Back
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
M. Shreesha, Presiding Member and Dr. S.M. Kantikar, Member
S. Lakshmanan —Petitioner
versus
New India Assurance Co. Ltd.
and Ors. —Respondents
Revision Petition No.1183 of 2013
(Against the Order dated 26/07/2012 in Appeal No. 631/2010 of the State Commission Tamil Nadu)
Decided on 22.1.2019
Counsel for the Parties:
For the Petitioner:Mr. Rajat Agnihotri, Advocate
For the Respondents: NEMO
IMPORTANT POINT
Insurance Company, keeping in view principle of natural justice should clarify to Petitioner with respect of withdrawal of any circular.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Group Insurance Policy—Treatment for cancer—Insurance Company stopped paying bills raised by Complainant—State Commission vide its impugned order, modified order of District Forum by directing Insurance company to reimburse sum of Rs.15,919/- along with 9% interest and cost of Rs.500/-—However, State Commission set aside award of compensation of Rs.7500/-— Respondents have been continuously accepting premium payable towards Mediclaim Policy—Insurance Company, keeping in view principle of natural justice should clarify to Petitioner with respect of withdrawal of any circular and also clarify if any such expenses can be given to Petitioner who is an employee of their own company—Apart from reimbursement of expenses Petitioner is entitled to compensation of Rs.50,000/- for having not been informed at an appropriate time regarding any cancellation or withdrawal of circular relied upon by him and also with respect to any new circular/ rules if issued by Insurance Company and also for continuously accepting premium amount.
Held: The District Forum allowed the Complaint and directed the Insurance Company to pay a sum of Rs.15,919/- towards the medical expenses along with Rs.7500/- towards compensation for mental agony and Rs.500/- towards costs.
The Insurance Company preferred an Appeal before the State Commission which, vide its impugned order, partly allowed the same and modified the order of the District Forum by directing the Insurance company to reimburse a sum of Rs.15,919/- along with interest @ 9% p.a. from the date of repudiation till realization and cost of Rs.500/-. However, the State Commission had set aside the award of compensation of Rs.7500/-.
Admittedly, the Respondents have been continuously accepting the premiums payable towards the said mediclaim policy and the learned counsel contended that the Petitioner should be entitled to the benefits of the Insurance Policy till 31.03.2013. A brief perusal of the prayer of the Complainant shows that he is seeking the direction for reimbursement of the medical bills from April, 2007 to December, 2007 and till date and thereon.
Keeping in view the aforenoted circulars, facts and circumstances of the case together with submissions of the learned counsel for the Petitioner we are of the view that the Insurance Company, keeping in view the principle of natural justice should clarify to the Petitioner with respect of the withdrawal of any circular and also clarify if any such expenses can be given to the Petitioner, who is an employee of their own company. Apart from the reimbursement of expenses we are of the considered view that the Petitioner is entitled to a compensation of Rs.50,000/- for having not been informed at an appropriate time regarding any cancellation or withdrawal of the circular relied upon by him and also with respect to any new circular/ rules if issued by the Insurance Company and also for continuously accepting the premium amount.
(Paras 4, 5, 10 and 13)
Result: Revision Petition disposed of.
M. Shreesha, Presiding Member—By this Revision Petition under Section 21(b) of the Consumer Protection Act, 1986 (for short the “Act”) Sh. S. Lakshmanan (hereinafter referred to as “the Complainant”) challenges the order dated 26.07.2012 in Appeal No. 631/2010, passed by the Tamil Nadu State Consumer Disputes Redressal Commission, Chennai (for short “the State Commission.”). By the impugned order, the State Commission has partly allowed the Appeal, preferred by New India Assurance Co. Ltd. (hereinafter referred to as “the Insurance Company”) and modified the order of the District Consumer Disputes Redressal Forum, Tiruchirapalli (for short “the District Forum”) by setting aside the award of compensation.
2. Briefly put, the facts of the case are that the Complainant being an employee of the Insurance Company, during his service tenure, entered into a Group Insurance Policy with the Insurance Company. He was diagnosed with cancer in the left lobe of thyroid, he underwent treatment for Hodgkin’s disease treated with radiotherapy. Due to his health condition, he had taken voluntary retirement in April, 2004 and was relieved from the service. However, he continued to pay the premium and receive the medical benefits from the Insurance Company. It was stated that since the Complainant was a cancer patient he had to take treatment regularly and he used to claim the reimbursement of the expenses incurred by him towards his treatment and medicines every month and the Insurance Company allowed and paid the same till March, 2007. However the Insurance Company, all of a sudden, stopped paying the bills raised by the Complainant w.e.f. April, 2007. On his enquiry he was told that his claim was rejected due to audit objections.
The Complainant sent a letter to the Insurance Company on 05.05.2007 which replied vide its letter dated 23.05.2007, stating therein that a person who is suffering from cancer cannot obtain benefits of mediclaim policy. It was further stated by the Complainant that on the basis of the circular dated 05.09.1990, he was entitled to claim Domiciliary Hospitalization and even though the said fact was brought to the notice of the Insurance Company, the Insurance Company failed to pay the amount to him and took the stand that the Circular dated 05.09.1990 was not applicable in his case. The Insurance Company was informed that a similarly situated employee got this benefit and in spite of that the Insurance Company did not pay him the claim amount to the tune of Rs.15,919/-. Feeling aggrieved, the Complainant filed a Complaint before the District Forum seeking directions to the Opposite Party to pay a sum of Rs.15,919/- along with Rs.50,000/- towards damages for mental agony and Rs.25,000/- towards compensation for deficiency in service together with costs.
3. The Insurance Company filed its Counter Affidavit stating therein that the Complainant had opted for VRS and the same was allowed in April, 2004. The Insurance Company floated a scheme titled “Group Mediclaim Policy” for the welfare of its employees and it was made applicable to the retired employees as well. Complainant had also opted for the said Scheme and was paying necessary premium year after year by renewing the said policy and the policy was in vogue till 31.03.2008. It was stated that the Complainant had filed 9 claim forms claiming reimbursement of expenses incurred on medicine for the period from April to December, 2007. He claimed the bills as reimbursement on domiciliary hospitalization expenses based on a circular of GIC dated 05.09.1990. The Insurance Company was honouring the bills under bona fide belief till the objection was raised by the audit wing. It was submitted that the bills under domiciliary hospitalization are reimbursable in such a circumstance where the condition of the patient is such that he cannot be moved to the hospital for
