Per Sri A. Hazarath Rao,  President:-

          The complainant filed this complaint u/s 12 of the Consumer Protection Act directing to rechange the policy from individual health insurance                  policy, 2010 to individual mediclaim policy; payment of Rs.50,000/- towards variation coverage amount, Rs.10,000/- towards mental agony, Rs.10,000/- towards compensation and Rs.5,000/- towards expenses.

2.   In brief the averments of the complaint are these:

          The complainant obtained individual mediclaim policy from the opposite party for a sum of Rs.1,00,000/- in 2003 covering the risk of himself and his wife.   The complainant renewed the policy every year.   The complainant obtained the policy for the year 30-10-2011 to 29-10-12.  As per terms and conditions incorporated in the policy at clause (7), the complainant is entitled to cumulative bonus facility of 5% every year subject to maximum accumulation of ten years.   The policy holder is thus entitled to get the insured amount from Rs.1,00,000/- to Rs.1,25,000/-.   The complainant is entitled to 100% cash reimbursement in case of any hospitalization or any surgery under coverage.   The opposite party renewed the policy from 30-10-12 to 29-10-13, without complainant’s consent the opposite party changed the nature of policy from individual mediclaim policy to individual health insurance policy, 2010.   Due to change of policy by the opposite party the complainant lost the benefit of bonus and 100% cash facility.   The internal circulars issued by the opposite party to the disadvantage of any insured will not bind the insured and it amounted to deficiency of service.   The complaint therefore be allowed.

3.   The contention of the opposite party in nutshell is hereunder:

          The opposite party renewed the individual health insurance policy bearing No.150800/48/12/97/00000673 to the complainant with his consent and the period of policy is from 30-10-12 to 29-10-13.   As per the terms and conditions of existing health insurance policy the opposite party paid Rs.80,000/- towards complainant’s claim.   The circular dated 25-02-09 clearly revealed that the revised terms will automatically become applicable for all renewals from 08-07-10.   The opposite party rightly acted as per the circulars and guidelines of the head office.   Rest of the allegations contra mentioned in the complaint are all false and are invented by the complainant to suit his case.   The complaint therefore be dismissed.

4.   Exs.A-1 to A-8 and Exs.B-1 to B-5 on behalf of complainant and opposite party were marked respectively.

5.   Now the points that arose for consideration in this complaint are:

1. Whether the opposite party committed deficiency of service by issuing individual health insurance policy, 2010?
2. Whether the complainant is entitled to Rs.10,000/- towards mental agony?
3. Whether the complainant is entitled to Rs.10,000/- towards compensation?
4. To what relief?

6.  POINT No.1:-    Ex.A-1 is the individual mediclaim policy covering the period from 30-10-11 to 29-10-12.   Ex.A-2=Ex.B-1 is the individual health insurance policy from 30-10-12 to 29-10-13.   Clause (7) of Ex.A-1 deals with cumulative bonus and says that sum insured under the policy shall be progressively increased by 5% in respect of each claim free year of insurance, subject to maximum accumulation of 10 claim free years of insurance.  Clause (9) of Ex.A-1 deals with cost of health check up and says:

          “In addition to cumulative bonus, the insured shall be entitled for reimbursement of the cost medical check up once at the end of block of every four underwriting years provided there are no claims reported during the block.  The cost so reimbursable shall not exceed the amount equal to 1% of the amount of average sum insured during the block of four claim free underwriting years”.

7.   Ex.A-2=B1 did not deal with cumulative bonus.   The opposite party has not specifically denied about the complainant taking individual mediclaim policy from 2003 onwards.   It is not the contention of the opposite party that the complainant made any claim towards medical expenses earlier.   It can therefore be inferred that the complainant took individual mediclaim policy in 2003 and is renewed every year.   Absence of clause of cumulative bonus in Ex.A-2=B1 policy amounted to deficiency of service, as the internal circulars did not bind the complainant.   Under those circumstances, we are of the opinion that the opposite party committed deficiency of service by change of nature of policy and the complainant is entitled to cumulative bonus of Rs.40,000/- (Rs.5,000/- per year) till obtaining Ex.A-2=B1 policy (as the complainant made 8 renewals till Ex.A-2=B1 policy).    We therefore answer this point accordingly.

          Under Ex.A-4 the complainant submitted his claim for Rs.1,16,160/-.   The opposite parties paid Rs.80,000/- only.   As already observed the complainant is entitled to Rs.1,40,000/- inclusive of cumulative bonus.   The complainant did not file all the policies into this Forum.   In Ex.A-7 notice the complainant mentioned as detailed infra:     

                   “Due to change of policy our client loose his benefits for coverage in respect of claim reduces from 100% to 80% and         total assured amount      from Rs.1,30,000/- to Rs.1,00,000/-       (5% cumulative bonus increased on sum     assured)……………………….The surgery was conducted on 16-04-13.           The hospitalization total charges of           Rs.1,60,000/-. You         reimbursed of        Rs.80,000/- only   instead of Rs.1,30,000/-.             You paid Rs.70,000/-      directly        to KIMS hospital    and    Rs.10,000/- paid to our client’s         account”.    

       In the absence of earlier policies before this Forum, the cumulative bonus accrued will be Rs.30,000/- only.   As the opposite party paid Rs.80,000/- only, the complainant is entitled to reimburse the remaining amount of Rs.50,000/-.   We therefore, answer this point against the opposite party.

8.  POINTS 2 & 3:-     The complainant claimed Rs.10,000/- towards mental agony and Rs.10,000/- towards compensation.  Change of policy unilaterally by the opposite party and reduced payment caused mental agony in our considered opinion.   The complainant is therefore, entitled to Rs.5,000/- as damages.   We therefore, answer this point accordingly in favour of the complainant.

9.  POINT No.4:-   In view of above findings, in the result the complaint is partly allowed as indicated below:

1. The Opposite party is directed to pay Rs.50,000/- (Rupees fifty thousand only) (being the variation amount of the policy) to the complainant.
2. The Opposite party is directed to pay Rs.5,000/- (Rupees five thousand only) towards damages and Rs.2,000/- (Rupees two thousand only) towards costs to the complainant.
3. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of the copy of the order.

          Typed to my dictation by Junior Steno, corrected by me and pronounced in the open Forum dated this the 19^th day of March, 2014.

MEMBER                                  MEMBER                                PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite party:  

        PRESIDENT

NB:   The parties are required to collect the extra sets within a month after receipt of this order either personally or through their advocate as otherwise the extra sets shall be weeded out.