Punjab

Ludhiana

CC/19/18

sunil Kumar - Complainant(s)

Versus

Max Bupa Health Ins.Co.Ltd - Opp.Party(s)

R.K.Soodan Adv.

08 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:18 dated 04.01.2019.                                                 Date of decision: 08.05.2023.

 

1. Sunil Sharma, aged 53 years son of Shri Hem Raj Sharma son of Sh. Parma Nand Sharma
2. Smt. Neetu Sharma, aged 48 years wife of Sh. Sunil Sharma and daughter of Sadhu Ram Sharma
3. Tarkesh Sharma, aged 24 years son of Sh. Sunil Sharma,

All residents of House No.3088, Street No.6, New Tagore Nagar, Haibowal Kalan, Ludhiana. ..…Complainants

                                                Versus

1. MAX BUPA Health Insurance Company Limited, Kunal Tower, Mall Road, Ludhiana through its concerned Branch Manager.
2. MAX BUPA Health Insurance Company Limited, MAX House, 1, Dr. Jha Marg, Phase-III, New Delhi through its concerned Person/Incharge/Director/Branch Manager.

…..Opposite parties 

Complaint Under section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. Harish Rai Dhanda, Advocate.

For OPs                          :         Sh. V.S. Mand, Advocate.

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that complainant No.1  wanted to get her medically insured for which she was contacted by official of opposite parties who lured them to get the insurance policy from the company with assurance that the company would come forward and would immediately comply with its duties and would provide every facility covered by the policy without any hindrance. Believing the assurance, only complainant No.1 for himself obtained insurance from the opposite parties and paid first time premium in the year 2010 @ Rs.6617/- but later on in the year 2013, complainant No.2 and complainant No.3 were included in the policy by making a premium of Rs.14,352/-. In the year 2014, the premium was increased as Rs.16,295/-, in the year 2015 again the premium was increased as Rs.17,528/- and lastly in the year 2015, the premium was paid as Rs.18,189/- to the opposite parties to protect the complainants medically and to avoid any kind of financial difficulties which might had arose with regard to health purpose.

                   The complainants stated that when they made premium for the policy for the year 2017-18, they shocked to know that the opposite parties without any rhyme and reasons and by taking baseless and vague excuse refused to continue with their policy. On 12.07.2017, the opposite parties sent email to the complainants and asked to renew their policies by making the payment but after making the payment, the opposite parties returned the premium of Rs.14,280/- on 22.09.2017 and also sent an email dated 28.09.2017 for rejecting continuation of the policy by mentioning that complainant No.1 was having history of Coronary Artery Byepass Grafting (CABG) in 2010. The opposite parties further mentioned that complainant No.1 had not disclosed that he was taking medicines in the year 2010 for hypertension, blood thinner and cholesterol. The complainants further stated that complainant No.1 immediately contacted with officials of opposite parties and showed the proposal form filled by their agent when the policy was started in the year 2010 and on the third page in the column of additional information wherein agent mentioned himself severe chest pain, surgery done, taking medicines and the procedure of taking medicines was going on. Complainant No.1 fully satisfied the officials of opposite parties but they were not ready to listen and openly declared that as age of complainant No.1 and 2 is increasing day by day, hence company will certainly get loss in future if their policy is renewed. The complainants requested the opposite parties not to do so by stating that the complainants will suffer loss if they shift to some any other company and they have to pay huge premium for the policy but the opposite parties did not accede to the requests of the complainants which amounts to deficiency in service on the part of the opposite parties.  In the end, the complainants prayed for issuing direction to the opposite parties to continue the policy in question and to pay a sum of Rs.87,556/- already paid as premium  and to further pay compensation of Rs.3,00,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the opposite parties filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, the complaint being an abuse of process of law and suppression of material facts by the complainant. The opposite parties stated that the policy in question is a Heart Beat Silver Plan and the first policy No.30006824201000 was issued on 27.08.2010 which was opted by the complainant for health insurance for himself and his family. As per regulations of IRDA (Protection of Policyholders Interests) Regulations, 2002 the policy and the terms and conditions was sent to the policy holder along with policy documents thereby giving an opportunity to the policyholder to re-examine the policy and further the insured was duly informed vide the policy terms and conditions that in case he is not satisfied with the policy or their terms and conditions, then he had the option to return/cancel the policies within free look period i.e. within 15 days from the date of receipt of policy documents. According to the opposite parties, the complainant retained the policy documents and did not raise any objection towards the policy nor had approached them during free look period with any grievance regarding the policy or terms and conditions meaning thereby that the insured agreed to the policy terms and conditions. All policy documents were duly issued to the complainant on payment of premiums. The policies were issued for the year 2011-12, 2012-13, 2013-14, 2014-15, 2015-16 and 2016-17. The opposite parties further stated that with respect to the premium for the next year i.e. 2017-18, due diligence with respect to all the policies of the company were conducted and it was found that there were certain discrepancies with respect to the heath of complainant No.1 prior to issuance of the policy.  Although he had mentioned in the policy that he had suffered from chest pain and undergone surgery but he failed to mention that he had hypertension prior to issuance of the policy and was taking medicines for the same. Accordingly, the company could not continue the policy of the complainant. Thereafter, a review of the policy was done and it was decided that in spite of the fact it is clear case of non-disclosure of material facts with respect to the health of the insured and the company as a matter of good gesture considering the fact that the complainant has been continuing the policy for a long period has decided to reinstate the policy. The opposite parties further stated that they are ready and willing to reinstate the policy subject to the complainant making the payment for renewal and submitting the necessary documents to them. The opposite parties had informed the complainant about their decision but he has not come forward to deposit the premium and do the necessary formalities for reinstatement of the policy.

