Order-12.
Date-21/07/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case, in short, is that one Sandip Kumar Guha, Unit Manager of Religare Health Insurance in the month of February, 2016 in a rotary programme held at E-CCO Park, Salt Lake approached the complainant with a proposal to transfer the complainant’s health insurance policy under the National Insurance Company to Religare Health Insurance. The complainant had a policy being No.101800/48/15/85000000970 dated 03-05-2017 under the National Insurance Company Ltd. and was renewed up to 02-05-2016. It is stated that Sandip Kumar Guha, Unit Manager, assured the complainant that Religare Health Insurance Policy will provide more benefits than the National Insurance regarding health related issues. He also assured that the said policy will be done without any medical examination as her existing policy is continuing with National Insurance Company Ltd. and the complainant after receiving the policy will have her blood test, ECG. Urine Test etc. free of cost once in a year at the cost of company Ltd. The OP Company representative assured more benefits in all heads than National Insurance Co. Ltd. provided. The complainant states that Sandip Kumar Guha filled up the relevant portion of the first page of the proposal form being No.11004000768215 in front of the complainant and asked the complainant to hand over a cheque of Rs.16,282/- dated 12-03-2016 drawn on SBI Hatibagan Branch in favour of Religare Health Insurance Ltd. It is also stated that no signature of the complainant was taken in any form. The complainant handed over the aforesaid cheque along with photo copy of PAN, photocopy of Electronic Identity Card and some original previous running policies issued by National Insurance valid till May, 2016. The said agent of insurance company said that he would fill up the entire portion of the Form at his office as he does not have the time at that point of time. The complainant states that after receiving the policy of medical insurance company No,10583014 dated 29-03-2016 issued by M/s. Religare Health Insurance, it was revealed that the said insurance company has made some deliberate mistakes in the said policy for unduly enriching Religare Health Insurance Company Ltd. It was also revealed that in the portion for portability there are two boxes one for making “yes” and the other for “no” and said Sandip Kumar Guha deliberately ticked in “no” box. The policy, as such, showing as a fresh policy and the complainant is deprived of portability benefits of the National Insurance w.e.f. 03-05-2007 to 02-05-2016. It is also alleged that the complainant’s date of birth and her son’s date of birth have been wrongly printed. It is also alleged that the signature of the policy holder is also forged. The complainant immediately after receipt of the policy contacted the said agent but there was no fruitful response. Raja Guha, an agent of the Company also told the complainant that he has despatched the corrected policy document to the address of the complainants through Blue Dart Courier, Service on 25-08-2016. The complainant alleges that nothing has been received by her. It is also alleged that Sandip Guha in spite of the repeated demand by the complainant refused to return her original running policies issued by National Insurance Company. The son of the complainant being a nominee made a representation dated 09-08-2016 before the competent authority of the Company stating that his mother being a senior citizen aged about 68 years is in need of a policy and requested the company to issue the continued policy of her mother’s previous mediclaim policies, sum assured Rs.1,50,000/- and accumulated bonus earned by her more than Rs.60,000/- and to take a proper action against erring person of the company. The company collected a sum of Rs.16,282/- from the complainant. The son of the complainant received a letter dated 12-09-2016 from Religare Health Insurance stating, inter alia, that they apologized for such inconvenience caused to the complainant and the said authority forwarded the case to their concerned team and assured that necessary instruction has also been given to them. The complainant states that one Mr. Subhas Karmakar along with Mr. Arnab Ray visited the complainant on 17-09-2017 and requested the complainant to fill up a new form and the complainant accordingly filled up necessary form and handed over the necessary documents to them. Complainant also handed over a cheque bearing No.550629 dated 17-09-2016 amounting to Rs.9,981/- as additional payment. It is alleged that the insurance company, thereafter, sent her ECG Report, Urine Examination Report dated 19-03-2016. It is alleged that such reports are false and manufactured and no medical examination has ever been provided by the OP to the complainant and complainant has never visited any diagnostic centre. The OP insurance company also informed her that the basis of aforesaid false medical report the Company issued a policy No.10583014 dated 29-03-2016 and rejected her proposal No.1100401089960 for health insurance on account of medical ground and by deducting Rs.825/- on account of medical cost out of total amount of Rs.26,243/- refunded the amount of Rs.25,418/- to her SBI Account. The complainant has alleged deficiency in service and unfair trade practice against the OPs. It is alleged that medical reports are all manufactured and the OPs have repeatedly harassed the aged lady and damaged her regular medical insurance policy with National Insurance Company. It is also alleged that the signatures of the complainant are also forged. It is alleged that at no material point of time medical test was done to the complainant and the signatures on the medical reports were also false. It is alleged that the OPs have practiced unfair trade and have induced her to make payment and she has been duped as such. It is alleged that the complainant has been the victim of unfair trade practice. Hence, this case.
