Chandigarh

DF-II

CC/1066/2019

Nitika Bansal - Complainant(s)

Versus

Apollo Munich Heath Insurance Co. Ltd., - Opp.Party(s)

Balwinder Singh Adv.

21 Dec 2023

ORDER

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

Versus

 

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.

…. Opposite Parties

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

  1.     The complainant has filed the present complaint pleading therein that on 07.12.2017, the complainant took health policy from the OPs by paying premium of Rs.6571/- and after the expiry of the policy, the complainant again paid the premium amount in time to the OPs.   Subsequently, the complainant got treatment for myomectomy for fibroids  by paying the expenses of Rs.82,982/- from her pocket from the IVF and Sant Memorial Nursing Home, Sector 20, Chandigarh and subsequently, she submitted the claim along with the documents with the OPs but the same was rejected vide letter dated 14.05.2019. Subsequently, the complainant served the legal notice upon the OPs  but to no effect. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to refund Rs.82,982/- along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
  2.     After service of notice, the OPs appeared before this Commission and filed their written version. While admitting the factual matrix of the case, the OPs have stated that the claim submitted by the complainant was analyzed by the doctors of the OPs and it was found that the surgical removal of fibroid was done through laparoscopic myomectomy (a benign tumor of uterus).  However, the claim was not payable as per the terms and conditions of the policy, because the surgery has two years waiting period from the date of policy inspection as per Exclusion Clause No.5(A)(ii) of the terms and conditions of the policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, the OPs prayed for dismissal of the complaint.
  3.     The complainant filed replication to the written reply of the OPs controverting their stand and reiterating his own.
  4.     The parties filed their respective affidavits and documents in support of their case.
  5.     We have heard the Counsel for the contesting parties  and have gone through the documents on record, including written submissions.
  6.     The main question to be determined in the present complaint is whether the OPs have rightly repudiated the claim or not?
  7.     In order to find out answer to the above mentioned issue, it is necessary to discuss the following facts and circumstances of the case:-

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 Commission

21/12/2023                           Sd/-

 

(AMRINDER SINGH SIDHU)

PRESIDENT

 

Sd/-

 

(B.M.SHARMA)

MEMBER

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