Date of filing: 14.01.2019
Date of disposal : 28.04.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU.P.VINODH KUMAR, B.Sc., B.L., .....MEMBER -I
THIRU.P.MURUGAN,M.Com.ICWA(Inter),B.L., ....MEMBER-II
RBT/CC. No.62/2022
THIS FRIDAY, THE 28th DAY OF APRIL 2023
(CC.No.44/2019 sent from DCDRC, Chennai North)
Vignesh Venkatachalam,
Flat 3D, Ashiana Apartments,
86/79, Aspiran Garden 2nd Street,
Kilpauk, Chennai 600 010. ……Complainant.
//Vs//
Niva Bupa Health Insurance Company Limited,
Rep. by its Director,
Ampa Manor, 107/2, Nelson Manickam Road,
Aminjikarai, Chennai 600 029. .......Opposite parties.
Counsel for the complainant : M/s.Anu Ganesan, Advocate.
Counsel for the opposite party : Mrs.Elveera Ravindran, Advocate.
This complaint has been filed before DCDRC, Chennai (North) as CC.No.44/2019 and transferred to this commission by the order of the Hon’ble State Consumer Disputes Redressal Commission, Chennai and taken on file as CC.No.62/2022 and this complaint coming before us on various dates and finally on 11.04.2023 in the presence of M/s.Anu Ganesan counsel for the complainant upon perusing the documents and evidences of both sides, this Commission delivered the following:
ORDER
PRONOUNCED BY THIRU P.VINODH KUMAR, MEMBER - I
This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service against the oppostie party for seeking direction to refund balance sum of Rs.1430/- to the complainant, to pay a a sum of Rs.4,90,000/- towards compensation for the mental agony and hardship caused to the complainant with 12% interest from the date of complaint till the date of realization along with cost.
Summary of facts culminating into complaint:-
The Complainant and his wife hold a Health Insurance policy with the Opposite Party for the last three years. His mother, Brother and Nephew were covered under a health Insurance policy from M/s Oriental Insurance for the past 3 years. The Complainant wanted for portability of the policy from M/s Oriental Insurance to Opposite Party and the said policy was set to expire on 15.12.2018. Hence, he had contacted the Opposite Party for portability of the policy and informed that his Mother had undergone Hysterectomy in the year 2007. The complainant paid the premium of Rs.40,300/- on 22.11.2018 and proof of the same along with scanned copy of existing insurance policy were sent to Opposite Party vide email dated 22.11.2018. The Opposite Party asked the Complainant’s Mother to undergo medical tests on 30.11.2018 and the Opposite Party informed the complainant that the policy for his mother could not be processed since she had undergone Hysterectomy and LDL Cholesterol level was 221 as against the reference range.
The Complainant had taken 2nd Blood test for his Mother after getting approval from Opposite Party since the 1st blood test report was erroneous. The complainant emailed lab report to Opposite Party on 11.12.2018 indicated that the LDL Cholesterol level was well within reference range. But the Opposite Party informed over phone that 2nd blood test report was not accepted since the said lab was not affiliated with the Opposite Party. Mean time the complainant renewed the policy for the family with the existing insurer on 20.12.2018. The complainant issued legal notice dated 20.12.2018 seeking refund of Rs.40,390/- and upon receipt of legal notice the complainant refunded Rs.38,960/- with a short fall of Rs.1430/-. The Complainant suffered severe loss and hardship due to the act of opposite party and hence the present complaint was filed.
Crux of the defence put forth by the opposite party:-
That the Opposite Party received a fresh proposal under portability scheme dated 23.11.2018 from Mr.Manikandan Venkatasalam for porting policy from existing insurer the Oriental Insurance. On the basis of information received, the Opposite Party subjected Mrs.Lakshmi into medical examination taking into consideration age of the person to be insured under portability scheme. That taking into consideration value of sum assured applied for and post assessment of the medical risk of the member insured in the application, as per underwriting norms of the opposite Party, the Opposite Party could not offer health insurance cover to Ms.Lakshmi and the same was duly communicated citing reasons, that subnormal lipid profile and Hysterectomy in 2005. However, the Opposite Party informed that they would consider the other proposed insured in the same application for further risk assessment. The premium for revised terms would be reduced proportionately.
