ORDER

SRI.H.R. SRINIVAS.  PRESIDENT

1. This is the Complaint filed by the Complainant against the Opposite Parties (herein referred to as OPs) under Section 12 of the Consumer Protection Act praying this Commission to direct the OPs to pay Rs.25,055/- being the expenses spent for medical treatment in the hospital,  during the period of the policy and for Rs.10,00,000/- towards damages for causing mental harassment, mental agony and deficiency of service, cost of the litigation and for such other reliefs as the Hon’ble District Commission deems fit and under circumstances.

2.     The brief facts of the complaint are that, the Complainant  purchased health insurance policy by paying Rs.15,182/- from O.P No.2 who is the branch office of Op.No.1. The policy was for a period of 09.07.2018 to 08.07.2019 for himself and his wife Premalatha Jain.

3.     It is contended that, since he fell ill, was admitted to St.Martha’s hospital for treatment and took treatment from 28.08.2018 to 29.08.2018 and after discharge, he had to pay Rs.25,055/- being the medical treatment and for the drugs prescribed by the hospital.  Afterwards he submitted the discharge summary, medical bills for Op for reimbursement. Inspite of it, Op did not honour the claim and on 15.02.2019 sent an email stating that they are refunding the policy premium amount of Rs.17,211/-.  Instead of paying the medical reimbursement claim as per the terms and conditions of the policy, all of a sudden without issuing notice, abruptly on 15.02.2019 cancelled the policy, sent the policy premium amount, which has caused him unbearable mental agony as he was in the hope of getting the medical reimbursement. In respect of the treatment availed and also for the future medical insurance.  When the policy was in full force, OP cannot cancel the policy and return the premium which is unfair trade practice and also deficiency of service. He had to issue legal notice to OPs demanding for reimbursement of the amount, also for damages of Rs.10,00,000/- for causing him mental agony and hardship. Hence the complaint.

4.     Upon the issuance of notice, OP.No.1 and 2 appeared before the Commission. Even though they took several times for filing version, they did not file the same. Their right to file the version forfeited. Since they did not file the version within the statutory period of 45 days.

5.     In order to prove the case, Complainant filed his affidavit evidence and produced documents. Whereas, OPs though given opportunity did not do so and did not file any documents. Arguments of the complainant heard. The following points arise for our consideration:-

1) Whether the complainant has proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainant is entitled to the relief prayed for in the complaint?

6.     Our answers to the above points are:-

POINT NO.1:            In the Affirmative

POINT NO.2:            Partly in the affirmative.

                                For the following.

REASONS

POINT No.1:-

7.     As per the contents of the complaint and the affidavit evidence and the documents produced by the complainant, OP No.2 has issued insurance policy to the complainant by loading 15% for high BMI for the complainant and 10% loading for High BMI in respect of the wife of the complainant i.e. Smt.Premalatha Jain.  The insurance policy produced as Ex.P2 clearly shows that the said insurance policy is issued for the period from 09.07.2018 to 08.07.2019 and the sum assured for each individual is for Rs.3,00,000/-. It is also mentioned that co-payment is zero. ICU charges 2% of the sum insured and room type 1% of sum assured. No exclusions have been mentioned therein.  OP.No.2 has received Rs.17,211/- i.e. Rs.13,543/- towards basic premium and Rs.1,719/- towards loading.  Premium certificate is also issued for complainant to avail the income tax rebate if any. Discharge summary is produced by the complainant shows that he was admitted to hospital on 29.08.2018  and discharged on the same day. It was diagnosed that he was having “PROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (recurrent) REVERTED WITH IV ADENOSINE NORMAL LV SYSTOLIC FUNCTION VITAMIN D DEFICIENCY (newly detected)”.  He has also produced the medical prescription and the bill from the hospital and in the final bill he has paid Rs.21,816/- to the hospital and the remaining towards purchase of the medicines. 

