Chandigarh

DF-I

CC/252/2021

Harinder Singh - Complainant(s)

Versus

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

Arjun Grover

01 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

Mr. Harinder Singh, S/o Sh.Sukhdev Singh, R/o House No.272, VPO Landran, Tehsil Mohali, near Axis Bank, Mohali, Punjab-140307.

… Complainant

V E R S U S

1. M/s Max Bupa Health Insurance Co. Ltd., through its Managing Director/Authorized Representative having office at: SCO No.55-56-57, 2^nd Floor, Sector 8-C, Madhya Marg Chandigarh-160018. Email:-
2. Insurance Regulatory and Development Authority of India, through its Chairman/Authorized representative, having office at Gate No.3, Jeevan Tara Building, first floor, Sansad Marg, New Delhi-110001.

Email: … Opposite Parties

Per Suresh Kumar Sardana, Member

1.      Averments are that the complainant, in the year 2014, took a health insurance policy in his name through OP No.2, an authorized agent of OP No.1, while opting for family first silver 1Lac/- + 10 lacs/- plan by paying gross premium of Rs.12,814/- to the OPs, in order to get the complainant and his wife insured for a sum of Rs.12 lacs by OP No.1 in case of health exigency to the complainant and his wife (Annexure C-1) Collectively. It would be suffice to state that the ibid health insurance policy was to expire on 28.10.2020. However, unfortunately, this time, OP No.2 miserably failed to apprise the complainant, verbally (telephonically) as well as in writing, about the timely renewal of the policy, before the expiry of the policy as a result the policy lapsed. Thereafter in the month of January, 2021, the complainant continuously approached the customer care wing of OP No.1, while inter alia narrating his plight, the complainant requested to OP No.1 to renew the ibid policy. However, the OP No.1 refused to renew the same. Thereafter, on 17.04.2021, the OP No.1, sent an email to the complainant, wherein the OP No.1, offered the complainant for the renewal of the lapsed policy. However, upon contacting the Op No.1, verbally for the renewal of the policy, the OP No.1 once again denied to renew the ibid policy of the complainant (Annexure C-7). Despite no fault of complainant, as the complainant had been regularly/duly/timely paying the health insurance premium since, the year 2014 to the OPs, the complainant had to run from post to pillar for the renewal the ibid policy. Hence, is the present consumer complaint.
2.     OP No.1 contested the consumer complaint, filed its written reply and stated that the renewal premium for FY 2020-2021 could not be paid by the complainant on time as he had not been duly intimated regarding the same. It is relevant to state that in the earlier policy bond for the year 2018 it was duly mentioned that the renewal due date would be 28.10.2020. Further as per clause 11.4 company is under no obligation to give any intimation regarding renewal of policy but even then the complainant was intimated regularly through SMS and calls about the renewal of the premium. The complainant cannot take the plea that he had not been informed about policy renewal. It is very much the duty of the insured to pay the renewal premium on time. It is further submitted that as per the terms and conditions of the policy if the policy is not suitable, the policy holder may get his/her policy reviewed by returning the policy and policy documents within 15 days (free look period) from the day the policy holder received the policy. In the present case, the complainant after the receipt of the subject policy and policy documents did not approach the replying OP to get his subject policy reviewed/cancelled within free look period implying that the complainant duly accepted the subject policy and its documents with its terms and conditions. Denying all other allegations made in the complaint a prayer for dismissal of the complaint has been made.
3.     Notice of the complaint was sent to OP No.2 seeking its version of the case. However, nobody appeared on behalf of OP No.2 despite following proper procedure, therefore it was proceeded ex-parte on 02.03.2022.
4.     OP No.3 contested the consumer complaint, filed its written reply and stated that the complainant is not a consumer of the OP No.3 i.e., IRDAI within the meaning of Section 2(7) of the Consumer Protection Act, 2019. It is further submitted that the OP No.3 i.e., IRDAI in exercise of its statutory duties does not collect any fees or other charges from the policy holders for the performance of functions assigned to it under the IRDAI Act. Denying all other allegations made in the complaint a prayer for dismissal of the complaint has been made.
5.     Rejoinder was filed and averments made in the consumer complaint were reiterated.
6.     Parties led evidence by way of affidavits and documents.
7.     We have heard the learned counsel for the parties and gone through the record of the case.
8.     On perusal of the complaint, it is observed that the main grievance of the complainant is that the health insurance policy held by him since 29.10.2014 and being renewed till 28.10.2020 was not renewed further by OP No.1, due to the fault of OP No.2, being the agent of OP No.1 (principal).
9.     On perusal of the complaint, it is an admitted fact that the health insurance policy held by the complainant w.e.f. 29.10.2014 was being renewed by OP No.1 every year up to 28.10.2020. It is also observed that the said policy was not further got renewed by the complainant, as the OP No.2 being the agent of Principal OP No.1, did not take timely action to inform the complainant.
10.     We have perused the regulation 8 & 26, the code of conduct issued by IRDAI annexed by the complainant as Annexure C-8 which are reproduced here below:-

    Regulation 8- Code of Conduct-Clause 3

        “Every insurance agent shall, with a view to conserve insurance business already procured through him, make every attempt to ensure remittance of the premiums by the policy holders within stipulated time, by giving notice to the policy holder orally and in writing.”

    Regulation 8- Code of Conduct-Clause 5

         “The insurer shall be responsible for all acts and omissions of its agents including violation of code of conduct specified under these regulations, and shall be liable to a penalty which may extend to one crore rupees.”

    Regulation 26- Code of Conduct for Corporate agents-Clause (1) “Every Corporate agent shall abide by the code of conduct as specified in schedule III of these regulations & Clause (2) “The Corporate agent shall be responsible for all acts and omissions of its principal officer, specified persons and other employees including violation of code of conduct specified under these regulations and liable to a penalty which may extend to one core rupees under the provisions of Section 102 of the Act.”

    Schedule III, Code of Conduct-III Post-sale code of conduct-4 b “with a view to conserve the insurance business already procured through him, make every attempt to ensure remittance of the premiums by the policy holders within the stipulated time, by giving notice to the policyholder orally and writing.”

11.     Significantly, OP No.2 did not appear to contest the claim of the complainant and preferred to proceed against ex-parte. This act of the OP No.2 draws an adverse inference against it. The non-appearance of the OP No.2 shows that it has nothing to say in its defence against the allegations made by the complainant. Therefore, the assertions of the complainant go unrebutted and uncontroverted and we safely draw the conclusion that OP No.2, did not follow code of conduct by not giving notice to the policyholder orally and in writing.
12.     On perusal of annexure C-6 (colly), it is observed that the complainant took up the matter regarding renewal of policy consistently with OP No.1, and finally on perusal of Annexure C-7, it is observed that the OP No.1, offered on 17.04.2021, for renewal of lapsed policy, but the due to non-working of online link and inspite contacting the representative of OP No.1, the said policy could not be renewed. It is also observed that when the complainant filed the complaint on 03.05.2021 praying for renewal of his health policy OP No.1 was not serious enough on the offer made by it on 17.04.2021 (Annexure C-7) rather it opted to take a stand that he is not entitled to the relief prayed backing out on its own offer of renewal on 17.04.2021, offered vide annexure C-7.
13.     In view of above we are of the concerted view that due to non timely action on the part of OP No.2 (being the agent of OP No.1, Principal), the policy could not be renewed, in time by OP No.1 and the complainant had to suffer mentally & physically and financially also as he had to resort to take another health policy to cover him & his family, till the complaint is decided.
14.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP No.1 & 2 are directed as under :-

1. to issue a fresh policy, immediately on the same terms and conditions as, were applicable on the last lapsed policy, treating it as continuous, from the date of inception of first policy on charging of necessary premium for the current term.
2.  to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

15.     This order be complied with by the OP No.1 & 2 within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amount mentioned at Sr.No.(ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
16.     The consumer complaint qua OP No.3 stands dismissed with no order as to costs.
17.     Certified copies of this order be sent to the parties free of charge. The file be consigned.