FINAL ORDER / JUDGMENT   

SMT. SUKLA SENGUPTA, PRESIDENT

This is an application filed by the complainant U/s 35 of the CP Act 2019.

The fact of the case in brief is that complainant imparts education from class pre-nursery to class 12 from school which is affiliated to the council for Indians School Certificate Examination ICSE/ISC, New Delhi.

On the contrary, the OP is a Health Insurance Co., governed by the Insurance Act, 1938 as well as Insurance Regulatory and Development Authority, IRDA (Health Insurance) Regulations, 2012.

It is further stated that in the year August,  2001, the complainant/school was approached for group insurance coverage of its employees by the OP named as CHNHB Association. Having agreed to said proposal, the complainant as a group organization by a forwarding letter dated 30.08.2001 sent a sum of Rs. 17,588/- to the OP then named as CHNHB Association towards premium for group insurance of its 20 teaching and non teaching staff and the OP by a letter dated 05.09.2001 acknowledged receipt of such  money from the complainant. The OP issued the policy certificate in the name of said employees of the complainant through their letter dated 10.09.2001 and also informed the complainant to that effect.

It is further stated by the complainant that the OP used to make communication to the complainant as a group organization and also received premium from the complainant time to time. So, complainant is a consumer as per provision of CP Act, 2019 and the OP is a service provider letter dated 30.08.2001  of the complainant and the letter of the OP dated 05.09.2001 and 10.09.2001 as well as money receipt issued by the OP are collectively annexed hereto as annexure-A.

The complaint further stated that the policy condition of the group members are identical.

It is further stated by the complainant that the OP made a several schedule namely schedule 1 to 11 indicating various events where OP would reimburse medical expense owned by the insured persons.

 It is further case  of the complainant that as per advice of the complainant while admitting a staff of the complainant as new member of health insurance group,   the OP issued mediclaim policy, certificate of insurance to the member certifying that if any event described in the schedule shall happen to the member all his registered dependent during the period of insurance for which if the member or his member dependent as admitted as inpatient in a hospital or nursing home, the OP will paid to the member in Indian rupees at Kolkata  the compensation specified  in schedule. A copy of medical policy/certificate of health insurance issued to one of the group members namely Ajit Kr.  Roy for the period from 01.09.2001 to 31.08.2002 (annexure D). A copy of the policy condition issued by the OP to the teaching and non teaching staff of the complainant as annexed as annexure-C.

The complaint further stated that on a sudden vide letter dated 04.03.2002, the OP named as CHNHB Association informed the complainant about the enhancement of premium for schedule i, ii and iii (annexure-D).

The OP also adduced an addendum to the policy condition applicable to the policy to issue /renew on or after 1^st June 2009 (annexure-E).

It is further stated by the complainant that on 31 August, 2009, the OP issued an amendment of policy conditions stating that the said amendment was made in relation of condition No. (c) registered in 1^st addendum  being part of annexure-D herein. It was mentioned in said amendment that the benefit of said amendments will be available to the policies renewed on or after 1^st Sept, 2009. A copy of said amendment of policy conditions dated 31.08.2009 is annexed as annexure-F.

Accordingly, on 30.08.2010, the complainant sent a letter along with a cheque of a sum of Rs. 1,78,146/-  to the OP as premium for renewal of mediclaim policy of the members of teaching and non teaching staff of the school for the period  on and from 01.09.2010 to  31.08.2011. The OP by their letter dated 15.09.2010 demanded additional premium of Rs. 2,17,209/- on the ground that  payments made by the school during the earlier three year had exceeded of total premium receipt during the said years but in that year,  the OP claimed the total excess payment + 5 % of the amount paid as premium and service tax.

It is further stated the complainant that in respect of the said claim of excess money by the OP,  a meeting was held between the representative of the complainant and the OP and in the said meeting,  it was agreed  that the complainant would pay 70 % of the amount demanded by the OP which was recorded by the OP in their letter dated 17.09.2010.

