Karnataka

Bangalore 4th Additional

CC/2651/2017

Sri M.D. Diwakar - Complainant(s)

Versus

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

Sri Shylesh kumar

25 Jul 2019

ORDER

Complaint filed on: 27.09.2017

Disposed on: 25.07.2019

 

BEFORE THE IV ADDL DISTRICT

CONSUMER DISPUTES REDRESSAL FORUM, BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H.ROAD, SHANTHINAGAR, BENGALURU – 560 027

 

 

CC.No.2651/2017

DATED THIS THE 25^th JULY OF 2019

 

 

PRESENT

 

 

 

 

SMT.PRATHIBHA. R.K., BAL, LLM, PRESIDENT

SMT.N.R.ROOPA, B.A., LLB, MEMBER

 

 

Complainant/s: -                           

Sri.M.D Diwakar,

Aged about 62 years,

S/o Late S.Boregowda,

R/o Villa No.3, “Trinetra”,

Behind Rennisance Prospero Apartments,

Byatarayanapura,

Bellary Road,

Bangalore-560 092.

 

Advocate – Sri.R.Shailesh Kumar

 

V/s

Opposite party/s:-    

 

1. Max Bupa Health Insurance Company Limited.,

Corporate office at B1/1-2,

Mohan Cooperative Industrial Estate,

Mathura Road,

New Delhi – 110044.

By its Director.

 

2. Max Bupa Health Insurance Company Limited.,

Registered address

Max House, 1,

Dr.Jha Marg, Okhla,

New Delhi – 110020.

By its Director.

 

3. Max Bupa Health Insurance Company Limited.,

Vaishnavi Silicon Terrace,

No.30/1, Hosur Main Road,

Adugodi, Opp.Prestige Acropolis,

Bangalore – 560 095.

By its Director.

 

Advocate – Sri.H.N Keshava
         Prashanth

 

 

ORDER

 

 

 

SMT.PRATHIBHA. R.K., PRESIDENT

 

 

 

            This complaint is filed by the Complainant against the Opposite party No.1, 2 & 3 (herein after called as OPs), under section 12 of the Consumer Protection Act, 1986. The Complainant prays to direct the OPs jointly and severally to refund of premium amount, damages and cost of Rs.5,89,896/- with interest @ 24% p.a from the date of claim petition and cost of the and grant such other reliefs.

 

2. The brief facts of the complaint is as under:

 

The Complainant obtained an insurance policy from OP-3 vide policy bearing No.30115826201200 dated 19.07.2012 sum assured Rs.35,00,000/- by paying a premium amount of Rs.64,537/-.  The complainant submitted that the above said policy for a period of one year.  After expiry of the aforesaid policy the complainant took an another insurance policy bearing No.30115826201301 dated 15.07.2013 sum assured Rs.35,00,000/-.  For the above said policy complainant paid a premium of Rs.67,686/-.  The said policy was valid for one year.

The complainant further submitted after expiry of the aforesaid policy complainant once again took another insurance policy bearing No.30115826201402 dated 14.07.2014 sum assured Rs.35,00,000/- by paying premium amount of Rs.81,243/-.  The said policy was for the period of one year.  Again after expiry of the aforesaid policy the complainant took another insurance policy No.30450978201500, dated 19.07.2015 for a sum of Rs.35,00,000/-.  The complainant opted “FAMILY FIRST GOLD FIVE LAKHS PLUS FIFTEEN LAKHS” and paid the premium of Rs.1,59,792/- for the period from 19.07.2015 to 18.07.2017 for two years.  The said policy duly covered the complainant, his wife and two major children.

 

The complainant submitted that as per the terms and conditions of the policy the policy was for a period of two years and the premium payable only once.  The complainant paid the premium amount through his account by way of fund transfer.  The complainant submitted that due to unavoidable reasons, the complainant requested OP through mail for cancellation of policy and refund of the premium amount.  Initially the OP gave a positive reply regarding cancellation of the policy and refund of the amount.  The OP had cancelled the policy and gave an evasive reply stating that the length of the policy exceeds 180 days as such there would be no refund of the premium amount.  The complainant submitted that complainant had taken policy which is for a period of two years and the premium payable in one single installment as such the OP claim that the length of the policy exceeds 180 days was not sustainable hence the complainant is entitled to the refund of the amount as claimed.

 

Complainant further submitted that OP violates the norms laid down/enumerated by Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations and further more the evasive reply given by the OP for complainants refund of the premium amount stating that the complainant’s cancellation and refund of the premium amount is not possible in view of the clause that it exceed the 180 days limit of complainant’s policy is highly ridiculous and not correct and moreover against the facts on hand and law in force and moreover the OP are practicing unfair trade practices.  Therefore complainant got issued legal notice dated 08.11.2016 and 15.12.2016 calling upon the OP to refund the premium amount.  The notice was duly served on the OPs.  The OPs neither replied the said notice nor refunded the amount.  Hence complainant filed this complaint.   

 

3. After service of the notice from the Office, the OPs appeared before this forum and filed objections.  OP submitted that the present complaint is false, frivolous, vexatious and gross abuse of process of this Forum.  The complaint is liable to be dismissed under section 26 of the Consumer Protection Act.  OPs submitted that complainant had approached the OP Company for availing insurance policy.  As per the process involved the policy holder submitted proposal form bearing bar code No.100004664243 dated 16.07.2012 for issuance of an insurance policy namely Family First Gold 5 Lacs + 10 Lacs so as to provide an insurance cover to the complainant, his wife, a son, a daughter in law and his daughter.  The policy holder/complainant had signed and submitted the proposal form after going through the terms and conditions of the policy.  It is pertinent to mention that the policy holder had full knowledge of the terms and conditions of the policy and the same was explained to him by the insurance agent thoroughly and properly, had signed the proposal form.  However, the said policy No.30115826201200 was renewed in the subsequent years and was subsequently cancelled due to incorrect date of birth on 19.07.2015 and a fresh policy number 30450978201500 was issued to the complainant for period starting from 19.07.2015 to 18.07.2017.

 

Further OP submitted that in accordance to Clauses 4(1) and 6(2) of the Insurance Regulatory and Development Authority (Protection of Policy holders Interests) Regulations, 2002 every policy document sent by the OP company is accompanied with the terms and conditions of the policy which clearly mentions that if the policy holder is not satisfied with the features or the terms and conditions of the policy complainant can withdraw/return the policy within 15 days i.e., under the “Free Look Cancellation Period”.  That this provides an opportunity to the insured to review the contents in the policy documents and approach the OP company for any discrepancy/rectification/cancellation.  Since no such request was received by OP Company from the complainant herein the policy continued as per the terms and conditions.

 

OP further submitted that the OP Insurance Company received a Pre-authorization request for admission of Ms.Tejasvi Poorva for her treatment for Acute Bronchitis at MALLYA hospital from 17.03.2016 with admission for 3-4 days.  The same was approved by the OP Company vide letter of authorization dated 17.03.2016.  However the OP Company cancelled the Pre authorization request of the insured on the grounds of ‘treatment of Psychiatric condition falls under permanent exclusions” vide letter dated 18.03.2016.  OP further submitted that the complainant/policy holder sent an email dated 15.07.2016 requesting the OP Company to cancel the policy since 18.07.2016.  That the OP Company immediately acting upon the request of the complainant, cancelled the policy of the complainant and send a cancellation letter via email dated 15.07.2016.  That the complainant raised his grievance with the customer care of the OP Company which was duly replied by the OP Company within reasonable time.  Hence, there is no deficiency on the part of OPs. Hence, prays this forum to dismiss the complaint, grant costs and legal expenses and pass such other for further orders and directions in favour of OP.

 

4. In the course of enquiry into the complaint, the Complainant and the OP-1 have filed their affidavit reproducing what they have stated in their respective complaint and objection.  Complainant has filed written arguments.  Both parties have produced documents which were marked.  We have heard the arguments of both sides and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.  

 

5. Based on the above materials, the following points arise for our consideration;  

 

 

1. Whether the Complainant has proved that there is deficiency in service on the part of the OPs, if so, whether he entitled for the relief sought for?

 

2.  What order?

 

6. Our findings on the above points are as under:

Point No.1:  In the Affirmative

Point No.2:  As per the order below

 

REASONS

 

7. Point No.1: On perusal of the pleadings and evidence of both the parties, it is an admitted fact that, the complainant had obtained a health insurance policy bearing No.30115826201200 from OP/s for the period from 19.07.2012 to 18.07.2013 by paying premium amount of Rs.64,537/-, sum assured of Rs.35,00,000/- as per Ex.A-1.  Thereafter the complainant had renewed the policy by paying a premium amount of Rs.67,686/- for one year i.e., from 19.07.2013 to 18.07.2014 and period from 19.07.2014 to 18.07.2015 by paying Rs.81,243/- as per Ex.A-2 & A-3 respectively.  In the year 2015 the complainant opted “FAMILY FIRST GOLD FIVE LAKHS PLUS FIFTEEN LAKHS” and paid the premium of Rs.1,59,792/- for the period from 19.07.2015 to 18.07.2017 for two years.  On 15.07.2016 the complainant had requested the OP to cancel the policy and refund the premium and for year 2016-2017.  Thereafter OP has cancelled the policy & issued letter to comply stating that the policy has been cancelled as per the terms and conditions Ex.C-4 clause.5 (h) (1), since the policy inception more than 180 days passed, hence premium amount cannot be refunded.  Clause 5 (h) (1) the terms and conditions of the policy reads here as under:

