Tamil Nadu

South Chennai

CC/57/2016

M/s.S.Balaji - Complainant(s)

Versus

TheManager, ReligareHealth Insuranc Company Ltd - Opp.Party(s)

M/s.K.Baskar

26 Aug 2022

ORDER

Date of Complaint Filed : 28.01.2016

Date of Reservation      : 29.07.2022

Date of Order               : 26.08.2022

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

PRESENT:    TMT. B. JIJAA, M.L.,                                            : PRESIDENT

                        THIRU. T.R. SIVAKUMHAR, B.A., B.L.,           :  MEMBER  I 

                        THIRU. S. NANDAGOPALAN., B.Sc., MBA.,   : MEMBER II

CONSUMER COMPLAINT No. 57/2016

FRIDAY, THE 26^th DAY OF AUGUST 2022

Mr. S. Balaji,

S/o. R. Srinivasan,

Flat No.1, BFI Srinivasa Apartments,

Thirumalai Main Road,

Pammal,

Chennai - 600 075.                                                       ... Complainant                 

..Vs..

1.The Manager (Claims),

   Religare Health Insurance Company Ltd,

   D-3, P3B District Center,

   Saket,

   New Delhi - 110 017.

2.Mr.N.Balaji, Branch Manager,

   Indus Ind Bank,

   Velacherry,

   Chennai - 600 042.                                                   ...  Opposite Parties

******

Counsel for the Complainant          : M/s. S. Baskar

Counsel for the 1^st Opposite Party   : M/s. M.B. Gopalan

Counsel for the 2^nd Opposite Party   : M/s. Ramalingam & Associates

        On perusal of records and after having heard the oral arguments of the Counsel for the Opposite Parties and having treated the written arguments of the Complainant as oral arguments, we delivered the following:

ORDER

Pronounced by the Member-I, Thiru. T.R.Sivakumhar, B.A., B.L.,

1.      The Complainant has filed this complaint as against the Opposite Party under section 12 of the Consumer Protection Act, 1986 and prays to directing both the Opposite Parties to pay a sum of Rs.1,00,000/- towards hardship and mental agony suffered by the Complainant and directing the 1^st Opposite Party to pay a sum of Rs.1,07,131/- towards hospital expenses being the insurance claim and directing the Opposite Parties to pay a sum of Rs.10,000/- towards costs.