                   On merits, the opposite parties reiterated the crux of preliminary objections. However, opposite parties stated that they have acted as per the terms and conditions of the policy contract which are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. The words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. The opposite parties denied any deficiency in service on their part and in the end, prayed for dismissal of the complaint.

3.                In support of their claim, the complainant No.1 Sh. Sunil Sharma tendered affidavit Ex. CA in which they reiterated the allegations and the claim of compensation as stated in the complaint. The complainants also tendered documents Ex. C1 is the copy of proposal form, Ex. C2 is the copy of premium receipt dated 28.08.2010, Ex. C3 is the copy of policy documents, Ex. C4 is the copy of premium receipt dated 06.09.2014, Ex. C5 is the copy of payment summary of Axis Bank, Ex. C6 is the copy of email dated 18.08.2018, Ex. C6/A is the copy of policy declining letter and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Ms. Chandrika Bhattacharya, Chief Manager of the opposite parties along with documents Ex. OP1/1 is copy of authority letter, Ex. OP1/2 is the copy of policy documents and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinder, affidavit and annexed documents and written reply along with affidavits and documents produced on record by both the parties. We have also gone through the written arguments submitted by the opposite parties.

6.                Admittedly, on the basis of proposal form Ex. C1, the opposite parties issued a Heart Beat Simple Plan policy to complainant No.1 on 27.08.2010 and complainant No.1 paid a premium of Rs.6617/- vide receipt Ex. C2. In the year 2013, complainant No.1 included his wife Neetu Sharma and son Tarkesh Sharma complainant No.2 and 3 as additional insured persons. These policies were renewed by the opposite parties for the year 2011-12, 2012-13, 2013-14, 2014-15, 2015-16 and 2016-17. On 18.08.2018, the opposite parties issued an email Ex. C6 calling upon the complainants to renew their existing policy and further  offered benefit worth up to 10% of the last premium amount in addition to loyalty bonus etc. Accordingly, the complainants paid a premium of Rs.14,280/-. However, on 28.09.2017, the opposite parties sent an letter Ex. C6/A whereby the continuation of the policy was rejected and premium paid for renewal of the policy was returned. The operative part of letter Ex. C6/A reads as under:-

                   Reason(s):

Sunil Sharma: Decline since inception. History of Coronary artery byepass grafting (CABG) with three vessels involved in 2010. Hypertension since 2010, taking blood thinners, cholesterol medicines.

Pease note that our decision to process your request for insurance is purely on the basis of risk evaluation and findings by our underwriters, based on the information provided by you and/or your medical examination reports and our underwriting policy. We have initiated refund for your proposal and it will be processed within 8 working days.”

7.                The issue for consideration arises whether the opposite parties were justified in declining the continuation of existing policy for the year 2017-18.

8.                Perusal of letter Ex. C6/A shows that the continuation has been declined on the ground that there was a history of Coronary artery byepass grafting (CABG) with three vessels involved in year 2010. Hypertension since 2010 and taking of blood thinners, cholesterol medicines.

9.                Perusal of column No.7 (additional information) of proposal form Ex. C1 explicitly depicts that complainant Sunil Sharma has specified the symptoms of medical condition as severe chest pain and he also disclosed that he underwent surgery and he is taking medicine at the time of availing first policy. So there was disclosure of the material facts with respect to the health of the insured. Secondly, the complainants had been condemned unheard and no show cause notice was ever issued to the complainants before discontinuing the policy. They were not afforded any opportunity of being heard, more so, when they were continuously availing and renewing policies for the last seven years. Needless to say, continuation of the policy gives insured person certain rights and benefits and abrupt cancelation certainly deprive those persons from the indefeasible rights so occurred with the passage of time. Therefore, there is a gross violation of principles of natural justice and equity by the opposite parties and they were not justified in declining the continuation of the policy. As such, there is a deficiency in service and adoption of unfair trade practice on their part.

10.              While submitting written statement, it appears that the opposite parties have realized their mistake and mentioned in their written statement that the opposite parties are ready and willing to reinstate the policy subject to the complainant making payment for renewal and submission of necessary documents with them.  Even they made a prayer to this effect in the written version itself also. Considering the aforesaid facts and circumstances, this Commission is of the considered view that the complainants are entitled to reinstatement/continuation of the policy from the date of the rejection with its all consequential and incidental benefits subject to payment of premium at the rate applicable for the corresponding year(s) during which the policy remained discontinued. The opposite parties are also burdened with composite cost of Rs.10,000/-.

11.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to reinstate/continue the policy from the date of  the rejection with its all consequential and incidental benefits subject to payment of premium at the rate applicable for the corresponding year(s) during which the policy remained discontinued, within 30 days from the date of receipt of copy of order. The opposite parties shall further a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant.  Compliance of the 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.

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

 

(Monika Bhagat)          (Jaswinder Singh)                     (Sanjeev Batra)

Member                         Member                                       President         

 

Announced in Open Commission.

Dated:08.05.2023.

Gobind Ram.

 

 

Sunil Kumar Vs Max Bupa Health Insurance                           CC/19/18

Present:       Sh. Harish Rai Dhanda, Advocate for the complainants.

                   Sh. V.S. Mand, Advocate for the OPs.                 

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to reinstate/continue the policy from the date of  the rejection with its all consequential and incidental benefits subject to payment of premium at the rate applicable for the corresponding year(s) during which the policy remained discontinued, within 30 days from the date of receipt of copy of order. The opposite parties shall further a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant.  Compliance of the 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.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:08.05.2023.

Gobind Ram.