For the Complainants - Mr. K. Chakraborty, Advocate
For the OPs - Mr. Debasish Nath, Advocate
FINAL ORDER/JUDGEMENT
SHRI SWAPAN KUMAR MAHANTY, PRESIDENT
This is an application u/s.12 of the C.P. Act, 1986.
Facts, in brief; relevant to decide this consumer complaint are that the complainant No. 1 took a Floater Mediclaim Policy for himself and his spouse fromNational Insurance Company Ltd. Subsequently, complainants ported the said policy with OP-1 Religare Health Insurance Co. Ltd. for a sum insured of Rs. 10,00,000/- on an assurance that they would get full continuity benefits and 100 % reimbursement of claim against fresh medical test.Prior to expiring third year of the policy, complainants were informed over telephone that they are entitled to get 80 % of the claim. Immediately, Complainants met with Rana Chatterjee, representative of OP-1 who had assured to continue of full benefits. Complainants agitated their grievance to the OP-1 vide email as well as letter.Complainants are victims of false representation of OPs. There is unfair trade practice on the part of the OPs. Finding no other alternative, complainants have filed the instant consumer complaint praying for direction upon the OPs to grant all continuity benefits along with 100 % reimbursement benefits as rendered by the National Insurance Company Ltd. together with compensation and litigation cost.
The OPs have contested the case by filing W.V. denying all the material allegations of the complainants. The specific case of the answering OPs is that the complainant No. 1 purchased a Health Insurance Policy bearing No. 10197384 (Plan-Care) for himself and his spouse for the period from 11.03.2015 to 10.03.2018 subject to policy terms & conditions. The said policy again renewed for the period from 11.03.2018 to 10.03.2021. Complainant No. 1 was above 61 years at the time of purchase of the said policy and therefore, complainants are entitled to get 80 % of the total claim amount from the OP-1 and remaining 20 % would be born by the complainants themselves as per clause -3 (3.2) of the said policy condition. OP-1 replied the letter dated 09.01.2018 of the complainant No. 1. Consumer complaint is premature as there is no allegation of deficiencyin service against the OPs. There was no false representation made by the representative of the OP-1. Thus, the OPs have prayed for dismissal of the consumer complaint.
Points for Determination
On the pleadings of the parties , the following points necessarily came up for determination.
1) Whether the complainantshave a Health Insurance Policy being No. 10197384 (Plan-Care) with the OP-1?
2) Whether the OPs sold the Health Insurance Policy to the Complainants on false representation?
3) Whether there was any unfair trade practice on the part of the OPs?
4) Whether the complainants are entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to4 :-
All the points are taken up together for sake of convenience and brevity in discussion.
Both parties have tendered evidence through affidavit. They have also given reply against the questionnaire set forth by their adversaries. Both parties have also filed their Brief Notes of Arguments.
We have gone through the evidence coupled with documents on record.
It remains undisputed that complainant No. 1 purchased a Health Insurance Policy being No. 10197384 (Plan-Care) for himself and his spouse for the period from 11.03.2015 to 10.03.2018 subjectto the policy terms & conditions from OP-1 and the said policy was again renewed for the period from 11.03.2018 to 10.03.2021. It is also true that the sum of insured is Rs. 10,00,000/- and the policy was ported from the National Insurance Company Ltd. subject to the terms & conditions of the policy. Policy was issued against submission of proposal form duly filled in and signed by the complainant No. 1. Under the terms & conditions of the said policy, it is the duty of the proposer to give correct answers to all questions, in the proposal form. The sole responsibility of filling complete proposal form, is on the proposer. It is also the responsibility of the proposer to read and understand the forms and the terms and conditions of the policy, before, signing the same.
The core question for consideration is whether the fact that at the time of purchasing the Health Insurance Policy, complainant No.-1 was beyond 61 years of age. According to the OPs at the time of policy inception, policy holder Mr. Roop Narayan Kaul was 65 years. As such, the policy holder shall bear 20 % of the Final Claim Amount assessed by the company. On bare perusal of Clause 3 (3.2)of the policy terms & conditions. We find that “the policy holder shall bear 20 % of the Final Claim Amount assessed by the company in accordance with the table below and the company’s liability shall be restricted to the balance amount payable.”
Cover Type | Entry Age of Insured Person or Eldest Insured Person(in case of Floater) | Applicable To |
Individual | 61 Years | Individual Insured Person |
Floater | 61 Years | All insured Persons |
The Co-payment shall be applicable to each and every claim, for each insured Person.
In view of the foregoing discussion and as per Clause 3 (3.2) of the policy terms & conditions, complainants are entitled to only 80 % of the claim and balance 20 % would have to be paid by the complainants from their own pocket as on the date of ported the subject policy complainants were aged about 65 years. Thus, the allegation of misrepresentation on the part of the OPs is not correct. If the complainant No. 1 disagree with the terms &conditions of the policy he may return the policy stating reasons for his objection within Free Look Period in terms of Clause 6.11 of the policy. The complainant No.1 did not return the policy within the Free Look Period and agitated the matter after renewal of the policy for the period from 11.03.2018 to 10.03.2021. So, the question of misrepresentation on the part of the OPs does not arise.
In oriental Insurance Company Ltd. Vs. Sawmayanallur Primary Agricultural Co Operative Bank reported in (1999) 8 SCC the Hon’ble Apex Court has been pleased to observe that the Insurance Policy has to be constructed having reference only to the stipulations contained in it and no artificial for fetched meaning could be given to the words appearing in it. In a decision reported in 2017 (2) CPR 508 (NC) the Hon’ble NCDRC has been clearly observed that insurance claim cannot be settled ignoring the terms & conditions of the policy. Thus, the OP-1 was justified to direct the policy holder to bear 20 % of the claim amount as per Clause 3 (3.2) of the special conditions of the policy terms & conditions. In our opinion, there is no laches and/ or unfair trade practice on the part of the OPs for intimating such information containing the specific clause of the policy terms & conditions.
Going by foregoing discussion, we are of the view that the complainants are not entitled to get any relief against the OPs. Thus, all the points under determination are disposed of.
In result, the case fails.
Hence,
Ordered
That the complaint case be and the same is dismissed on contest against the OPs. No cost is imposed upon any of the parties.
Complainants may ventilate their grievance before the competent Civil Court, if so desire.