2.     The averments of Complaint in brief are as follows:-

The Complainant is a handicapped person and his wife Mrs.Kanchana Devi holding a Savings Bank Account No.100030779247 in the Indus Ind Bank, Velacherry Branch, Chennai - 600 042 had been to the said bank for a transaction when she happened to meet the Branch Manager Mr. N. Balaji, the 2^nd Opposite Party herein who suggested a  health insurance scheme and explained about the advantages of the insurance packages offered by the 1^st Opposite Party. The 2^nd Opposite Party being the agent of the 1^st Opposite Party convinced the Complainant to take out a family insurance scheme. Based upon the convincing words of the 2^nd Opposite Party the (Group Care Scheme 2 Opposite Party she opted for 11B) Insurance Scheme for himself and his family members namely master B. Purushothaman (son) and Mrs. B. Kanchana Devi (wife) as nominees. He paid the policy amount of Rs.21,985/- for the period from 24.03.2015 to  23.03.2016 by way of cheque No. 290029459774 drawn on the Syndicate Bank, Pammal branch, Chennai for Rs.21,985/- to and in favour of the 1^st Opposite Party, which was duly encashed by the 1^st Opposite Party where upon the Insurance policy was duly effected upon. His wife Mrs. Kanchana Devi suffering from acute stomach pain was admitted in the B.P. Jain Hospital at Pammal at about 5.30 p.m. on 11.08.2015.  The Doctors on analysis confirmed that Mrs. Kanchana Devi was suffering from umbilical hernia and that she had to be operated upon at the very earliest. The B.P. Jain Hospital sent the medical report pertaining to Mrs. Kanchana Devi to the first Opposite Party at about 10.00 a.m. on 12.09.2015 on receipt of which the 1^st Opposite Party asked the B.P. Jain Hospital for the latest scan port since the one sent earlier was a month old. B.P. Jain Hospital sent the latest scan report at about 6.00 p.m. on 12.09.2015,  to the 1^st Opposite Party. After a gap of 40 hours by 6.00 p.m. on 14.09.2015 the 1^st Opposite Party sent the pre-authorization request by SMS to the patients registered Mobile No. 9884990560. He got shocked and surprised on hearing the news from the B.P. Jain Hospital authority that the 1^st Opposite Party had sent them the non registration claim vide intimation No.80050885 dated 14.09.2015 rejecting the insurance claim for the present ailment umbilical hernia for the reason two year waiting period for treatment of all types of hernia. The 1^st Opposite Party’s to reject/non-registration of insurance claim on flimsy grounds inspite of valuable sum of Rs.21,985/- towards Policy Premium amount. The 2^nd Opposite Party being the authorized agent of the 1^st Opposite Party miserably and deliberately failed to point out the so called insurance clauses for rejection of the insurance claim namely the two year waiting period for treatment of all types of hernia. If 2^nd Opposite Party had explained about the rejection of insurance claim would not have taken the family health cum insurance policy and moreover the certificate of insurance booklet printing is too small which can be read with the help of magnified glass/lens which would go a long way in showing the first Opposite Party's reluctancy in order to deprive the Complainant/insured from their lawful claim amount and as such the 1^st Opposite Party cannot simply absolve his responsibility in paying the Complainant/ insurance claim amount of Rs.1,07,131/-. Since the first Opposite Party had rejected the insurance claim amount he has to pay the necessary operation/surgery charges for the umbilical hernia of his wife, to the hospital. It was not the time to bicker about the claim amount, due from the first Opposite Party but, rather he had to expedite the process for saving the life of his wife. Immediately mobilized the required funds for the above surgery from friends and known persons with which he paid the hospital fees to the tune of Rs.1,07,131/- in order to save the life of his beloved wife Mrs. Kanchana Devi. He was constrained to  send a legal notice through his counsel dated 16.11.2015 to both the opposite parties calling upon them to pay the sum of Rs.1,07,131/ towards hospital expenses being the claim amount together with the sum of Rs. 1,00,000/- for hardship and mental agony caused to the Complainant due to the inept of both the opposite parties in non-payment of claim amount. The 1^st Opposite Party having received the legal notice sent a reply dated 10.12.2015 stating that the insurance claim was rejected for waiting period of 2 years and has also stated any claim for or arising out of any of the following illness or surgical procedures shall not be admissible during the first 24 consecutive months from the first policy cover starting date with the 1^st  Opposite Party namely all types of hernia, hydrosol. It is absurd on the part of the 1^st Opposite Party rejecting the claim amount for the reason of two year waiting period. But whereas it is to be noted that the policy period is for one year only i.e. from 24.03.2015 to 23.03.2016 which clearly establishes the facts that the 1^st Opposite Party is legally bound and ought to pay the insurance claim amount.  Hence the complaint.

3. Written Version filed by the 1^st Opposite Party in brief is as follows:-

The allegations in the complaint that the Complainant obtained health insurance without being fully aware of terms of the Policy or that the terms of the Policy, particularly conditions and exclusions were not provided to her or made known etc. which are all false and self-serving for the purpose of the case. Admittedly the insurance was availed after the Complainant was explained about the Policy by the 2^nd Opposite Party. Admittedly provided with a booklet containing the features,  terms and conditions, which he has suppressed from this Hon'ble Forum except to produce the Certificate of Insurance.  The fact remains that the Complainant had applied for coverage under Group Care health insurance issued to Indusind Bank customers and submitted an Application on 23.03.2015. In the Application itself, attention of the Complainant to the terms and conditions of the Policy has been drawn and the Complainant has acknowledged as under;

"I have read and understood the scheme details/brochure/ prospectus/sales literature/Terms and Conditions of the Group Policy and confirm to abide by the same"

Based on the Application submitted by the Complainant, the Opp. Party provided coverage to the Complainant covering himself, his wife and son, under the Group Health Care insurance commencing from 23.03.2015 under Certificate of Insurance No.10240197 under Group Policy No 10087119 together with the Key Terms and Conditions as clearly stated in the Certificate itself. In fact the Complainant himself has acknowledged receipt of the terms and conditions. Although he has alleged in an untenable manner that they are in small print. If the Complainant had any difficulty in reading or understanding the terms of the insurance, he ought to have informed so and sought any clarifications on receipt of the Policy the Policy in fact permits a Free Look Period of 15 days, within which the Complainant was entitled to return the Certificate and seek cancellation without any loss of premium, if he did not agree to the terms and conditions stipulated. The fact that the Complainant simply accepted the insurance as well as the terms would clearly reveal an intention to enjoy the benefit of cover, as per such terms provided by the Opposite Party, which are binding on the Complainant.

