BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION AT BANGALORE (URBAN)

DATED 25^th DAY OF OCTOBER 2021

Complainant/s: -                           

1. Dr.Vamadevaiah Hiremath,                    S/o panchakasharaiah.H.M., aged abouot 65 years, Profession – Retired Principal Scientist, R/at No.1A, 59, 2^nd Cross, 20^th Mainth, BTM Layout II Stage, Bengaluru-560076.
2. Smt.Rajeshwari Hiremath, W/o Dr.Vamadevaiah Hiremath, aged about 61 years, Profession: Housemaker, R/at No. 1A, 59, 2^nd Cross, 20^th Mainth, BTM Layout II Stage, Bengaluru-560076.

By Sharan B Tadahal, Adv.

V/s

Opposite party/s:-    

The Religare Health Insurance Company Limited, Site No.8, 80 Feet Road, S.T.Bed Area, 1^st Floor, Koramangala, Bengaluru-560034 (Represented by its Authorized Signatory).

By Sri Jai Patil, Adv.

ORDER

SRI. S.L PATIL, PRESIDENT

The Complainants have filed this complaint U/s.12 of Consumer Protection Act 1986, seeking direction against the Opposite Party (herein after called as OP) to renew the insurance policy as directed by the insurance Ombudsman as the same falls well within the stipulated period of time, to pay Rs.2,00,000/- as damages, to pay Rs.25,000/- towards legal expenses and to grant such other reliefs.     

2. The brief facts of the complaint are as under:

The complainants submit that they have been insured for health insurance under OP’s company from 29.01.2015 under policy No.10200526 which was renewed from time to time and which was valid till the end of January 2019. Further complainants submit that complainant No.2 was admitted to Apollo Hospital, Bannerghatta Road, Bengaluru on 26.11.2018 due to severe pain in her right abdominal region and was subsequently advised by the doctors to undergo necessary procedure for Cholecystectomy for which the total medical expenditure inclusive of post hospitalization charges was Rs.4,65,254/-.

Further complainants submit that complainant No.2 was discharged on 01.12.2018 after her surgery was successful and when the claim to reimburse the said medical expenditure was made by complainants, the same was rejected by OP though the claim limit was set of Rs.6,00,000/- which was inclusive of non-claim bonus. Further complainants submit that OP company gave an approval only for Rs.1,60,000/-.  The main reason given by OP company in rejecting the claim was that complainant No.2 had undergone a MVD surgery for Trigeminal Neuralgia, that too way back in 2010, whereas in the form provided by OP company to fill out to obtain health insurance which clearly sought the information if any of the insurers had undergone any procedure within 48 months before obtaining the insurance, to which complainants had obviously mentioned as “NO” as the procedure was completed way back in the year 2010 and they had opted to get insurance only in the year 2015.

Further complainants submit that after being frustrated and agitated by OP’s unreasonable rejection were left with no option but to approach the Insurance Ombudsman.  The said authority after having understood the grievance of complainants was pleased to rule in their favour and awarded Rs.4,65,000/- along with interest at 8.25% p.a. from the date of filing the complaint before them till the actual date of payment.  Further the authority even ordered to OP company to renew the policy of complainants, after receiving the necessary premium amount.  After such an order came to be passed, OP company has miserably failed to comply with the same in full/completely. The complainants submit that OP in a very malice manner has only refunded the above mentioned amount without paying interest and also for best reasons known to them, has not renewed the policy of complainants.  Further complainants again approached the Insurance Ombudsman to implement the remaining portion of the order only to be informed that the said authority does not get into implementation of their own order.

Further complainants submit that despite numerous requests, OP has not come forward to rectify the same but Op has deliberately chosen not to respond to the request and queries of them.  Further they submit that OP has failed to provide the services that they were supposed to do.  The willful act of OP not forthcoming to rectify the same has resulted in Deficiency in service and Unfair trade practice. Hence, complainants issued legal notice to OP on 05.02.2020 to rectify their mistake by paying interest on  the amount awarded by Insurance Ombudsman at the rate of 8.25% pa and also to pay damages etc., for which Op has not tendered a reply till date. 

The cause of action in respect of the complaint arose on 28.05.2019 when the Insurance Ombudsman passed the award in favour of complainants and lastly on 05.02.2020 when the legal notice was dispatched to the Op.     

3. OP did appear through its counsel but not filed any version.  

4. To substantiate the case, Complainants have filed their affidavit evidence and produced the documents which are marked as Ex.A.1 to Ex.A.10 and also filed written arguments.  Heard the counsel for complainant.

6. The points that arise for our consideration are:

1. Whether the Complainants prove the deficiency of service on the part of OP, if so, entitled for the relief sought for?
2. What order?

