CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

Udyog Sadan, C – 22 & 23, Institutional Area

(Behind Qutub Hotel)

New Delhi – 110016

         Case No.87/2017

MR. PUNEET BANGA,

S/O SH. J.K BANGA

PASCHIM VIHAR,

NEW DELHI - 110087                                               …..COMPLAINANT

Vs.   

M/S RELIGARE HEALTH INSURANCE CO LTD.

19^TH CHAWLA HOUSE

5^TH FLOOR, NEHRU PLACE

NEW DELHI-110019                                                   …..RESPONDENTS

Date of Institution-23.02.2017

Date of Order- 12.01.2024

  O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in not porting the group insurance health policy to individual insurance health policy.

2. Facts as stated in complaint are that the complainant was employed with Itochu Corporation Liaison Office, New Delhi and thereafter with M/s Itochu India Private Limited. The complainant resigned from the said company in May, 2016.

3. The complainant and his family members were covered under the Group Health Insurance Policy bearing No. 10344361 of M/s Itochu India Private Limited issued by OP since 2009.  The complainant and his family were insured for a sum of Rs.4,87,000/-. The policy was renewed regularly by M/s Itochu India Private Limited and an equivalent premium was deducted from salary of the complainant.

4. The policy was last renewed on 31.07.2015 which was valid till 30.07.2016. The complainant on 9.5.2016 sent a letter to OP to convert this policy into an Individual Mediclaim Floater Policy along with continuity benefits. On receiving no response the complainant visited OP’s office on 23.5.2016. Complainant alleges that he was made to sign a proposal form and was assured that his proposal will be expeditiously processed.

5. The complainant received a mail from OP dated 31.5.2016 intimating the complainant of non-conversion of group health insurance policy to an individual health insurance policy in terms of portability guidelines. The complainant sent an email dated 2.6.2016 stating that he is entitled to continuity benefits as per IRDA Regulations and Guidelines.

6. The complainant received an email from Deputy Manager, Customer Service of OP on 10.6.2016. He was advised to submit the documents pertaining to resignation in order to initiate the process of migration along with details about sum insured. The complainant sent requisite documents on the same date.

7. OP rejected the proposal for portability vide email dated 16.6.2016. Several emails were exchanged between the parties. The complainant filed a claim in insurance ombudsman. The ombudsman vide order dated 28.11.2016 rejected the claim.

8. The complainant prays for migration from group health policy to individual health policy with continuity benefits, Rs.1,00,000/- as litigation cost and Rs.10,00,000/- towards mental agony.

9. The complainant made a submission on 24.11.23 for dropping the prayer of migration from the prayer clause and only seeks compensation.

10. OP in its reply submits that a master policy no. 10344361 was issued to Master Policyholder Itochu India Pvt. Ltd. from 25.7.2015 to 24.06.2016 wherein the current employees and the dependents are insured. The complainant was relieved from his job on 13.5.2016. The policy period ended on 24.07.2016. The complainant resigned before 60 days from the end date of policy period and the said policy had not completed one year tenure. Therefore, as per clause 16(b) of Health Regulation, 2016, portability could not be offered to the complainant.

11. OP has also admitted that the employer of the complainant was having Group Health Insurance Policy on behalf of complainant since 2009 as being matter of record. OP states that the said Group Insurance Policy provides cover to the employees during the term of their employment.

12. OP states that the Group Insurance Policy was valid from 25.7.2015 to 24.7.2016. It was a one year policy and was never renewed previously. OP has denied receiving letter dated 9.5.2016. OP further clarifies that as the complainant was no longer in employment from 13.5.2016.  Hence, post expiry of complainant’s employment, there was a break-in period and   portability to retain plan could not be provided.  OP asserts that as the tenure of Group Policy expired on 25.7.2016, OP bonafidely asked for relevant documents in email dated 10.6.2016.

13.  OP admits emails dated 31.5.2016, 2.6.2016, 10.6.2016, 16.6.2016, 21.6.2016, letters dated 30.6.2016, 19.7.2016, 6.7.2016, 27.7.2016 and copies of IRDA Regulations and Circular.

14. Complainant has filed rejoinder and reiterated the averments made in the complaint. The complainant submits that his wife who was also covered under the said policy was admitted in AIIMS on 14.5.2016 till 7.6.2016 for treatment in the Neurology Department. OP reimbursed part of medical expenses incurred. OP paid Rs.2,51,212.60/- on 8.7.2016 towards medical reimbursement. Therefore, the policy had not expired on 14.5.2016.

15. Complainant has filed his evidence and exhibited the following documents:

1. Copy of letter is exhibited as Exhibit CW1/1.
2. Copy of e-mails are exhibited as Exhibited CW/1/2 and CW1/3.
3. Copy of IRDA Regulation, 2016 and Circular are exhibited as Exhibit CW1/4 and CW1/5.
4. Copy of e-mails is exhibited as Exhibit CW1/6 to CW1/10.
5. Copy of letters are exhibited as CW1/11 and CW/12 respectively.
6. Copy of response is exhibited as Exhibit CW1/13 and Exhibit CW1/14 respectively.
7. Copy of Account Statement of the complainant is exhibited as Exhibit CW1/15.
8. Copy of discharge summary of the wife of the complainant is exhibited as Exhibit CW1/16.
9. Copy of the complaint filed before the Insurance Ombudsman is exhibited as Exhibit CW1/17.
10. Copy of the order passed by Insurance Ombudsman is exhibited as Exhibit CW1/18.

16. OP has filed its evidence and exhibited the following documents:

1. Copy of the Order of Insurance Ombudsman is marked as Ex.R1.
2. Copy of the Policy Certificate is marked as Ex.R2.
3. Copy of the Policy terms and conditions are marked as Ex.R3.
4. Copy of the relieving letter is marked as Ex.R4.
5. Copy of the Health Regulations are marked as Ex.R5.
6. Copies of the letters are marked as Ex.R6.

17. This Commission has considered the pleadings and materials on record. It is admitted by both the parties that Group Health Insurance Policy bearing No. 10344361 was issued to M/s Itochu India Private Limited. The complainant and its family were covered under the said policy. It is also admitted that the Group Health Insurance Policy was continuing since 2009. It is also admitted that complainant resigned on 13.5.2016.

18. The complainant vide letter dated 9.5.2016 has requested to convert the Group Insurance Policy to Individual Policy with continuity benefit. OP denied receiving this letter.

19. Email dated 23.5.2016 from complainant to customer care of OP is as follows:

In the subject matter today I visited office of Religare Health Insurance Co. Ltd. 19^th Chawla House, 5^th Floor Nehru Place. Delhi 110019 and submitted my request in the subject matter (copy attached)

I met Mr. Tarun Sharma, Agency Manager and signed the Proposal Form filled by Mr. Tarun Sharma.

I also met Mr. Ravinder Singh Senior Official of Religare Health Insurance Co. Ltd and had detailed discussion  in the subject matter.

I am given to understand by Mr. Ravinder Singh that they will discuss the matter with ‘under writer’ and inform the amount of premium to be paid in the subject matter.

You are requested to kindly inform the amount of premium payable in my case to maintain the continuation of benefits in the subject policy.

20. Email dated 24.5.2016 from customer care of OP to complainant informs the complainant to contact the branch where his request has been submitted.

21. Email dated 25.5.2016 from complainant to OP is as follows:

This is further to my visit to your office in the subject matter on 23.5.2016 and my communication to Customer Care dated 23.5.2016.

I have received the communication from Customer Care vide mail dt 24.5.2016 at 23:02 advising me to contact your branch in the subject matter.

In this regard your are requested to kindly let me know the amount of premium payable by me in the subject matter and also let me know your bank details etc to enable me to remit/ transfer on line the amount of premium payable in my case immediately to maintain continuity of the mediclaim policy.

22. Email dated 31.5.2016 from OP to the complainant is as follows:

This is in reference to your conversation dated 31.05.2016 regarding your query

We would like to update you that No Continuity Benefits would be offered from Group (GMC) to Individual Retail or proposal received from members covered under this Group Policy for conversion to Retail Plan vide Portability guidelines shall be dealt with as per laid down guidelines.

Further we apologize for the inconvenience caused to you during this period.

23. Email dated 2.6.2016 from complainant to OP again request for portability.

24. OP vide letter dated 10.6.2016 to complainant is as follows:

We would like to update you that request for migration of Policy No. 10344361 from Group Insurance to family floater policy can only be processed once current tenure of the group policy is over along with your Resignation acceptance/ HR confirmation on the same once one your tenure of the policy is over.

Kindly let us know Sum insured you want to opt for so that we can provide you relevant premium details. Also our concern team will review the details basis on our medical underwriting guidelines and will update you status of proposal post that.

25.  The complainant sent requisite details vide email 10.6.2016. OP rejected the request vide email dated 16.6.2016. The relevant portion is as follows:

We regret to inform you that as policy period of aforesaid Group policy is less than one year with Religare Health Insurance and as per your letter your last working day was on May 13, 2016 therefore portability of the said policy cannot be offered.

26. The complainant filed a claim in insurance ombudsman vide order dated 28.11.2016 rejected the claim as follows:

In Health Regulation, it is clearly stated that “Individual member, including the family members covered under any group health insurance policy of a General Insurer or Health Insurer shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater policy with the same insurer provided he should apply at least 45 days before, but not earlier than 60 days from the premium renewal date of his/her existing policy.”

In the instant case the complainant resigned on 13.05.2016 and did not apply for portability 45 days before, therefore as per Health Regulation, 2016 portability could not be offered. Therefore, I see no reason to interfere with the decision of the Insurance Company.

27. The policy document has been placed on record by OP. The policy is valid from 25.7.2015 to 24.7.2016. The relevant terms and conditions annexed with the policies is as follows:

5. General Terms and Conditions

1. Mid-term addition of the Insured Member

Any person may be added as an Insured Member during the Policy Period provided that his application for cover has been accepted by Us, additional premium, on pro rata basis in respect of such Member has been received by Us and We have issued an endorsement confirming the addition of such person as an Insured Member.

2. Mid-term deletion of the Insured Member

Name of any Insured Member who is covered under the Policy and whose name specifically appears in Annexure A may be deleted on Your request during the Policy Period. Refund of premium shall be made on pro-rata basis provided that Primary Insured Member or any of his Dependent has not made any Claim during the Cover Period under this Policy.

5.20 Portability and Continuity Benefits

Insured Members covered under this Policy shall have the right to migrate from this Policy to an individual health insurance policy or a family floater policy offered by Us and the credit for wait periods would be given in the opted in individual health insurance policy or a family floater policy offered by Us.

28. OP has relied on Gazette notification dated 12.7.2016 vide F.No. IRDAI/Reg/17/129/2016 Schedule 1 deals with portability of policy are as follows:
29.  

Portability of Health Insurance Policies offered by General Insurers and Health Insurers.

1. A policyholder desirous of porting his/her policy to another insurance company shall apply to such insurance company to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days from the premium renewal date of his/her existing policy.

2. Insurer may not be liable to offer portability if policyholder (a) fails to approach the new insurer at least 45 days before the premium renewal date, or (b) approached the new Insurer more than 60 days prior to the premium renewal date.
3.  

16. Portability shall be allowed in the following cases:

a. All individual health insurance policies issued by General Insurers and

Health Insurers including family floater policies.

b. Individual members, including the family members covered under any group health insurance policy of a General Insurer of Health Insurer shall have the right to migrate from such a group policy to an individual health insurance policy or a family floater policy with the same insurer. Thereafter, he/she shall be accorded the right mentioned in 1 above.

29. The policy in question covers a period of one year from 31.07.2015 to 30.07.2008. The complainant has been covered by this policy from year 2009. The complainant resigned on 13.5.2016. The policy cover ended on 30.7.2016.

30. As per gazette notification dated 12.07.2016, a policy holder is allowed to migrate from Group Health Insurance Policy to Individual Health Insurance Policy. As per the terms and conditions of the policy relied on by OP, the insured members have the right to migrate from this group policy to Individual Health Insurance Policy or a Family Floater Policy along with the credit for wait period (continuity benefits). The said policy also shows that an insured member can be deleted only on request during the policy period. No such request by the group policy holder for deletion of complainant’s name has been placed on record by OP. It is clear that the complainant could migrate from this Group Policy to Individual/ Family Floater Insurance Policy as long as there was no request for the deletion of his name on his employer’s behalf. 

31. OP has relied on the gazette notification dated 12.07.2016, wherein a policy holder can port his policy to another insurance company and the request for portability has to be made between 45 and 60 days before the end of the policy. However, the said guidelines applicable when a policy holder is porting his policy to another insurance company as clarified in Clause 2 of Schedule 1 of Gazette notification. In the present, the policy holder is migrating in the same insurance company.

32. Letter dated 9.5.2016 has been denied by OP. The first email communication requesting the portability of policy is on 23.5.2016 and is duly admitted by OP.

33. OP’s email dated 31.05.2016 from OP states that no continuity benefits would be offered to the complainant. OP’s email dated 10.06.2016 shows that the migration can only migration from Group Policy to Individual Policy can be processed only after the current tenure of the group policy is over. OP vide email dated 16.06.2016 states that the policy period of the group policy is less than one year with OP’s insurance company and the last working day for the complainant was 13.05.2016. It can be seen from the series of these emails that OP has wrongly stated that the Group Policy is less than one year. When it was clearly admitted that the Group Policy was continuing since 2009. Moreover, OP in its email states that the migration can only be done after the tenure is over. OP in its written statement takes a contrary stands and states that portability has to be applied between 45 to 60 days from the completion of the tenure of the policy. OP states that the policy cover of the complainant lapses from the date of the resignation. However, OP has paid reimbursement claim in June, 2016, after the resignation of the complainant. OP is completely silent about the reimbursement of claim.

34. The complainant has stated that his wife has been unwell and was undergoing medical treatment. The complainant’s family has been without medical cover/ or insurance without continuity benefits from 2016 onward even though, his family was covered by OP  Insurance Company since 2009.

35. Hence, we find OP guilty of deficiency in service in not porting the complainant’s policy and direct it to pay Rs.50,000/- as compensation for mental harassment and physical inconveniences. We also award Rs.10,000/- towards litigation expenses.

36. File be consigned to record room. Order to be uploaded on website.