellants had produced identity card Ex. R-3 of Smt. Bhajan Kaur wife of Hari Singh issued by Bhai Ghanhya Sehat Sewa Scheme in which her age was mentioned as 53 and also produced Ex. R-4 i.e. voter card issued by the Election Commission in which her age was mentioned as 55 years on 1.1.2006. No doubt in both the documents the age of Bhajan Kaur was mentioned differently.
14. Before the acceptance of date of birth mentioned in the member enrollment form under Bhai Ghanhiya Sehat Sewa Scheme, no objection was raised regarding the age of Bhajan Kaur by the appellants and even till the submission of the claim by respondent No. 1, no query was raised by the appellants regarding the age of Bhajan Kaur mentioned in the Member Enrollment Form.
15. 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 enrollment 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."
16. It is also settled law that if once the insurance co. accepts the age of the life assured, they have no right to repudiate the insurance claim by alleging her age to First Appeal No. 1407 of 2010 5 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. 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."
17. 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;
(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.
18. 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 First Appeal No. 1407 of 2010 6 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."
19. In view of the above proposition of law, it is proved that the appellants have wrongly repudiated the claim of respondent No. 1 on the ground that age of her wife Smt. Bhajan Kaur was wrongly mentioned in the enrollment form and this ground of the appellant is not justified as per the settled law and respondent No. 1 is entitled to receive Rs. 1,50,000/- from the appellant spent on his treatment.
20. The order passed by the learned District Forum is legal and valid and there is no ground to interfere with the same. The appeal being without any merit is dismissed and the impugned order of the District Forum is affirmed and upheld. No order as to costs.
21. The arguments in this appeal were heard on 10.10.2012 and the order was reserved. Now the order be communicated to the parties.
22. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to respondent No. 1by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants.
23. Remaining amount shall be paid by the appellants to respondent No. 1 within 30 days from the receipt of the copy of the order.
24. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(PIARE LAL GARG) PRESIDING MEMBER (JASBIR SINGH GILLL) MEMBER October 22, 2012.
As Kalyan
First Appeal No. 1407 of 2010 7