Chandigarh

DF-II

CC/603/2018

Indu Bala - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

Devinder Kumar Adv.

19 Aug 2019

ORDER

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

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Consumer Complaint  No	:	603 of 2018
Date  of  Institution	:	31.10.2018
Date   of   Decision	:	19.08.2019

 

 

 

 

Indu Bala wife of Late Sh.Harsh Kaushal, r/o House No.1828-D, Randhawa Road, Kharar, District Mohali.

             ……..Complainant

 

Versus

 

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

2]  Religare Health Insurance Company Limited, Correspondence Address: Vipul Tech Square Tower C, 3^rd Floor, Sector 43, Gold Course Road, Gurgaon 122 009 through its Managing Director.

 ………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

         SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Sh.Devinder Kumar, Adv. for complainant

Sh.Sachin Ohri, Adv. for Opposite Parties.

 

PER PRITI MALHOTRA, MEMBER

 

                                The case of the complainant in brief is that her husband Late Sh.Harsh Kaushal got himself insured by purchasing an International Travel Policy No.12237445 Platinum Ex US-Canada (Single) from Opposite Party, which was valid from 18.3.2018 to 28.3.2018 (Ann.C-1). It is averred that Late Sh.Harsh Kaushal, insured left India on 18.3.2018 and reached Armenia on 19.3.2018 and unfortunately died in Armenia on 22.3.2018 (Ann.C-2). Thereafter, the complainant being nominee under the said policy and wife of insured, lodged claim with OPs along with all requisite documents, but the same was rejected by the OP Insurance Company vide letter dated 8.5.2018 illegally and arbitrarily alleging exclusion clause.

         It is submitted that the insured Sh.Harsh Kaushal (since deceased) was never supplied any terms & conditions of the policy as relied upon by the OPs.  It is also submitted that as per policy Ann.C-1, supplied to Late Sh.Harsh Kaushal, insured, the Opposite Parties are bound to pay the expenses incurred on the Repatriation of mortal remains from the place of death to India.  It is further submitted that to bring the body of insured Harsh Kaushal from Armenia to India, the complainant has spent 1860 Dollars (Indian Rs.1,30,000/- approx..) (Ann.C-4 & C-5).  The complainant again represented the OPs, but they did not pay any heed. Hence, this complaint has been filed alleging the said rejection of claim as illegal, arbitrary and deficiency in service on the part of OPs.

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that as per terms & conditions of the policy, the benefit of Repatriation of Mortal Remains is covered under the Policy only when insured person dies solely and directly due to an Accident, whereas the insured died due to disease of Liver Cirrhosis and not due to an accident, therefore, the claim was rightly rejected under Clause 2.10 of the policy terms & conditions (Ann.R-4). Denying other allegations and pleading no deficiency in service, the Opposite Parties have prayed for dismissal of the complaint.

 

3]      The complainant filed replication thereby reiterating the assertions as made in the complaint and controverting that of the Opposite parties made in the reply.

 

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 present complaint pertains to rejection of the claim filed by complainant, a widow & nominee of insured Late Sh.Harsh Kaushal, by the Opposite Parties. 

 

7]       It is well proved on record that the policy holder Late Sh.Harsh Kaushal obtained Policy No.12237445 – ‘Platinum Ex US-Canada (Single) Policy’ valid from 18.3.2018 to 28.3.2018 i.e. having duration of 11 days. Unfortunately, the insured policyholder Sh.Harsh Kaushal expired on 5^th day of the policy coverage i.e. on 22.3.2018 (Ann.C-2) in Armenia and the body was repatriated to India on 9.4.2018  (Ann.C-4).  The nominee under the Policy i.e. Indu Bala wife of Late Sh.Harsh Kaushal filed claim with Opposite Parties for the reimbursement of expenses incurred on the repatriation of the mortals remains but the claim was rejected by the OPs.

