Delay of 3 days in filing the Revision Petition is condoned.

               Challenge in this Revision Petition under Section 21(b) of the Consumer Protection Act, 1986 (for short “the Act”) is to the order dated 21.04.2016 passed by the State Consumer Disputes Redressal Commission, Punjab (for short “the State Commission”) in FA No.525 of 2015.  By the impugned order, the State Commission dismissed the Appeal preferred by Apollo Munich Health Insurance Company Limited, (hereinafter referred to as “the Insurance Company”) and concurred with the finding recorded by the District Consumer Disputes Redressal Forum, Jalandhar (for short “the District Forum”) which had partly allowed the Complaint directing the Opposite Parties to pay ₹1,30,000/- along with interest @ 9% p.a. from the date of repudiation or cancellation of the policy till the date of realization and costs of ₹3,000/-.

               The brief facts as set out in the Complaint are that the Complainant had been taking individual hospitalization and domiciliary benefit policy from New India Assurance Company Limited, Jalandhar since 2001.  The Complainant stated that he was induced by the tempting lucrative benefits of Easy Health Individual Standard Apollo Munich Health Insurance Policy (hereinafter referred to as “Health Insurance Policy”) and switched over under the portability provision from New India Assurance Company Limited to Apollo Municipal Health Insurance Company Limited.  It was stated that the Complainant had agreed to switch over under the portability provision on the assurance that he would not lose any renewal benefits.  Opposite Parties covered the risk to indemnify the inpatient treatment expenses for a period of more than 24 hours, pre-hospitalization, hospitalization for any ailment and surgical treatment, domiciliary treatment at any Nursing Home/Hospital including cashless facility of the Complainant and his wife Sunita Khanna as under:

               The Policy No.180200/11201/1000320947 was for a period of insurance coverage from 14.09.2012 to 13.09.2013.

               While so, on 30.04.2013, the Complainant was admitted as in-patient and discharged on 06.06.2013 as he was diagnosed as suffering from Cryptococcal Meningitis.  The Complainant was denied cashless facility by the Opposite Parties against specific provisions in the Health Insurance Policy.  Subsequent to discharge from the said Hospital, the Complainant submitted his claim along with the bills and payment receipts for an amount of ₹2,51,251/- incurred by him.  On 12.06.2013, the Complainant received a letter from the second Opposite Party that the policy No.1000320947 was cancelled ab initio in view of the non-disclosure of sacroidosis of Shashi Kumar Khanna.  It was averred by the Complainant that the cancellation was arbitrary and is not binding on the Complainant as the Opposite Parties had granted Health Insurance Policy by switching over under the portability provision of IRDA and all the benefits flowing from the previous insurance policy are applicable and payable to the Complainant.  Hence the Complaint seeking direction to the Opposite Parties to reimburse ₹2,30,000/-, i.e., sum assured of ₹2,00,000/- and bonus of ₹30,000/- with interest, compensation and costs.

               The Opposite Parties filed their Written Version stating that the Complainant had fraudulently suppressed the past history of sacroidosis and also the factum of having taken medication for the same.  It was, further, averred that the policy kit containing all the relevant documents were duly signed and delivered to the Complainant at various time thereby giving an opportunity to him to verify and examine the benefits, terms and conditions of the policy taken by the Complainant.  The medical examiner report is based on the standard medical tests conducted as per the declaration made in the proposal form.  This is an optional process done solely by the Insurance Company at its best option based on the information provided to the Insurance Company by the proposer in the proposal form.  Had the Complainant disclosed about the history of sarcoidosis, some tests relating to the same might have been advised to evaluate the coverage before the issuance of the policy.  A claim for cashless request was received on 02.05.2013 which was rejected on the basis of the discharge summary dated 30.04.2013 in which it was observed that the Complainant was a known case of pulmonary sarcoidosis and on steroids off and on.  There was a request from the Complainant to review the letter dated 06.05.2014 rejecting the cashless request and he submitted the report dated 10.10.2012 of Centre for Chest Disease, Allergy and Sleep Disorders which mentioned that the Complainant was diagnosed for sarcoidosis State II/I with depressive illness (Mild) with EDS decreased than before.  At the end of the prescription, it was stated that the condition was improved.  On 05.05.2013, Dayanand Medical College and Hospital, Ludhiana certified that the duration of sarcoidosis is of two years and that the said record was not available.  It was averred that since the duration of the treatment was of two years, the policy would not have been issued had it been disclosed at the inception itself and hence, there is no deficiency in service on their part.

               Based on the evidence adduced, the District Forum allowed the Complaint directing the Opposite Parties to pay ₹1,30,000/- with interest @ 9% p.a. from the date of repudiation till the date of realization and costs of ₹3,000/-.  The District Forum, while allowing the Complaint, observed as follows:

    “However the complainant is entitled to the credit gained by him under the old policies before shifting to the Opposite Party insurance company by way of portability for pre-existing conditions and time exclusion in the policy Ex.C21 issued by New India insurance Company Limited in coloum of details of pre-existing disease NA i.e. not applicable is mentioned.  So under the new policy with Opposite Party insurance company, the complainant is entitled to this credit.  However, he is not entitled to the enhanced insurance sum but he is entitled to the sum insured i.e. ₹1 Lac and cumulative bonus of ₹30,000/- to which he was entitled under the old policy with New India Insurance Company Limited before shifting to Opposite Party insurance company by way of portability.

