Nitika Bansal filed a consumer case on 21 Dec 2023 against Apollo Munich Heath Insurance Co. Ltd., in the DF-II Consumer Court. The case no is CC/1066/2019 and the judgment uploaded on 21 Dec 2023.
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
U.T. CHANDIGARH
Consumer Complaint No. | : | 1066/2019 |
Date of Institution | : | 24.10.2019 |
Date of Decision | : | 21.12.2023 |
Nitika Bansal aged about 40 years wife of Sh.Rajan Gupta, Flat No.304, Galaxy Tower, Chandigarh Enclave, M.C. Zirakpur, Distt. SAS Nagar, Mohali.
... Complainant
1. Apollo Munich Health Insurance Co. Ltd., Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500033 (Telangana) through its Managing Director/Dirctor.
2. Apollo Munich Health Insurance Co. Ltd., 4th Floor, SCO No.50-51, Sector 34-A, Chandigarh 160022 through its Branch Manager.
BEFORE: |
| |
| SHRI AMRINDER SINGH SIDHU, | PRESIDENT |
| SHRI B.M.SHARMA | MEMBER
|
Present:- |
|
Proxy Counsel for Sh.Sumesh Mahajan, Counsel for the complainant
Proxy Counsel for Sh.Sachin Ohri, Counsel for the OPs
ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT
8. From the submissions of the parties and the documentary evidence on record, it is observed that the claim for reimbursement of Rs.82,982/- incurred on the treatment of the complainant for myomectomy for fibroids was repudiated only on the ground that the surgery in question has two years waiting period from the date of policy inspection i.e. 07.12.2017 as per Exclusion Clause No.5(A)(II) of the terms and conditions of the policy. It has been argued on behalf of the complainant that the representatives of the OPs have got the signatures of the complainant on blank proposal form and the same were filled up later on by the OPs as per their requirement and the terms and conditions of the policy have neither been supplied nor explained to the insured. Thus, the burden is shifted upon the OPs to prove that the terms and conditions of the policy were ever supplied or explained to the complainant. However, the OPs have failed to place on record any documentary evidence in this regard. Therefore, the terms and conditions of the Insurance Policy especially the Exclusion Clauses are not binding upon the complainant. Otherwise also, the complainant is bona fide consumer of the OPs, but the representatives of the OPs did not disclose the actual terms and conditions of the Insurance Policy but sold out the same in a deceptive manner which not only amounts to unfair trade practice but also deceptive trade practice. Hence, the OPs are liable for the acts and conducts of their representatives/agents.
9. It is further observed that several complaints from different consumers having different backgrounds and residing at different parts of the country are making similar allegations that the representatives/agents of the Insurance Companies are not disclosing the actual terms and conditions of the insurance policies but sell out the policies in a deceptive manner. Hence, the persons from different walks of life cannot make similar allegations, who are residing in the different parts of the country, having different backgrounds without element of truth in the above said pleadings that agents sell out the policy in deceptive manner in order to achieve the target or for the sake of their commissions.
10. A similar view is taken in Modern Insulators Ltd. v. Oriental Insurance Co. Ltd. (2000) 2 SCC 734, “(8) It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the facts which the parties know. The insured has a duty to disclose and similarly it is the duty of the Insurance Company and its agents to disclose all material facts in their knowledge since the obligation of good faith applies to both equally.”
11. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich”.
12. In the present case, the representatives of the OPs have sold the policy in question to the complainant in a very deceitful manner without disclosing the real facts of the policy and made her to sign on the dotted lines of the proposal form by assuring that they will take care of the rest but when the complainant went to the OPs for getting the claim, the same was repudiated by relying upon the exclusion clauses which were never supplied to the insured. Hence, the OPs have illegally repudiated the claim of the complainant, which amounts to deficiency in service and adoption of unfair trade practice on their part.
13. In view of the above discussion, the present complaint deserves to be partly allowed and the same is accordingly partly allowed. The OPs are directed to reimburse the medi-claim of Rs.82,982/- to the complainant from the date of its repudiation letter i.e. 14.05.2019 till the date of its actual realization.
This order be complied with by the OPs jointly and severally, within ninety from the date of receipt of its certified copy.
14. The pending application(s) if any, stands disposed of accordingly.
The Office is directed to send the certified copy of this order to the parties, as per rules and regulations of the Consumer Protection Act, 2019. After compliance file be consigned to record room.
Announced in open Commission21/12/2023 Sd/- | |
(AMRINDER SINGH SIDHU) PRESIDENT | |
Sd/- | |
(B.M.SHARMA) MEMBER |
Consumer Court | Cheque Bounce | Civil Cases | Criminal Cases | Matrimonial Disputes
Dedicated team of best lawyers for all your legal queries. Our lawyers can help you for you Consumer Court related cases at very affordable fee.