Punjab

Ludhiana

CC/22/359

Mukesh Nayyar - Complainant(s)

Versus

Care Health Insurance Ltd - Opp.Party(s)

Amandeep sharma

04 Nov 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  359 dated 09.09.2022.                                       Date of decision: 04.11.2024. 

 

Mukesh Nayyar S/o. Sh. Parshotam Singh Nayyar, R/o. House No.891-92, Brown Road, Hotel Abhishek, Near Luxmi Cinema, Ludhiana. M. No.83603-31765, Gmail ID-           ShubhamSharmaadv@786gmailcom.                                                                                                                             ..…Complainant

                                                Versus

  1. Care Health Insurance Company Limited, Feroze Gandhi Market, Ferozepur Road, Ludhiana, Through its Branch Manager-141001.
  2. Care Health Insurance company Limited, Vipul Tech Square, Tower C, 3rd Floor, Sector-43, Gold Course Road, Gurgaon-122009, through its Authorized Person.                                                                                                                                                   …..Opposite parties 

Complaint Under Section 35 Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Amandeep Sharma, Advocate

For OPs                         :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER MONIKA BHAGAT, MEMBER

1.                In brief, the facts of the case are that the complainant is a senior citizen having aged about 76 years, who purchased one health care policy No.32960497 from the OPs on premium of Rs.1,53,425/- on 19.09.2021. At the time of purchasing the policy, the OPs assured the complainant that he is covered under all types of disease like chronic disease or any other ailment, with assurance to pass every claim in future. The complainant stated that when he approached the OPs relating to his disease, the OPs denied to cover the disease, upon which he requested the OPs to cancel his policy on 01.10.2021 and to refund the amount of Rs.1,53,425/-  but the OPs paid only Rs.1,35,425/- by deducting the amount of Rs.18,000/- without any reason. The complainant again approached the OPs to refund the deducted amount of Rs.18,000/- but the OPs did not refund the same despite several requests made by the complainant. The complainant sent a legal notice dated 30.06.2022 upon the OPs to which the OPs sent a false and frivolous reply but did not refund the amount. Hence this complaint, whereby the complainant prayed for issuing direction to the OPs to refund the amount of Rs.18,000/- along with compensation of Rs.30,000/-.

2.                Upon notice, the OPs appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the grounds of maintainability; lack of cause of action etc. The OPs stated that they issued “Care Individual” insurance policy No.32960497 w.e.f. 18.08.2021 to 17.08.2024 on premium of Rs.1,53,425/- for a sum insured of Rs.5,00,000/-, which was duly sent and received by the complainant on 19.09.2021. However, vide application dated 01.10.2021, the complainant approached them for cancellation of said insurance policy, upon receipt of which the OPs cancelled the said policy and refunded the premium of Rs.1,35,782/-. The OPs further stated that after expiry of free look period, the policyholder may write a notice in writing to the company for cancellation of the policy, in which case the company shall from the date of receipt of the notice, cancel the policy and refund the premium for the unexpired period at the short period scale as per clause 7.11 (b) of the policy terms and conditions provided no claim has been made under the policy by the insured. As the complainant made request for cancellation of the policy within 1 to 3 months policy period bracket and has policy tenure of 3 years, as such, the insured was liable to receive 88.50% refund of the premium paid. Therefore, the OPs refunded Rs.1,35,782/- being 88.50% of the premium received as per policy terms and conditions under Clause 7.11(b).

                   The OPs further stated that it is the complainant who approached them after a span of one month of coverage for cancellation of the policy. Had the complainant had any grievance with the intent and purpose of the policy, then he could have applied for cancellation of the policy within the free look period of 15 days as per clause 7.8 of the policy terms and conditions.

                   On merits, the OPs reiterated the crux of averments made in preliminary objections. The OPs have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of legal notice dated 30.06.2022, Ex C2 is the copy of reply dated 22.07.2022 to legal notice dated 30.06.2022  and closed the evidence.

