BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no.124 of 2018
Date of Institution : 12.04.2018
Date of Decision : 04.09.2019.
Saurabh Garg son of Shri Raj Kumar Garg, 214, Friends Colony, Mandi Dabwali.
….Complainant.
Versus
- Apollo Munich Health Insurance Co. Ltd., Central Processing Center, 2nd & 3rd Floor, iLABS Centre, Plot no.404-405, Udyog Vihar, Phase-III, Gurugram- 122016.
- Apollo Munich Health Insurance Co. Ltd., Haryana Corporate Office, 1st Floor, SCF-19, Sector-14, Gurugram (Haryana).
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SHRI R.L. AHUJA………………………..PRESIDENT
SHRI ISSAM SINGH SAGWAL…………MEMBER
SMT. SUKHDEEP KAUR………….……MEMBER.
Present: Sh. A.K. Gupta, Advocate for the complainant.
Sh. R.K. Mehta, Advocate for opposite parties.
ORDER
Case of complainant, in brief, is that complainant was having health insurance from New India Assurance Company Ltd., and Oriental Insurance Company for the last seven years and during this period, he never claimed any reimbursement regarding any type of illness. That in November, 2017, the agent namely Rajni Jindal alongwith her husband namely Ankur Jindal who was previously known to complainant approached the complainant and assured that their company is going to grant more health benefits regarding the coverage than the New India Assurance Company against almost the same premium and that private companies take care of the claims in a better way. Believing the representations made by the agents of the ops, the complainant agreed to port his previous health insurance to the ops’ company. It was also assured that there would be no waiting period in the present policy for any claim and they are only going to port the name of the company being regulated under the IRDA. It is further averred that at the time of filling up proposal form, the complainant had given the details of the previous policies held by the complainant. That the complainant had undergone a TMT test and had been further advised for angiography and accordingly the complainant undergone angiography test and was advised for inserting stents in Medanta Hospital. Accordingly, the complainant remained admitted in Medanta Hospital and necessary procedure was performed. That during this time, the complainant had received the policy duly accepted by the op’s office and premium was also paid for two years through cheque drawn on HDFC Bank Mandi Dabwali. It is further averred that it was assured at the time of porting of the policy that cashless facility would be available to the complainant. Accordingly the complainant informed to agent of ops at Madanta Hospital and lodged the claim, but to his surprise, cashless facility was declined by taking a plea that it was a pre-existing disease at the time of inception of the policy which is against the insurance norms and the rules and also against the terms and conditions of the policy. It is further averred that it was not a new policy issued by the ops, rather the previous policies were ported and as per the terms and conditions of the policy, there is no waiting period prescribed in the case of porting of the policy. That now the complainant has received the letter whereby the op company has terminated the said policy illegally and the ops have no right to terminate the policy and same is against the instructions issued by IRDA which permits porting of the policy. The act of termination of the policy by the ops and also forfeiting the premium illegally amounts to a breach of the policy terms as well as an act of monopolistic and unfair trade practice. The ops are highly deficient in their services and have caused a wrongful loss to the complainant. The termination of the policy would also deprive the complainant of his right to remain insured throughout his life as now the complainant shall have to resort to some other company for his further insurance thereby depriving him of his continuous insurance. It is further averred that a total amount of Rs.2,15,518/- was charged by Medanta Hospital, Gurugram which the complainant is entitled to receive from the ops. That complainant also got issued a legal notice upon the ops on 24.1.2018 but to no effect. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding maintainability, cause of action, complaint is barred by law of limitation, estoppel, suppression of material facts, jurisdiction, non joinder and mis joinder of necessary parties etc. It is submitted that as per the process involved, the complainant has submitted proposal form bearing No. JY70XJIEYP dated 18.11.2017 for issuance of an insurance policy namely Optima Restore Policy so as to provide an insurance cover for himself, wife, two daughters and one son. That believing said declaration as mentioned in proposal form, information and details provided in the proposal form to be true, correct and complete in all respect, a policy No.112000/11122/AA00700594 was issued for sum assured of Rs.5,00,000/- for period from 26.11.2017 to 25.11.2019. It is further submitted that the policy kit containing all relevant documents were duly sent and admittedly delivered to the complainant/ proposer thereby giving an opportunity to complainant to