Haryana

Ambala

CC/289/2020

Saravjeet Singh - Complainant(s)

Versus

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

22 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case no.         :    289 of 2020

                                                          Date of Institution           :     02.12.2020

                                                          Date of decision    :              22.08.2022.

Saravjeet Singh aged 39 years, son of Sh. Ram Singh, resident of House No.1121/30(I), Mohinder Nagar, Ambala City, Haryana.

                                                                                ……. Complainant.

                                                Versus

Max Bupa Health Insurance Company Limited, B-1/1-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044, India.

                                                                                   ….…. Opposite Party.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.            

Shri Vinod Kumar Sharma, Member.

 

Present:       Complainant in person.

                             Shri Sunil Sharma, Advocate, counsel for the OP.

 

Order:        Smt. Neena Sandhu, President

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’) praying for issuance of following directions to it:-

(i)      To issue policy documents to the complainant with immediate   effect.

(ii)     To refund Rs.4,088/- being the proportionate amount of premium for the period commencing from 16.07.2019 till 04.10.2019, as during the said period, the complainant didn't remain under effective insurance period as the policy documents were not issued to the complainant by the opposite party.

(iii)    To refund proportionate amount of premium for the period   commencing from 16.07.2020 till date on which the policy       documents are actually provided by the opposite party to the   complainant.

(iv)    To rectify in records the contact no. of the complainant as   9416862030 in place of wrongly mentioned contact no.       9823855169.

(v)     To pay Rs.20,000/-, as  compensation for the mental agony     and physical harassment suffered by the complainant.  

(vi)    To pay Rs.20,000/- as litigation   Costs.                                                           OR

Grant any other relief which this Hon’ble Commission may deem fit.

2.                 Brief facts of the case are that in the year 2017, the complainant purchased a group health insurance policy from the opposite party, covering himself, his wife (Dr. Sarvjit Kaur) and a minor son (Jaskirat Singh). The overall sum insured under the said policy was Rs.20,00,000/- against payment of annual premium of Rs.18,653/-. The complainant authorized auto debit of his account no.01050100018021 with Bank of Baroda, Ambala City, by opposite party, for the amount of premium. In the years 2017, 2018 and 2019, the policies were issued to the complainant by the opposite party. Since, the last policy, was to expire on 15.07.2020 as such, on 14.07.2020, the opposite party debited the premium amount thereof, in the manner stated above, yet, till date, the policy documents have not been provided by the it. After waiting for about three months, on 21.10.2020, complainant registered his grievance with the opposite party by sending an email to its customer care. In response to said email complainant received a reply dated 21.10.2020, from the opposite party, whereby service request no.5219826 was provided to him and the OP assured to respond within next three days but to no avail. The complainant again sent an email to the opposite party on 26.10.2020, reminding it in the matter. In response to said email, the opposite party vide reply dated 26.10.2020 gave fresh service request no.5237832 to the complainant and again promised of responding within 3 days but of no avail. Thereafter, complainant received an email dated 29.10.2020 (Annexure C-9) in context of earlier service request no. 5219826, whereby the opposite party informed him that it will get in touch within next 2 days, but to no avail. Complainant tried his level best to retrieve policy documents from the online applications floated by the opposite party, but in absence of policy no., the policy documents could not be retrieved/downloaded. The opposite party has failed to supply even policy no. to the complainant. Even after a period of 4 years, no health card has been issued to the complainant by the opposite party. Even in the preceding year i.e. 2019, the policy document was sent to the complainant by the opposite party only in the month of October 2019 as evident from the email dated 04.10.2019, sent by the opposite party to the complainant and that too after repeated requests. As per own version of the opposite party as found in the policy document downloaded from the website of the opposite party, no claim for reimbursement of medical expenses or claim for cashless treatment at network provider hospitals can be made in the absence of policy document and policy number which clearly implies that the insurance cover doesn't begin until the policy no. and policy documents are supplied by the opposite party to the insured. Under these circumstances, the insurance cover can't be said to have begun until the policy document is supplied by the opposite party to the complainant. Therefore, the opposite party cannot be allowed to unduly enrich itself by charging the premium of whole period commencing from 16.07.2020 till 15.07.2021. By not issuing the policy documents despite the fact that premium for the same had been received, the OP has committed deficiency in service and is also guilty of adoption of unfair trade practice. Hence, the present complaint.
3.           Upon notice, OP appeared and filed written version, raised preliminary objections with regard to maintainability, cause of action, not come with clean hands and suppressed the material facts etc. On merits, while admitting factual matrix of the case with regard to the fact that the complainant had obtained the insurance policies against  payment of premium, it has been stated that in the year 2020, the insurance policy valid for the period from 16/07/2020 12.00 AM to 15/07/2021 11.59 PM. was duly issued and sent to the complainant on 18/07/2019. However, still the OP is ready and willing to provide the Policy Bond again to the complainant. Since the insurance cover was never stopped as such refund of proportionate amount of premium to the complainant did not arise. The complainant has, on facts, been found to have not established any wilful fault, imperfection, shortcoming or inadequacy in the service of the OP. Rest of the averments of the complainant were denied by the answering OP and prayed for dismissal of the present complaint with costs.
4.           Complainant tendered his affidavit as Annexure C-X alongwith documents as Annexure C-1 to C-11 and closed the evidence on his behalf. On the other hand, learned counsel for the OP tendered affidavit of Mr. Pradeep Kumar Vohra, Manager Operations and Authorized Representative of OP i.e Niva Bupa Health Insurance Company Limited as Annexure RX alongwith documents Annexure R-1 and R-3 and closed the evidence on behalf of the OP.
5.           We have heard the complainant and learned counsel for the OP and carefully gone through the case file.
6.           Complainant has submitted that despite the fact that premium for the insurance to be covered for the period from 16/07/2020 to 15/07/2021 was received from him by the OP, yet, it failed to supply the insurance cover and policy in respect of the same, despite number of request having been made in the matter, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on the part of the OP. 
7.           On the contrary, learned counsel for the OP has submitted that the insurance policy valid for the period from 16/07/2020 12.00 AM to 15/07/2021 11.59 PM. was duly issued and sent to the complainant on 18/07/2019 but he is suppressing this fact, therefore the question of refund of any part of premium amount did not arise. However, still the OP is ready and willing to provide the Policy Bond again to the complainant.
8.           The issuance of polices for the years 2017, 2018 and 2019 as mentioned in the complaint are not in dispute between the parties. It is also not in dispute that the opposite party has received premium amount from the complainant for the insurance policy pertaining to the year 2020 which was to be valid for the period from 16/07/2020 to 15/07/2021. Under these circumstances, the only moot question which needs to be decided by this Commission is, as to whether, the policy for the year 2020 which was to be valid for the period from 16/07/2020 to 15/07/2021 was issued and sent to the complainant on 18.07.2019 as alleged by the OP or not. It is evident from the account statement issued by the Bank of Baroda, Annexure C-4 that an amount of Rs.18,635/- has been debited from the account of the complainant, on 14.07.2020, which was admittedly against the premium in respect of the policy in dispute (2020). It is coming out from the record that thereafter when the policy documents were not sent by the OP to the complainant, an email dated 21.10.2020, Annexure C-5 was written by him and in response thereto, the OP vide email dated 21.10.2020, Annexure C-6, gave one service request number i.e. 5219826 and conveyed that it will respond within 3 working days. However, when the OP failed to respond, the complainant again sent reminder email dated 26.10.2020, Annexure C-7 in the matter, and in response thereof, again stereotype answer was received from the OP vide emails dated 26.10.2020 and 29.10.2020, Annexure C-8 and C-9 respectively. It is significant to mention here that there is nothing on record that after acknowledging receipt of these email by the OP, the  policy documents pertaining to the period 16/07/2020 to 15/07/2021 were ever sent to the complainant. In the absence of any proof/cogent evidence having been produced by the OP that the policy documents pertaining to the year 2020 were ever sent to the complainant, the bald assertions of the OP, especially, in the fact of the emails referred to above, that the policy documents were delivered to the complainant well in time, cannot be believed.
9.           It is significant to mention here that though the insurance cover under the policy in dispute was for the period from 16/07/2020 to 15/07/2021, yet, now it is August 2022 and as such, in the eyes of law, the complainant alongwith his family members remained uninsured under any insurance policy, for the period from 16/07/2020 to 15/07/2021. Thus, in our considered opinion, since the premium amount of Rs.18,635/- has also been admittedly received by the OP from the complainant for the period 2020 to 2021, against which no policy was issued to him (as has been held above), as such, under these circumstances, if we order the OP to issue insurance policy in favour of the complainant alongwith his family members, valid from 16.07.2022 till 15.07.2023 that will meet the ends of justice. 
10.           It is further coming out from the record that even the insurance policy/certificate of insurance against policy no.00209500201903 pertaining to the year 2019 was also not sent by the OP to the complainant in time, and it was sent only vide email dated 04.10.2019, Annexure C-10 instead of sending the same on 16.07.2019 i.e. after a delay of about three months, after expiry of earlier insurance (16.07.2018 to 15.07.2019). Relevant contents of the email Annexure C-10 is reproduced hereunder:-

