CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

  Udyog Sadan, C – 22 & 23, Institutional Area

          (Behind Qutub Hotel)

   New Delhi – 110016

    Case No.143/20

Dr. Poonam Gulati

K-73, Sarita Vihar

Delhi-110076                                                     …..COMPLAINANT

Vs.

Bajaj Allianz General Insurance Co. Ltd.

Mr. Ehetsham Haque

Chairman& Managing Director

6^th Floor, 93 Ashoka Bhawn,

Nehru Place

New Delhi-110019.                                               …..RESPONDENTS

Date of Institution-01.10.2020

            Date of Order-10.05.2024

         O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in not refunding the premium in free look period.

2. The facts outlined in complaint are: The complainant applied for an extra cover policy from Bajaj Allianz GIC Ltd. bearing No.OG-20-1105-8432-00000142 on 15.07.2019.  He sent an email dated 22.07.2019 asking them to send the policy documents.  He sent another reminder email.  The policy was received by the complainant vide email on 22.08.2019.

3. The complainant requested OP, the insurance company, for refund within two hours of receipt of the policy stating that he wanted to return the policy within free look period of 15 days as it was issued through misrepresentation.  On 09.09.2019, he was informed that 20% of the amount paid will be deducted as the policy was cancelled on 09.09.2019 and the amount paid for medical tests will be deducted

4. It is alleged that the complainant was not informed about any medical test before the inception of the policy.  It is further stated the complainant was never examined by the doctor alleged to have conducted the examination.  It is further alleged that the complainant’s signature has been forged on the medical documents i.e. the ECG tracing submitted in the insurance company. The complainant submits that he was conducting surgery at Batra Hospital at the time of the alleged medical examination.

5. It is submitted that the complainant has failed to receive value for the paid up premium on account of the refusal by the insurance.  The complainant has send various request for refund but to no avail.  The complainant prays for a compensation of Rs.50,000/- and any other relief.

6. OP, Bajaj Allianz GIC Ltd., in its reply submits that the complainant had approached the insurance company for an extra cover policy and paid Rs.10,028/- and issued policy No. OG-20-1105-8432-00000142 covering the period from 15.07.2019 to 14.07.2020.  The complainant has not approached the insurance company during the Free Look period which is fifteen days time provided from the date of receipt of the first policy documents to review the terms and conditions of this policy.  The insurance was approached for cancellation of the policy on 22.08.2020.  The insured is ready to refund the applicable remaining premium amount to the insured as per IRDAI guidelines.

7. OP is ready to refund the premium after deduction of the medical test cost and prorata premium for the risk period. Consequently refundable amount will be Rs.8,103/- on prorate basis as on 22.08.2019. Medical expenses was Rs.725/-+GST = Rs.856/-.  Hence the total refund mount will be Rs.8,103/- i.e. Rs.8,959/-Rs.856/-=Rs.8,103/-.

8. OP prays for dismissal of complaint. 

9. The complainant in his rejoinder states that he asked for cancellation within minutes of receiving the policy on 22.07.2019.  OP with malafide intention proposed to refund the amount after deducting the expenses incurred on medical examination. The complainant states that he was operating in Batra Hospital on 27.07.2019 when the alleged medical examination by the insurance took place.  The complainant is an urologist who has filed OT list showing that he had operated on four patients on the day of alleged medical examination.  The ECG tracing has been clipped to conceal the identity of patient and instead his name was hand written.

10. Complainant has filed evidence by way of affidavit and exhibited the following documents:-

1. Copy of the respondent’s advertisement through their brochure is exhibited as EX (P)(P)A
2. Copy of the receipt of payment is exhibited as EX (P)(P)B
3. Copy of for asking cover note is exhibited as EX (P)C
4. Copy of the email  is exhibited as EX (P)D
5. Copy of policy cancellation  is exhibited as EX (P)E
6. Copy of false medical report is exhibited as EX (P)F
7. Copy of the list at Batra Hospital is exhibited as EX (P)G
8. Copy of the signatures on medical report is exhibited as EX (P))F
9. Copy of the Insurance Fraud Monitoring Framework is exhibited as EX (P))H- APPENDIX 1
10. Copy of affidavit affirming recording of conversation with Dr. Jalaj Ranjan is exhibited as EX (P))F- Pg2,4,5,6,11
11.    Pendrive is exhibited as EX(P)I
12. Copy of the ECG Tracing by the insurance  is exhibited as EX (P))F- Pg11
13. Copy of the complainant’s ECG tracing is exhibited as EX (P))F- Pg11

11.  OP has filed evidence by way of affidavit through Assistant Manager (Legal). OP has filed the IRDA guidelines, proposal form and medical checkup report of the complainant.