 

8]       It is perused that in the Policy Certificate (Ann.C-1) under Schedule of Benefits, it is mentioned at Clause 8 that Repatriation of Mortal Remains are insured Upto USD 50,000 and the same are payable without any deduction.   The claim lodged by the complainant with Opposite Parties for reimbursement of the expenses incurred on repatriation of body of insured Late Sh.Harsh Kaushal, was rejected by the OPs on the ground that since the death of the insured occurred due to disease Liver Cirrhosis and not on account of an accident, so not entitled for the benefit under the policy as per Exclusion Clause 2.10(A) of the Terms & Conditions of the Policy.

 

9]       The only issue which comes out of the above facts that whether the deceased policyholder was ever supplied with those terms & conditions on which the repudiation of the claim is based. It is vehemently agitated by the ld.Counsel for the complainant that no terms & conditions of the policy were ever supplied to the policyholder nor exclusion Clauses were disclosed at the time of issuing of the policy in question.  On the contrary, the ld.Counsel for the Opposite Parties stated that they duly sent the terms & conditions of the policy in question at the email address of the policyholder and that the policyholder never raised issue with regard to non-receipt of terms & conditions of the policy.  This plea of the OPs is devoid of any evidence on record as no such evidence revealing that the terms & conditions of the policy were ever sent at the email address of the policyholder, has been placed on record nor it has placed on record any document revealing the dispatch of terms & conditions of the policy at the address of the insured. There is no iota of evidence produced by the Opposite Parties showing that policyholder was ever made aware or known to the additional exclusion clause of the policy in question. Thus the rejection based on the alien terms & conditions to the insurance contract in question is illegal, unjustified and amounts to deficiency in service on the part of Opposite Parties. 

 

10]      In the Insurance Certificate (Ann.C-1) under the Schedule of Benefits, it is mentioned at Sr.No. 8 that Repatriation of Mortal Remains are covered for Sum Insured Upto USD 50,000/-.  However, in the said Insurance Certificate (Ann.C-1) it is nowhere mentioned that such benefit can only be available only in case of accidental death.  The Opposite Parties cannot wriggle out from their responsibility by relying upon the terms & conditions which were not the part of Insurance Certificate nor that were ever supplied/sent to the policyholder or had explained the same. 

 

11]      For the decision above, we also put reliance on the decision of Hon’ble Supreme Court of India in M/s.Modern Insulators Ltd. Vs. Oriental Insurance Co. Ltd., I(2000) CPJ 1 (SC), wherein it has categorically been held that “Exclusion Clause” Neither Part of Contract of Insurance Nor Disclosed to Insured : No Benefit available to Insurance Company.

         Also it has been held by the Hon’ble National Commission in case titled National Insurance Company Ltd. Vs. D.P.Jain, decided on 15.5.2007, that exclusion clause if not explained, they are not binding on insured and required to be ignored while considering the claim of the complainant.

 

12]      In view of the above discussion & findings, as discussed in the preceding paragraphs, and also the law laid down by the Hon’ble Supreme Court, we are of the opinion that the Opposite Parties have rendered deficient services to the complainant by rejecting her genuine claim in the garb of undelivered and also unexplained exclusion clause. Therefore, the present compliant is allowed against the OPs No.1 & 2 with following directions:-

a]  To pay an amount of Rs.1,30,000/- (equivalent to US$ 1860) along with interest @9% per annum from the date of rejection of the claim i.e. 8.5.2018 till realization;

b)  To pay an amount of Rs.15,000/- as compensation on account of deficient services.

 

c)  To pay litigation cost of Rs.8000/- to the complainant.

 

         This order shall be complied with by the Opposite Parties No.1 & 2 within a period of 30 days from the date of receipt of its copy, failing which the Opposite Party shall pay additional compensatory cost of Rs.20,000/- apart from the above relief.  

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

19^th August, 2019                            

                                                                   Sd/-                      (RAJAN DEWAN)

PRESIDENT

         

 

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER