Delhi

East Delhi

CC/599/2016

KIMTI LAL SHARMA - Complainant(s)

Versus

RELIGARE HEALTH - Opp.Party(s)

10 Feb 2020

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 599/16

 

Shri Kimti Lal Sharma

C-149, Anand Vihar

Delhi – 110 092                                                           ….Complainant

Vs.    

 

M/s. Relligare Health Insurance Co. Ltd.

Branch Office: 206, 2^nd Floor

Roots Tower, District Centre,

Laxmi Nagar, Delhi – 110 092                                          …Opponent

 

 

Date of Institution: 09.11.2016

Judgement Reserved on: 10.02.2020

Judgement Passed on: 12.02.2020

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By: Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Shri Kimti Lal Sharma against Religare Health Insurance Co. Ltd. (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.       The facts in brief are that the complainant applied for a health insurance policy in the name of his son Vikram Sharma on 08.08.2015 for one year and handed over a cheque no. 164661 dated 08.08.2015 for      Rs. 4,448/-, drawn on IDBI Bank, New Rajdhani Enclave in favour of Religare Health Insurance Co. Ltd. (OP) to company representative         Mr. Abhay Pratap Singh on the same day.

          The complainant have received a policy no. 10410614 (client ID 52620801) for the period 02.10.2015 to 01.10.2016 instead of 08.08.2015 vide letter dated 07.10.2015.  He informed Religare Health Insurance       Co. Ltd. (OP)  to rectify the issuing date in policy certificate vide letter dated 02.11.2015, but no reply was received by him.   He contacted company’s customer care service on 27.06.2016, 04.07.2016, 07.07.2016, 11.07.2016, 14.07.2016, 16.07.2016, 19.07.2016, 21.07.2016 and 01.08.2016 and was assured for rectification in the policy certificate, but all in vain. 

          It was stated that Mr. Vikram Sharma, son of the complainant met with an accident on 19.09.2015 and was admitted in Pushpanjali Crosslay Hospital, Vaishali from 19.09.2015 to 21.09.2015.  He submitted the claim for Rs. 99,183/- for reimburse with OP which was rejected vide their letter dated 31.08.2016.  Hence, the complainant has prayed for directions to OP to reimburse the hospital bill of Rs. 99,183/- alongwith interest of             Rs. 48,605/- (@ 24% from 19.09.2015 to 31.08.2017) and compensation of Rs. 50,000/-. 

3.       In reply filed on behalf of Religare Health Insurance Co. Ltd. (OP), they have stated that the complainant submitted an unsigned, partially filled proposal form on 08.08.2015 alongwith cheque dated 08.08.2015.  The incomplete proposal form was completed by the complainant in October, 2015, enhancing the sum insured to Rs. 4,00,000/-.  Hence, OP encashed the premium cheque and issued policy no. 10410614 on 07.10.2015 for a sum insured of Rs. 4,00,000/-, valid from 02.10.2015 to 01.10.2016 and delivered the policy kit to the complainant on 10.10.2015 vide Blue Dard AWP No. 43933980635 which was received by the complainant. 

          It was further stated that the claim of the complainant for his son    Mr. Vikram Sharma was filed on 31.07.2016 according to which Mr. Vikram Sharma was admitted in the hospital from 19.09.2015 to 21.09.2015 (before inception of policy).  The claim was rejected by OP vide letter dated 31.08.2016 on the ground that the risk was not covered under the policy because the policy was valid from 02.10.2015 to 01.10.2016 and son of the complainant was admitted in the hospital from 19.09.2015 to 21.09.2015.  Acceptance of proposal and issuance of policy was subject to receipt of completed proposal form, premium payment, medical reports (wherever applicable) and underwriting decision of the company.  Other facts have also been denied.   

4.       Complainant have filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas.

5.       In support of its case, the complainant have examined himself.  He has deposed on affidavit.  He has narrated the facts which have been  stated in the complaint.  He has also got exhibited copy of proposal from and receipt issued by Mr. Abhay Pratap Singh (Ex.CW-1/2), letter dated 07.10.2015 (Ex.CW-1/3), letter dated 02.11.2015 (Ex.CW-1/4), bills of hospital (Ex.CW-1/5) and rejection letter dated 31.08.2016 (Ex.CW-1/6). 

          In defence, OP-2 have examined Shri Ankit Shekhar Bhardwaj, who have also deposed on affidavit.   He has also narrated the facts which have been stated in the WS.  He has got exhibited copy of original proposal form (Ex.RW-1/A), copy of policy certificate alongwith policy terms and conditions (Ex.RW-1/B), copy of amended and previously filled proposal page (Ex.RW-1/C), copy of claim form (Ex.RW-1/D), copy of discharge summary (Ex.RW-1/E) and copy of rejection letter (Ex.RW-1/F). 

6.       We have heard the complainant in person and Ld. Counsel for OP.  We have also perused written arguments filed on behalf of the complainant.  It has been argued by the complainant that the complainant have issued the cheque alongwith the proposal form on 08.08.2015 which has been got exhibited as Ex.CW-1/2 and the policy was issued late for the period from 02.10.2015 to 01.10.2016.

          If a look is made to the contents of the acknowledgement, it is noticed that it has been stated that “Please note that this is only an acknowledgement receipt and does not amount to acceptance or risk or commencement of policy”.  No doubt, the complainant have given the cheque alongwith the proposal form on 08.08.2015 and commencement of the policy has been from 02.10.2015 to 01.10.2016 and the claim of the complainant has been for the period from 19.09.2015 to 21.09.2015, this acknowledgement does not confer any right on the insured to claim any amount between the period of submission of the proposal form and the issuance of policy documents.  Thus, the claim of the complainant has not been covered under the policy which was for the period from 02.10.2015 to 01.10.2016.  Therefore, rejection of the claim by the insurance company was justified.    

          In view of the above, we are of the opinion that the complaint of the complainant deserves its dismissed and the same is dismissed.  There is no order as to cost.

Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

 

 

(DR. P.N. TIWARI)                                               (HARPREET KAUR CHARYA)

       Member                                                                             Member 

 

(SUKHDEV SINGH)

                   President