4.                On the other hand, the counsel for the OPs tendered affidavit Ex RA of Sh. Parth Arora, Manager of the OPs office at Gurugram (Haryana) along with documents i.e. Ex. R1 is the copy of welcome letter and policy documents, Ex R2 is the copy of letter dated 01.10.2021 of the complainant for cancellation of the policy, Ex C3 is the copy of letter dated 29.10.2021 of the OPs, Ex. R4 is the copy of legal notice dated 30.06.2022 as well as its reply dated 22.07.2022 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents as well as written statement, affidavit and documents produced on record by both parties. We have also gone through written arguments submitted by the complainant.

6.                By filing the present complaint, the complainant, a senior citizen has raised a grievance of non-refund of Rs.18,000/-out of the total single premium of Rs.1,53,425/- received by the OPs at the time of issuance of the policy. The said amount of Rs.18,000/- was deducted by the OPs vide letter dated 29.10.2021 Ex. R3. Operative part of letter Ex. R3 reads as under:-

“In reference to your request 1467568 dated 01-Oct-2021 your Health Insurance Policy 32960497 has been cancelled. The effective date of cancellation is 01-Oct-2021.

In accordance with the terms and conditions of the Policy, online payment towards refund of your premium on your credit/debit card has been initiated as per the following detail.

Refund Amount     : 135782/- (Refund Details provided below for                                  reference)

Refund Date                   : 29-Oct-2021

Refund Details:

Premium Amount

153425/-

Policy Period Start Date

18-Aug-2021

Policy Cancellation Date

10-Oct-2021

Refund

135782/-

Note:- Expect Credit in next 7 working days from date of refund.

Note

Refund is as per cancellation grid of Policy Terms & Conditions

Please note that we are absolved from any and all liabilities under this Policy and no further amount is payable under the same.”

 

7.                Now the point of consideration arises before this Commission whether the OPs were justified in deducting Rs.18,000/- out of total premium of Rs.1,53,425/-.

8.                Perusal of policy certificate Ex. R1 shows that an individual “Care Shield” policy No.32960497 was issued to the complainant w.e.f. 18.08.2021 to 17.08.2024 on single premium of Rs.1,53,425/-. But as per welcome letter Ex. R1 policy certificate,  premium acknowledgement, key policy information, claim process as well as policy terms and conditions was dispatched to the complainant on 04.09.2021. The complainant might have received the policy documents within 3 days from the date of its dispatch. The cancellation of policy in this case was moved by the complainant vide letter dated 01.10.2021 Ex. R2 i.e. within 30 days from the date of receipt of policy documents. In reply dated 22.07.2022 Ex. C2 = Ex. R4 to legal notice of the complainant dated 30.06.2022 Ex. C1 = Ex. R4, the OPs averred that they have calculated the refund of Rs.1,35,782/-  i.e. 88.50% of the premium amount as per clause 7.13(b) of the policy terms and conditions as they have received the cancellation request from the complainant on 01.10.2021 i.e. within 1 to 3 months from the policy start date. As the policy documents were sent to the complainant by the OPs vide welcome letter dated 04.09.2021 Ex. R1, therefore, the stipulated period was to be reconsidered the OPs from the date of receipt of policy documents presumably w.e.f. 08.09.2021 and not from the date of start of the policy. In this manner, the OPs were required to calculate the refund of premium at the rate of 91.50% and not by 88.50% as per Cancellation/Termination clause 7.13. As such, the OPs were not justified in treating the policy date 17.08.2021 as by that time no policy documents were supplied to the complainant. An amount of 3% has been arbitrarily  deducted by the OPs in excess which is liable to be refunded to the complainant. Therefore, keeping in view the facts and circumstance of the case, it would be just and appropriate if the OPs are directed to recalculate the refund of premium to 91.50% instead of 88.50%and to pay the said amount to the complainant within 30 days from the date of receipt of copy of order. The OPs are also burdened with composite costs of Rs.5,000/-.

9.                As a result of above discussion, the complaint is partly allowed with direction o the OPs to recalculate the refund of premium at the rate of 91.50%  instead of 88.50% and to pay the said amount to the complainant within 30 days from the date of receipt of copy of order. The OPs shall further pay a composite costs and compensation of Rs.5,000/- (Rupees Five Thousand only) to the complainant. Compliance of order be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.   

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:04.11.2024.

Gobind Ram.

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