BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHABAD.
Complaint no.180/2018.
Date of instt.02.07.2018.
Date of Decision:13.11.2019.
Anil Kumar aged 54 years son of Sh. Gurdayal Singh, resident of Shadi Ram Wali Gali, Tehsil and District Fatehabad.
..Complainant.
Versus
Head of Operation India, HDFC ERGO General Insurance Company Limited, 1st Floor 165-166 Backbay Reclamation H.T. Parekh Marg Church Gate Mumbai.
..Respondent/OP.
Complaint under Section 12 of Consumer Protection Act, 1986.
Before: Sh.Raghbir Singh, President.
Sh. Jasvinder Singh, Member.
Argued by: Sh. Naresh Sachdeva, Advocate for the complainant.
Sh. U.K. Gera, Advocate for OPs.
ORDER
The present complaint under Section 12 of Consumer Protection Act, 1986 has been filed by the complainant against the Opposite Party (hereinafter to be referred as OP) with the averments that the complainant is a holder of Health Insurance Policy with the OP since the year 2006 bearing policy no.93674582-00003. The complainant had been paying an annual installments up to date with the OPs for renewal of the above said policy. However in between the complainant was also diagnosed with Cancer and also took the claim amount from time to time from the opposite party. It is further submitted that in the year 2014 aggrieved from the services of the OPs, the complainant filed a complaint under Section 12 of the Consumer Protection Act before this Forum and during the proceeding of the complaint, the counsel for the opposite party made a statement that the opposite party will pay Rs.40,000/- as outstanding amount at that time and will renew the policy, if the complainant will apply and make payment of premium. As per the above statement, the complainant withdrew the above said complaint on 27.03.2015 and as per the order dated 27.03.2015 both the parties were bound by this Forum by their statements.
2. It is further submitted that in the year 2015-16, the complainant sent a cheque of Rs.6962/- on 25.4.2015 for the renewal of the policy and thereafter a claim of Rs.16,725/- was also received by the complainant from the OPs. Thereafter, on 15.04.2016, the complainant again sent a cheque of Rs.6,962/- to the OP for renewal of the policy for the year 2016-17 but the OP did not sent the health policy for the above said period. Thereafter on 10.4.2017 the complainant again sent a cheque of Rs.6962/- for renewal of the policy for the year 2017-18. But the above said request of the complainant was returned by the OP on 13.07.2017. Thereafter, on 05.4.2018 the complainant again sent a cheque of Rs.7,651/- along with requisite forms for the renewal of the policy for the year 2018-19. In response to the above said letter, a letter dated 12.04.2018 was received by the complainant on 19.04.2018 with the directions to the complainant to provide the pending documents to any of the nearest office of HDFC Ergo within a period of 7 days from the date of issuance of the letter. However the said letter was received by the complainant after a period of 7 days. Therefore, the complainant could not approach the nearest office within a period of 7 days. Moreover, within a distance of 100 kms from the residence of the complainant, there is no branch office of the OPs. It is further submitted that all the relevant documents were submitted by the complainant with the OPs and the premium amount was also deposited in time. However, the policy was not renewed in favour of the complainant. It is further submitted that the abovesaid act on the part of Ops amounts to deficiency in rendering service to the complainant and as such the complainant is also entitled for compensation. The complainant has further prayed that the OP may be directed for making payment of the outstanding claim amount along with interest and to regularize the policy of the complainant. The complainant has also further prayed that the compensation of Rs.7,00,000/- on account of mental agony and physical harassment suffered by him be also awarded in his favour. Hence, the present complaint.
3. Upon notice, the OP appeared through its counsel and resisted the complaint by filing a written statement wherein various preliminary objections with regard to maintainability, cause of action, locus standi, jurisdiction and concealment of true and correct facts etc., have been raised.
4. In reply on merits, it is submitted that the answering OP had already complied with the contents of compromise as reached by the parties and have also complied the order dated 27.03.2015 passed by this forum in CC No. 48 of 2014. It is further submitted that the complaint was lodged by the complainant against the policy pertaining to the year 2015 for the hospitalization and the claim amounting to Rs.33,210/- as claimed by the complainant against the said hospitalization was paid to the complainant. It is also submitted that the policy pertaining to the year 2016-17 and 2017-18 was not issued to the complainant as discrepancy was found in the claim and the same was never resolved by the complainant. Therefore, the amount of premium deposited by the complainant was refunded to him. It is further submitted that there is no deficiency on the part of OP in rendering service to the complainant and as such the present complaint is without any merit and the same is liable to be dismissed.
5. The learned counsel for the complainant tendered in evidence the affidavit of the complainant as Annexure CW-1/A along with the documents as Annexure C-1 to Annexure C-8. On the other hand, the learned counsel for the OPs tendered in evidence affidavit of Pankaj Kumar, Legal Manager as Annexure RW1 in the evidence of the OP along with the documents as Annexure R-1 and R-2 and closed the evidence of OP.
6. We have duly considered the arguments advanced by learned counsel for the parties and have also perused the documents placed on record. It is the case of the complainant that he is a holder of the Health Insurance Policy with the OP since the year 2006. However, in between the complainant suffered from cancer and he also took the claim amount from the OPs from time to time. It is further the case of the complainant that in the year 2014 aggrieved from the services of the OP a complaint was filed by the complainant before this Forum. During the proceedings of that complaint the learned counsel for the OP made a statement that the opposite party will make a payment of Rs.40,000/- as outstanding amount at that time and will also renew the health insurance policy, in case the complainant applies for the same and makes payment of the premium. In view of the abovesaid statement of the OP the complainant withdrew the abovesaid complaint on 27.3.2015 and vide order dated 27.3.2015 passed by this Forum both the parties were bound by their statements.
7. It is further the case of the complainant that in the year 2015-16 the complainant had sent a cheque of Rs.6,962/- on 25.4.2015 and the policy was renewed by the OP and an insurance claim of Rs.16,725/- was also received by the complainant. However, thereafter on 15.4.2016 the complainant again sent a cheque of Rs.6,962/- to the OP for renewal of the policy for the year 2016-17 but the OP did not send the health insurance for the abovesaid period. Thereafter, on 10.4.2017 the complainant again sent a cheque of Rs.6,962/- for renewal of the policy for the year 2017-18. However, the abovesaid request of the complainant was declined by the OPs on 13.7.2017. Thereafter, on 5.4.2018 the complainant again sent a cheque of Rs.7,651/- alongwith requisite forms for renewal of the policy for the year 2018-19. In response to the abovesaid letter, a letter dated 12.4.2018 was received by the complainant on 19.4.2018 with the directions to the complainant to provide the pending documents to any of the nearest branch of the OP within a period of 7 days from the date of issuance of the said letter. However, the said letter was received after a period of 7 days and as such the complainant could not approach the nearest office within a period of 7 days. Moreover, within the distance of 100KM from the residence of the complainant there is no branch of OP. It is further the case of the complainant that all the relevant documents were submitted by the complainant with the OP alongwith the amount of premium but the policy was not renewed in favour of the complainant. It is further the case of the complainant that the abovesaid act on the part of OPs in not renewing to his health insurance policy is in violation of the order dated 27.3.2015 passed by this Forum and the same amounts to deficiency on the part of OP in rendering service to the complainant.
8. On the other hand, it is the case of the OP that the OP had complied with the order dated 27.3.2015 passed by this Forum in C.C. No.48 of 2014. It is further the case of the OP that an amount of Rs.33,210/- was paid by the OP for hospitalization of the complainant for the year 2015. It is also the case of the OP that the insurance policy pertaining to the year 2016-17 and 2017-18 was not issued to the complainant as discrepancy in the amount of premium was found and the same was never resolved by the complainant. Therefore, the amount deposited by the complainant as premium was refused to him. Therefore, there is no deficiency on the part of OP in rendering service to the complainant.
9. In view of the aforesaid discussion, it is not disputed that in compliance of the order dated 27.3.2015 the OP had renewed the health insurance policy for the year 2015-16 and insurance claim for hospitalization of the complainant was also paid to him. However, the insurance policy for the year 2016-17 and 2017-18 was not issued by the OP to the complainant on the ground that there was discrepancy in the amount of premium deposited by the complainant for issuance of the abovesaid policy. In this regard, the OP had also issued letters Annexure R-1 and Annexure R-2 to the complainant. However, the complainant in response to abovesaid letters neither resolved the problem nor communicated any response to the OP. We are, therefore, of the opinion that there is no deficiency on the part of OP in not issuing of the insurance policy to the complainant for the year 2016-17 and 2017-18. Regarding the issuance of the health insurance policy for the year 2018-19, it is evident from letter dated 12.4.2018 issued by the OP that a request was submitted by the complainant for issuance of the health policy for the year 2018-19. In response to the request of the complainant the OP vide its letter dated 12.4.2018 had directed the complainant to provide the pending documents to any of the nearest HDFC Ergo offices within 7 days from the issuance of the letter dated 12.4.2018. However, from perusal of the letter dated 12.4.2018 Annexure C-7, it is revealed that the said letter received by the complainant on 19.4.2018 i.e. after a lapse of 7 days and as such he could not approach to the office of the OP for submitting the documents. It is also the contention of the complainant that all the documents and the amount of premium was deposited by him in time but the health insurance policy was not issued by the OP. However, the OP in its written statement is silent about the request of the complainant for issuance of the insurance policy for the year 2018-19 whereas, it is evident from the letter dated 12.4.2018 placed on record as Annexure C-7 that a request was sent by the complainant to the Ops for issuance of health insurance policy for the year 2018-19. We are, therefore, of the considered opinion that there is deficiency on the part of OP in not issuing the insurance policy to the complainant for the year 2018-19.
10. In view of the aforesaid discussion, we are of the considered opinion that the complainant has been able to prove deficiency on the part of OP in not issuing the health insurance policy of the complainant for the year 2018-19. The present complaint is accordingly allowed partly and the OPs are directed to make the payment of outstanding claim for the year 2018-19 to the complainant if any by keeping in view the terms and conditions of the insurance policy. The Op is further directed to regularize the policy for the year 2019-20 on payment of the requisite premium and completion of other formalities by the complainant. The present order be complied with within a period of 45 days from the date of passing of this order. Copy of this order be communicated to the parties free of costs. File be consigned to the record after due compliance.
Announced in open Forum.
Dated: 13.11.2019.
(Jasvinder Singh) (Raghbir Singh)
Member President
