By.Smt. Beena. M, Member:-

            This is a complaint filed under section 35 of the Consumer Protection Act 2019.

            2.  Facts of the case in brief: The Complainant has been holding an insurance policy with the Opposite Party No.2 firm since 2015.  The Complainant was added to the health insurance policy by the  Opposite Party No.1.  The Complainant was admitted in DM WIMS, Meppadi on 25.04.2018 due to Cardiac ailment and was discharged on 27.09.2018.  The Complainant had incurred an amount of Rs.85,780/- towards treatment expenses.  The Complainant took the policy on the basis of the representation of the Opposite Party No.1 and 2 that they would provide premium benefit as cashless facility for all diseases.  But the Opposite Party refused to give claim on the ground that they are not eligible for policy benefit and cashless facility for heart attack.  Hence, this complaint.

            3.  Notice was duly served upon the Opposite Parties and after receiving the notice, the Opposite Parties appeared and the Opposite Party No.1 filed version.  Even though the Opposite Party No.2 appeared before the Commission, they failed to file version, hence set them ex-parte.  Later, the complaint was amended and supplementary Opposite Party No.3 was impleaded.  The Opposite Party No.1 filed version with following contentions.  The Opposite Party No.1 is an unnecessary party to this case. The Complainant on availing the service offered under his Health Insurance Package might or might not have suffered deficiency in service from the Opposite Party No.1, but all the averments mentioned in the complaint does not come under the extent of service that can be offered by the Opposite Party No.1. The Opposite Party No.2 is an Insurance Company Ltd., having its branches all over India and Opposite Party No.1 is a Banking company constituted under the Banking Companies Act. These two are separate entities, the role of Opposite Party No.1 is only an intermediary between the insured and insurer and there is no Privity of contract between Opposite Party No.1 and the Complainant. Therefore, it’s prima facie clear that Opposite Party No.1 acts just as an agent in fulfilling the insurance services and do not take part directly in any kind of procedures for initiation, issuance or remittance of the claim.  It has already been informed to the Complainant upon the rejection letter. Contrary to the statement made by the Complainant, Opposite Party No.1 has specifically informed the Complainant that this Insurance facility is intended to cover all medical conditions as promised at the time of Contract. But here, in the above case, the rejection of Cashless Claim was on the ground of 'Incorrect Good Health Declaration’. Acting within the capacity of an Agent to the Insurance Company, this Opposite Party No.1 was very keen to explain the facts with reasons which was done by fulfilling our duty to intimate that, the condition called POLIOMYELITlS WITH RESIDUAL PARALYSIS was not declared while taking policy which are observed in the documents provided during hospitalization. The Opposite Party No.1 cleared that this is an information letter which doesn’t mean to reject the entire Insurance Facility but to intimate the legal and technical reason which led to the situation where Cash less Facility could not be made enforceable. The Opposite Party No.1 further submitted that the Bank’s role in the Contract of Insurance is to furnish a medium to transact the premiums from Insured to the Insurer and the nature of services which can be availed from Opposite Party No.1 is limited to this. This Opposite Party No.1 would again like to submit that Cashless denial never indicates the denial of the Claim and the same can beclaimed for Reimbursement by producing Treatment records. Therefore, denial of Cashless facility and non-submission of medical records for Reimbursement regarding the insurance facility should not come under the obligation of the Opposite Party No.1. Therefore, it is submitted that, the Opposite Party No.1 has intimated the Insurance Company about the claim raised and made earnest efforts to get fasten the process of the claim thereby fulfilling its duty absolutely. Opposite Party No.1 condemn the situation gone through by the complaint but his claims in deficiency of service is not meant for Opposite Party No.1 as Bank has made sincere efforts to intimate and settle the claim and there is no latches or delay or deficiency of service and the complainant is not entitled to get Compensation from the Opposite Party No.1.   Hence the Complaint is liable to be dismissed with the cost to the Opposite Party for being falsely dragged into a frivolous litigation like the present Complaint.

            4.  The Opposite Party No.3 appeared and filed version stating that the Opposite Party Housing Development Finance Corporation Ltd. (HDFC Ltd.) has acquired a majority stake (i.e., 51.16%). Based on the said acquisition, Apollo Munich Health Insurance Company Limited has been renamed as HDFC ERGO HEALTH INSURANCE LIMITED with effect from 8.01.2020. The complaint filed by the complainant is time barred and hence not maintainable. That the policy issuing office is not located within the jurisdiction of the Commission and hence the complaint must be dismissed on the ground of territorial jurisdiction.  It is humbly submitted that the Complainant had taken Easy Health policy through intermediary Canara Bank for the period from 02.12.2017 to 01.12.2018. The policy of Insurance is a contract binding both the party and neither party can traverse beyond the scope and ambit of the policy terms and conditions. That the complainant has reported a cashless claim for ACS STEMI ACUTE AWMI COPD and after scrutiny of the medical documents at while processing the cashless claim it was observed that, the insured was a known case of POLIOMYELITIS WITHRESIDUAL PARALYSIS and the Insured for reason best known had not disclosed the same at the time of taking the policy. Hence, the cashless claim was denied on the ground of incorrect good health declaration.