“…This is with reference to service request number 3918034, where you have requested for certificate of insurance for your Policy no. 00209500201903

Please find the certificate of insurance for your reference.…….”

 

In our considered opinion the aforesaid acts of the OP certainly amounts to deficiency in providing service, negligence and adoption of unfair trade practice and the said act would have definitely caused mental agony and physical harassment to the complainant, in case, he or his family members who purchased the said policy, had applied for any claim for the  period from 16.07.2019 till 03.10.2019 and also 16.07.2020 to 15.07.2021 because during these periods, neither any policy number had been issued to him nor the insurance certificate was supplied by the OP. In this view of the matter, in our considered opinion, if  we order to refund the proportionate premium amount for the period from 16.07.2019 (date when the policy pertaining to the year 2019 was to be issued) to 04.10.2019 (policy pertaining to year 2019 issued only on 04.10.2019) to the complainant that will meet the ends of justice. The OP is also held liable to compensate the complainant for causing him mental agony and physical harassment on these counts. 

11.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OP, in the following manner:-
    1. To issue policy documents to the complainant valid for the period from 16.07.2022 till 15.07.2023, after adjusting the premium amount of Rs.18,635/- already received on 14.07.2020.
    2. To refund the amount of Rs.4,088/- being proportionate amount of premium for the period from 16.07.2019 (date when the policy for the year 2019 was to be issued) to 04.10.2019 (the date on which policy pertaining to the year 2019 was issued) to the complainant alongwith interest @4% p.a. from 16.07.2019 onwards.
    3. To pay Rs.3,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    4. To pay Rs.2,000/- as litigation costs.
    5. To update the correct mobile number of the complainant in its record.

                   The OP is further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 22.08.2022.

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

              Member                         Member                       President