8.     Ex. P7 is the letter written by the complainant to OP.No.2 stating that inspite of he submitting the original bills and medical records, he has not received the reimbursement of medical claim and the reply to his claim.  Another document dated 07.12.2019 written by OP.No.2 to the complainant stating that they have raised the service issue and the same is under investigation and they will call within 48 hours to update.  Ex. P11 is the copy of the payment advise wherein on 15.02.2019 they have refunded Rs.17,211/- to the complainant in respect of policy refund account.  Email correspondence is also sent on 04.03.2019 addressed by the agent who has processed the insurance to the complainant wherein, he has intimated the insurance company that “While signing he asked me why that collection an additional premium I said nothing to worry company has took this because your weight is heavy but I don’t have checked what the weight was declared over and only blind faith in company and respective manager Mr.Branhmajit, submitted the application and premium paid. Thereafter also company removed one person from the policy after a month. Kindly let me know the error occurred. Recently just I was going through all applications so far I came across, the weight mentioned in application while login is 90 kg but actual is 111kg. The mistake has been done by manager Brahmajit.” Ex P9 is the copy of the legal notice issued to OPs which has been served and the same has not been replied. 

9.     Inspite of the complainant paying additional premium amount of Rs.1,719/-  in respect of loading as they are having high BMI, no reason assigned by the OP as to why they have not paid the amount claimed for reimbursement of the hospital charges and why they have refund the premium amount of Rs.17,211/-. There is no mention or communication for what reason they have refunded the policy amount by cancelling the insurance.  No notice copy informing the complainant that they are going to terminate the policy has been issued and produced before this Commission which is required under the Insurance Act. The act of OPs rescinding the insurance policy and also not paying the claim amount when that too the policy in force amounts to deficiency in service and also unfair trade practice which is to be deprecated. Hence we answer POINT NO.1 IN THE AFFIRMATIVE and complainant is entitle for refunded of Rs.25,055/- along with interest at 12% per annum on the said amount from the date of discharge from the hospital and a sum of Rs.25,000/- for causing mental agony, loss of peace, causing mental stress as damages and Rs.5,000/- towards litigation expenses. Hence, we answer POINT NO 2 PARTLY IN THE AFFIRMATIVE.

10.   The act of OP in cancelling the policy abruptly without issuing the statutory notice to the complainant/policy holder amounts to unfair trade which is to be deprecated. OPs are directed not to repeat the same from here onwards without providing an opportunity for the policy holder to explain in case of any clarification required for the due cancellation of the policy and pass the following:-

ORDER

1.  Complaint is allowed in part with cost.
2.  OP No.1 and 2 are jointly and severally hereby directed to pay sum of Rs.25,055/- along with interest at 12% per annum from 29.08.2018 i.e. date of discharge of the complainant from the hospital, till the payment of entire amount to the Complainant.
3. Further OP No.1 and 2 are hereby directed to pay Rs.25,000/- towards damages and Rs.5,000/- towards cost of litigation.
4.  The OPs are further directed to comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this Commission within 15 days thereafter.
5.  Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be destroyed as per the C.P. Act and Rules thereon.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this day the 04^th day of February 2021)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Copy of the letter written by OP asking to pay additional premium of Rs.2029/-

Ex P2: Copy of welcome letter along with insurance certificate

Ex. P3: Copy of premium certificate.

Ex P4: Copy of Insurance card

Ex P5: Copy of the Discharge summary issued by St.Marthas Hospital

Ex P6: Copies of Medical bills and receipts.

Ex P7: Copy of the letter written by Op and related correspondences.

Ex P8: Copy of the claim form.

Ex P9: Copy of the legal notice.

Ex P10: Postal acknowledgement.

Ex P11: Copy of Policy refund advise.

 2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: - Nil-

Copies of Documents produced on behalf of Opposite Party/s

- Nil -

MEMBER                        PRESIDENT

RAK*