               Aggrieved by the said order, the Insurance Company preferred an Appeal before the State Commission which, while concurring with the finding of the District Forum, observed as follows:

“It was 2 years before switching over the policy with OPs.  Therefore, once the portability scheme was accepted by OPs then they had no right to decline the claim upto the amount of sum assured of previous insurance policy in case it was within the terms and conditions of the policy.  As stated above, the policy with New India Assurance Company was continuing since 2001 and counsel for OPs was unable to pin point how the claim to the extent of ₹1,30,000/- allowed by the District Forum was not payable under the policy.  Clause 1..  referred above speaks that under portability right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from one insurer to another insurer or from one plan to another plan.  Under that scheme whatever has been gained by the insured under the policy insured by the previous insured will be gained by the insured under the portability scheme.  Therefore, we do not agree with the plea raised by counsel for OPs that terms and conditions of another insurance company will not apply.  Even otherwise, the policy was continue one since 2001.  Counsel for OPs was not able to refer any clause under which the claim of the complainant to the extent of ₹ 1 Lac + cumulative bonus can be rejected.  It was justified for the OPs to resist the enhanced insured claim.  Enhanced amount was rightfully declined by the District Forum.  We are of the affirmed view that the complainant was entitled to the sum assured of               ₹ 1 Lac + cumulative bonus of ₹30,000/- which he carried from the previous insurer of OPs under portability scheme accepted by the OPs.  In these circumstances, the District Forum was justified to allow the claim to the complainant to the extent of ₹1,30,000/-.  We are of the opinion that the order so passed by the District Forum is justified.  We do not see any reason to set aside this order.

               Respondent, who lodged a caveat, sent his written submissions by FAX.

               Heard learned Counsel for the Petitioner at length.

               Learned Counsel for the Petitioner submitted that, while interpreting the IRDA Circular (IRDA/HLT/MISC/CIR/209/09/2011) “the State Commission has completely overlooked the right of the Petitioner, as an Insurance Company to underwrite the proposal in line with its underwriting policy and convey its decision in accordance with para 4 (6) of IRDA (Protection of Policy Holders Interest) Regulations, 2002 which decision could be either to accept or to terminate the insurance policy.  Para 4 is reproduced below:

    “4.   Proposal for insurance

     (6)  Proposals shall be processed by the insurer with speed and efficiency and all decisions thereof shall be communicated by it in writing within a reasonable period not exceeding 15 days from receipt of proposals by the insurer.”

     The relevant excerpts from the aforesaid circular ÏRDA (IRDA/HLT/MISC/CIR/209/09/2011)”basis which the impugned order has been passed are reproduced herein below:

1.1   Portability means the right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from one insurer to another insurer or from one plan to another of the same insurer, provided the previous policy has been maintained without break…

               It was vehemently argued that the State Commission has completely missed the essence of Portability Guidelines viz-a-viz pre medical conditions while fixing the liability upon the Petitioner.

               It is an admitted fact that the Complainant was taking medical claim policy from New India Assurance Company from 2001 onwards and after that under portability scheme issued by IRDA, the Complainant accepted the switching over policy of Opposite Parties.  It has also not been in dispute that the sum assured was ₹1,00,000/- and when it was switched over to Opposite Parties, the amount was enhanced to ₹2,00,000/- + the cumulative bonus of ₹30,000/-.  The main point for consideration is that when the Complainant filled up the proposal form he had not disclosed as pre-existing disease i.e. sacroidosis the last                   two years before switching over the policy with the Petitioner Company.

               It is pertinent to note that instead of repudiating the enhanced claim, the Petitioner Company had cancelled the policy issued in favour of the Complainant, whereas according to IRDA Regulations 2002, they have the right to investigate the matter for a period of 15 days and in case they completed their investigation and issued a policy then later such a policy cannot be cancelled.  Once the Portability scheme was accepted by the Petitioner Company, they cannot decline the claim at least up to the amount of sum assured of the previous insurance policy which was continuing from the year 2001, as the portability right accorded is only for transfer of the credit gained by the insured when the policy holder switched over from one insurer to another insurer. 

               For all the afore-mentioned reasons, and also taking into consideration that it is a concurrent finding of fact by both the Fora below which have only awarded the sum assured of ₹1,00,000/- and the cumulative bonus of ₹30,000/- which the Complainant was covered under the old policy, with reasonable interest @ 9% p.a., it is not a fit case to exercise limited Revisional Jurisdiction as envisaged by the Hon’ble Apex Court in “Mrs. Rubi (Chandra) Dutta vs. M/s United India Insurance Co. Ltd., 2011 (3) SCALE”.

               It is also observed from the record that an amount of ₹1,00,000/- was deposited before the State Commission which was directed to be withdrawn by the Complainant together with statutory amount of ₹25,000/- and also having regard to the fact that the principal amount awarded is ₹1,30,000/- out of which ₹1,25,000/- has already been withdrawn, this Revision Petition fails and is dismissed accordingly.  No order as to costs.