verify and examine the benefits, terms and conditions of the policy. The complainant/ insured never approached the ops stating that any information given in the documents in the policy kit was incorrect or any term and condition therein was not acceptable to him within free look period i.e. 15 days from the receipt of the policy document to review the terms and contract of the policy. It is further submitted that ops have issued the policy based on information disclosed by the proposer. It is submitted that as per the document of Global Healthcare Hospital, the complainant had history of angina on exertion before policy inception, however, this condition was never disclosed in the proposal form. So, in light of non disclosure of material facts by the complainant, cashless request was rejected and policy of the complainant also cancelled as per terms and conditions of the policy. With these averments, dismissal of complaint prayed for.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The complainant in order to prove his complaint has furnished his affidavit Ex.CW1/A in which he has deposed and reiterated all the averments made in the complaint. He has also furnished copy of information sheet Ex.C1, copy of letter Ex.C2, copies of cards Ex.C3 to Ex.C5, copy of schedule Ex.C6, copies of medical record, bills, reply to notice and letters Ex.C7 to Ex.C18. On the other hand, ops have furnished affidavit of Ms. Deepti Rustagi as Ex.RW1/A in which she has deposed and reiterated all the averments made in the written statement. The ops have also placed on file copy of power of attorney Ex.R1, copy of proposal form Ex.R2, copy of policy schedule Ex.R3, copy of pre-authorization form with medical record and bills Ex.R4, copy of denial letter of cashless service Ex.R5, copy of notice for termination of policy Ex.R6 and copy of letter regarding cancellation of policy Ex.R7.
6. It is undisputed fact between the parties that complainant has purchased a policy from ops on payment of premium through alleged agent Rajni Jindal. It is also admitted fact on record that policy was issued by Apollo Munich Health Insurance Company Ltd. Gurugram and claim was lodged with ops at Gurugram and same was repudiated by ops at Gurugram office. The perusal of complaint reveals that though complainant has alleged that this policy was purchased by complainant from ops through their agent Rajni with code number 80212746 who alongwith her husband had come to their place, but however, the complainant has not impleaded said agent Rajni as a party in the present complaint due to reason best known to him. Moreover, complainant has not impleaded branch office, if any at Sirsa in order to seek the jurisdiction of this Forum. The perusal of the evidence of complainant also reveals that complainant has not led any such evidence from which it could be presumed that proposal was filled, payment was made and policy was issued in the territorial jurisdiction of this Forum.
7. During the course of arguments, though learned counsel for complainant has strongly contended that policy was purchased online from ops, but pleading to this extent is also missing and silent in the complaint. The complainant has not led any evidence in order to prove this plea that that policy was purchased online from ops. No document has been produced by complainant in order to prove that this policy was ever issued in the territorial jurisdiction of this Forum at Sirsa. Rather it appears from evidence of complainant that policy was issued by ops at Gurugram and claim was lodged there which was repudiated by their office at Gurugram. So, it appears that present complaint is not maintainable before this Forum and barred by jurisdiction. Section 11 (2) of the Consumer Protection Act, 1986 for the purpose of territorial jurisdiction reads as under:-
11 (2) A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction,-
- the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or (carries on business or has a branch office or) personally works for gain, or
- any of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides, or (carries on business or has a branch office), or personally works for gain, provided that in such case either the permission of the District Forum is given, or the opposite parties who do not reside, or (carry on business or have a branch office), or personally work for gain, as the case may be, acquiesce in such institution; or
- the cause of action, wholly or in part, arises.
8. No cause of action or part of cause of action arose to the complainant within territorial jurisdiction of District Forum, Sirsa and as such complaint is not maintainable and as such same is hereby dismissed for want of territorial jurisdiction. But however, complainant at is at liberty to approach any other Forum/ Court of law having jurisdiction for the same and may also seek exemption of time during which the present complaint remained pending before this Forum for calculation of period of limitation, as per law. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced in open Forum. Member Member President,
Dated:04.09.2019 District Consumer Disputes
Redressal Forum, Sirsa.