 By a letter dated 15.02.2010, the OP further stated that in terms of the policy conditions in question,  additional premium would be  payable in case of claim payment excess the premium receipts  and the recovery of additional  premium  was limited to recovery of the claims paid in excess of 95 % of the premium plus 10.30% of the excess amount towards service tax including Educational Cess and Secondary Higher Education Cess (SHEC) now. It seen that no such condition was stipulated in the policy condition. The school represented by its teacher had acknowledged that such additional premium would be claimed only after obtaining approval from IRDA and recording such condition in the policy conditions. Copies of the letter dated 30.08.2010, 15.09.2010 and 17.09.2010   are annexed herewith as annexure-G.  

As per demand of the OP,   the complainant sent a cheque of a sum of Rs. 3,29,492/- to the OP vide letter dated 25.08.2020 towards renewal premium  and GST @ 18 % for renewal of the medical policy of the teaching  and non teaching staff of the school.

It is further stated by the complainant that the OP vide its letter dated 21.09.2020 intimated the complainant school that due to non-payment of the claim of loading charges by way of additional premium,  they cancelled the medical policy of the teaching and non teaching staff of the school on and from 01.09.2020 and they adjusted the amount of Rs. 2,79,000/- excluding GST paid by the complainant with the alleged dues on account of loading charges and they further claimed  of a sum of Rs. 8.22 lacs + GST @ 18 % p.a.  thereon from the complainant school  and also  claimed of a sum of Rs 45,680/- more.

The complainant on several occasions tried to communicate the OP and requested them to renew the policies of the teaching and non-teaching staff of the school but in vain. Hence, without having any other alternative, the complainant school filed this case before the  commission/forum with a prayer for setting aside the cancelation of the policy in question of the teaching and non teaching staff of the complainant school vide letter dated  21.09.2020 and also prayed for giving direction to the OP that there is/was no dues to be paid by the complainant in respect of health insurance  policy  for the period on and from 01.09.2020 to  31.08.2021 and also prayed for giving direction to the OP for renewal of the policy of teaching and non teaching staff of the school w.e.f. 01^st September, 2020.

The complainant further prays for giving direction to the OP to release the claim made by Sri Arup Kr. Das member of Group Health insurance policy issued by the OP and also giving direction to OP to pay compensation to the complainant for a sum of Rs.  7,20,000/- for mental pain and agony and also prayed for giving direction to the OP for refund of a sum of Rs. 9,78,233/- collected from the complainant in the name of additional  premium/loading  charges and GST for the year  2017-2018,  2018-2019 and 2019-2020 along with litigation cost of Rs. 50,000/-.

The OP (CHNHB) Health Insurance Co. Ltd. has contested the claim application by filing a WV denying all the material allegations leveled against it.

As per OPs case, the petition of complaint is false, frivolous and without having any cause of action, the complainant has filed this case with malafide intention.

 It is further stated by the OP that as per policy conditions as perceiving in relevant  time clause 14 of the said policy conditions in question  authorized  the OPs to impose loading on the premium in respect of members comprising a good admittedly. The complainant has purchased the health insurance policy for teaching and non teaching staff from the OP Insurance Company. The OP further stated that with due compliance of guidelines of IRDAI and in terms of the policy in question,  the OP demanded additional premium  for the relevant policy period as referred paragraph 10 of the petition of complaint.

The OP further stated that charging of loading based in cases where the claim payments for immediately there proceedings finally year exceeded premium receipt in each of the proceedings years as stipulated in clause 15 of policy condition in question. So, nothing erroneous therein as alleged by the complainant. The OPs further stated that the payment of the additional premium demanded by the OP for the policy in question during the period of 01.09.2020 to 31.08.2021 is accordance with provisions stipulated in the policy conditions of the OPs.

The additional premium is levied in respect of members comprising  a group and that the IRDAI Regulations allowed the OPs to impose the additional  premium in that regard, ref. is done 25 of (Health Insurance), Regulations 2016 in that regard charging of additional premium is also known’s as loading charge in clause 15 of the policy conditions.

