Chandigarh

DF-II

CC/297/2019

Jawahar Lal Khanna - Complainant(s)

Versus

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

Devinder Kumar Adv.

03 Jul 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	297 of 2019
Date  of  Institution	:	08.05.2019
Date   of   Decision	:	03.07.2020

 

 

 

 

 

Jawahar Lal Khanna son of Sh.Roshan Lal Khanna, aged about 70 years, r/o H.No.3826,   Sector 47-D, Chandigarh   

             …..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, 3rd Floor, Sector 43, Golf Course Road, Gurgaon 1220099 through its Managing Director.    

 

    ….. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN              PRESIDENT

         SMT.PRITI MALHOTRA             MEMBER 

                    SH.B.M.SHARMA                      MEMBER

                               

For Complainant      :    Sh.Devinder Kumar, Advocate

For OP(s)            :    Sh.Gaurav Bhardwaj, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

          The case of the complainant, in brief, is that he and his wife Veena Khanna had gone to Australia and their period of stay in Australia was from 1.6.2018 to 25.11.2018 (Ann.C-1).  It is averred that the complainant booked air tickets from M/s B.R.Forex Enterprises, Sector 34, Chandigarh and the representative of OPs also issued an International Travel Insurance Policy No.12237445 Platinum Ex US-Canada (Single) to the complainants.  As per said policy, the complainant and his wife were insured for the period from 1.6.2018 to 26.11.2018 (Ann.C-2).  It is also averred that as per said policy, in the event of Trip Cancellation and Interruption, then the OPs will have to indemnify the insured. 

         It is stated that during the stay in Australia, unfortunately, the mother of complainant expired on 30.9.2018 in Chandigarh, India, thus, the complainant had to change their travel plan and returned back to India on 2.10.2018 to attend the last ceremonies of his mother (Ann.C-3).  It is also stated that while changing travel plan, the complainant has spent a sum of Rs.68,000/- (Rs.34,000/- per person) (Ann.C-4) on the air tickets from Australia to Delhi, in addition to Rs.8800/- towards travel expenses from Delhi to Chandigarh.  Thereafter, the complainant lodged claim with OPs and submitted all requisite documents.  However, the Ops paid only Rs.33,999.53 on 29.1.2019 to the complainant (Ann.C-6) and when the complainant enquired about the short payment, it was told that the claim amount of complainant Jawahar Lal Khanna has been released but the claim amount of his wife Smt.Veena Khanna is under process.  Thereafter, the complainant kept on sending emails with reminder for releasing the balance amount of the claim, but to no avail.  Hence, this complaint has been filed alleging the said act & conduct of the OPs as gross deficiency in service.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the claim of the complainant being payable under Clause 2.111A(i) was duly approved and paid to the tune of Rs.33999.53 (Ann.OP-2).  It is stated that so far as the claim of wife of the complainant is concerned, the same being non-payable as per policy terms & conditions, was repudiated.  It is submitted that the claim under clause 2.11.2A(i) is admissible only if the Insured member’s immediate family member dies or is hospitalized and as per policy terms, an immediate family member means an Insured Person’s spouse, children and parent only.  Therefore, the claim of Mrs.Veena Khanna was repudiated and it was intimated vide letter dated 27.11.2018 (Annexure OP-3). Denying all other allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint. 

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the reply filed by Ops.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the complainant, ld.Counsel for OP and have perused the entire record written arguments of OPs.   

 

6]       The admitted facts are that the complainant opted for Travel Insurance Policy covering the complainant and his spouse for the period from 1.6.2018 to 26.11.2018 for a total sum insured of USD 50000.  Also admitted that during the currency of the insurance policy, the insured trip got interrupted and hence cancelled in between due to the death of complainant’s mother and both the complainant and his spouse flew back to India for which a substantial amount was spent.  Being insured under the policy in question, rightful claim was lodged by the complainant for reimbursement of the expenses incurred due to change of travel programme and against that claim, the OPs paid only an amount of Rs.33,999/- and rejected rest of the claim pertaining to complainant’s spouse claiming that she is not covered under the Clause 2.11.2A(i) of the policy. 

7]       We have gathered from the record that clarification given and the request made by the complainant against the rejection of the claim were not entertained and the claim was again rejected citing clause 2.11.2A(1) and stating it not payable as per policy terms & conditions. 

8]       For the sake of convenience, we feel it appropriate to reproduce the said term being relied upon by the OPs and the same is reproduced as under:-

“The Insured Person’s Immediate Family Member dies or is Hospitalized in an Emergency due to an unforeseen illness or Injury and such Hospitalization continues for at least 2 consecutive days.”

9]       From the bare reading of the above clause, it is quite clear that the claim of the insured person is admissible if the family member, who has expired is connected with the insured person as an immediate family member.

10]      The OPs while interpreting the said clause, opted to interpret the clause in a negative manner claiming that the mother-in-law of the complainant’s spouse is not immediate family member to her, which legally is not correct.  For this we apt to reproduce the term ‘Immediate Family Member’ as denied under the policy:-

“Immediate Family Member means an Insured Person’s lawful spouse, children and parents only.”

 

11]      The complainant’s spouse being insured under the policy in question, in our considered opinion, is very well legally covered under this clause, as under the ‘Hindu Marriage Act’, the husband and wife, though have separate legal entity, but considered as one.  It is a well established custom which is duly protected under the Hindu Marriage Act that after the marriage, the wife leaves the house of her biological parents and become eternal part of the family of her husband and lawfully the parents of her husband became her parents and are thus immediate family members.  Under the customary law, even certain ceremonies performed during the last rites of the deceased    mother-in-law are broadly performed by her daughter-in-law only, so how can the OPs whimsically interpret the term of ‘immediate family member’ ignoring the legal aspect.  Therefore, it is established that the complainant and his wife/spouse, both are very well covered under the definition of ‘immediate family member’ and thus, the OPs have wrongly & illegally rejected the genuine claim pertaining to complainant’s spouse for which they are liable to pay.  The deficiency in service on the part of OPs is writ large. 

        Apt to mention that the OPs have already made payment of Rs.33,999/- to the complainant, after applying all deductions, under the policy against the claim lodged, so we quantify the same amount of claim for his wife/spouse to be just.  Also the complainant has not agitated against the amount paid to him as insured.   

12]      Taking into consideration the discussion and findings, as aforesaid, we are of the opinion that the OPs have wrongly rejected the part of the claim of the complainant pertaining to his spouse and as such rendered deficient services. Therefore, the present complaint is allowed with directions to the Opposite Parties to reimburse the remaining amount of Rs.33,999/- towards the claim pertaining to spouse of complainant. The OPs are also directed to pay compensation amount of Rs.10,000/- to the complainant for causing mental agony, harassment, along with litigation cost of Rs.7,000/-.

         This order shall be complied with by the OPs within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional cost of Rs.15,000/-apart from above relief.

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

Announced

3^rd July, 2020                                                                                                                                                                          Sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

 

Sd/-

(B.M.SHARMA)

MEMBER