DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016

Case No.271/2015

Mrs. Ritu Sud

TNC-022, DLF Trinity Towers

Phase-V, Gurgaon, Haryana                                           ….Complainant

Versus

1.       National Insurance Company Ltd.

          Malviya Nagar Branch

          E-2/5, Ist Floor, Main Market Road,

          Malviya Nagar-New Delhi-110017

2.       Medi Assist India Pvt. Ltd.

          B-20, Sec-2, Noida

          Near Sector-15, Metro Station,

          Opp. HCL Connect, U.P.                                    ….Opposite Parties

                                                  Date of Institution        :30.09.15     Date of Order      : 01.12.18   

Coram:

Sh. R.S. Bagri, President

Ms. Naina Bakshi, Member

Ms. Kiran Kaushal, Member

ORDER

Member - Kiran Kaushal

Briefly stated facts of the complaint are:-

1. The complainant, Mrs. Ritu Sud took a medical insurance policy from National Insurance Company Ltd. (hereinafter referred to as OP No.1) for the period of 05.09.13 to 04.09.14 for Rs.4 lakhs. The husband of the complainant also opted for a health insurance cover from OP No.1 at the same time. Thus, the complainant and her husband opted for one health insurance policy each.
   1. It is averred by the complainant that once the initial insurance policy was generated by OP No.1 the complainant requested for issuance of some papers/documentary evidence to that effect. However, OP No.1 never sent any insurance policy papers to the complainant or to her husband.
   2. In October, 2013 the complainant was detected with cancer. The complainant for her treatment wanted to claim insurance cover for herself. The complainant averred that after informing the OP No.1 about her illness and thereafter sending several reminders, OP No.1 finally sent the copy of the policy and the terms & conditions of the policy which are annexed as Annexure-A and Annexure-B respectively.
   3. It is alleged by the complainant that she had taken a policy of Rs.4 lakhs from OP No.1 however, OP No.1 has settled the claim of the complainant for a paltry sum of Rs.2,25,000/- against the total claim amount of Rs.4 lakhs. On enquiry the complainant  was informed that the insurance cover which the OP No.1 had given her is a “Parivar  Policy” i.e. it is  a family  medical claim insurance policy wherein she can claim only half of the insurance amount. The complainant was shocked and surprised to know that the OP No.1 had issued a family insurance cover (Parivar Policy ) to an individual. It is next averred that an individual cannot constitute a family and hence issuance of family insurance cover for an individual is ex-facie wrong. Disturbed at the appalling behaviour of OP No.1, the complainant  made enquiries and got to know by one of the senior officials of OP No.1 that ‘Parivar Policy’ is meant for families and covering individuals under this insurance is prohibited. A copy of the e-mail received by the official is annexed as ‘Annexure F’.
   4. It is next stated that as the complainant  and her husband had opted for an insurance cover each, when the complainant  had enquired about the difference in the amount of premium paid by her and her husband, she was informed that the premium charged for her is less since she comes under an age bracket  that is lower than that of her husband and hence the amount of premium payable by her differs from that of her  husband. The complainant and her husband thus continued to pay the premium amount as demanded by the OPs.
   5. Troubled by the apathetic behaviour of OP No.1 the complainant knocked the doors of this Forum with the prayer that OPs be directed to pay a sum of Rs.1,99,975/- towards the amount of insurance claim alongwith interest @ 18% per annum, to pay a sum of Rs.5 lakhs towards compensation on account of mental agony and harassment and Rs.75,000/- towards legal expenses.

2. OP No.1 resisted the complaint on the ground that the complainant  had taken a Parivar Mediclaim Policy which was duly issued with her consent and denies the stand of the complainant  that she had taken an individual policy. The OP No.1 further states that the terms and conditions of the Parivar Mediclaim Policy were also handed over to the complainant  and it was very much within the knowledge of the complainant  that the policy given to her  was Parivar Mediclaim Policy.
   1. It is next stated that the Medi Assist India TPA Pvt. Ltd. (OP No.2) has already settled the claim of the complainant according to the terms and conditions of Parivar Mediclaim Policy for Rs.82,850/- (i.e.50% of the assessed amount by the TPA). Therefore the allegations made in the present complaint are false and baseless and devoid of any merits. OP No.1 prays for dismissal of the complaint with heavy cost.
3. OP No.2 was proceeded exparte vide order dated 02.06.16.
4. Rejoinder and evidence by way of affidavit are filed by complainant wherein averments made in the complaint are reiterated.
5. OP No.1 controverted the averments made in the complaint by filing its written statement but failed to lead its evidence and hence OP No.1’s evidence was closed on 21.10.16.
6. Written arguments have been filed on behalf of the complainant  and OP No.1.
7. We have heard the arguments on behalf of the complainant. However, none appeared on behalf of the OP No.1 to advance oral arguments despite affording opportunity in this behalf. Material available on the record is perused.
8.  Admittedly the complainant had taken an insurance policy for the period of 05.09.13 to 04.09.14 for Rs.4 lakhs. Dispute between the parties arose when the complainant was detected with Cancer and thereafter she applied for the claim of the insurance cover. OP No.2 Medi Assist India Pvt. Ltd. (TPA) after investigation and assessment settled the claim and paid 50% against the total claim amount of Rs.4 lakhs. The complainant’s claim  was restricted  to 50% by TPA on the ground that OP No.1 had offered her  a ‘Parivar Mediclaim Policy’. It is pertinent to note that it was only after the complainant had informed OP No.1 about her illness and after sending them several reminders that the complainant received a copy of the insurance policy as well as terms and conditions of the policy.
9. Further aggrieved by receiving the paltry sum of Rs.8,20,25/- out of Rs.3,03,324/-, the complainant made enquires and got to know that Parivar Mediclaim Policy cannot be given to an individual. To substantiate her point she has annexed an e-mail with the complaint as Annexure-F from Sr. Divl. Manager of the OP No.1 Company. The e-mail of the said officer is reproduced as under:-

“ Dear Sir

thanks for query.

Parivar mediclaim policy is meant for parivar, as the name suggests.

An individual cannot have this one.”

10. The contention of OP No.1 that the complainant was duly issued a Parivar Mediclaim Policy and that she was also well aware about the terms and conditions of the said policy does not appeal to this Forum, as OP No.1 has failed to controvert the fact that how can an individual be given a Parivar Policy. The e-mail produced hereinabove has not been controverted. Bald averments made by the OP No.1 without any substantial evidence holds no water in the eyes of law. Therefore, this Forum is of the opinion that OP No.1 has indulged in unfair trade practice as it has denied the valid claim to the complainant. It is further noticed that complainant and her husband purchased the insurance policy almost together. There is no reason as to why would the complainant purchase ‘Parivar Policy’ and her husband would separately opt for an individual health cover.
11. Hence, this Forum is of the opinion that OP No.1 has indulged in unfair trade practice. Therefore, the complaint is allowed. OP No.1 is directed to pay Rs.1,99,975/- to the complainant  towards the amount of the insurance claim alongwith interest @ 6% per annum from the date of accrual till its actual payment within a period of one month from the date of receipt of copy of this order.  Additionally Rs.10,000/- be paid to the complainant  by OP No.1 on account of mental agony, harassment and legal expenses. Failing which the OP No.1 shall pay the interest @ Rs. 9% per annum on the sum of Rs.1,99,975 from the date of accrual till realization.
12. Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.

Announced on 01.12.18.