Which is reproduced below:-

(the Board of the Company may imposed loading on the premium and grant on withdraw discount on premium in respect of the policy holder comprising a group loading and discount will apply also to the covered dependence of a policy holder. loading becomes applicable for the fourth year (the relevant year) in case were the claim payment for the immediately three proceeding financial years exceed the premium receipt in each of three proceeding years.

The loading amount is limited with recovery of the paid in the relevant year in excess of 95 % of the premium receipt in the year.

This process of determination and imposition of loading will continue in the subsequent year on the same basis as mentioned above.

Copy of policy in condition is annexed herewith as annexure A.

On the basis of various correspondences made in between this case the OP has no other option but to cancel the policy of the complainant because of its failure to pay the premium and additional premium in time.

The OP further stated that it is not possible for any commercial establishment like the OP to provide health insurance services continuously to the complainants staff unless premium and is paid in advance.

From the fact that the complainant paid loading charges for the earlier policy period will go show that admittedly the complainant admitted the position that the loading charges is leviable contractual  and lawful.

Hence,

The petition of complaint is baseless and the complainant has no cause of action to file the case. So the case is liable to be dismissed.

In view of the fact and circumstances, the points of consideration are as follows:-

1. Is the case maintainable in its present form?
2. has the complainant any cause of action to file the case
3. Is the complainant a consumer?
4. Is there any deficiency in service on the part of the OP?
5. Is the complainant entitled to get relief as prayed for?
6. To what other relief or reliefs is the complainants entitled to get?

Decision with reasons

All the points of consideration are taken up together for convenience of discussion and to avoid unnecessary repetition.

On a close scrutiny of the materials on record it appears that the case is well maintainable in the eye of law and this Commission has got ample jurisdiction to try this case both territorial and pecuniary. 

Admittedly the complainant school purchased the health insurance policy in question for its teaching and non teaching staffs from the OP on payment of required premium and the OP insurance Co. issued the policies to that effect. Hence, the complainant is a consumer as per provision of the CP Act, 2019 and the OP insurance Co. is the service provider.

Let us see whether there is / was any deficiency in service on the part of the OP CHNHB Health Insurance Co. Ltd.

It is case of the complainant that it is a school and a Society, Resister under the West Bengal Societies Registration Act, 1961 and it imparts education from classes Pre-Nursery  to class-XII. The complainant is affiliated to ICSE – ISC, New Delhi. From the facts and circumstances of this case and materials on record it is revealed that the OP is a Health Insurance Co and is covered by the Insurance Act, 1938 as well as Insurance Regulatory Development Authority (Health Insurance) Regulations, 2012.  From the evidence on record, it is revealed that the complainant purchased the group insurance coverage for its teaching and non teaching staffs from the OP CHNHB on payment of required premium. The OP insurance Co. issued the policy certificate in the name of the staffs of the complainant and informed the same to the complainant school vide its letter dated 10.09.2001, from which it was appeared that the policy condition for all the members are/were identical. From the Evidence on record as adduced by the parties to this case it is revealed that an addendum to the policy conditions application to this policy issued / renewed on or after 01.06.2009 was issued by the OP insurance Co.  In the said addendum it is provided that “many change in the premium structure or terms of the policy conditions or scope of covered under different schedule of benefits will be made only after such changes are filed with and accepted by IRDA”. Admittedly the OP further issued  another addendum granting certain reliefs to the senior citizens effective from 01.07.2009 and vide its letter dated 31.08.2009 (Annexure – F), the OP insurance co. proposed to annex policy conditions. A notice was issued by the OP to that effect on 30.08.2013 but there was no whisper about the loading / additional premium for renewal of policies in the aforesaid addendum issued by the OP. 

It is alleged by the complainant school that while renewing the policies for the period from 01.09.2017 to 31.08.2018, 01.09.2018 to 31.08.2019 and 01.09.2019 to 31.08.2020 the OP insurance Co. illegally claimed renewal premium as well as additional premium when in all the aforesaid year the insurance co. claimed the renewal premium from the year September, 2009 to 31^st August, whereas additional premium was claimed for the period on and from 1^st April to 31^st March of the preceding year.  On good faith the complainant school paid the said amount.