OPs 1 to 3 have contested the case in filing written version contending, inter alia, that the case is not maintainable either in fact or in law. It is stated that answering OP company had issued policy No.10583014 on the basis of information received in proposal form bearing No.1100400768215 providing insurance coverage to the complainant herein with effect from 15-03-2016 to 14-03-2017 for a sum of Rs.3 lakhs. It is also stated that proposal form dated 14-03-2016 was filled and signed by the complainant. After careful studying and examining the contents therein and on the basis of said proposal form the above mentioned policy was issued to the complainant by the OP Company. The complainant had raised certain grievances with the answering OP with regard to her policy bearing No.10583014. Hence, as a customer service gesture the company cancelled the said policy and got another proposal bearing No.1100401089970 duly filled and signed by the complainant. However, the complainant this time surprisingly mentioned certain disclosures pertaining to her medical condition. Her proposal bearing No.1100401089970 contained various health related disclosures which were not disclosed earlier by the complainant. Hence, the said proposal was rejected in adherence to the approved underwriting guidelines of the answering OP Company. OPs also refunded the proposal amount of Rs.26,243/- paid by the complainant after deducting a sum of Rs.825/- towards cost of medical test. It is stated that there is no deficiency of service on the part of the OP Insurance Company. It is denied that no signatures were taken from the complainant on the proposal form. It is submitted that if the complainant chose to sign the document without reading the same she herself is waiving her right and this amounted implied consent. It is denied that Sandip Kumar Guha deliberately ticked ‘no’ to deprive the complainant of continuation benefit of the previous policy. It is denied that OP Company by issuing a fresh policy has acted in detriment to the interest of the complainant. It is denied that Sandip Kumar Guha has filled up the proposal form. It is denied that the signature of the complainant holder showing in the proposal form is forged or that Mr. Raja Guha filled the proposal form. It is denied that the medical records specified in the complaint are all false manufactured. It is denied that the signatures on medical records and reports are all forged. It is stated that the complainant has come before the Ld. Forum with unclean hands. It is stated that there is no deficiency of service on the part of the answering OPs. It is also denied that the OPs have indulged in unfair trade practice. These OPs have prayed for dismissal of the case.
OP5 has also filed written version stating that no specific relief is sought against OP5 and there is no averment about OP5 other than as a Regulator of insurance business and, as such, no role of OP5 arises in the matter. It is stated that OP5 has raised a facilitating role in resolution of grievances as it discharges regulatory and supervisory conditions. It is also stated that complainant had not hired the services of OP4 and complainant is not a consumer under OP5 within the meaning of Section 2(1)(d)(ii). This OP has prayed for dismissal of the case against it.
OP4 and 6 have not contested the case and the case has proceeded ex parte against them.
Point for Decision
- Whether the OPs are deficient in rendering service to the complainant?
- Whether the OPs insurance company has indulged in unfair trade practice?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have perused the documents on record i.e. Xerox copy of policy bearing No.1100400768215 duly filled in, Xerox copy of cheque bearing No.501841 dated 12-03-2016 amounting to Rs.16,282/-, Xerox copy of another proposal form bearing no.1100401089970, Xerox copy of payment information, Xerox copy of regret letter dated 14-10-2016, Xerox copy of policy certificate policy No.10583014, Xerox copy of medical examination reports, Xerox copy of policy No.101800/48/12/850000891 of National Insurance Company, Xerox copies of E-mails on different dates and other documents on record.
