Delhi

North East

CC/45/2022

Dr. Ashok Kumar Sharma - Complainant(s)

Versus

Care Health Insurance Co. - Opp.Party(s)

02 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.45/22

In the matter of:

 

1.     2.	Dr. Ashok Kumar Sharma, S/o Sh. B.S Sharma   Dr. Geeta Sharma, W/o Dr. Ashok Kumar Sharma, Both R/o B -120, Plot No. 35, Khasra No. 776/704/508, Gali No. 5, Hardevpuri, Near 100 Ft. Road, Delhi 110093   Also At: B-34, Law Apartments, Near Amar Jyoti Hospital, Karkardooma, Delhi 110092	Complainants
	Versus
	Care Health Insurance Ltd., (Formerly Known As Religare Health Insurance Ltd.), Office AT 206, Second Floor, Roots Tower, Plot No. 7, District Centre, Laxmi Nagar, Delhi 110092	Opposite Party

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

02.03.2022 17.08.2023 02.11.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 35  of the Consumer Protection Act, 2019.

Case of the Complainants

1. The case of the Complainants as revealed from the record is that the Complainants had taken a health insurance policy from the Opposite Party. The period of the said policy was from 15.04.2020 to 14.04.2021. It is his case that Complainant No. 1 renewed the said policy for the next year i.e. from 15.04.2021 to 14.04.2022 and paid a sum of Rs. 49,680/- as premium through online transaction. Opposite Party acknowledged the payment made by the Complainant. After 10 days i.e. on 25.04.2021, Complainant received an email from the Opposite Party and Opposite Party thanked the Complainants for choosing the insurance and renewing the same. It is his case that Opposite Party instead of sending new/renewed policy, they had sent the policy of previous year i.e. 2020-2021. The Complainant No. 1 lodged a complaint on 30.04.2021 through email and requested to give new/renewed policy for the period 15.04.2021 to 14.04.2022. Complainant also stated that his new policy had not been delivered as yet. On 03.05.2021, Complainant received an email from the Opposite Party stating that the payment made by the Complainants is not traceable. Complainant again communicated to the Opposite Party and also sent the screenshot of the successful premium payment. On 08.05.2021, Complainant received a message on whats app from the Opposite Party and stating therein that the policy had been renewed but no new policy was sent to the Complainant. After that the Complainant approached IRDA in July 2021 and IRDA responded the Complainant on 05.08.2021 wherein it was informed that the complaint of the Complainant had been addressed and resolved by the insurance company, whereas the grievance of the Complainant was never addressed by the Opposite Party. Complainant also approached the Ombudsman but no reply was received. Complainant also sent a legal notice to the Opposite Party and in reply to the legal notice, Opposite Party stated that the company was unable to track any information related to policy. Complainant has prayed to handover the renewed health insurance policy as on current date for the next year, to refund back of Rs. 49,680/- along with interest @ 12 %. Complainant also prayed for Rs. 5,00,000/- on account of mental harassment and Rs. 25,000/- on account of litigation expenses.

Case of the Opposite Party

2. The Opposite Party contested the case and filed its written statement. It is stated that the complaint is not maintainable. It is admitted that the Complainants were having policy coverage starting from 15.04.2019 to 14.04.2020 for a sum insured up to Rs. 7,00,000/- which was subject to policy terms and conditions. The said policy was further renewed from 15.04.2020 to 14.04.2021 subject to the terms and conditions. It is submitted that during the renewal of health insurance policy for the period from 15.04.2021 to 14.04.2022, it was observed that there was non-disclosure of heart disease by the Complainant. It is stated that as per the progress note of M/s Max Super Speciality Hospital, the Complainant underwent CAG in April 2019. As per discharge summary dated 29.01.2020 of All India Institute of Medical Science, New Delhi, the Complainant was diagnosed with Paraoxysmal AF in 2003. It was observed that the Complainant was suffering from heart disease prior to the inspection of the policy which was not disclosed by the Complainant. Therefore, the insurer took the decision not to further renew the insurance policy. The Complainant at the time of filing the proposal form did not disclose about the ailment which is mis-declarations. It is stated that refund of premium was initiated by the Opposite Party through cheque no. 104550 on 30.10.2021 and the same was not encashed by the Complainant. The allegations of the Complainant have been denied and it is prayed that the complaint be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party, wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint. It is stated that the Opposite Party has not renewed the insurance policy nor returned back the premium amount to the Complainants. Complainants have stated that they did not receive any cheque bearing no. 104550 on account of refund of the premium amount.