5.  That it is further submitted Cashless claim settlement means a specialized service provided by an insurance company or a third-party administrator (TPA), where the payment for the cost of treatment undergone by the policyholder is directly made by the insurer to the network provider in accordance with the policy terms and conditions. Hence, it is evident that Cashless benefit which the insured can avail from any network hospital. That we further submit denial of the cashless per se does not mean the denial of the claim. That the insured or claimant are within their rights to file a reimbursement claim without delay with all the necessary documents for the company to pursue the claim and decide on the admissibility based on the policy terms and conditions. The insured has not exercised the said option. In order to establish Non-Disclosure there need not be any nexus with the current ailment. That further submit that the policy of insurance is a contract binding both the party and neither party can traverse beyond its scope and ambit.  That the cardinal Principle of insurance is based on the maxim of utmost good faith. The proposer at the time of availing a policy is required to furnish and disclose previous and present medical conations/ailment or any past or current surgery for the underwriting team to decide whether to cover the loss and underwrite the policy. In absence of such a disclosure at the time of the claim the same can be rejected and policy cancelled.  The claim of the insured was denied on the ground of non-disclosure of material fact. The fundamental principle is that insurance is governed by the doctrine of uberrimaefidei, this postulates that there must be complete good faith on the part of the insured. This principle has been formulated in Mac Gillivray on Insurance Law succinctly. Thus, the Insured must disclose to the insurer all facts material to an insurer's appraisal of the risk which are known or deemed to be known by the Insured but neither known or deemed to be known by the insurer. Breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms. The relationship between an insurer and the insured is recognized as one where mutual obligation of trust and good faith are paramount.

6.   It is further submitted that as the insurance company had repudiated the cashless claim as per the terms and conditions of the policy on the ground of non-disclosure of material fact.  Therefore, Opposite Party prays that the complaint be dismissed with costs.

7.  The Complainant filed proof affidavit and was examined as PW1 and the documents produced were marked as Ext.A1 to A3 series.  The Opposite Parties submitted that they have no oral evidence. 

8.  The points for consideration are as follows:

1. Whether there is any deficiency in service on the part of Opposite Parties…?

2. Relief and Cost.

9.   Point No.1 and 2: Heard both sides and perused the materials on record.

On perusing the evidence on affidavit and the documents filed by the Complainant it appears that in this case the Complainant’s side has not submitted any claim against Opposite Party No.1 bank authority in the complaint.  At the same time the Complainant’s side has also failed to make out any case of claim against Opposite Party No.1 Canara bank and so it is clear that his case is not maintainable against Opposite Party No.1 bank  and for that reason this case is liable to be dismissed against Opposite Party No.1.  That during the pendency of this complaint a petition was filed by the Complainant to implead HDFC ERGO General Insurance Company as Opposite Party No.3 as most of the shares of the 2^nd Opposite Party brought by them.  The petition was allowed and HDFC ERGO General Insurance Company impleaded as Opposite Party No.3. It is well established that the Complainant was hospitalized for heart diseases on 25.09.2018.  The treatment is covered for the period from 02.12.2017 to 01.12.2018. The expenditure incurred for treatment is Rs.85,780/-.  Here the Opposite Party No.3 admitted on record that the cashless claim application was received, but they denied on the ground of incorrect good health declaration and they further submitted that the insured are within their rights to file a reimbursement claim with all the necessary documents and the Opposite Party No.3 shall have to process the claim as per terms and condition of the policy.

Therefore, the Complainant is directed to submit the claim for reimbursement with complete documents and filed with the Opposite Party No.3 and the same shall have to be decided within two months from the date of this order by the Opposite Party No.3, if the Complainant is not satisfied with the proceeding of the Opposite Party No.3 he is at liberty to file complaint before this commission as per law.  We do not see any fault with the Opposite Party bank on deficiency in service and no specific relief is sought against the Opposite Party bank. So the Opposite Party bank is at free from such liability of deficiency in service.   There is no order as to costs and compensation. The Complaint is disposed accordingly.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 12^th day of November 2024.

Date of Filing:-31.12.2024.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Ashraf.                                                                      Nil.

Witness for the Opposite Parties:-

                        Nil.     

Exhibits for the Complainant:

A1.                  Copy of Certificate of Insurance.                       Dt:09.12.2016.

A2.                  In-patient Final Bill.                                                Dt:27.09.2018.

A3(Series).   Policy Covered Card (3 Nos).

Exhibits for the Opposite Parties:-

                        Nil.     

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-