We find that complainant Smt. Sudipa Roy had taken an insurance policy from M/s. National Insurance Company Ltd. vide Policy No.101800/48/15/85000000970 dated 03-05-2007 and is renewed every year up to 02-05-2015. Believing the assurances of higher benefits and continuation of no claim bonus and other existing benefits of the previous mediclaim policy made by Mr. Sandip Kumar Guha, Unit Manager representing OPs1 to 4 on 12-03-2016, the complainant took a health insurance policy from OPs1 to 4 and paid an amount of Rs.26,243/- vide proposal No.1100400768215 dated 14-03-2016 and also vide proposal No.1100401089970 discontinuing the existing mediclaim policy from National Insurance Company Ltd. Complainant has alleged that the OPs 1 to 4 have made several deliberate mistakes in the policy viz. not providing the benefit of portability and continuation of bonus benefits as new policy was issued a fresh, date of birth was mentioned incorrectly, signature of the policy holder was forged, medical documents fabricated etc. etc. The complainant took up the matter with the OPs in writing letters etc. but there was no response from the OPs 1 to 4 for her several requests for correction of those mistakes and issuance of health insurance policy as per the assurance. Finally son of the complainant vide a letter dated 07-10-2016 made a representation to issue the health insurance policy. The OPs thereafter, contacted the complainant at his resident on September 17, 2017 and requested the complainant to fill up a new form on the said company for health insurance and she duly filled up the necessary form. The complainant also handed over the necessary documents including a copy of the valid I.D. Proof document. The complainant also handed over a cheque being No.550629 dated September, 17, 2016 drawn on SBI Hatibagan Branch for a sum of Rs.9,981/- as additional payment. We find that OP insurance company finally rejected her proposal No.110040189970 for health insurance on account of mediclaim ground. OP Company also returned a sum of Rs.25,418/- on the account of the complainant being SBI, Hatibagan Branch, deducting a sum of Rs.825/-. It is alleged that the insurance company annexed certain medical reports which are manufactured in her name and she never visited any diagnostic centre for such tests and the signatures appearing on the report are also forged.
We find that the complainant’s grievance pertains to policy No.10583014 and old proposal for being No.1100400768215. We have compared the handwriting appearing in the said proposal form bearing No.1100400768215 with the handwriting appearing in the new proposal form being No.1100401089970. We find that the handwriting appearing on the first proposal form differs from the handwriting of subsequent new proposal form. Admittedly, complainant herself filled in the new proposal form bearing No.1100401089970. The complainant’s grievance is that first proposal form was filled up by one Sandip Kumar Guha, Unit Manager of OP Insurance Company and also by one Raja Guha, a formal agent of the OP Company. It is alleged that the signature on the proposal form of the policy letter showing therein was also forged by the said Raja Guha. We find that the new proposal form being no. 1100401089970 was filled in by the complainant herself and such fact has not been challenged or controverted from the side of the OP Company and as the handwriting appearing in the new proposal form differs from the handwriting as appearing in the first proposal form, we find substance in the allegation of the complainant that the first proposal form was filled in by Sandip Kumar Guha, Unit Manager of OP Insurance Company in collusion with other agent Shri Raja Guha, code no.20028396. Moreover, the question remains why the complainant would forego the privilege of portability in taking the policy from the OP Insurance Company. We find that in the portion of portability there are two boxes, one for making “yes” and other for “no” and it is alleged that Sandip Kumar Guha deliberately ticked in “no” box. So, we find that the complainant is deprived of continuation of the previous policy of National Insurance Policy w.e.f. 03-05-2007 to 02-05-2016. We cannot believe that complainant would herself act in detriment to her own interest giving a go bye to the benefits of portability would tick in ‘no’ box.