It is further alleged by the complainant in its petition of complaint as well as evidence and written argument that for renewal of the mediclaim policy for the period of 01.09.2020 to 31.08.2021 the OP demanded a sum of Rs.16,31,727/- and the said total amount of Rs16,31,727/- was inclusive of Rs.11,00,589/- towards additional premium for the period on and from 01.04.219 to 31.03.2020 and GST @ 18% amounting to Rs.2,48,908/-. From the statement as enclosed with the letter of the OP it is found that the renewal premium for the said period of Rs.2,82,230/- only and the additional premium and GST was Rs.13,82,819/-. The complainant rightly refused to pay the additional premium of Rs.11,00,589/- and the GST calculated on the said amount as there was no such provisions in the policy conditions as well as IRDA regulation for renewal of Group Health Insurance Policy. It is the allegation by the complainant that the OP insurance Co. demanded the said amount without any approval of IRDA for imposing any additional premium and / or loading on renewal premium.  The OP in his written argument stated that the Board of the Co. may impose loading on the premium and may grant or withdraw discount on premium in respect of policy holders comprising a group, the OP demanded that whichever is done by it, it is done as per terms and condition of the policy in question (Annexure –A).  The OP claimed that it is authority of the OP to charge loading charges. Admittedly the complainant issued a cheque of Rs.3,29,492/- and GST @ 18% to the OP towards renewal premium and GST @ 18% on renewal premium to renew Group Health Insurance for a period of one year with effect from September 2020 by a forwarding letter dated 25.08.2020 which was encashed by the OP. But the OP over telephone demanded extra amount on account of additional premium / loading charges and they admitted that they demanded the same without approval of IRDA which the OP cannot. The complainant vide his letter dated 09.09.2020 requested the OP to renew the group insurance policy but the OP vide its letter dated 21.09.2020 intimated the complainant that they had cancelled the mediclaim policies for teaching and non teaching staffs  from 01.09.2020.

On a close scrutiny of evidence on record and written argument of both parties, it appears that the OP Insurance Co. arbitrally  demanded the insurance and loading charges from the complainant school without having any approval of the IRDA which cannot be done by the OP and the OP did it arbitrally  and illegally.  The OP arbitrally  cancelled medicalim policies of the teaching and non teacher staffs of the complainant school from 01.09.2020. The complainant school requested the OP on several times to renew the policies but the OP did not pay any heed to that request which compelled the school to come before this Commission for getting relief and caused harassment to the complainant. Such conduct of the OP is nothing but the deficiency in service on its part and also unfair trade practice for which the OP Insurance Co. is liable to pay compensation to the complainant school.

In view of the discussions made above, it is held by this Commission that the complainant school being a consumer could be able to prove the case against the OP Insurance Co. beyond all reasonable doubt and entitled to get relief as prayed for.

The case is properly stamped.

Hence,

Order

that the instant case be and the same is decreed on contest with cost of Rs.5,000/- against the OP .

The complainant do get the decree as prayed for.

The OP Insurance Co. is directed to renew the cancelled Health Insurance Policy for the teaching and non teaching staffs of the complainant school by considering that there was no dues of premium for the period on and from 01.09.2020 to 31.08.2021 and is also directed to treat the mediclaim policies of teaching and non teaching staffs of the complainant school as renewed on and from 01.09.2020 and also directed to release the claim made by Sri Arup Kumar Das, a Member of Group Health Insurance Policy within 45 days from this date of order.  

The OP Insurance Co. is further directed to pay compensation of A sum of Rs.1,00,000/- to the complainant school for harassment, mental pain and agony and to refund amount of Rs.9,78,233/- as collected by the complainant towards additional premium / loading charge and GST for the year 2017-18, 2018-19 and 2019-20 along with litigation cost of Rs.5,000/- within 45 days from the date of order i/d the complainant is at liberty to execute the decree as per law.

 Copy of the judgment be uploaded forthwith on the website of the Commission for perusal.