 

Evidence of the Complainant

4. The Complainants in support of their complaint filed the affidavit of Complainant No. 1, wherein he has supported the averments made in the complaint. He has also stated that he has received Rs. 49,760/- in his bank account on 28.06.2022.

Evidence of the Opposite Party

5. To support its case Opposite Party has filed affidavit of Mr. Path Arora, wherein, he has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

6. We have heard the parties. We have also perused the file and written arguments filed by the Complainants and Opposite Party.  The case of the Complainants is that they were having a health insurance policy issued by the Opposite Party from 15.04.2019 to 14.04.2020 and thereafter the same was renewed for 15.04.2020 to 14.04.2021. It is their case that they have further renewed the said policy for further period of one year from 15.04.2021 to 14.04.2022 and paid the premium of Rs. 49,680/-. It is their case that they were informed that policy has been issued to them and later on they came to know that in fact no policy for the period from 15.04.2021 to 14.04.2022 was issued. The case of the Opposite Party is that they have issued the insurance policy for the two years i.e. from 15.04.2019 to 14.04.2020 and 15.04.2020 to 14.04.2021. It is the case of the Opposite Party that the Complainant No. 1 was suffering from heart disease and at the time of purchasing the policy he has not disclosed his heart disease. The Opposite Party has relied upon the report of Max Super Speciality hospital and AllMS hospital, Delhi to support its contention. The case of the Opposite Party is that the Complainant has not disclosed his previous ailment in the proposal form and the same amounts to mis-representation which is violation of terms and conditions of the policy.
7. The Opposite Party has relied upon the report of Max Super Speciality Hospital and AIIMS which shows that the Complainant was suffering from the heart disease. On the other hand, the Complainants have not rebutted this by leading any evidence that the Complainant No. 1 was not suffering from any heart disease. Therefore, it is established that the Complainant was suffering from heart disease. The case of the Opposite Party is that as the Complainant has not disclosed his heart disease in the proposal form and the same was violation of the terms and condition of the policy. The Complainants have not led any evidence that this was not violation of terms and conditions of the health policy.
8. The perusal of the file shows that during the correspondence between the Opposite Party and Complainants prior to the filing of this complaint, the stand of the insurance company was that the payment made by the Complainants was not traceable. However, in its written statement the Opposite Party has taken the stand that the Complainant was issued cheque dated 30.10.2021 on account of refund of the premium amount. Thus, it is clear that the insurance company has taken altogether a different stand regarding receiving the payment from the Complainants on account of premium amount. The case of the Opposite Party is that cheque dated 30.10.2021 was sent to the Complainants on account of the refund of the premium amount. However, neither the complete details of the cheque i.e. the name of the cheque on which it was drawn has been disclosed. Nor nothing has been brought on record to show that this cheque was delivered to the Complainants. Hence, it is concluded that the Opposite Party did not give any such cheque to the Complainants on account of the premium amount. After the insurance company has received the premium amount, it was requiring to issue the insurance policy to the Complainants. However, in the present case the insurance company did not issue the insurance policy to the Complainants on the ground that there was mis-representation made by the Complainants in the proposal form. However, in this event the Opposite Party was bound to refund the premium amount to the Complainants as the insurance company did not lead any evidence that in case of                          mis- representation, the insurance amount was to be forfeited. Therefore, we are of the opinion that there was deficiency of service on the part of the Opposite Party.
9. In their rejoinder, the Complainants have submitted that an amount of          Rs. 49,760/- was transferred in their account on 28.06.2022. Thus, it is clear that the insurance company has refunded the premium amount even after a considerable time after filing the complaint. Hence, we deem it proper and in the interest of justice to award damages of Rs. 75,000/- to the Complainants on account of mental harassment. This amount shall be paid by the Opposite Party to the Complainants along with interest @ 9 % p.a. from the date of filing the complaint till recovery. Opposite Party shall also pay an amount of          Rs. 25,000/- to the Complainants on account of litigation expenses along with interest @ 9 % p.a. from the date of this order till recovery.
10. Order announced on 02.11.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)