Chandigarh

DF-II

CC/444/2017

Hatinder Gupta - Complainant(s)

Versus

Religare Health Insurance Company Limited, SCO No. 56-58, Top Floor, Sector 9-D, Chandigarh-160017 - Opp.Party(s)

Adv. J.P.Nahar

22 Mar 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	444 of 2017
Date  of  Institution	:	01.06.2017
Date   of   Decision	:	22.03.2018

 

 

 

 

Hatinder Gupta, House No.698, Sector 10, Panchkula (Haryana) PIN 134109     

             …..Complainant

Versus

Religare Health Insurance Company Limited, SCO No.56-58, Top Floor, Sector 9D, Chandigarh 160017 through its Branch Manager.

                          ….. Opposite Party

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

         MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

Argued by: Sh.J.P.Nahar, Adv. for complainant

 Sh.Sachin Ohri, Adv. for Opposite Party

 

 

PER RAVINDER SINGH, MEMBER

 

 

         The facts in issue are that the complainant was having health insurance policy of Star Health and Allied Insurance Co. Ltd. since the year 2011 and changed/ported it to Religare Health Insurance Company Limited by obtaining insurance policy bearing No.10746210 for the period from 3.9.2016 to 2.9.2017 for sum insured of Rs.10 lac and paid premium of Rs.19,183/- (Ann.C-1 to C-4).  It is averred that after some time, the complainant received a letter dated 6.12.2016 from OP for cancellation of the policy (Ann.C-6), which was replied by the complainant, but the OP vide letter dated 10.1.2017 cancelled the policy of the complainant leaving him and his family members without any insurance coverage.  Thereafter, the complainant requested the Opposite Party vide letter dated 4.2.2017 to reconsider the cancellation of the policy, but to no avail.  Hence, this complaint has been filed alleging the said act of the Opposite Party as deficiency in service.

 

2]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that the complainant while proposing for the policy, in order to get unjust benefit of cumulative bonus, did not disclose in the proposal form about his lodging of any claim with his previous insurer and hence, the complainant is guilty of non-disclosure of material facts and therefore, the policy was rightly cancelled as per terms & conditions thereof.  It is submitted that the Opposite Party later on came to know that the complainant had availed claim of Rs.28,300/- from his previous insurer, but this fact was not disclosed by the complainant at the time of porting of the policy with Opposite Party.  Pleading no deficiency in service and denying rest of the allegations, the Opposite Party has prayed for dismissal of the complaint.

 

3]       Complainant also filed rejoinder thereby reiterating the assertions made in the complaint.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       The complainant took Health Insurance Policy from Religare Health Insurance Company bearing Policy No.10746210, which was valid from 3.9.2016 to 2.9.2017 after payment of premium of Rs.19,813/- (Ann.C-1).  The complainant was under medical health insurance from Star Health Insurance Company Limited since 2011 and only on 3.9.2016 he ported the Health Insurance Policy from Star Health Insurance Company to Religare Health Insurance Company/Opposite Party. 

 

7]       The Opposite Party vide letter dated 10.1.2017 (Ann.C-7) cancelled the Health Insurance Policy bearing No.10746210 pertaining to the complainant with following observations:-

“your case cannot be considered because of the non-disclosure of the material information at the time of proposal. Had the same been disclosed at the time of proposal, we would not have issued the policy.

Therefore your Health Insurance policy No.10746210 stands void ab-initio due to non-disclosure of material information and premium stands forfeited as per Policy Terms and Conditions.”

 

8]       The guidelines issued by Insurance Regulatory & Development Authority of India (IRDA) dated 9.9.2011 (Ann.C-10), it is stipulated under Clause No.9:-

“9. If on receipt of complete information and data within the above time frame, the insurance company does not communicate its decision to the requesting policyholder within      15 days then the insurance company shall not retain the right to reject such proposal and shall have to accept the proposal.”

 

9]       The Health Insurance Policy of the complainant was issued on 3.9.2016 and the notice for cancellation was issued by the Opposite Party vide letter dated 6.12.2016 and consequent thereon the policy was cancelled on 10.1.2017 after an inordinate and unexplained delay of 95 days.  As per IRDA guidelines/instructions, as referred above, if the insurance company does not communicate its decision to the policyholder within the 15 days, then the insurance company shall not retain the right to reject such proposal and shall have to accept the proposal.

10]      In view of the above instructions, the decision of the Opposite Party regarding cancellation of insurance policy of the complainant as communicated vide letter dated 10.1.2017 (Ann.C-7) is untenable and against the terms & conditions/instructions/guidelines issued by IRDA on the subject.

         The complainant has received the medical claim of Rs.28,300/- on 29.8.2016 only after formulation of insurance policy with the Opposite Party on 3.9.2016.  The complainant seems to have under bona fide mistake of fact failed to intimate this fact of lodging of this claim with previous insurer/Star Health Insurance Company. The omission regarding lodging of earlier claim by the complainant does not, in the present facts & circumstances, seems to be mala-fide.    

 

11]      The Opposite Party has illegally cancelled the health insurance policy of the complainant and forfeited the premium amount and as such suffers from unfair trade practice as well as deficiency in service on its part.

 

12]      Keeping into consideration the facts in issue in the present matter, the complaint is allowed against Opposite Party. The policy period under the policy in question from 3.9.2016 to 2.9.2017 has already lapsed and as such, to meet the ends of justice, the Opposite Party is directed to issue a fresh policy in the name of complainant and his family members, as per previous policy, for the period 3.9.2017 to 2.9.2018 on the earlier received premium of Rs.19,813/- and it would be treated as continuation/renewal of the previous policy    without any gap/lapse. Apart from this, the Opposite Party shall also pay to the complainant an amount of Rs.7,000/- as compensation and litigation expenses Rs.5,000/-, within a period of 30 days from the date of receipt of copy of this order.

 

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

22^nd March, 2018                                                

                                                                                      Sd/-  

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER