S.P. SHARMA vs NATIONAL FERTILIZER LTD. & ORS.

Revision Petition No. 725 of 2013 has been filed by the petitioner/complainant against the order dated 7.9.2012, passed by Haryana State Consumer Disputes Redressal Commission, Panchkula (for short, "State Commission") in First Appeal No.246 of 2012.

Brief facts of the case as per petitioner/complainant are that the respondent no.1/OP No.1 as per its circular No.NFL/PT/P&A/MIP-2010-2011 offered a cash less medi-claim policy for the families of their ex-employees. The petitioner is an ex-employee of respondent no.1 having E-code No.5617. To become a member of cash less medi-claim policy for the year 2010-2011 i.e. w.e.f. 1.4.2010 to 31.3.2011, as desired by the respondent no.1, the petitioner applied for getting the above scheme vide application dated 26.3.2010 and deposited membership fee (Annual) of Rs.7,100/- vide cheque No.021423 dated 26.3.2010 payable at Bank of India, Panipat.

The petitioner personally met with officials of respondent no.1 many times to enquire about his policy as he had not received the same even after a lapse of so many days. In spite of issuing the policy on 27.9.2010, cards No.G10R0101350379 & G10R0101350380 were received by the petitioner through respondent no.1 which could not be undelivered earlier since it was dispatched by respondent no.3 without any house number at an incomplete address. Further, petitioner was surprised to note that the validity of the cards for availing cashless medical treatment was only for a period of six months i.e. upto March, 2011 whereas membership fee is for 12 months was made.

The petitioner immediately informed through an e-mail dated 28.9.2010 in this regard to the respondent nos.1, 2 & 3 and requested to extend the validity of the cards for another six months or to refund the amount of six months. Not getting any response from respondents, the petitioner again sent reminder through an e-mail dated 9.10.2010 to all respondents. Then, on 11.10.2010, through an e-mail of respondent no.3 informed that cards were re-issued to the petitioner on 1.10.2010.

On 21.10.2010, again the same No. ID cards were received with the same validity period of six months i.e. upto March, 2011 against which the petitioner had already protested vide his various e-mails and requested to revise their validity period completing 12 months period since amount was paid for 12 months and not for six months. The respondents have not taken any action so far, either to issue the ID cards for a 12 month period or to refund an amount of Rs.3,550/- to the petitioner.

The respondents have failed to discharge their obligation under which the medi-claim policy was obtained by the petitioner. They have also failed to give satisfactory services to the petitioner in respect of dispatching the policy and ID cards well in time to provide cover for 12 months'' period for which the amount was paid by the petitioner.

It was therefore prayed by the petitioner that this Forum may order the respondent company :- Either to issue the insurance policy valid for the period of 21.10.2010 to 20.10.2011 and re-issue the ID cards for the said period or refund an amount of Rs.3,550/-. To pay Rs.50,000/- as reimbursement for harassment and mental agony to the petitioner and as cost upon the respondents for utilizing the hard money of the innocent consumer. Any other expenses which Hon''ble Court deems fit and proper to give justice to the petitioner for the acts committed by the respondents on account of unfair trade practices.

Respondent nos.1 in their reply before the District Consumer Disputes Redressal Forum, Panipat (short, ''District Forum'') has stated that ; " The contents of para no.1 of the petition are admitted. It may be further informed that Corporate Office of answering respondent has been coordinating and taking Group Medi-claim Policy for all the retired employees of NFL and their spouses for indoor medical treatment only. The respondent - insurance company decided to take medi-claim policy for its retired employees for the year 2010-2011 and accordingly, letters were sent to all ex-employees of NFL who were eligible under the scheme for submitting their option in prescribed proforma to take membership of the medi-claim policy. It is relevant to submit that along with the letters salient features of the medi-claim policy proposed to be taken were also sent to all the ex-employees including the complainant. The complainant submitted his application/request for membership of the medi-claim policy after studying and understanding salient features of the policy as is evident from declaration (a) of the aforesaid application. After receiving the request from the employees, answering respondent company got issued/renewed the medi-claim policy bearing No.211600/48/11/2011/80 from the Oriental Insurance Co.Ltd., respondent no.2 for the period from 1.4.2010 to 31.3.2011.

As and when the complainant contacted the officials of the answering respondent, he was informed that medi-claim policy stood issued/renewed from the Oriental Insurance Co. and ID cards will be issued directly either by the insurance company or Third Party Administrator, i.e. Genins India TPA Ltd., respondent no.3 as per the terms and conditions of the policy. There is no question of using of the premium amount by the answering respondent as the same has been utilized for making payment of premium towards the policy. It may be submitted here the ex-employees were required to pay very nominal premium amount depending upon the date of retirement/death of the employee subject to maximum of Rs.7100/- for period of one year and average total amount of the premium paid per employee by NFL under the policy approximately comes to Rs.15,628/- and, therefore, NFL is contributing the balance amount of the same. NFL is taking the medi-claim policy as a part of the company''s commitment towards welfare measures for its retired employees and not for any other purpose.

It is further wrong and denied that any ex-employee was to be issued separate medi-claim policy or any assurance was given to the complainant that he would be issued separate medi-claim policy since the answering respondent has taken Group Medi-claim Policy.

It may be mentioned that as per the clause nos.3.14 & 15 of the policy, ID cards were to be issued to the complainant directly by the third party Administrator, i.e. M/s Genins India Ltd., respondent no.3 and NFL had no role whatsoever in this regard. The ID cards were dispatched to the complainant by the TPA which somehow could not be received by him for not mentioning the complete address on the envelope containing the ID cards. On being informed about the non-delivery of the cards, fresh ID cards were sent by TPA to the answering respondent with the request to deliver the same personally to the complainant. The answering respondent informed the complainant over the telephone about the receipt of their ID cards and delivered the same to him. In this regard, it is pointed out that answering respondent communicated to the insurance company the correct address of the complainant as mentioned by him in the application dated 26.3.2010 referred above. This fact is also clear from schedule of insured persons attached to the policy wherein the name of the complainant is appearing attached to the policy wherein the name of the complainant is appearing at Sr.No.832 along with correct address. Therefore, there is no deficiency of service on the part of the answering respondent in this regard. All the ID cards are valid for a period of one year, which is the tenure of the policy. The medi-claim cards issued to the complainant are also valid for one year. After depositing the premium and issuance of the policy by the insurance company, all the insured persons/members including the complainant are entitled (eligible) to avail of medical facility merely by quoting their employee code No. already allotted to them by NFL while in service. It is not condition precedent under policy that for getting the treatment insured must have ID cards. Even otherwise, the complainant has nowhere stated in the complaint that due to non-delayed issuance of the ID cards he or his spouse was denied the treatment as admissible under the policy or was denied reimbursement against the treatment taken by them."

Respondent no.2 filed separate written statement and in their reply, they denied all the contentions of the petitioner and stated that there was no cause of action against them.

Respondent no.3, M/s Genins India TPA Ltd. did not appear and were proceeded ex-parte before the District Forum.

District Forum vide order dated 24.1.2012 while dismissing the complaint observed that :- "After hearing counsel for the parties and going through the documents it is clear that group medi-claim policy was issued for the total number of employees covered 1106 and total number of dependents covered 998 and insured name is mentioned National Fertilizers Ltd. Hence, the policy was issued to the insured no question arises at all to issue the policy document to all the beneficiary employee. With regard to ID card, insurance company has to issue the ID card and e-mail C12 shows that on the request of complainant card was issued on 1.10.2010. Complainant through this complaint requested to issue the insurance policy from 21.10.2010 to 20.10.2011 and re-issue the ID card but the policy was already been issued by the insurance company to the insured NFL from the period 1.4.2010 to 31.3.2011 after receiving the premium. No premium was received by the insurance company for issuance of a new policy from 21.10.2010 to 20.10.2011. Hence, the complainant is not entitled for the relief claim. In the present case, deficiency of service on the part of the opposite parties is not proved by the complainant by any believable evidence. Hence, the present complaint deserves dismissal."

Aggrieved by the order of the District Forum, petitioner filed an appeal before the State Commission. The State Commission in its impugned order dated 7.9.2012 while dismissing the appeal observed as under :- "From the perusal of the case file, we are of the considered view that group medi-claim policy was issued for the total number of employee covered 1106 to the National Fertilizers Ltd. Hence, the policy was issued to the National Fertilizers Ltd. no question arises at all to issue the policy document to all the beneficiary employee. With regard to ID card, insurance company has to issue the ID card and e-mail C12 shows that on the request of complainant card was issued on 1.10.2010. Complainant through this complaint requested to issue the insurance policy from 21.10.2010 to 20.10.2011 and re-issue the ID card but the policy was already been issued by the insurance company to the insured NFL from the period 1.4.2010 to 31.3.2011 after receiving the premium. No premium was received by the insurance company for issuance of a new policy from 21.10.2010 to 20.10.2011. Hence, the complainant is not entitled for the relief claim. District Consumer Forum after considering each and every aspect of the case rightly dismissed the complaint of the complainant. Accordingly, this appeal is dismissed."

Hence, the revision petition.

We have heard the petitioner in person as well as counsel for respondents nos.1 and 2 and carefully gone through the record.

The petitioner, in person argued that :- The District Forum and the State Commission have gone wrong in holding that since the policy was issued to respondent no.1, therefore, there was no requirement to issue the policy document to all the beneficiary employees. While holding so, the learned Forums below had failed to consider that the ex-employees were the real beneficiaries under the policy and to avail the benefits/treatment under the policy, the respondents were bound to provide at least the basic documents/particulars of the policy to them, which was not done in the present case or with much delay of 6 months. Therefore, there was apparent deficiency in services on the part of the respondents towards the policy holder employees. Therefore, the impugned orders were not sustainable.

The learned forums below have committed an error in dismissing the complaint because under the policy, the employee was entitled to have cash less treatment at the network hospitals, but in-spite of various reminders, the revisionist was not supplied any information in that regard. Further, even for the purpose of availing the cashless treatment facility, the employee was required to have the ID card alongwith the list of paneled hospitals but for about six months, ID cards and list of paneled hospitals were not supplied to the revisionist. Therefore, there was an apparent deficiency in service on the part of the respondents.

Learned counsel for the respondents on the other hand argued that there was no deficiency of service. The respondents had taken a group insurance policy and each beneficiary was not to get a separate policy. Even if the cards were delayed, the petitioner could have availed of the insurance and preferred a claim.

It is an admitted fact that the respondent no.1, National Fertilizers Ltd. had been coordinating and taking Group Medi-claim Policy for all the retired employees of NFL and their spouses for indoor medical treatment only. The respondent no.1 had decided to take medi-claim policy for its retired employees for the year 2010-2011 and letters were sent to all ex-employees of NFL who were eligible under the scheme for submitting their option in prescribed proforma to take membership of the medi-claim policy. Alongwith letters they were also sent salient features of the mediclaim policy proposed to be taken. The petitioner had opted for the mediclaim policy and hence his name has been included. The mediclaim policy was issued/renewed from the Oriental Insurance Company and ID cards were issued directly by the insurance company or Third Party Administrator i.e. Genins India TPA Ltd. Each employee had to pay maximum of Rs.7100/- for one year and average total amount of the premium paid per employee by NFL under the policy approximately came to Rs.15,628/-. NFL was contributing the balance amount of the same. NFL was taking mediclaim policy as a part of the company''s commitment towards welfare measures for its retired employees. As it was a group insurance policy, there was no question of issue of individual insurance policy for each beneficiary. The ID cards also had to be issued by the insurance company or by Third Party Administrator. It is a fact that cards were received after six months, however, the petitioner has nowhere in his complaint alleged that he was denied any claim on account of late receipt of the medi-claim cards. It is also not alleged that he could not avail of any indoor medical treatment due to late receipt of cards. As per respondent no.1, petitioner was entitled to avail of medical facility merely by quoting their employee code No. already allotted to them by NFL while in service. It was not condition precedent under policy that for getting the treatment insured must have ID cards. The petitioner has failed to establish any deficiency of service on part of the respondents due to which he was denied the right to claim the benefits under the group insurance policy to which he has subscribed.

Hon''ble Supreme Court in Mrs.Rubi Chandra Dutta Vs. M/s United India Insurance Co. Ltd., 2011 (3) Scale 654 has observed ; "Also, it is to be noted that the revisional powers of the National Commission are derived from Section 21 (b) of the Act, under which the said power can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view than what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the Courts below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. In this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21 (b) of the Act has been transgressed. It was not a case where such a view could have been taken by setting aside the concurrent findings of two fora."

Thus, no jurisdictional or legal error has been shown to us to call for interference in the exercise of powers under Section 21 (b) of Act. Since, the both the foras below have given detailed and reasoned order which do not call for any interference nor they suffer from any infirmity or erroneous exercise of jurisdiction or material irregularity. Thus, the present revision petition is hereby dismissed. No order as to cost.