The said Mr.Manikandan did not provide his consent and therefore the Opposite Party rejected the proposal and the same was communicated to Mr.Manikandan vide letter dated 17.12.2018. The Opposite Party refunded Rs.38,960/- after deducting Rs.1430/- towards charges for medical examination to the Complainant. It is the discretion of insurance company to issue or reject the proposal of insurance taking into consideration of facts disclosed and under writing policy of the company. There is no deficiency in service of the Opposite Party. The present proposal under dispute was rejected purely due to current adverse medical history of Mrs.Lakshmi and which has adverse impact on risk apatite of the Opposite Party. Hence, the Opposite Party prays to dismiss the complaint.
On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A13. Though the opposite party filed written version they did not file any proof affidavit, written arguments and also adduce oral arguments and hence on their side written arguments and oral arguments were closed.
Points for consideration:
Whether there is any deficiency in service on the part of the opposite party as alleged by the complainant?
If so to what reliefs the complainant is entitled?
Point No.1:-
It is the case of the complainant that he wanted to portability of health insurance policy of his family members from existing insurer i.e. The Oriental Insurance to the opposite party which was going to expire on 15.12.2018. The Complainant contacted the Opposite Party customer service and informed about his decision. The Complainant informed that his mother had undergone Hysterectomy in the year 2007 and the same had been mentioned in the existing policy. The complainant paid a sum of Rs.40,390/- towards premium and sent the said receipt along with scanned insurance policies to the staff of the Opposite Party. The Complainant’s mother Mrs.Lakshmi had undergone medical examination. The Opposite Party informed on 30.11.2018 that health policy for his mother could not be processed due to subnormal lipid profile and Hysterectomy in 2005.
The Complainant submitted 2nd Medical test report from reputed lab to the Opposite Party wherein it was mentioned that LDL Cholesterol level is within the reference range. But the Opposite Party refused to accept the report submitted by the complainant. Hence, the complainant was constrained to take health policy from existing insurer on 14.12.2018. The Opposite Party refunded Rs.38,960/- to the complainant after receipt of legal notice and retained Rs.1430/- without assigning any reasons.
To prove the case the complainant filed the following document in support of his contentions;
Policy No.131300/48/2018/14096 held by the family of the complainant with M/s. The Oriental Insurance company limited was marked as Ex.A1;
Online payment receipt issued by the opposite party to the complainant dated 22.11.2018 was marked as Ex.A2;
Email from the complainant to the opposite party dated 22.11.2018 was marked as Ex.A3;
Test report of Mrs. Lakshmi issued by Kumaran Hospital dated 30.11.2018 was marked as Ex.A4;
Email from the opposite party to the complainant dated 30.11.2018 was marked as Ex.A5;
Email from M/s.Orbito labs to the complainant enclosing test report dated 08.12.2018 of Mrs. Lakshmi dated 11.12.2018 was marked as Ex.A6;
Emails from complainant to the opposite party dated 11.12.2018 & 12.12.2018 were marked as Ex.A7 &Ex.A8;
Policy No.411800/48/2019/2323 renewed by the family of complainant with M/s. Oriental Insurance dated 14.12.2018 was marked as Ex.A9;
Email from the opposite party to the complainant dated 15.12.2018 was marked as Ex.A10;
Legal notice from the complainant to the opposite party with proof of delivery dated 20.12.2018 was marked as Ex.A11;
Bank statement of the complainant dated 02.01.2019 was marked as Ex.A12;
CD containing audio recordings between the complainant and the opposite party was marked as Ex.A13,
Per contra, the Opposite Party interalia contended that taking into consideration age of the person insured under portability scheme, the Opposite Party advised General medical examination for the person to be insured. The Opposite Party could not after health insurance cover to complainant’s mother due to subnormal lipid profile and Hysterectomy in 2005. However, the Opposite Party informed that the Opposite Party would consider the other proposed insured to the same application for further risk assessment. The said Mr.Manikandan did not provide his consent to proceed further and therefore Opposite Party was constrained to reject the proposal. The Opposite Party had refunded Rs.38,960/- after deducting Rs.1430/- towards charges for Medical examination. It is the discretion of Opposite Party to issue or reject the proposal taking into consideration of facts disclosed and underwriting policy of the company. The Opposite Party had not filed a adduced any evidence by way of filing proof affidavit.
ExA1 is the health insurance policy issued by the Oriental Insurance company Ltd., to complainant’s relatives (Mother, Brother& Nephew), wherein it has been mentioned that the complainant’s mother had undergone Hysterectomy in 2007. Moreover, it is stated by the complainant that he had explained the Opposite Party about the Hysterectomy prier to payment of premium. The Opposite Party having accepted the explanation from the complainant advised him to pay the premium amount of Rs.40,390/- on perusal of ExA2 it revealed that the complainant had paid the premium on 22.11.2018.