12. The Commission has considered the pleadings and material on record.  It is admitted by both the parties that the complainant applied for Extra Care Plus policy.  OP insurance vide an undated letter welcomed the complainant for choosing the policy and requested the complainant to go through the policy schedule and terms and conditions.  The policy documents show that period of insurance was from 15.07.2019 to 14.07.2020.  The policy was issued on 30.07.2019.  The premium paid was Rs.10,028/-. 

13. The email trail between the parties are as follows :

1. 22.07.2019 :1.28 a.m. - Complainant requests for policy details. He also states that he need the policy urgently so that he can return it within free look period.
2. 22.07.2019:1.30 a.m - Complainant requests for policy cover note.
3. 22.07.2019 : 6.20 a.m. - OP informs the case is under process.
4. 22.08.2019           : 9.37 a.m.  -Policy document are sent to complainant.
5. 22.08.2019   : 11.21 p.m. -The complainant request for cancellation of policy as he was dissatisfied with terms and condition.
6.  22.08.2019          : 11.25 p.m. -OP acknowledges the earlier email and states that the complainant will be informed in the next 24 hours.
7.  27.08.2019          :5.15 p.m. - The complainant states that he is waiting for OP’s revert in 24 hours.
8. 30.08.2019:          -OP states that they are unable to process the complainant request.

14. Thereafter various emails were exchanged between the parties.  OP vide email dated 16.9.2019 was ready to refund the amount after 25% deduction. The signature on the medical checkup and medical examination report is different from the signatures of the complainant in the petition. The complainant has also filed OT list dated 27.07.2019. The medical examination report is dated 27.7.2019.

15. The complainant has filed a recording of his conversation with Dr. Jalaj Ranjan who had allegedly conducted the medical examination. The said doctor clearly refuted conducting any medical examination. OP was deducting Rs.856/- towards cost of examination in case of refund of premium.

16. From the emails between the parties, it is seen that the complainant requested for policy documents on 22.07.2019 at 1:28am. He was informed at 6:20am by OP that his case is under process. The policy document shows that policy commenced on 15.07.2019 but the policy was issued on 30.07.2019. The email dated 22.08.2019 indicates that the policy document was sent on that day at 9:37am. The complainant requested for cancellation on the same day at 11:21pm. His mail was acknowledged by OP at 11:25 pm. The complainant again sent a mail to OP requesting OP to revert in 24 hours. OP vide email dated 30.08.2019 states that they are unable to process complainant’s request for cancellation. OP agreed vide email dated 16.09.2019 to refund the amount paid by complainant towards premium after 25% deduction.

17. OP in its reply has submitted that it is ready to refund premium after deduction of medical cost and prorata premium for this period as the complainant had not made the request within free look period of 15 days. The medical examination is signed by Dr. Jalaj Ranjan, who has categorically denied conducting any medical test on the complainant.

18. OP has failed to provide any evidence of delivering the insurance policy to the complainant. The policy commenced on 15.07.2019, and in an email dated 22.07.2019, OP informed the complainant that their case was under process. Although the policy was issued on 30.07.2019, the complainant received it via email dated 22.08.2019. On the same day, the complainant requested cancellation. There is no explanation as to how this cancellation is not covered under the free look period, which is typically 15 days from the receipt of policy documents.

19. Moreover, OP’s stance on deductions lacks clarity. Initially, they proposed deducting the premium on a prorata basis and additionally deducting the cost of a medical test that never occurred. OP has not provided any clarification regarding any specific provision in the policy upon which they are relying.

20. Thus, OP has indulged in unfair trade practice and deceptive trade practice by firstly not cancelling the policy within free look period and refunding the premium. OP has further aggravated its wrongful conduct by placing on record false medical tests of the complainant. Hence, we direct OP to pay:

1. To refund Rs.10,028/- with 9% interest from the date of commencement of the policy till payment.
2. To pay Rs.20,000/- as compensation for mental harassment caused to complainant.
3. To pay Rs.5,000/- towards litigation expenses.

21. File be consigned to record room.