We also find that the complainant raised the grievances on all such points with the insurance company with regard to her policy bearing no.10583014. The Company subsequently cancelled the said policy and again got another proposal bearing No.1100401089970 duly filled and signed by the complainant. However, this time the complainant mentioned certain disclosures pertaining to her medical condition which included operation for gallbladder stone in September, 1989, operation of appendix in May, 1985, hysterectomy in Sept., 1987 and medication taken by the complainant etc. etc. However, on the basis of disclosures made in the proposal form, the said proposal was rejected by the OP Company. We find tht policy bearing No.10583014 was issued to the complainant and subsequently it was cancelled on the ground that complainant mentioned certain disclosures in the new proposal form with regard to her medical condition and the said proposal was rejected on the basis of underwriting guidelines of the company. So, we find that the complainant was harassed by the Unit Manger, Sandip Kumar Guha. It is stated that Sandip Kumar Guha, the Unit Manager from their stall installed by the OP Company sometime in the month of February, 2017 in a Rotary Programme held at Eco Park, approached the complainant with the proposal to transfer the complainant’s health insurance policy under the National Insurance Company Ltd. to Religare Health Insurance, OP. The complainant believing such assurances that the said health care insurance will have benefits offer and above the medical policy held with the National Insurance Policy took the policy from OP Company. OPs also intimated that no claim benefit accrued from the earlier insurance policy and other accrued benefits will stand transferred in the complainant’s name and will be duly reflected in the present policy to be issued by the OP Insurance Company but we find that actually it did not happen. The forms were also filled up by the Unit Manager in collusion with other agent Raja Guha and the benefit of portability was also sacrificed at the altar of the new policy in detriment to the interest of the complainant. We think that the complainant has been harassed by the OPs and the OPs 1 to 4 have been deficient in rendering services to the complainant. The OPs have also damaged the earlier medical insurance policy of National Insurance Company of the complainant by giving her false assurance. The OPs could have intimated the complainant that no policy can be issued in the name of the complainant when she was suffering from various diseases or when she is an old lady of 68+ but the Unit Manager of the OP Company did not do so or did not meet up the liability of holding the real picture before the complainant. We think that OPs 1 to 4 insurance Company are liable for the misdeed, acts and activities of its Unit Manager and agent.
We find that Op5 being IRDA is a statutory body under the IRDA Act, 1999 and performing statutory duties and did not render any service within the meaning of the Consumer Protection Act. There is no relationship of consumer between OP5 and the complainant and OP5 which is a statutory body set up by act of Parliament. It does not charge any fees or receives any consideration for the services rendered. OP5 is neither a proper nor necessary party in the proceeding.
It is alleged by the complainant that she was deprived of the continuity of the existing health insurance policy issued by the National Insurance Company which was valid till 02-05-2016 as well as the benefit of bonus to the tune of Rs.60,000/-. She has also alleged that she had to suffer a monetary loss to the tune of Rs.4,50,000/- at the rate of Rs.1,50,000/- per year. We find that no policy was issued in favour of the complainant. It is stated by the complainant that she has been compelled to take out a new policy for the month of December, 2016 from National Insurance Company Ltd. for which complainant has to wait at least for 3 years to get benefit under the new Health Insurance Policy and in the process complainant has also suffered monetary loss and loss on account of bonus.
But no such new policy of National Insurance Company Ltd. is filed by the complainant to establish the bona fide of her claim. The complainant is not also entitled to future compensation as claimed as per C.P. Act.
Be that as it may, we find that OPs 1 to 4 have been deficient in rendering services to the complainant, they have been negligent in performing their duties and have duped the complainant to transfer her insurance policy from National Insurance to Religare Health Insurance Policy. The policy was ultimately denied to her. We think that the complainant needs to be compensated as such for the deficiency in service on the part of the OPs 1 to 4.
It has to be borne in mind that the complainant had her National Medical Policy under the National Medical Policy under the National Insurance Company from 03-05-2017 to 02-05-2016. The complainant also enjoyed the privileges under such policy during the said period of time. The proposal for new policy was not entertained by OP on health ground of the complainant but we cannot support the gesture on the part of the OPs in inviting or alluring the complainant to take health insurance policy under the OPs with assurance of higher benefits, continuation of no claim bonus and other existing benefit of previous mediclaim policy. Moreover, OPs have made several deliberate mistakes in not providing benefit of portability and continuation of bonus, benefits, Date of birth was also mentioned incorrectly, signature of the policy holder was forged etc. etc. We think that the OPs 1 to 4 have demonstrated a gesture of deficiency in service and the complainant needs to be compensated as such.
Consequently, the case merits success.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the OPs 1 to 3 and ex parte against OP4.
The instant case is dismissed on contest against OP5 being IRDA and ex parte against OP6 being Ombudsman.
OPs 1 to 4 are jointly and severally directed to pay an amount of Rs.1(One) lakh to the complainant as compensation apart from litigation cost of Rs.10,000/- within one month from the date of this order.
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision in C.P. Act.
