This case is coming for final hearing on 07.01.2015 in the presence of Smt.Pedapati Lakshmi Mani Kumari, Complainant appeared in person and of Sri Sanapala Karuna & Smt.Sanapala Sailaja Advocates for Opposite Parties and having stood over till this date, the Forum delivered the following:

: O R D E R :

(As per Smt. K.V.R.Maheswari, Honourable President(FAC) on

behalf of the Bench)

1.       The case of the complainant is that on 26.06.2012 Mrs. Shanti & Mr.Rajendra Prasad Senior Agency Manager from M/s Birla Sun Life Insurance Company Ltd., Visakhapatnam Branch have personally attended the complainant’s residence and explained about the “Saral Health Plan” that covers the complainant’s health benefit up to 20 years i.e., 30.06.2032 and after five years from the date of policy obtained, the policy shall cover the health benefit of complainant’s husband by name P.Namassivaya and children having below the age of 25 years and the compliant also confirmed the above said benefit plan in consultation with their Branch office at Visakhapatnam. The complainant had agreed with the offer with an intention that the policy is helpful to her and her family for their health benefits and she agreed to have a policy under Saral Health Plan and paid an amount of Rs.21,243/- and the cash receipt was issued on 28.06.2012.  The complainant stated that against the above payment of Rs.21,243/- the Saral health plan policy document was issued bearing No.005645458 dated 30.06.2012 in the name of complainant, after that she had gone through the 24 pages of the original policy, but she could not found the clause “ coverage of health insurance to her family members like husband and children after five years from the date of obtaining the policy issued i.e., 30.06.2012” as explained earlier by the agents of opposite parties who proposed her to have Saral Health Plan.  After inducing the lack of clause in the policy document, the complainant contacted employees of opposite parties and insisted them to make necessary arrangements for issue of modified policy document incorporating the clause, if incorporation of the clause is not possible arrange for refund of the amount of Rs.21,243/- in full by cancelling the policy, but all the officials tried to convince her to have a separate paper assuring the coverage of clause separately.  But the complainant have not agreed to receive the separate paper except the revised/modified policy document, as the company may not agree legally in due course for implementation of clause on the plea that the first issued policy document was not speaking about the clause.  Then, the complainant brought this matter to the notice of Mr.K.Narasimha Reddy, Branch Head, Visakhapatnam, Sri K.Jagan T.M., OPS, VSP and Ms.Sahana Shaik, Grievances Officer, BSLI by e-mail, dated 05.10.2012. 

2.       On 17.10.2012 a letter received from Mr.Manish Sonawane, Customer Service Officer, BSLI Co. Ltd., Thane-400601 letter dated 12.10.2012 stating that any amendments may be admitted by the company within the Free Look i.e., within 15 days.  Then, the complainant again addressed a letter on 18.10.2012 to the Grievances Officer, BSLI Co. Ltd., through e-mail marking copy to Sri K.Jagan, T.M., OPS, BSLI Co., Ltd., Visakhapatnam which are self-explanatory.  The three officers of opposite parties dragged the matter to such a long period saying that they are contacting their higher officials to look into the matter for further steps instead of giving specific instructions to the complainant to apply for cancellation within the time.  On advise of branch head of opposite party, the complainant approached the customer service No.18002707000 and booked complaint on 03.10.2012.  But the company has not responded to her policy Document No.005645458 dated 30.06.2012  but giving several replies quoting other policy number by which the company is confusing the complainant.  The complainant addressed a letter to grievance officer on 10.11.2012 asking for justification.  These are all clearly shows that the company is taking lenient view of the policy holder leaving aside the promises/offers made by their agents or employees which clearly shows the deficiency in service on their part.  Hence, this complaint to direct the opposite parties to:

a)      to issue revised/modified document incorporating the clause “coverage of health insurance with the complainant and her family members after five years from the date of obtaining the policy or refund the amount of Rs.21,243/- with 24% interest from the date of payment till the date of realization.

b)      to pay Rs.50,000/- towards compensation besides costs of Rs.3,000/-.

3.       On the otherhand, the opposite parties filed their counter and denied the allegations mentioned in the complaint and pleaded that the complaint is not maintainable and there is no cause of action.  The complainant voluntarily applied for the insurance policy after fully well about the terms and conditions of the policy.  As per clause-6(2) of the Insurance Regulatory and Development Authority, “While acting under regulation 6(1) in forwarding the policy to the insured, the insurer shall inform by letter forwarding the policy that he has a period of 15 days from the date of receipt of the policy document to review the terms and conditions of the policy and where the insured disagrees to any of those terms and conditions, he has the option to return the policy stating reasons for his objections, when he shall be entitled to a refund of the premium paid, subject only to a deduction of a proportionate risk premium for the period on cover and the expenses incurred by the insurer on medical examination of the proposer and stamp duty charges”.  Being an educated person, the complainant must have gone through the terms and conditions at the time of filling the application which was signed by her.  In the case of “Prema and others Vs Life Insurance Corporation of India Ltd., IV(2006)CPJ 239 (NC) it was observed that in para-8 of the judgment “without understanding the contents of the relevant items putting signatures in the proposal forms even after having minimum knowledge of the matter is not correct”.  Here in this case, the complainant never raised any objection at the time of signing the application.  In the case of General Assurance Society Ltd., Vs Chandmull Jain (1966)3 SCR 500, it was observed that “in interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves”.  Regarding the jurisdiction, the State Commission in its case Oriental Insurance Company Ltd., Vs Munimahesh Patel, 2006(IV) CPJ 1 wherein it is stated that the complex factual position requires that the matter should be examined by an appropriate court of law and not by the Commission.  The same was held in Harbans & Co. Vs State Bank of India, II (1994) CPJ 476. As per Jayantilal Keshavlal Chauhan Vs The National Insurance Co. Ltd., 1994(1)CPR 396 held that if fraud is alleged, it is desirable that the complainant directed to civil court as investigation about such fraud is required to be done.  Thus, in this case, the complaint after completely understanding the terms and conditions only the complainant applied for BSLI Sarla Health Plan and obtained insurance policy vide proposal form bearing No.43043104 dated 28.06.2012 and the premium amount of Rs.21,243/- on annual basis for a term of 10 years and the benefits are restricted to the policy holder only as per the policy contract and the complainant had not applied for any further riders as such the policy holder was not given riders for the family.  After receipt of the initial premium, the opposite party issued policy bearing NO.005645458 and the commencement date is 30.06.2012.  After that the policy document was delivered on 06.07.2012 to the address of the complainant.  The said policy contained a notice on free look whereby the policy holder has a right to reconsider her decision to purchase the policy within 15 days after receipt of the policy document in case she does not agree to the terms and conditions of the said policy.  But the Complainant failed to do so and never raise any complaint.  After that on 05.10.2012, the opposite party received the communication for cancellation of the policy from the complainant and upon which the opposite party replied on 12.10.2012 stating that the said request is beyond the free look cancellation, thus the complainant had not acted in good faith and as the contract of insurance is a contract of uberime fide and as the opposite parties have performed their part of contract by providing their service.  The Opposite parties stated that the complainant has not set up any nexus between the damages claimed and the alleged injury sustained, hence she cannot entitle any relief, as such the complaint is to be dismissed. 

4.       At the time of enquiry, the complainant filed evidence affidavit along with documents which are marked as Exhibits A1 to A9.  On the other hand, the opposite parties filed their counter, but not filed their evidence affidavit and written arguments.  No documents are marked on behalf of opposite parties even after imposing costs, the opposite parties had not come forward to submit arguments at the time of hearing, hence treated it heard for opposite parties.  Heard the complainant in person who reiterated his version.

5.       In view of the respective contentions, the point that would arise for determination is:-

Whether there is any deficiency in service on the part of the opposite parties, if so can the complainant entitle for the reliefs prayed for?

6.       The fact that Ex.A1 dated 28.06.2012 i.e., cash receipt bearing No.35063369 for an amount of Rs.21,243/- and Ex.A2 is the policy document bearing No.005645458 dated 30.06.2012 is itself in dispute, as the opposite parties mentioned in their counter that the receipt No.005645458 and the policy No.005796887.  The Opposite parties even after receipt of copies of the document filed by the complainant, they mentioned that the cash receipt number and the original policy number is not matched with the cash receipt and policy bond filed by the complainant.  Only the amount and dates were same but the numbers are different.  Ex.A3 is the letter addressed by the complainant to the officer of the opposite parties on 05.10.2012 which was issued by the husband of the complainant regarding the coverage of health insurance to family members as explained by the officials of the opposite parties and also request made by the complainant in that letter to the authorities of the opposite parties to revise or modify the policy document or to return the premium amount paid by her.  Ex.A4 is the letter issued by the opposite parties to the complainant bearing policy No.5645458 dated 12.10.2012 wherein, the opposite parties mentioned that if she wish to opt for any amendments she can do so under the free look option i.e., within 15 days from the date of receipt of the policy document and the opposite parties regret to inform that they would be unable to cancel the complainant’s policy. 

7.       Exhibit A5 is the letter addressed by the complainant to the grievance cell as per the advise given by the opposite parties in Ex.A4 on 12.10.2012. Ex.A6 is the e-mail letter dated 06.11.2012 by the opposite parties to Mr. Pedapati wherein, they mentioned that “they delivered the policy document No.005646233 through Blue Dart Courier to P.L.M. Kumari i.e., the complainant and the same was received by her, but within the free look period the opposite parties not received any concern towards the said policy hence they are unable to accede the request of the complainant for any changes or cancellation of the policy”. 