 

1. Cancellation by you

 

 

You may terminate this Policy by giving 7 days’ prior written notice to us.  We shall cancel the Policy and refund the premium for the period as mentioned herein below, provided that no claim has been made under the Policy by or on behalf of any Insured Person:

 

Length of time Policy in force	Refund of premium
up to 30 days	75%
up to 90 days	50%
up to 180 days	25%
exceeding 180 days	0%

 

 

8. Further on perusal of the customer information sheet, it is mentioned in the policy tenure - “one year and two year.  For a two year policy tenure a discount of 12.5% would be applicable on second year premium”.  Admittedly the complainant had obtained the policy in the year 2012 and continuously it was renewed from 2012 to 2015.  To avail the benefit of 12.5% discount the complainant had obtained a policy for 2 year, for the year 2015-16 and 2016-17.  The complainant requested the OP to cancel the policy on 15.07.2016 & to refund the amount for the year 2016-17, which he has paid the premium in advance and not availed the facility of the OP for the year 2016-17.  Admittedly the complainant had opted policy on 19.07.2015 to 18.07.2017, on 15.07.2016 he sought for cancellation after completion of one year and requested for refund.  Since he had completed one year from 19.07.2015 to 18.07.2016 and had paid the premium amount for two years and had rightly sought for refund after one year.  The OP ought to have accepted the request and repaid the premium amount of 75% which he is entitle as per clause 5 (h) (1).  The complainant is entitled to cancel the policy since he made a request to pay the premium amount at the end of one year. 

 

9. Hence in our opinion the complainant is entitled for refund the premium amount which he has paid in advance for the year 2016-17.  In view of the facts and circumstances of the case we are of the opinion that, the complainant is successful in proving the deficiency of service on the part of OPs.    Therefore OPs have to be directed to refund 75% of the premium amount paid together with interest from the date of cancellation of the policy i.e, 15.07.2016 to till the date of realization with costs.  The conduct of OPs must have put the complainant to great inconvenience and mental agony.  Therefore, we direct OPs to pay compensation of Rs.30,000/-.  Accordingly we answered point No.1 in the Affirmative.

 

10. Point no.2: In the result, for the foregoing reasons, we proceed to pass the following order.

 

ORDER

 

The complaint filed by the Complainant is allowed in part.

 

2. OPs.1 to 3 jointly and severely directed to refund 75% of the premium amount paid for the year 2016-17 together with interest @ 9% p.a from the date of cancellation of the policy dated 15.07.2016 to till the date of realization.

 

3. OPs.1 to 3 are further directed to pay compensation of Rs.30,000/- to the complainant for having caused him inconvenience and mental agony together with litigation cost of Rs.10,000/-.

 

4. This order is to be complied by the OPs.1 to 3 within 45 days from the date of receipt of this order.

 

          Supply free copy of this order to both parties. 

 

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by us in the Open Forum on this, the 25^th day of July 2019)

 

 

 

(ROOPA.N.R)       MEMBER

(PRATHIBHA.R.K)    PRESIDENT

 

 

 

 

1. Witness examined on behalf of the complainant by way of affidavit:

 

Sri.M.D Divakar. 

 

Copies of Documents produced on behalf of Complainant/s:

 

Ex-A1	Insurance policy No.30115826201200 dated 19.07.2012.
Ex-A2	Insurance policy No.30115826201301 dated 15.07.2013.
Ex-A3	Insurance policy No.30115826201402 dated 14.07.2014.
Ex-A4	Insurance policy No.30450978201500 dated 19.07.2015.
Ex-A5	Copy of mail correspondence/cancellation.
Ex-A6	Reply by opposite party.
Ex-A7	Copy of letter rejecting the refund of premium amount.
Ex-A8	Copy of legal notice dated 24.08.2016.
Ex-A9	Copy of postal acknowledgment and receipt.
Ex-A10	Copy of reply notice.

 

1. Witness examined on behalf of the OP/s by way of affidavit:

 

Sri.Sinu Joseph, who being the Authorized Representative of OP-1 Insurance Company.

 

 

Copies of Documents produced on behalf of OP/s:

 

 

Ex-B1	Copy of proposal form, policy documents of the policy No.30115826201200 and system generated cancellation.
Ex-B2	Discharge summary
Ex-B3	Pre authorization form (cashless)
Ex-B4	Letter of authorization.
Ex-B5	Denial of authorization.
Ex-B6	Copy of email dated 15.07.2016
Ex-B7	Copy of cancellation letter
Ex-B8	Copies of emails.

 

 

 

(ROOPA.N.R)       MEMBER

(PRATHIBHA.R.K)    PRESIDENT

 

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