Subsequently the Complainant had taken second Medical test at reputed lab and submitted the said report to Opposite Party vide Ex A7. The Opposite Party had refused to accept said Medical report since the said lab is not affiliated with them.
Ex A8 is the new health insurance policy taken from Oriental Insurance. Ex A11 is the Legal notice issued by the complainant only after receipt of legal notice, the Opposite Party had refused Rs.38,960/- to the complainant after deducting Rs.1430/- towards charges for Medical examination.
We have carefully perused the pleading and documents filed by both the parties. The Opposite Party would have verified all the documents from the complainant before receiving payment from him. It is clearly mentioned in the existing policy that the complainant’s mother had undergone Hysterectomy in 2007. The Opposite Party had not verified the above documents.
It is not disputed by the Opposite Party that the complainant submitted the proposal for health insurance for his mother, brother and nephew under portability scheme. The Complainant had paid the premium of Rs.40390/- on 22.11.2018 vide Ex A2 and on the same day he had sent the premium receipt and existing insurance policy to the Opposite Party vide Ex A3.
Further the Opposite Party indulged the complainant’s mother for medical examination and the said medical report (Ex A4) revealed that total reference range. On perusal of Ex A6, we came to know that the Opposite Party refused to offer health insurance to complainant’s mother due to subnormal lipid profile and Hysterectomy in 2005.
Moreover, subnormal lipid profile is not a deadly disease and refusal of policy on that ground alone is not acceptable. The Opposite Party refused to accept the Ex A7 the second medical test report citing some reasons. The Opposite Party ought to have verified the documents and medical records prior to payment of premium by the complainant. The Opposite Party tailed to do so. Hence, we have come to the conclusion that the Opposite Party had committed deficiency in service. This point is answered accordingly.
Point No. 2:-
Since we have come to the conclusion that Opposite Party had committed deficiency in service, the mental agony and loss suffered by the complainant has to be compensated suitably. Hence we are unclaimed to award Rs.50,000/- towards compensation for mental agony and hardship suffered by the complainant and to pay Rs.10,000/- towards litigation expenses. The complainant is not entitled to refund Rs.1430/- since the amount is utilised for medical examination for his mother. These points are answered accordingly
In the result, the complaint is partly allowed against opposite party directing them;
a) To pay a sum of Rs.50,000/- (Rupees fifty thousand only) towards compensation for the mental agony and hardship caused to the complainant within six week from the date of receipt of copy of this order;
b) To pay a sum of Rs.10,000/- (Rupees ten thousand only) towards litigation expenses to the complainant.
Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 28th day of April 2023.
Sd/- Sd/- Sd/-
MEMBER-II MEMBER I PRESIDENT
List of document filed by the complainant:-
Ex.A1 19.12.2017 Policy No.13100/48/201/14096 held by the family of the complainant with M/s.Oriental Insurance. Xerox
Ex.A2 22.11.2018 Online payment receipt issued by the opposite party to the complainant. Xerox
Ex.A3 22.11.2018 Email from the complainant to the opposite party. Xerox
Ex.A4 30.11.2018 Test report of Mrs.Lakshmi issued by Kumaran Hospitals. Xerox
Ex.A5 30.11.2018 Email from the opposite party to the complainant. Xerox
Ex.A6 11.12.2018 Email from M/s.Orbito labs to the complaiantn enclosing test report dated 08.12.2018 of Mrs.Lakshmi. Xerox
Ex.A7 11.12.2018 Email from the complainant to the opposite party. Xerox
Ex.A8 12.12.2018 Email from the complainant to the opposite party. Xerox
Ex.A9 14.12.2018 Policy No.411800/48/2019/2323 held by the family of the complainant with M/s.Oriental Insurance. Xerox
Ex.A10 15.12.2018 Email from the complainant to the opposite party. Xerox
Ex.A11 20.12.2018 Legal notice from the complainant to the opposite party with proof of delivery. Xerox
Ex.A12 02.01.2019 Bank Statement of the complainant. Xerox
Ex.A13 ............. CD containing audio recordings between the complainant and the opposite party. original
Sd/- Sd/- Sd/-
MEMBER-II MEMBER I PRESIDENT
