DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

Anil Kumar Malhotra aged about  59 years, S/o Sh. R.S Malhotra, R/o # 364, Sector 46-A, Chandigarh-160047.

                        …...Complainant

                                                          Versus

1. M/s Max Bupa Health Insurance Co. Ltd, through its Manger SCO No. 55-56-57, 2^nd Floor, Sector 8-C, Madhya Marg, Chandigarh.
2. Mr. Rakesh Sehgal, Insurance Agent, Flat No. 27-A, Imperial Garden Society, Peer Muchalla, Zirakpur.
3. Mr Satnam, Sr. Manager, Branch Head, M/s Max Bupa Health Insurance Co. Ltd.,  SCO No. 55-56-57, 2^nd Floor.
4. Mr. Vikas Pathania, Sr. Manager, Branch Head, M/s Max Bupa Health Insurance Co. Ltd., SCO No. 55-56-57, 2^nd Floor, Sector 8-C Madhya Marg, Chandigarh-160018

    ….. Opposite Parties

BEFORE:  MR.AMRINDER SINGH SIDHU,            PRESIDENT

                    MR.B.M.SHARMA                               MEMBER

Present         :           Sh. Pankaj  Chandgothia , Advocate  Counsel of Complainant.

                                    Sh. Gaurav Bhardwaj, Advocate Counsel of Opposite Parties   No. 1, 3 & 4.

                                    Opposite Party No. 2  Ex-party.

ORDER BY AMRINDER SINGH SIDHU, M.A (Eng.),LLM,PRESIDENT

1.    The complainant filed the present complaint under Section 35 of the Consumer Protection Act, 2019 pleading that he is a Consumer of Opposite Parties by the reason of taking a Max Bupa heartbeat family, first policy since several years, the latest one being policy Number 30367037201804 from 15.10.2018 to 14.10.2019 from a Opposite Party No. 1 at Chandigarh for himself and his wife, having coverage of Rs. 17.20 lacs. The policy was purchased through Opposite Party No. 2 who is the agent of Opposite Party No 1. The Complainant stated in his Complaint that he is insured with O.P.s since 2014, without any break. Therefore, the present policy period was the fifth consecutive year. Unfortunately the Complainant suffers from heart problem and he was taken to hospital on 04.09.2018 and discharge on 07.09.2018. The Complainant under went coronary angiography and Angioplasty.  The complainant submitted the claim form to Opposite Party No. 2 agent of Opposite Party No 1, who visited at his residence in Chandigarh. The claim amount was Rs. 3,78,000/- was filed as advised and filled up by the officials of the O.P. themselves. The O.P. did not give copy of the claim form to him but assured him that it would be processed within one month. The complainant has annexed a copy of hospital bill, on which claim is based, as Annexure C-6. The complainant alleged that the OP No 2, as is the practice, received the cheque of Rs.40,142/- dated 13.10.2018  from the complainant for the renewal of the policy with effect from 15 October 2018. A copy of cheque issued by the complainant is annexed with the complaint as Annexure C-7. On the basis of receipt of cheque by OP NO 2, office issued the current policy which is annexed as Annexure C-1. The complainant alleged that without receipt of the cheque, the office would not have issued any policy cover note to the complainant. This implies that the said cheque was lying with them and was to be presented by them for clearance. Out of the cheque amount of Rs.40,142/-, an amount of Rs.31,043/-was due towards complainants policy and the balance amount of Rs.9099/- was due towards renewal of another policy taken by the complainant from the OP insurance company for his children. Although the OP no.2 had admittedly taken the said cheque from the complainant for encashment yet it seems that he or the other officials of the OP forget to present the cheque for clearance to bank. The policy issued by OP.s in the name of children of the complainant was “Health champion variant 1” and it was valid from 14th of December 2017 to 13th of December 2018 with a premium of Rs.8970/-.(Annexure C-8). OP told the complainant that renewal premium amount was to be Rs.9099/-and therefore this amount was included in the cheque issued along with premium due towards the complainants own policy. In the meanwhile, a claim against the policy arose, upon which the complainant again called the OP No.2, who visited the complainant to take claim from him and assured the complainant about the Clearance of the claim within one month. upon being asked about the clearance of the cheque, he once again said the complainant need not to worry as the cheque was lying with the company and and it would be presented for Clearance within reasonable time. O P.No.3 & 4 return the cheque Annexure C7 in original to the complainant by making lame excuse, and asked him to issue fresh cheque for his policy, premium amount only. The complainant have no option but to issue the cheque accordingly in November 2018, after the date of incident of Mediclaim. The complainant received a message on 08-02-2019  from O.P. stating that,” We regret to inform you that your claim cannot be  proved on the basis of terms of your policy”. The complainant alleged that O.P.s repudiated his claim in a mechanical manner without due application of mind and on unreasonable grounds, which amounts to deficiency in service and unfair trade practice. Lastly Complainant prayed for the direction to the opposite parties to pay the principal Mediclaim amount of Rs.3,78,000/-along with interest, compensation and litigation expenses.
2. After the service of notice upon the opposite parties, the opposite parties filed their separate written versions to the complaint taking preliminary objections that complainant has not approached this Hon’ble  Commission with Bona fide  intentions; complaint is frivolous and misconceived ; complainant has not approve discretion with clean hands, be being guilty of suppressio veri and suggestion falsi.

