Chandigarh

DF-I

CC/488/2020

Gurinder Singh - Complainant(s)

Versus

Religare Health Insurance Co. Ltd. - Opp.Party(s)

S.S. Sidhu

03 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/488/2020
Date of Institution	:	27/10/2020
Date of Decision	:	03/01/2024

 

Gurinder Singh resident of House No.2162, Sector 15-C, Chandigarh.

… Complainant

V E R S U S

1. Religare Health Insurance Co. Ltd., through its Managing Director, 5^th Floor, Chawla House, Nehru Palace, New Delhi 110019.
2. Religare Health Insurance Co. Ltd., through Incharge, Unit No.604-607, 6^th Floor, Tower-C, Unitech Cyber Park, Sector 39, Gurugram 122001.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh.S.S. Sidhu, Advocate for complainant
	:	Sh.Amarpreet Singh, Advocate, proxy for Sh.Ramdeep Partap Singh, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Gurinder Singh, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that initially, in the year 2010, complainant had obtained a health insurance policy (Annexure C-1) from ICICI Lombard which was valid w.e.f. 3.6.2010 to 2.6.2012 with sum insured of ₹3.00 lacs. Thereafter the complainant got the said policy renewed from the aforesaid insurer annually by paying premium upto 26.6.2016 and copies of the policies for the aforesaid period are Annexure C-2 to C-4. In the year 2016, complainant ported the previous health policy to the OPs company who issued policy certificate valid w.e.f. 24.6.2016 to 23.6.2017 (Annexure C-5). The said policy was further renewed annually and the last policy (hereinafter referred to as “subject policy”) was issued by the OPs which was valid w.e.f 21.7.2019 to 20.7.2020 (Annexure C-8) with sum insured of ₹5.00 lacs and No Claim Bonus of ₹1,50,000/-. The complainant had further received notice dated 6.4.2020 (Annexure C-9) from the OPs for renewal of the policy.  The complainant fell ill and was admitted to Max Super Specialty Hospital on 5.3.2019 and was discharged on the same day.  The complainant was diagnosed with “Transient Global Amnesia” and the copy of discharge summary is Annexure C-10.  Thereafter the complainant had lodged a claim with the OPs for reimbursement of the expenses, but, the OPs had displayed on their website that the claim lodged had been rejected.  Thereafter, the complainant received emails dated 1.7.2020, 2.7.2020 and 9.7.2020 (Annexure C-11 to C-13) and only then he came to know that the OPs had repudiated the claim and have cancelled the subject policy. Vide email dated 17.7.2020 (Annexure C-15), OPs sought consent of the complainant for cancellation of the policy and refund of premium.  Thereafter the OPs cancelled the policy and refunded the premium amount of ₹27,624/- to the complainant in the month of October 2020. Even as per Insurance Regulatory and Development Authority (IRDA) regulations, OPs were required to refund the No Claim Bonus earned by the complainant from the previous insurer and since the same has not been refunded by the OPs to the complainant, till date, and the OPs have wrongly repudiated the genuine claim of the complainant and cancelled the subject policy, the said acts amount to deficiency in service and unfair trade practice on their part.  OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of facts etc.  However, it is admitted that the subject policy was issued to the complainant and previously the complainant had obtained the health policy from ICICI Lombard which as ported to the OPs and the same was renewed by the complainant from time to time.  However, it is alleged that the No Claim Bonus of the complainant was rejected on the basis of non-disclosure of material facts/pre-existing ailment at the time of proposal since the complainant had not disclosed about the pre-existing disease of “Global Amnesia” from which he was even suffering since long.  Accordingly, as per clause 7.1 of the subject policy the claim was repudiated and policy was cancelled as per clause 7.13 since during investigation it was found that the complainant was suffering from the said disease prior to the purchase of the subject policy. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had previously purchased a health insurance policy from ICICI Lombard in the year 2010, as is also evident from the copy of the policy (Annexure C-1) which was valid w.e.f. 3.6.2010 to 2.6.2012 and the said policy was renewed by the complainant, from time to time, on payment of premium upto 23.6.2016, as is also evident from the copies of policies (Annexure C-2 to C-4) from the said insurer and thereafter the complainant ported the previous policy with the OPs regarding which OPs had issued policy certificate (Annexure C-5) which was valid w.e.f. 24.6.2016 to 23.6.2017 and the same was continuously renewed annually by the complainant upto 20.7.2020, as is also evident from the policy certificates (Annexure C-6 to C-8) and further the complainant has not sought revival of the subject policy (Annexure C-8), which has already been cancelled, or the reimbursement of the expenses incurred on his treatment, rather the complainant has sought refund of the No Claim Bonus, which was payable by the previous insurer and was acknowledged by the OPs alongwith the premium amount, and further that the premium amount has already been refunded to the complainant by the OPs whereas the No Claim Bonus (NCB) amount has not been refunded, till date, the case is reduced to a narrow compass as it is to be determined if there is deficiency in service and unfair trade practice on the part of OPs and the complainant is entitled to the NCB amount, as is the case of the complainant, or if the OPs have rightly rejected/repudiated the claim of the complainant and the consumer complaint is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, repudiation letter and other documents having been relied upon by the parties.
   3. As per the case of the complainant, OPs have denied the cashless request for pre-authorization of cashless hospitalisation and repudiated the claim of the complainant vide letter (Annexure R-3)   and have also issued notice (Annexure R-4) for cancellation of the policy on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal. The relevant portion of the letter (Annexure R-3) is reproduced below for ready reference :-

“We have reviewed your request, and hereby inform you that the cashless hospitalization cannot be approved as per the terms and conditions of the policy stated below.

• NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL. K/C/O GLOBAL AMNESIA
• NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL.
• Further, the relevant portion of the notice dated 27.4.2020 (Annexure R-4) for cancellation of the subject policy is also reproduced below for ready reference :-

“There has been Non Disclosure of Material Facts/Pre-Existing ailments at the time of Proposal. Patient Mr.Gurinder Singh had a history known case of Amnesia, however this fact was not disclosed at the time of taking Policy.

In accordance with Policy Terms and Conditions, we hereby serve you a notice of 15 days, from the date of this letter. within which you should furnish correct facts supported by valid documentary proof, in case you dispute the same failing which we would be entitled to cancel the Policy as per Policy Terms and Conditions and forfeit the entire premium.”

 

5. Thus, one thing is clear on record that the OPs have firstly denied the pre-authorisation of cashless hospitalisation of the complainant on the ground of non-disclosure of material facts/pre-existing ailment at the time of proposal as the complainant had been suffering from “Transient Global Amnesia” before that and similarly notice for cancellation of the policy was also issued to the complainant as he was a history/known case of “Global Amnesia” which fact was not disclosed by him at the time of obtaining the subject policy. 
6. It is an admitted case of the parties that the complainant had been purchasing/obtaining the health insurance policy since the year 2010 from the ICICI Lombard and continued with the aforesaid insurer till the year 2016 and after that he ported the said policy with the OPs vide policy (Annexure C-5), the portability details given in the said policy (Annexure C-5) are relevant for the decision of the present case as the complainant is only seeking refund of the No Claim Bonus and the same are reproduced below for ready reference :-

        “Portability Details (if applicable)

Name	Previous Insurer	First Policy Number	Date of First Enrollment	Expiry Policy SI ₹ (Original SI +CB)
Gurinder Singh	ICICI Lombard General Ins. Co.	4128i/H.8956	03-June-2010	300000.0+15000000

 

7. On behalf of complainant, reliance has been placed on the circular/guidelines dated 1.1.2020 issued by the IRDA through which certain guidelines have been issued for the portability of policy, including health policy, and the relevant portion of the same in case of migration of the policy is reproduced below for ready reference :-

“4. Migration shall be applicable to the extent of the sum insured under the previous policy and the cumulative bonus, if any, acquired from the previous policies.

5. Only the unexpired/residual waiting period not exceeding the applicable waiting period of the previous policy with respect to pre-existing diseases and time bound exclusions shall be made applicable on migration under the new policy.

6. Migration may be subject to underwriting as follows:

a. For individual policies, if the policyholder is continuously covered in the previous policy without any break for a period of four years or more, migration shall be allowed without subjecting the policyholder to any underwriting to the extent of the sum insured and the benefits available in the previous policy.

b. Migration from group policies to individual policy will be subject to underwriting.

c. Where underwriting is done, the insurance company shall convey its decision to the policyholder within 15 days as per Regulation 8(6) of IRDAI (Protection of Policyholders' interests) Regulations 2017.”

 

8. Since it has come on record that the complainant had not purchased the health policy first time from the OPs in the year 2016, rather the health policy was originally purchased by the complainant from the previous insurer i.e. ICICI Lombard in the year 2010 and after portability of the same, the said policy continued upto 2020 i.e. the subject policy, even as per the terms and conditions of the subject policy (Annexure R-1), the disease (Global Amnesia), from which the complainant had suffered in the year 2011 and 2016, does not cover under the pre-existing disease, especially when the exclusion clause 4(iii) specifically says that in case of pre-existing disease, claims will not be admissible for any medical expenses incurred for hospitalisation in respect of diagnosis/treatment of any pre-existing disease until 48 months of continuous coverage has lapsed since the inception of the first policy with the company.  In the present case, the date of inception of the first policy shall be counted as 3.6.2010 when the first policy was issued by previous insurer i.e. ICICI Lombard and later on when the same was ported with the OPs. Thus, even as per the guidelines issued by the IRDA in the aforesaid circular, the case of the complainant is not covered under the exclusion clause of pre-existing disease on the basis of the discharge summary which has been relied upon by the OPs which clearly indicates that the past medical history was noticed by the hospital only in the year 2016 and 2011 i.e. after issuance of the first policy.
9. In this manner, as it stands proved on record that the complainant was entitled for the No Claim Bonus at the time of porting of the subject policy from the previous insurer to the OPs in the year 2016, which was also acknowledged by the OPs in the portability details of the policy (Annexure C-5) and withholding of the aforesaid No Claim Bonus by the OPs, till date, certainly amounts to deficiency in service and unfair trade practice on their part and to that extent the complainant has proved the cause of action set up in the consumer complaint.  Accordingly, the present consumer complaint deserves to succeed and the OPs are liable to pay to the complainant the amount of No Claim Bonus alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay the No Claim Bonus of ₹1,50,000/- to the complainant alongwith interest @ 9% per annum from the date of cancellation of the subject policy onwards.
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

03/01/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member