First Appeal No. 1025 of 2010

16th July, 2012

Petitioner Counsel: Mr. M.G. NADKARNI.

JUDGMENT

-Mr. S.B.Mhase, Hon'ble President :- Opponent's advocate is absent. No one is authorized to represent the opponent. We heard Mr. M.G.Nadkarni-Advocate for the appellant.

2. This appeal is directed as against the order passed by District Forum, Central Mumbai in consumer complaint no.1/2010 decided on 17/08/2010. Complainant has approached the District Forum claiming insurance claim of eye surgery for '22,665.78 ps. Said claim was not given by the opponent/respondent and, therefore, above referred consumer complaint was filed. However, said consumer complaint was dismissed by the District Forum on the above referred date. Therefore, being aggrieved and dissatisfied with the order of District Forum, Central Mumbai in consumer complaint no.1/2010, original complainant has preferred this appeal.

3. The facts which are eloquently crystal clear are as follows:-

4. Opponent is a company having Central Government incorporation Registration no.11/105363. In order to avail the membership of the opponent, complainant appellant has paid an amount of '25,925/- as subscription for getting membership and other benefits. Accordingly, luxury membership was given to the appellant/ complainant. Under this luxury membership, appellant/ complainant was entitled to have 61 Room Nights Purchased. Surrender value of non utilization of the room rent facility is quoted to be '51,850/-. Thus, as per this membership, appellant/ complainant was entitled for stay in the various hotels, restaurants of the respondent company. Apart from the hospitality benefits conferred upon the said membership, there was further benefit of insurance. Under this appellant was entitled to have Personal Accidental/Death Insurance to the extent of '5,00,000/- being the sum insured and the validity of the said accident policy was 18/11/2005. There was also Mediclaim insurance benefit of '25,000/- and the commencement date of the said Mediclaim benefit was 23/11/2005. Total period of membership was/is six years and therefore, from 31/10/2005 to 31/10/2011, appellant/complainant being a member was entitled to have above referred facilities. It is also a fact that in the year 2007 the claim was made in respect of right eye cataract operation of the complainant and the claim was made for '19,656/- and it was accepted by the opponents. However, thereafter in April 2008 another cataract operation of left eye was carried out and expenses incurred by the complainant for the same were/are '22,665.78 ps. Therefore, complainant lodged the said claim. However, it was not paid and, therefore, consumer complaint has been filed.

5. It appears from the written version and the documents produced before the District Forum that initially opponent had taken group insurance policy known as 'Standard Group Insurance policy' covering the liability of '25,000/- and, therefore, when the first claim was made it was satisfied by the Insurance Company. Earlier policy which was taken by the opponent was for a period of one year and, thereafter, they had taken another Group insurance policy. Said Insurance policy is known as 'Janata Mediclaim policy' and while taking the said Janata Mediclaim policy opponent ought to have insured the complainant for an amount of '25,000/- as per the membership, but instead of that, to save the premium opponent had taken an insurance policy 'Janata Mediclaim policy' under which cataract operation was/is covered only to the extent of '10,000/-. It is also brought on record that cheque of '10,000/- was given by the Insurance Company to the opponent, but at no point of time the said cheque was forwarded by the opponent to the complainant/ appellant. Therefore, fact remains that even though amount of '10,000/- was admissible under 'Janata Mediclaim policy' and was received by way of cheque, the opponent did not bother to make payment of the same to the complainant.

6. What is important is to be noted that in view of the luxury membership, the opponents were under contractual obligation to provide insurance benefits as stated in the said luxury membership certificate as per the terms and conditions which are printed on the overleaf of the said membership. Terms and conditions contemplate Group Insurance policy. As per the assurance given to the complainant, opponents were under obligation to secure mediclaim insurance claim of the complainant to the extent of '25,000/-. However, it is revealed that by Janata Mediclaim policy claim was insured to the extent of '10,000/- so far as cataract or eye surgery is concerned. This they have done taking risk on them. No doubt even if they have not taken insurance policy for '25,000/- yet in view of contractual obligation with the member, they are under obligation to make payment under Mediclaim upto '25,000/-, whether they obtain it from the Insurance Company or they have to pay from their own funds. Even if the insurance is not taken, they themselves are under obligation to provide and pay insurance claim in view of their contractual relationship. Therefore, what we find that the cheque of '10,000/- was received by them from the Insurance company. So far as complainant is concerned, she is entitled to receive claim of '22,665.78 ps. and since claim of the complainant is pending since April 2008, the complainant is also entitled to get benefit of interest @ 15% p.a. All these aspects were not considered by the District Forum rightly and, therefore, order of the District Forum is required to be set aside. Hence, we pass the following order:-

ORDER

1. Appeal is allowed.

2. Order passed by the District Forum is quashed and set aside.

3. Respondent/original opponent is hereby directed to make payment of '22,665.78 ps. along with interest @ 15% p.a. from the date of operation i.e.22/04/2008 till the date of actual payment. Amount shall be paid within a period of one month. If there is failure to pay the amount within a period of one month, further penal interest @ 3% p.a. will be charged and recovered on a total amount.

4. By way of costs of this litigation, respondent/opponent shall pay to the complainant an amount of '10,000/-.

5. Pronounced in the open court.

6. Copies of the order be furnished to the parties.

Appeal allowed.