On merits, opposite parties denied all the allegations made against them in the complaint by the complainant and lastly prayed for the dismissal of the complainant with costs.

3.Replication has also been filed by the complainant thereby controverting the assertions of OP made in their reply and reiterating their stand in the Complaint.

4. Parties led evidence in support of their contentions.

5. We have heard the Counsel for the parties and have gone through the entire record.  

   The main issue involved in the present complaint is whether any to the opposite parties is deficient in providing service to the Complainant parties or not ?

   The claim of the complainant was repudiated by opposite party no.1 on the ground that the policy was set to expire on 14-10-2018 and the complainant paid the renewal premium amount on 08-11-2018. The complainant namely Anil Kumar Malhotra was admitted in the Ace Hospital on 04-11-2018 to 07-11-2018 for the treatment of acute coronary syndrome. However, the premium was received only on 08-11-2018. Therefore, the claim of the complainant repudiated as not payable under the terms and conditions of the policy.

           As per Definition 20. *Grace Period * means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue policy in force without loss of continuity benefits such as waiting periods and coverage of existing disease coverage is not available for the period for which no premium is received.”

   Moreover, clause 11.4  Renewal of policy.b. Grace period.

i. if you do not renew the policy by the due dates specified in the schedule of insurance certificate, you or any other eligible adult insured person may apply to renew the policy within the grace period of 30 days of the end of the policy period subjected to receipt of application and payment of premium from the such insured person and evidence satisfactory to us of the agreement of all other insured persons and you (except in the case of death). If we accept such application and the premium for the renewed policy is paid on time and deposit shall be treated as having been renowned without a break in cover.

   ii. Any claim made during the grace period will not be payable under this policy.

   So it is clear that any claim made during the grace period will not be payable under the policy and in the present complaint the insured/complainant was admitted in the hospital on 04-11-2018 to 07-11-2018 when the policy was under the grace period, and after getting discharged from the hospital immediately paid the premium of the policy, hence no claim is payable under the policy.

   In view of this, it can safely be concluded that there is no deficiency or unfair trade practice on the part of OP no.1.

   However, the complainant in his complaint specifically mentioned that the OP no 2 (agent) took the cheque from the complainant for the details of the policy with effect from 15-10-2018, as the early policy would expire on the midnight of 14 October 2018. The copy of the cheque dated 13-10-2018 issued by the complainant is annexed as Annexure C-7. In the present complaint, OP no 2 did not appear before this commission to file his written version to the complainant despite service, hence, he was proceeded against ex-party, the absence of OP no.2 before this commission, despite service and not filing any written version to the complaint clearly shows that OP no.2 has nothing to say in his defence.  When OP no.2 has received cheque dated 13-10-2018 from the complainant then,being agent of O.P no.1,he is duty-bound to deposit the same within 24 hours with O.P. No. 1 as per conditions of the insurance policy, failing which he is personally liable for the same. Therefore, complaint is partly allowed against O.P No. 2 and he  is directed to pay Rs 3,78000/-within 60 days from the date of receipt of copy of this order by him failing which he shall be liable to pay interest of 6% per annum from the date of order till t the date of its actual realisation.

6.     The pending application(s) if any, stands disposed of accordingly.

7.     Certified copies of this order be sent to the parties as per rules. After compliance file be consigned to record room.

Announced in open Commission.

17.05.2023

Place: Chandigarh.

                                                                                                                                                Sd/-

(Amrinder Singh Sidhu)

                                                                                          PRESIDENT

                                                                                                                              Sd/-

                                                                                          (B.M. SHARMA)

                                                                                          MEMBER.

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