BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.377/2017

DATED ON THIS THE 6^th July 2018

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

                     2) Sri. Devakumar.M.C.                  

                                                B.E., LLB., PGDCLP   - MEMBER

Sri. Devakumar,M.C.

Member

1.     The complainant filed the complaint under section 12 of the C.P.Act 1986, against the opposite parties, alleging deficiency in service and seeking a direction to refund the premium amount i.e. Rs.14,882/- and Rs.11,932/- with interest at  8% p.a. from the date of payment, till the disposal of the complaint and compensation of Rs.50,000/- towards the mental agony, harassment and cost of the litigation with such other reliefs.
2.     The complainant obtained health insurance policies, for himself and for his spouse, from the opposite party insurance company, on payment of a total premium of Rs.26,814/- with a coverage of Rs.5,00,000/- to each of them.  The said policies were valid between 25.11.2015 to 24.11.2016.  As per policy terms and conditions, the policy holders are entitled for health check-up, arranged by the opposite parties, which was not arranged throughout the policy period, in spite of demands for the same.  Aggrieved with the cancellation of the policy, filed the complaint seeking reliefs.
3.     The opposite parties filed common version and denies the allegations and submits as per the policy conditions the policy holders are entitled for a free health check-up at any of the network hospital, but due to some technical problems, they could not subject the complainant to health check-up.  After the lapse of the policy period, the same was discontinued for non-payment of premium amount.  As such, denies the allegation of deficiency in service and prays for dismissal of the complaint with costs.
4.     To establish their contentions, both parties filed their affidavit, in lieu of evidence and relied on several documents.  Written arguments filed.  Heard the respective counsels.  Perused the material on record and posted for orders.
5.    The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service on the part of opposite party for not arranging for their health check-up within the policy period, as per policy terms and conditions and thereby he is entitled for the reliefs sought?
2.  What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- Partly in the affirmative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant and his spouse obtained a health insurance policy from opposite party insurance company and paid a total sum of Rs.26,814/- towards premium for the same.  The policy was in force between 25.11.2015 to 24.11.2016.
8.    The policy provides a health check-up of the insured persons at any of its network hospitals.  As the same was not arranged by opposite party till 12.11.2016, the complainant demanded for the same.  The opposite party assured to arrange for a health check-up at their network hospitals, but failed to arrange for the same, for obvious reasons, inspite of several reminders. 
9.    In the meanwhile, the opposite party demanded for renewal of the policy, as the same was expired on 24.11.2016.  Thereby, the aggrieved called for refund of the premium amount with interest and sought for the reliefs.
10. The opposite party admitted the health insurance policy of the complainant and also admitted that, as per clause 2.10 of the policy terms and conditions, the policy holders are entitled for health check-up at any of their network hospitals.  The opposite parties have also promptly made attempts to arrange for health check-up of the complainant and his spouse and on confirmation only they attempted to communicate the same, but failed to do so, quoting technical problems.  In the meanwhile regretting their failure to arrange for health check-up, sought apology and on expiry of the policy period, demanded for payment of premium towards renewal of the policy.  Further, contended that, they have provided health insurance coverage for both the policy holder during the policy period (i.e. 25.11.2015 to 24.11.2016), except arranging for health check-up and hence, denies the allegation of deficiency in service and also the demand of refund of the premium amount as incorrect.  Hence, prays for dismissal of the complaint. 
11. On perusal of the material on record, as per the terms and conditions of the health insurance policy issued by the opposite party company, the insured persons (i.e. the complainant) are entitled for a health check-up under various benefits offered.  It is true that, the opposite party failed to arrange for the same until the fag end of the policy period.  In spite of reminders and requests, the opposite party failed to arrange for health check-up during the policy period.  In the meanwhile, the policy period expired on 24.11.2016, as such, the opposite party demanded for renewal of the policy, the complainant by payment of premium amount from the complainant.  Aggrieved with the attitude of the opposite parties, without renewal of the policy demanded for refund of the premium amount with interest.  However, the opposite parties extended health insurance coverage during the policy period and since there is no claims, the complainant not entitled for any benefits under the policy and not entitled for refund of the premium amount.  However, on failure to arrange for health check-up the opposite party have committed deficiency in service to the insured and liable to pay compensation for the same with litigation expenses.    Accordingly, the point No.1 is answered partly in the affirmative.   
12. Point No.2:- In view of the observations made under point, we proceed to pass the following :-

:: O R D E R ::

1. The complaint is allowed in part.
2. The opposite party Nos.1 to 3 are jointly and severally liable to pay compensation of Rs.5,000/- for the deficiency in service and Rs.2,000/- towards litigation expenditure to the complainant within 30 days of this order.  Failing to pay, the opposite parties liable to pay interest at 12% p.a. on the entire sum of Rs.7,000/-, until payment.
3. In case of default to comply this order, the opposite party Nos.1 to 3 to undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
4. Give the copies of this order to the parties, as per Rules.

(D