BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.355 of 2018
Date of Instt. 31.08.2018
Date of Decision:18.05.2022
Amrit Kaur W/o Pritam Singh R/o 280 Lajpat Nagar, Jalandhar.
..........Complainant
Versus
1. Apollo Munich Health Insurance Company, Jalandhar Branch Office FF Satnam Complex, BMC Chowk, Jalandhar.
2. Apollo Munich Health Insurance Company, 10th Floor, Building No.10, Tower-B, DLF City, Phase-II, DLF Cyber City, Gurgoan- 122002.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Vikas Sood, Adv. Counsel for the Complainant.
Sh. V. K. Gupta, Adv. Counsel for OPs No.1 and 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant and her husband Pritam Singh Luthra, both senior citizen have purchased one Health Insurance Policy from the OP bearing No.180200/11126/AA00076674-02 under the category Optima Senior Specially meant for senior citizens on 14.04.2014. The OPs have charged hefty premium from the complainant from the above said policy. After making thorough verification and medical examination of ailments by the impaneled doctors of the OPs and by leaving no chance of pre-existing ailment, the OPs by receiving the hefty premium from the complainant had insured her and her husband. The policy was in continuation and the complainant had been depositing the premium from time to time and the latest premium was accrued from 22.06.2016 till 21.04.2017. Thereafter, the husband of the complainant Pritam Singh Luthra felt a knee pain and got the surgery qua that pain. Pritam Singh never suppressed any fact and lodged his claim before the OPs. OPs repudiated the claim and canceled the entire policy. Pritam Singh has already filed one complaint before the District Consumer Redressal Forum, Jalandhar in the year 2016 qua this claim and the same is still pending before the said Forum. The sum assured for the complainant was Rs.5,00,000/- and the member ID of complainant was 10006980073. At the time of availing the policy, the complainant disclosed that her Uterus was removed in the year 1994. It was also disclosed that her Gall Bladder was removed in the year 2004. So, there was no suppression of any fact or material at the time of availing the facility of the policy, moreover the detailed and elaborate tests were performed and all the examination report is in favour of the complainant. So, the cancellation of the policy qua the health risk complainant is illegal. The OPs insured the complainant separately and for her separate ailments but repudiated and canceled the entire policy and deprived the complainant from her right accrued qua the insurance policy. No prior notice or intimation was ever served by the OPs to the complainant before cancellation of the insurance policy. Separate medical examinations of the complainant were conducted at the time of issuing the insurance policy initially. The complainant requested the OPs many times to continue with the insurance policy of the complainant, but the OPs not listening the request of the complainant. Due to the above said act of the OPs, the complainant has suffered mental tension, physical harassment, agony and financial loss and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to restore the insurance policy qua the risk cover of the complainant and give the complete benefits as per the policy period after deducting the interse period. Further, OPs be directed to pay Rs.1,00,000/- as compensation for causing mental tension and harassment to the complainant and OPs be also directed to pay litigation expenses.
2. Notice of the complaint was given to the OPs, who filed joint written reply and contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost. The complaint is hopelessly barred by limitation. The policy of the complainant alongwith her husband was cancelled and intimation to this effect was also given to the complainant and her husband vide letter dated 05.06.2016. Thereafter husband of the complainant has filed the consumer complaint tilted as Pritam Singh Vs. Apollo Munich and other on 01.072017 before this Commission and thereafter complainant has also moved an application for impleading herself as party in the said complaint and thereafter she has got withdrawn/or has got the said application dismissed, and now the fresh complaint is filed on 06.09.2018, that is after lapse of two years as such the present complaint is barred by limitation and is liable to be dismissed. It is further averred that the complainant has not approached this Commission with clean hands, complainant has suppressed various material facts in the present complaint. There is no deficiency in service or negligence or unfair trade practice on the part of the answering OPs. The present complaint is barred by principal of res-judicata. As per the order passed by the District Consumer Commission in said case on 18.09.2018 policy is to be considered as valid for the period 22.04.2016 to 21.04.2017 and in case the insured wants to continue the policy further then they have to pay premium for the lapsed period for policy benefits on continuation basis. On merits, the factum with regard to purchasing of the policy by the complainant is admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. Admittedly, the complainant and her husband Pritam Singh Luthra purchased one health insurance policy from the OP No.1 on 14.04.2014 after giving required premium as per Ex.C-2 and Ex.C-3. The policy was renewed from 22.04.2015 to 21.04.2016 as per Ex.C-4 and thereafter, the same was further renewed for 22.04.2016 to 21.04.2017 as per Ex.C-5. It is also admitted fact that the husband of the complainant felt knee pain and got surgery qua that pain and lodged the claim. It is also admitted fact that the claim was repudiated and the entire policy was cancelled as per Ex.C-1. It is proved that Pritam Singh Luthra challenged the repudiation order and filed complaint before the District Consumer Forum and the Hon’ble Court partly accepted the claim of the complainant and directed the OPs to consider the policy is still alive for the purpose of decision of the insurance claim of the complainant in question. The order has been proved as Ex.OP-2. All the above said facts are not disputed one.
