DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.235/2022
Mr. Sidharth Kumar
S/o late Prabu Das
Age about 63 years
R/o C-49, Inderpuri
New Delhi-110012.
Mrs. Pushpa Rani
W/o Mr. Sidharth Kumar
Age about 61 years
R/o C-49, Inderpuri
New Delhi-110012. …Complainants
VERSUS
M/s Niva Bupa Health Insurance Company Ltd.
Through its Directors
At:
C-98, First Floor, Lajpat Nagar, Part-1
New Delhi, Delhi-110024.
Also At
39, Samyak Tower, 3rd Floor, Pusa Road
Delhi-110005.
Also at:
14th Floor, Capital Cyberscape, Sector-59
Gurugram, Haryana – 122102. ….Opposite Party
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Date of Institution :25.02.2022
Date of Order :26.11.2022
Member: Sh. U.K. Tyagi, Member
Complaint under section 35 of CP Act, 2019
Upon the receipt of the application here in this Commission on 25.08.2022 vide CC No. 234/22; the case was listed for 01.09.2022. Shri Navdeep Dev Singh appeared on behalf of the complainant. The Counsel sought some time to bring some more documents on maintainability of the complaint. The case was listed on 29.09.2022, counsel for the complainant, Shri Navdeep Dev Singh appeared on video conference since the counsel could not show whether any dispute discloses between parties. Due to low audability, he was requested to appear physically on 13.10.2022.
Shri Navdeep Singh, counsel for complainant appeared on 13.10.2022. He submitted the copy of Insurance Regulatory and Development Authority of India (Health Insurance) Regulations 2016.
The counsel argued the case in detail and tried to enlist the dispute between M/s Niva Bupa Health Insurance Co. Ltd. (hereinafter referred to as OP) and the complainant. He stated that one Mr. Durgesh; an agent of OP was introduced to the complainants by the Bank Manager of Indian Overseas Bank Mr. Durgesh persuaded and assured the complainants to this effect that OP shall provide better services and more benefits than the present policy. The new policy of OP shall be in continuation with the old one and convinced the complainant and her father to part with the ongoing current effective health Insurance policy. Mr. Durgesh, an agent of OP sought copy of old policy, ID & address proof. The premium was made to the tune of Rs.8,102/- on 17.11.2021 from the S/B Account No.076601000023269, Indian Overseas Bank – Naraina in respect of M/s Kritika Sidharth whereas Rs.24,788/- paid from S/B Account 076601000023270, Indian Overseas Bank, Naraina, J. J. Colony, New Delhi in respect of M/s Himanshi Sidharth and Rs.50,181/- paid from S/B Account 076601000022090, Indian Overseas Bank, Naraina J. J. Colony, New Delhi in respect of Mr. Sidharath Kumar. All the above, payments were made on 17.11.2021 totalling Rs.83,071/-. In view of this, as of now, only two Application Nos.910300399327 and 910300399339 could be provided. In the failure of porting of policies, in the Niva Bupa Health Insurance Co. Ltd., 3 complaints vide CC no.234/22, 235/22 and 236/22 in the name of Ms. Kirtika Sidharth, Mr. Sidharth Kumar and Ms. Himanshi Sidharth respectively, were filed in this Commission. The facts of all these complaints having above CC No.are similar. (copy of Bank Statement is annexed with complaint).
As per complaint, the old policy was to expire on 07.12.2021. No response was received from OP about porting of the old policy. The complainant wrote letters on 15.03.2022 and 19.05.2022. Finding no resolution, the complainant got the legal Notice dated 03.06.2022 served upon on OP. The OP gave a vague reply dated 20.06.2022. During the arguments, it transpired that the amount of premium was returned by the OP. Bank statement in respect of all payments as indicated above have been enclosed with the complaints. The said amount has been returned as per para 8 of the new complaint.
The replies to the legal notice and Replication to the reply reveal that only two Applications No. 910300399327 and 300399339 have been provided so far through premium for all three complainants were paid. It was maintained by the company that the underwriter of the company evaluates each individual’s medical history and takes appropriate action based on severity and prognosis of the condition upon full assessment of facts. Insurer may not be liable to offer portability if policyholder (a) fails to approach the new insurer at least 45 days before the premium renewal date of the previous policy (b) approaches the new Insurer more than 60 days prior to the premium renewal date”. As such, a policy holders if desirous to port his/her policy alongwith his/her family members from one insurance company to another, shall apply at least 45 days before but not earlier than 60 days from the premium renewal date of the existing policy.
It is also pertinent to state herein that right to underirght a policy is an inherent right which has been provided to every insurer by IRDAI as maintained by the Insurance Company i.e. Niva Health Insurance Co. vide its letters dated 11.08.2022.
The underwriter has discretion to consider whether the proposed insured’s declared condition present a future medical risk and its quantum, and decide whether to accept the risk, or decline the risk based on the risk appetite of Insurance Company as claims in Insurance Company’s are paid out of common pool of funds created out of receipts of premia of policy holders.
Furthermore, the counsel for the complainant also submitted copy of IRDA (Health Insurance Regulation, 2016. The Schedule I of said Regulation provides as mentioned (a) & (b) above para. As per these Regulations, the insurer can also consider the portability in less than 45 days.
After considering the facts of this case and repudiation letter dated 11.08.2022 of the Insurance Company, this Commission weighs its decision in favour of Insurance Company. No merit is found in the complaint of the complainant. Hence the same is rejected as no dispute is found disclosed in the complaint.
File be consigned to the record room after order be uploaded on the website.
