NIC Ltd. v. Umar Ranjit Singh

First Additional Bench STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH. First Appeal No.1291 of 2011 Date of institution : 28.05.2011. Date of Decision : 24.03.2015. National Insurance Company Ltd., Sector 34 Chandigarh through its duly authorized officer. ..Appellant/Opposite party No.2. Versus Umar Ranjit Singh aged about 60 years S/o Ranjit Singh, r/o Village Naina Khurd, Tehsil and District Patiala. ..Respondent/Complainant. First Appeal against order dated 18.07.2011 of District Consumer Disputes Redressal Forum, Patiala. Before:- SH.J.S.KLAR, PRESIDING JUDICIAL MEMBER SH.VINOD KUMAR GUPTA, MEMBER Present:- For the appellant : Sh.Vinod Gupta, Advocate For the respondent : Ex-parte VINOD KUMAR GUPTA, MEMBER : This appeal has been preferred by appellant (the opposite party No.2 in the complaint) under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act) against respondent (the complainant in the complaint), challenging order dated 18.07.2011 in C.C. No.38 of 2010 passed by the District First Appeal No.1291 of 2011 Consumer Disputes Redressal Forum, Patiala (in short the District Forum), vide which, the complaint of the complainant was accepted and OPs were directed to reimburse the claim of the complainant for the sum of Rs.13,400/-, besides Rs.20,000/- as compensation for mental harassment and Rs.5,000/- as costs of litigation. OP No.2 (the present appellant) has been further directed to make the payment of the said amount to the complainant within one month from the date of receipt of the certified copy of the order, failing which, the complainant was held entitled to recover the amount with interest @ 10% w.e.f. 01.11.2009. The instant appeal has been preferred against the same by OP No.2, the present appellant in this appeal.

2. The brief facts of the case are that Sh.Umar Ranjit Singh, complainant filed the complaint under the Act, 1986 against the opposite parties on the averments that the complainant was got issued a medical insurance policy No.400140/46/08/85/00000096 under Bhai Ghaniya Sehat Sewa Scheme from OP No.2 (NIC) after fulfilling all the requirements under the said scheme. The said policy was valid for the period 01.10.2008 to 30.09.2009. The ID Card of the said policy was also duly issued to the complainant. Under the scheme of the policy, the complainant was insured upto the amount of Rs.2,00,000/- for medical expenses and the complainant could get himself treated in respect of diseases, as mentioned in the policy from the hospital, as provided in the list by the OPs. It was further pleaded that he got himself admitted in the Sadbhawna Medical First Appeal No.1291 of 2011 Hospital and Heart Institute Patiala, on 06.06.2009 for having suffered from hyper tension and gastritis and was discharged therefrom on 10.06.2009. During his treatment, he had submitted his I-card to the authority of the hospital, when they checked the same to see the validity, they told that the card had been cancelled. It was pleaded that the complainant incurred the expenses of Rs.13,400/-, which was paid by him from his own pocket to the hospital authorities. Thereafter, he was admitted in the DMC Hospital Ludhiana, which was also the approved hospital under the list of OPs and complainant spent Rs.50,000/- thereupon as well. It was further averred that the complainant repeatedly requested the coordinator of the scheme Dr.Preet Kamal Joshi, but she refused to reimburse the claim of the complainant. The complainant had also served legal notice to OP No.1 in this regard, but no reply was given to the same. The complainant filed the complaint seeking directions to the OPs to reimburse the claim of Rs.13,400/- for the expenses incurred by him on his medical treatment at Sabhbhawna Medical Hospital and Rs.20,000/- for mental harassment and to pay Rs.50,000/- on his treatment in the DMC Hospital, Ludhiana alongwith interest @ 12% and to further pay Rs.5,000/- as cost of litigation.

3. The complaint was contested by the opposite parties by filing the written reply before the District Forum raising preliminary objections that the complainant is not a consumer, since his claim has been repudiated and he has been informed accordingly. The District Forum has no jurisdiction to try and First Appeal No.1291 of 2011 decide the complaint, as the jurisdiction therefor lies with the Joint Registrar of Cooperative Societies Punjab Chandigarh only and the complaint is not maintainable in the absence of the Bhai Ghanaya Trust Sector 17, Chandigarh and Nain Khurd Cooperative Service Society. On merits, it was replied that the OP No.2 had issued group medical policy in favour of Bhai Ghaniya Trust Sector 17, Chandigarh under Bhai Ghaniya Seha Sewa Scheme for the period 01.10.2008 to 30.09.2009 covering the members and employees, as also their family members in respect of the eligible Co-operative Societies under the Punjab Co- operative Societies Act, 1961 covering the risk of treatment in respect of medical or surgical disease including 24 hours hospitalization upto the expenditure of Rs.Two Lacs per year, per family on floaters basis. It was further pleaded that Nain Khurd CASS had purchased the policy for its members including the complainant and his family members from Bhai Ghaniya Sehat Sewa Trust. It was further averred that the third party administrator (TPA), implemented the scheme considered the claim under the terms and conditions of the policy and found that the claim was not payable as the insured had declared the age of his wife Smt. Mohinder Kaur as 71 years at the time of enrolment and the same having been attested by the gazette officer of the Society but lateron, vide Voter ID No.PB/08/073/240257, it was revealed that Smt. Mohinder Kaur was aged 80 years. In that way, the complainant had intentionally given wrong date of birth of Smt. Mohinder Kaur at he time of purchasing the policy. It is further First Appeal No.1291 of 2011 submitted that as per terms and conditions, a person of more than

75 years is not covered under the policy and therefore, the policy is void abinitio and the card of the complainant was cancelled qua the member of his family. The information in that card was circulated to all the concerned quarters, vide letters no.228 dated 14.5.2009 and 288 dated 14.7.2009. The insurance company was not under any liability to pay Rs.11,100/-, as only a cataract surgery is covered under the policy and the company was not liable to pay for vitamins, tonic, room charges, diagnostic fee, nursing fee etc. and the company has a limited liability to pay Rs.6000/- for cataract surgery. Other allegations of the complaint were denied by the opposite parties and the dismissal of the complaint was prayed for.

4. The complainant tendered in evidence his affidavit Ex.C-1/A alongwith documents Ex.C-1 to C-13 and closed the evidence. On the other hand, the OPs tendered in evidence the affidavit of Jaspal Dr.Roli Aggarwal Ex.R-1 alongwith the documents Ex.R-3 to R-7 and closed the evidence. On conclusion of evidence and arguments, the District Forum, accepted the complaint of the complainant and directed the OPs to reimburse the claim of the complainant for a sum of Rs.13,400/- and also to provide him the compensation of Rs.20,000/- for mental harassment and Rs.5000/- as costs of litigation. The OP No.2 was directed to make the payment of the said amount to the complainant within one month on the date of receipt of the certified copy of the order failing which, the complainant was held entitled First Appeal No.1291 of 2011 to recover the amount of Rs.13,400/- with interest @ 10% w.e.f.01.11.2009, as the complainant had served OP No.1 with a notice date 14.10.2009. Dissatisfied with the above order of the District Forum, OP No.2 now appellant has filed this appeal against the same.

5. We have gone though the record of the case and heard learned counsel for the appellant as the respondent was proceeded against ex-parte in this appeal.

6. As per the affidavit of Umar Ranjit Singh complainant Ex.C-1/A, he deposed that he was issued a medical insurance policy No. No.400140/46/08/85/00000096 under Bhai Ghaniya Sehat Sewa Scheme by OP No.2 after fulfilling all the requirements under the said scheme. The said policy was issued and was valid for the period 01.10.2008 to 30.09.2009, which is proved on record vide Ex.C-1. As per the version of the complainant, he was admitted in the Sadbhawna Medical Hospital and Heart Institute on 06.06.2009 for having suffered from hyper tension and gastritis and was discharged therefrom on 10.06.2009, which is proved on record Ex.C-2. The complainant has placed on record the medical bills Ex.C-3 for Rs.9915/- and Rs.3485.30 Ex.C-4. We have perused Ex.R-3, the detail of members and Mohinder Kaur of policy No.400140/46/ 08/85/00000096, was recorded with date of birth shown as 01.01.1938 aged 71 years. As per the list of the voter card Ex.R- 4, the age of Smt.Mohinder Kaur was shown as 80 years. The version of the OPs is that the claim is not payable as the insured First Appeal No.1291 of 2011 had declared the age of his wife Smt.Mohinder Kaur as 71 years at the time of enrolment, which is much lesser than her actual age. However, lateron, vide her voter card ID No.PB/08/073/240257, it was revealed that she was actually aged 80 years. As per the terms and conditions of the policy, a person of more than 75 years is not covered under the policy and, thus, could not be insured. The card of the complainant was cancelled alongwith his family members on account of the age discrepancies of above Mrs.Mohinder Kaur. Thus, the information has been circulated to all the concerned quarters vide letters No.228 dated 14.5.2009 and 288 dated 14.7.2009 respectively. So, the claim of the complainant is not payable.