8.       Exhibit A7 is the letter issued by the complainant to the opposite parties on 10.11.2012 stating that “it is noticed that the company has taken 12 to 18 days to respond the letter of two pages issued by the complainant, then how can the policy holder decide herself within 15 days by going through the policy document consisting of 24 pages besides her regular works.  More over, there itself, the complainant also mentioned about the difference between the policy numbers mentioned in the letter issued by the opposite parties.  Ex.A8 is the letter issued by the opposite parties to Mr.Pedapati bearing policy No.005646233 wherein, the opposite parties reinstate about the cancellation of the policy and the refund of the premium since they are not in receipt of any concern within the free look period.  Ex.A9 is the e-mail correspondence received by the complainant from the opposite parties wherein, clearly mentioned in the top of the page that “FW:Sral Health Family Cover and can you please check on this, the below clause is mentioned in Saral Health Plan Policy document, but the same is mentioned in FAQ (Frequently asked questions)”.  “Can I claim Health Reimbursement Benefit for expenses incurred for my family members?  Yes – You can claim Health Reimbursement benefit for expenses incurred for your family members”.  There in that exhibit only one Mr.Rajendra Prasad asked a question that “Point 33 in Saral Health Plan FAQ was not shown in bond, customer asking the above doubt “please do the needful”.  For that the answer was given by Jagannadha Kanduri regarding the claim of reimbursement benefit for expenses incurred for the family members.

9.       The opposite parties main plea is that the complainant even after receipt of policy document, she failed to approach the company within the free look period if she is not satisfied with the terms of the policy or otherwise she has to approach opposite parties within 15 days. But the opposite parties received the communication for cancellation of policy on 05.10.2012, she received the document on 06.07.2012, thus, she failed to approach the opposite parties within time.  But after careful analysation of the facts of the complaint and counter with related documents Forum observed that the policy number mentioned by the opposite parties in the counter is 005796887 and in Exhibits A6 & A8 those are the letters issued by the opposite parties, the opposite parties mentioned the policy number as 005646233.  The opposite parties itself are in confusion and also make the Forum to confuse.  Ex.A2 i.e., original policy document bearing No.005645458 wherein, the name of the complainant is mentioned as Mrs. Lakshmi Manikumari P and the correspondences made by the complainant those are Exhibits A3, A5 and A7 wherein the complainant clearly mentioned her policy number but the replies given by the opposite parties not even mentioned that policy number and more over they failed to correct their mistake.

10.     It is to be noted that Ex.A9 clearly shows that regarding the Health reimbursement benefit for expenses incurred for the family members of the policy holder.  That too, the opposite parties failed to come to a conclusion regarding the policy numbers itself and also failed to clarify the doubts of the complainant against her policy number.  The facts of the cases, those decisions relied upon by the opposite parties are different with this case on hand. 

11.     In our opinion as per Ex.A9, the officials of the opposite parties explained about the coverage of health benefit with the family of the complainant, but it was not mentioned in the policy bond, then after perusal of the policy bond which is in very-very small letters and it is to be watched with a magnified glasses only.  The complainant made several correspondences to the opposite parties by mentioning her policy number either to cancel the policy or to modify the bond.  But with a negligent attitude, the opposite parties issued replies by mentioning wrong policy numbers and thus make the complainant confused.  Hence, in our view, the opposite parties has to refund the premium amount of Rs.21,243/- with 9% interest from 05.10.2012 within three months.

12.     The company has not responded to the complainant’s policy document number but gave several replies quoting other policy numbers by which the opposite parties are confusing the complainant and the opposite parties taking lenient view of the policy holder leaving aside the promises/offers made by their agents.  The policy holders are on the impression that the versions made by the employees of the insurance company are reliable and believable but when the issue is come into existence, then the policy holders came to know that is the fact.  More over, in our view if any uneducated person depends on the versions made by the agents without going through the terms and conditions they may not know what terms and conditions are mentioned in that policy until time comes.  For business promotion the insurance company appoints so many agents and employees, but Insurance company failed to pursue its agents and employees regarding their services are genuine or not.  Hence, there is clear evidence of deficiency of service on the part of opposite parties. 

13.     After perusal of the correspondences made by the opposite parties to the complainant and her husband, we came to know that the opposite parties itself get confused and make the complainant to confuse by mentioning wrong policy numbers and also failed to prove that the complainant or her husband have other policies than this policy by filing any documentary evidence.  Thus, the acts of the opposite parties clearly shows the deficiency in service on its part.  Hence allowing Rs.5,000/- towards compensation besides costs of Rs.1,500/- is just and proper. 

14.     In the result, the complaint is allowed directing all the opposite parties to pay premium amount of Rs.21,243/- (Rs.Twenty one thousand two hundred and forty three only) with 9% interest from 05.10.2012 to the complainant within three months, failing which to pay the same with 12% interest till the date of realization.  The opposite parties are further directed to pay Rs.5,000/- (Rupees Five thousand only) towards compensation besides costs of Rs.1,500/-(Rupees one thousand and five hundred only).

Dictated to the Shorthand Writer, transcribed by her, corrected and pronounced by us in the open Forum on this the 30^th day of January, 2015.

   Sd/-                                                                        Sd/-

Member                                                                 President (FAC)

                                                                   District Consumer Forum-I 

                                                                             Visakhapatnam

APPENDIX OF EVIDENCE

Exhibits Marked for the Complainant:

Exhibits Marked for the Opposite Parties:

                   NIL

   Sd/-                                                                        Sd/-

Member                                                                  President (FAC)

                                                                   District Consumer Forum-I

                                                                             Visakhapatnam

//VSSKL//