        7. Our answers to the above points are as under:

Point No.1:- Partly in the affirmative

Point No.2:- As per final order

REASONS

8. Point No.1: We have briefly stated on the contentions of the complaint. Though the OP did appear through its counsel, did not chosen to file the version. Hence, version taken as not filed.  Then allow the complainants to file affidavit evidence.

9. To substantiate their case, complainant No.1 filed his affidavit evidencewith documents which are marked Ex.A.1 to Ex.A.10. The non-filing of the version amounts to an admission of the claim of the complainants in the light of the decision reported in 2018 (1) CPR 314 (NC) in the case of M/s.Singla Builders & Promoters Ltd., vs. Aman Kumar Garg wherein it is held that

“Non-filing of written version to complaint before the forum, amounts to admission of the allegations levelled against them in consumer complaint”.

Any how, we place reliance on the available materials on record.

10. The reliefs i.e. sought for by the complainants as against the Op reads thus:-

a) Direct the OP to renew the insurance policy of the complainant/s as directed by the insurance Ombudsman as the same falls well within the stipulated period of time.

b) To pay Rs.2,00,000/- (Rupees two lakhs only) as damages for the mental agony, stress, humiliation that the complainant/s had to go through by loitering ground to fix the mistake of the OP themselves only due to the negligence of the OP and their deficiency of service.

c) To pay Rs.25,000/- (Rupees twenty five thousand only) towards the legal expenses.

d) To grant such other reliefs as may be deemed fit in the facts and circumstances of the case, in interest of justice and equity.

   Hence, he contentions of

11. Before approaching this Commission, the complainants approached the insurance Ombudsman for the alleged deficiency of the service who in his award dated 28.05.2019 No.10(BNG)/A/GI/0073/ 2019-20 pass the award reads thus:-

AWARD

“Taking into account of the facts and circumstances of the case and upon scrutiny of the documents submitted by both parties, the Respondent insurer is advised to settle the claim as per the terms and conditions of the policy along with interest @ 8.25% (Bank rate of 6.25% + 2%) from the date of filing of the last relevant document by the insured till the date of payment of the claim as per Regulation 16.1(ii) of IRDA (Projection of Policy Holders interests) Regulations, 2017. 

The respondent insurer is advised to revive the cancelled policy and provide the continuous insurance.

The complaint is allowed.

Compliance of award:

The attention of the complainant and the respondent insurer is hereby invited to Rule 17 (6) of the insurance Ombudsman Rules, 2017, where under the respondent insurer shall comply with the Award within 30 days of the receipt of the Award and shall intimate compliance of the same to the Ombudsman.

12. If the above award is strictly construed, the insurance Ombudsman specifically directed the OP to renew the insurance policy of the complainants. For the compliance of the award passed by the insurance Ombudsman as per Ex.A.3, complainants wrote a letter as per Ex.A.4, 5 and also send the E-mail correspondence as per Ex.A.6.  But, Op did not comply the said award passed by the insurance Ombudsman.  The award passed by the insurance Ombudsman is not yet challenged by the OP.  hence, the award passed by the insurance Ombudsman reached its finality.  Under such circumstances, OP has no other go except to honour the award passed by the insurance Ombudsman as per Ex.A.3. In this context, we come to conclusion that the non compliance of the award passed by the insurance Ombudsman shows lethargic attitude of the OP.  In this context, Op is not only found deficiency in service but also played the unfair trade practice.  Hence, we direct the Op to honour the award passed by the insurance Ombudsman.  With regard to pay Rs.2,00,000/- as damages for the mental agony, stress, humiliation that the complainant/s had to go through by loitering around to fix the mistake of the OP themselves: only due to the negligence of the OP and their deficiency of service.  In this context, we found there are reasonable grounds that the OP did not respond to complainants grievance and made the complainants to put into great hardship. In this context, we are of the opinion that award the amount of Rs.1,00,000/- being the compensation.  Further we fix the litigation cost of Rs.10,000/-.  Accordingly, we answer the point No.1 in partly in the affirmative.   

  13. Point No.2: In our view findings on the point No.1, the complainant is entitled for the reliefs sought for.  Accordingly, we passed the following:                        

  O R D E R

1. The complaint filed by the Complainants is allowed in part.

2. The OP is directed to renew the insurance policy of the complainants as directed by the insurance Ombudsman as per award dated 28.05.2019 No.10(BNG)/A/GI/0073/2019-20.

3. The Op is directed to pay Rs.1,00,000/- (Rupess one lakh only) as damages for the mental agony, stress, humiliation and also to pay litigation cost of Rs.10,000/- (Rupees ten thousand only) to the complainants.

4. OP shall comply this order within six weeks from the date of receipt of the order, failing which the complainants are at liberty to take steps as per Law.

5. Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Commission on this 25^th day of October, 2021).

Copies of Documents produced by the Complainants which are marked as Ex.A.1 to Ex.A.10: