Punjab

Rupnagar

RBT/CC/18/125

Pooja - Complainant(s)

Versus

Apollo Munich Health Ins.Co.Ltd. - Opp.Party(s)

Kamal Jatika adv

18 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CAMP COURT AT LUDHIANA

 

                                                RBT/Consumer Complaint No. 125 of 23.02.2018

                                                Date of Decision: 18.01.2023

 

          Pooja aged about 26 years wife of SH. Harpreet Singh, , resident of House No.B-1-237/28, Near Mahajan Karyana Store, New Kundan Puri, Civil Lines, Ludhiana. 

                                                                                                   ……Complainant

                                                         Versus

1. Apollo Munich Health Insurance Company Limited, Central Processing Centre, 2^nd and 3^rd Floor, iLBAS Centre, Plot No.404-405, Udyog Vihar, Phase III, Gurugram-122 016 through its authorized person/Generl Manager/Manager.

Registered office:-

          Apollo Hospitals Complex, 8-2-293/82/JM/DH/900, Jubilee Hills, Hyderabad, Talangana-500033 through its Authorized Person/General Manager/Manager

2.     Gurmeet Singh (Agent) of Apollo Munich Health Insurance Co. Limited, 146, Feroze Gandhi Market, Ludhiana. 

                                                                                             ….Opposite Parties

Complaint under Consumer Protection Act

QUORUM:-

                             SH. RANJIT SINGH, PRESIDENT

                             SMT. RANVIR KAUR, MEMBER

 

ARGUED BY:-

                             Sh. Kamal Jatika, Adv. For complainant

                             Sh. Ajay Chawla, Adv. for OP1.

                             Complaint not admitted against OP2 vide order dated 27.3.2018

 

ORDER:-

SH. RANJIT SINGH, PRESIDENT

The present order of ours will dispose of the above complaint received by way of transfer from District Consumer Commission, Ludhiana, filed under Consumer Protection Act, by the complainant against the opposite party on the ground that initially husband of the complainant had purchased one family health insurance policy under family health optima insurance plan from Star Health and Allied insurance company limited vide policy No.P/211218/01/2017/001569 having date of inception of policy 17.1.2017 and the husband of the complainant purchased the said policy for himself as well as for his wife namely Pooja, son namely Yuvraj Singh and another son namely Kabir Raj. Against the said policy the complainant and her husband never made and submitted any kind of claim with star health and allied insurance company limited at any point of time. Thereafter, due to some reasons, husband of the complainant merged/transferred above said policy with the OPs in the name of the complainant and OPs issued new policy to him in the name of complainant Mrs. Pooja and at that the complainant being good customer of the OPs submitted all the related documents with the Ops and after perusing the said documents and verifying the facts about the earlier policy, the OPs issued said policy in the name of the complainant and regarding the same prior from issuing the policy with the Ops in the name of complainant, the OPs charged premium from the complainant to the tune of Rs.14326/- through cheque. It is further averred that after this OPs issued letter dated 15.01.2018 in the name of the complainant and in the said letter, the Ops demanded documents from the complainant, which had already been submitted by the complainant and her husband Harpreet Singh at the time of transferring/merging of previous policy with the OPs, but even after the receipt of the said letter, the complainant and her husband submitted all the documents with the OPs and also declared to the Ops that they never took any kind of claim in their earlier policy with Star Health and Allied Insurance Company Limited. Now the complainant again received a letter dated 25.1.2018 from the Ops vide which the OPs informed to the complainant that the above noted policy of the complainant has been terminated by the OPs under section VIJ of Optima Restore Policy No.AA00706903 and Two Dimecasional Echocardiogrm Finding Since 29.8.2017 i.e. before policy incpcetion. However, at the time of transferring merging of the previous policy with the Ops, the complainant and her husband had already submitted all the documents and previous information to the Ops and after verifying the said facts, the Ops issued policy in the name of the complainant and also issued cards in the name of the complainant and her husband and sons. Thereafter, the complainant along with her husband many times approached the Ops and their local offices, but the OPs failed to hear anything from the complainant. Thus, alleging deficiency in service on the part of the OPs, the complainant sought the following reliefs against the OPs:-

1.       To pay Rs.2,00,000/- along with interest as compensation and further directed to pay the premium amount of the policy paid by the complainant to the Ops at the time of transfer the policy with the OPs.  

2.       Upon notice, the learned counsel for the OP1 filed written reply taking preliminary objections; that the complaint is not maintainable; that for the sake of brevity the OPs No.1 & 2 will be now referred only as opposite parties; that the averments made and contention raised in the complaint which are not specifically admitted; that without prejudice to the above objection, the Ops submits that at the outset the present complaint filed by the complainant is not at all maintainable either on question of fact or on question of law and as such is liable to be dismissed in limine; that the complainant has created a false story in his complaint to mislead this Hon’ble Commission by concocting and distorting the facts and circumstances of the present complaint; that there is no relation of consumer of the complainant with the OP; that the medical condition which were not  disclosed at the time of taking the insurance policy was the actual reason for termination of the policy. On merits, it is stated that as per Section 11 of the Insurance Act, 1938, the policy holder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk of enable the latter to assess properly the risk sought to be covered by a policy. Thus, it is evident that the act and the regulations framed there under also imposes a duty upon the policy holder/proposer/applicant to disclose all the material facts to the insurer to enable them to assess the risk to be undertaken. The insurance is done on the basis of doctrine uberrima fides and there was no reason for deponent/respondent to verify the correctness of the facts stated in the application, more so since the applicant had signed specific  declarations to that effect. Rest of allegations leveled by the complainant against the answering OP have been denied and prayed for dismissal the present complaint.   

3.       The learned counsel for the complainant has tendered certain documents in evidence along with affidavit and closed the evidence. The OP1 also tendered documents in evidence and closed the evidence.

4.       We heard the learned counsel for the complainant and OPs and have gone through the record file, carefully and minutely.

5.       In this present complaint, the complainant has suppressed the material from the OP company. as per Section 11 of the Insurance Act, 1938, the policy holder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk of enable the latter to assess properly the risk sought to be covered by a policy. Thus, it is evident that the act and the regulations framed there under also imposes a duty upon the policy holder/proposer/applicant to disclose all the material facts to the insurer to enable them to assess the risk to be undertaken. The insurance is done on the basis of doctrine uberrima fides and there was no reason for deponent/respondent to verify the correctness of the facts stated in the application, more so since the applicant had signed specific declarations to that effect. Therefore, the complainant is not entitled to any claim.

6.       In view of our above discussion, we feel, that the complainant has failed to prove his case and not entitled to any relief, therefore, the complaint stands dismissed. The certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

Announced:

18.01.2023                                                                 (RANJIT SINGH)

                                                                                      PRESIDENT

 

 

 

                                                                                       (RANVIR KAUR)

                                                                                       MEMBER