7. We have perused the affidavit of Dr.Rolli Aggarwal, Regional Manager, Med Save Health Care(TPA) Ltd. vide Ex.R-2, the relevant part reads as under :- "2. That the card of the complainant Mr.Umar Ranjit Singh-90108033400008Z and his family members are cancelled due to the age discrepancy of Mrs.Mohinder Kaur-90108033400008G mother of the complainant. That at the time of enrollment Mrs.Mohinder Kaur enrolled herself as 71 years. But, as per Election Commission Voter ID no.PB/08/073/240257 her age revealed as 80 years. That as per the policy terms & conditions, the person with age more than 75 years not covered under the policy. That we have also circulated this information to all the concerned quarters vide our letter no.228 and

288 dated 14th May, 2009 and 14th Jul, 2009 respectively." First Appeal No.1291 of 2011

8. The controversy between the parties, which led to the repudiation of the contract of insurance by the National Insurance Company, is on account of fraudulent age stated by the complainant to the OPs of his mother Mohinder Kaur or of his own age. The stand of the OPs Now appellant in this case is that fraudulent age of the mother of the complainant or of the complainant have been given in this case. The contract of insurance is based on utmost good faith and the insured is insured by the insurer taking his information to the credible one, as supplied. The appellants relied upon the Voter list Ex.R-4 contending that at serial no.584, Mohinder Kaur wife of Ranjit Singh is recorded as 80 years of age in the year 2009. The further contention of appellant is that a person beyond 75 years of age could not be insured under the contract of insurance, as per Clause 1.1 of guide book under the above scheme. We find force in the submission of the counsel for the appellant on the record. Appellant Umar Ranjit Singh has stated his age in the complaint as well as in his affidavit Ex.C-1/A as 60 years on 06.05.2010, vide Identity Card Ex.C-1, the complainant is recorded as 59 years of age. The matter is further precise by Ex.C-9, wherein the date of birth of complainant is specifically recorded as 9.10.1949. Ex.C-9 has proved that the complainant was born on 09.10.1949 and this is the own document of the complainant. The identity card of mother of the complainant Mohinder Kaur is Ex.R-3 on the record. Her date of birth is recorded as 1-1-1938 specifically in it. The age difference between the complainant and his mother Mohinder Kaur First Appeal No.1291 of 2011 is 11 years only. We are of this view that it is biologically impossible that the complainant was born to his mother, when she was eleven years of her age only. In the circumstances of the case, when the case of the complainant has crumbled with his own weight, hence, we can safely rely upon the voter's list Ex.R-4 recording Mohinder Kaur to be 80 years of age, which appears to be probable and believable. We are of this considered view that either complainant gave wrong date of birth deliberately of his mother or of his own to the OPs in a malafide manner. It vitiates the contract of insurance, which is based on utmost good faith. We find that the voter's list remained unrebutted by the complainant on the record and rather the evidence of the complainant is not worthy of any credence at all in this case. The District Forum has not appreciated the controversy in this case in the proper perspective. The order of the District Forum is liable to be reversed in this appeal.

9. Sequel to above discussion, the appeal filed by the appellant is accepted and the order of the District Forum under this appeal is hereby set-aside resulting into dismissal of complaint.

10. The appellant/OP No.2 has deposited an amount of Rs.20,000/- with this commission at the time of filing the appeal. The amount of Rs.20,000/- with interest accrued, if any, be remitted by registry to the appellant/OP No.2 by way of a crossed cheque/demand draft after the expiry of 45 days. First Appeal No.1291 of 2011

11. The arguments in this appeal were heard on 13.03.2015 and the order was reserved. Now the order be communicated to the parties.

12. The appeal could not be decided within the statutory period due to heavy pendency of Court cases. (J.S.Klar) Presiding Judicial Member March 24, 2015. (Vinod Kumar Gupta) Lb/- Member