DATE OF FILING : 12/01/17

IN THE CONSUMER DISPUTES  REDRESSAL FORUM, IDUKKI

Dated this the 30th  day of January  2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

           SMT.ASAMOL P. MEMBER

CC NO.  05/17

Between

Complainant       :  Thomas Sebastian,

                                                                             Kottarathil House,

                                                                             Vengalloor P.O., Thodupuzha.

(By Adv:  K.M.Sanu)

And

Opposite Party                                          :   The Manager,

                                                                         SBI General Insurance Co.Ltd., 

                                                                         Thodupuzha Branch, Thodupuzha P.O.

(By Adv: K.Pradeepkumar)

 

O R D E R

SRI. S. GOPAKUMAR (PRESIDENT)

 

The case  of the complainant is that,  

 

The complainant is having a mediclaim policy with the opposite party insurance company for a coverage of Rs.One Lakh.   From 2014 onwards he renewed it. On 09/12/16, the complainant got a remainder letter from the opposite party to renew the policy.  On receipt of the remainder letter, complainant approached SBI, Thodupuzha Branch where he maintained his account and discussed the matter with the officer of the insurance wing and expressed his willingness to enhance the coverage from one lakh to 2 lakhs.  After calculating the premium, the officer told that for renewing the present policy, the premium comes to Rs.13,400/-.  If it is enhanced to 2 lakhs coverage, the premium will come to a tune of Rs.23,600/-.  After discussion, the complainant submitted application for renewal of present policy with enhanced coverage of 2 Lakhs and he consecuted  to transfer the premium amount from his account.  After collecting premium for the enhanced coverage of 2 Lakhs, opposite party denied to enhance  it, and issued a E-Mail stating that they can renew it for the previous policies coverage and direct the complainant to give request for that.    But the complainant rejected the demand  of  the  opposite party and replied that it is not a fair practice to deny

                                                                                                                           (Cont....2)

-2-

 

the enhancement of coverage, after receiving the full premium.  The complainant further averred that, the opposite party company allowed to enhance the coverage of the policy after receiving his application and after verification of documents and it took 10 days.  It is the bounden duty of the opposite party company to issue policy as they discussed with the complainant after receiving the full premium amount.  Rejecting the policy application after receiving the full premium amounts to gross deficiency in service and this caused much mental agony to the complainant.  Against this complainant filed this petition seeking relief such as to direct the opposite party to issue a policy certificate as per the premium which they received from the complainant and direct the opposite party to pay compensation for the deficiency in their service and litigation cost.

 

Upon notice opposite party entered appearance and filed detailed reply version.  In their version opposite party contented that complainant had applied for the renewal for his Health Insurance Policy which had a coverage of Rs.1 lakh, for an enhanced coverage of Rs.3 Lakhs.  But as per the scheme of the policy only a person aged below sixty five years is eligible for enhanced coverage.  But the complainant at the time of renewal of policy had crossed the age of 65 years.  This was pointed out to the son of the complainant Mr.Melbin Thomas (Nominee of the policy), who was interacted with the SBI General.  He understood the provisions of underwriting and policy cover and got convinced during the course of his interaction with opposite party's Assistant Manager, Underwriting, Cochin, Smt. Simi Jose, Thekkaeniath.         Mr. Melbin advised this opposite party to issue the policy and accordingly policy No.0000000002353039-02 was issued to the complainant on 01/01/2017.  Policy period is from 01/01/17 to 31/12/17.  Gross premium of the policy is Rs.11,652.18 and service Tax is Rs.1,747.83.  Balance premium received by the opposite party was remitted back to the account of the complainant through EFT vide invoice dated 13/01/17.  Now he is estopped from going back, and making the claim, which cannot be granted as per the design of the product.  The opposite party further contented that, they are not attempting to cancel the policy issued as alleged.  The opposite party had issued policy for the coverage of Rs.1 Lakh only.  This opposite party has no intention to cancel it.

 

                                                                                                                           (Cont....3)

-3-

 

Evidence adduced by both the parties by way of documents.  Complainant filed policy certificate of the year 2014, 2015 and statement of account which are marked as Ext.P1 to Ext.P3.

 

From the defence side documents such as print out of E-Mail, policy documents, policy certificate and statement showing refund of amount were marked as Ext.R1 to Ext.R4 respectively.

 

Heard,

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties, and if so, for what relief the complainant is entitled to ?

 

The Point:- We have heard the counsels for the parties and have carefully gone through the records of the case.

 

The learned counsel for the complainant argued that the opposite party insurance company wilfully rejected the application for enhancement of insurance coverage from one Lakh  to two Lakhs after receiving the premium for Rupees 2 Lakhs and after conducting detailed enquiry about the insurance.  It is a gross deficiency in service as well as unfair trade practice and it should be compensated adequately.

 

On the other hand the learned counsel for the opposite party argued that, as per the scheme of the policy only a person aged below 65 years is eligible for enhanced coverage.  Complainant is aged above 65 years.  This fact was pointed out to the son of the complainant Mr.Melbin Thomas (Nominee of the policy), who was interacted with the concerned officer.  He understood the error and when he convinced this fact during the course of interaction with the opposite party's Assistant Manager, and Mr.Melbin advised the opposite party to issue the policy, and accordingly new policy was issued to the complainant on 01/01/2017.  Balance amount received by the opposite party was returned to the account of the complainant through electronic transfer.  The dispute raised by the complainant was settled through dialogue and policy was issued accordingly and balance premium was refunded to him.

                                                                                                                           (Cont....4)

-4-

We have given our thoughtful consideration to the case.  It is an undisputed fact the complainant had joined the health insurance policy of the opposite party from 2014 onwards and he renewed it periodically.  Ext.P1 and Ext.P2 are the policy certificate of the year 2014-2015, 2015- 2016.  Both these policies the sum assured was Rs. One Lakh.  The age of the complainant is stated in the policy certificate for the 2014-2015 is 64 years.  On perusing the other documents which produced by the opposite party, it is very clear that through Ext.R1 E-Mail communication, the opposite party intimated the complainant their difficulty in renewing the policy with the proposed sum insured of Rs.3 Lakhs, since they cannot deviate their IRDA filed structure will lead to compliance issue.  This mail sent by the opposite party to the son of the complainant on 11th January 2017.  On perusing Ext.R4 statement, it is seen that subsequent to the E-Mail communication opposite party refunded Rs.10,200/- to the complainant on 13/01/17, by deducting the policy premium for the current year.  From the records it is seen that, on 29/12/16 an amount of Rs.23,600/- is transferred to the account of the opposite party's Health Insurance Premium.  No specific evidence is produced by the complainant to convince the Forum that this amount is happened to transfered from his account to the opposite party's account was only due to the direction of opposite party.  Complainant has not took any step to direct the opposite party to produce the proposed form for the year 2016-2017, and application for enhanced coverage of Rs.3 Lakhs, which submitted before the opposite party.  On the other hand complainant received the excess amount which the opposite party is refunded on 13/01/17.  Complainant has not a case that, the Ext.R4 documents is false and such refund   was not done by the opposite arty.  More over complainant has not challenged the contention of the opposite party that they are unable to go beyond the IRDA filed structure of the Health Insurance Policy.

 

Hence we are of the considered view that the complainant is miserably failed to prove that amount which was transferred to the account of the opposite party  from the account of the complainant by way of enhanced health insurance premium was happened or done due to the direction of the opposite party and more over no evidence is produce to substantiate their plea that, the opposite party denied to enhance the coverage after sanctioning his application for enhancing the coverage from 1 Lakh to 3 Lakhs.

 

                                                                                                                           (Cont....5)

-5-

 

Hence the Forum is not in a position to consider the prayer of the complainant due to the absence of clear and cogent evidence.  Hence complaint dismissed.  No cost ordered. 

 

Pronounced in the Open Forum on this the 30th day of January, 2019.

 

                                                                                                     Sd/-

                                                                                      SRI. S. GOPAKUMAR (PRESIDENT)

                                                                                                            Sd/-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

            SMT.ASAMOL P.  (MEMBER)

 

APPENDIX

Depositions :

On the side of the Complainant :

Nil

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1            -  Policy certificate of the year 2014-2015

Ext.P2            -  Policy certificate of the year 2015-2016

Ext.P3            -  Statement of account

On the side of the Opposite Party :

Ext.R1      -  Print out of E-Mail

Ext.R2     -  Policy documents

Ext.P3     - Policy certificate 

Ext.P4     - Statement showing refund of amount

 

 

                  Forwarded by Order,

 

 

                      SENIOR SUPERINTENDENT