7. Now the complainant alleged that the OPs have wrongly cancelled the entire policy, whereas she was also co-insured and the policy qua her could not have been cancelled. She filed an application before the District Consumer Forum in a complaint filed by Pritam Singh Luthra to become a party, but the same was later on withdrawn. Now the complainant wants that her insurance policy qua the risk cover of the complainant should be restored and she should be given the complete benefits as per the policy period after deducting the interse period.
8. The contention of the OPs that the complaint is not maintainable as it is barred by the principles of res-judicata and the same is barred by limitation also, as the policy was alive till April 2017 as per Ex.C-5 is not tenable. It is not disputed that the application for impleading the complainant as a party was withdrawn by the complainant and the Order was passed on 18.09.2018, vide which the policy was ordered to be considered alive for the year 2016-17 though for the decision of payment of treatment obtained by the complainant, but at the same time, the act of OPs was held to be against the law for cancelling the policy. The complainant has not availed any benefit nor filed any claim, therefore, the same is not barred by res-judicata. The order was passed on 18.09.2018, but the complainant was not given any benefit for the policy period and the complaint was filed on 31.08.2018 i.e. prior to the decision of the complaint, but within the time when the policy was alive, therefore the same is within limitation also.
9. It has further been alleged by the OPs that as per the order of the District Consumer Forum Ex.OP-2, the policy was directed to be considered for the period 22.04.2016 to 21.04.2017 for the purpose of insurance claim of the husband of the complainant. The OPs have submitted that in case the insured wants to continue the policy she should have to pay the premium for the lapsed period for policy benefits. The policy cannot be restored as both the complainant and her husband have concealed the material facts i.e. regarding the prior disease. Both the complainant and her husband were requested to give consent to pay the loading charges as they have concealed the information and it was specifically told to the complainant and her husband that if they don’t give the consent, the policy shall be treated as cancelled for all purposes. The complainant did not disclose her past medical history of HTN since prior to policy inception, therefore, the policy cannot be restored without the premium for lapsed period.
10. Ex.C-2 to Ex.C-5 shows that the policy was alive w.e.f.14.04.2014 till 21.04.2017. Though, it has been alleged that the complainant and her husband did not give consent, therefore, the policy stood automatically cancelled, but there is no document on the record to show that the policy stood cancelled because of non-approval of consent by the complainant or her husband. Ex.C-1 shows that the claim of Pritam Singh Luthra i.e. the husband of the complainant was repudiated on the ground that the expenses occurred during 12.09.2016 to 17.09.2016 is beyond the policy period, whereas Ex.C-5 shows that the insurance was alive till 21.04.2017. No document has been filed by the OPs to show that any letter was sent to the complainant to give consent for extra premium. It has been observed by the Learned President, in a complaint case filed by Pritam Singh Luthra i.e. the husband of the complainant, that the act of the OP cancelling the policy is illegal and ab-initio against the law because when the complainant has already obtained an insurance policy after making payment of premium and if any requirement of the OP to increase the future premium, then they can renew the policy after getting the extra premium, but not to cancel the previous insurance policy obtained by the complainant. The Learned President has held the policy for the year 2016-17 as alive. Since the complainant’s husband had not filed a claim for reimbursement, therefore the policy was stated to be for the purpose of decision of insurance claim of the complainant.
11. As per the above discussion, it is held that the order cancelling the policy for the year 2016-17 without passing any order is illegal and wrong and the policy for the year 2016-17 is ordered to be considered as alive and if the complainant wants to continue with the policy, the OPs are directed to renew the same as per rules after obtaining the requisite premium as per rules as she is co-insured.
12. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to restore the insurance policy qua the risk cover of the complainant and consider the same as alive qua the complainant for the year 2016-17 and further to renew the same from 2017 onwards, if the complainant wants as per rules after taking the required premium. Further, OPs are directed to pay compensation of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
18.05.2022 Member Member President