Coverage under the Group Care insurance is subject to terms, conditions and exclusions of the Policy. In particular Exclusion 3.1 (b) (VIII) excluded any claim in respect of "All types of Hernia, Hydrocele" during the first 24 months from the Cover Start date viz., 24.03.2015. Clause 3.1(b)(vii) states that:

3.1. Waiting Period:

a…..

b.Specific waiting period.

i) Any Claim for or arising out of any of the following illness or Surgical Procedures shall not be admissible during the first 24 [twenty four] consecutive months from the cover start date:

vii. All types of Hernia, hydrocele.

           The Policy specifically excludes treatment for all types of Hernia. In this context, the Opposite Party submits that a Health Insurance Policy is by its nature expected to be renewed periodically and maintained without break once obtained, either with the Opposite Party or any other Insurer. Hence under Exclusions different Waiting Period even beyond the initial twelve month period of insurance are stipulated for certain ailments which is valid and binding on the Complainant. The report dated 12 September 2015 of BP Jain hospital, that the Complainant was suffering from "Para umblical hernia". The Complainant intimated hospitalization for treatment of Umbilical Hernia during September 2015. In as much as the treatment was within 7 months of insurance, it fell within the Exclusion 3.1(b) referred to above and claim for such treatment was not admissible. The Complainant who has obtained insurance subject to such Exclusion, bound by the terms of the Policy and is not entitled to put forth a claim for treatment of specified aiments during the respective Waiting Period. The terms of the Policy have to be strictly construed and the Complainant cannot claim benefits excluded from coverage under the Policy. In view of the fact that the treatment was plainly excluded by the Policy, the Opposite Party has no liability for the claim and hence authorization was declined and the claim was not subsequently settled The Opposite Party has not committed any deficiency in service in declining settlement of the claim. The decision in accordance with the terms of the contract governing the insurance. The claim itself is contrary to the Policy and the complaint is unsustainable under the Consumer Protection Act. Hence the complaint is to be dismissed.

4.   Written Version filed by the 2^nd Opposite Party in brief is as follows:-

The Complainant is not a 'Consumer' as defined under section 2 (d) of the Consumer Protection Act. There is no deficiency of service, unfair trade practice on the part of the 2^nd Opposite Party as alleged by the Complainant. That the complaint of the Complainant is not maintainable against the 2^nd Opposite Party, since 2^nd Opposite Party was not been put to prior notice about the issues raised in the complaint nor the 2^nd Opposite Party is aware about the claim lodged by the Complainant and subsequent repudiation of claim by the 1^st Opposite Party on the grounds of 2 years waiting period. The terms and conditions of Health Insurance policy were clearly explained to the Complainant who is related to the account holder Mrs.Kanchana Devi having Savings Account with 2^nd Opposite Party's Velachery Branch. Further the 2^nd  Opposite Party have also informed the Complainant that upon receipt of the policy he can go through the policy terms and if there is any terms which they are not agreeable then he is at liberty to return the policy by giving written notice with reasons thereof and the entire money paid by him would be refunded and this clause has been compulsorily included by IRDA to protect the interest of the persons availing insurance and also to avert the allegations of mis-selling on later date. The policy holder had received the policy but he had not raised any objections during the free look in period and hence it is deemed acceptance for the terms and conditions of Insurance Contract. The 2^nd Opposite Party bank know the facts only till payment of premium and issuance of insurance policy and all other averments alleged thereafter in the complaint with regard to Mrs. Kanchana Devi taking ill and getting admitted to hospital and been operated for Umblical Hernia and he had lodged a claim for hospitalization with 1^st Opposite Party and after gap of 40 hours he received SMS rejecting the claim of Complainant stating that 2 year waiting period are not aware to this Opposite Party. The Complainant after fully being understood the terms and conditions of policy had availed the policy and just because the claim was repudiated by the insurer based on the terms of insurance contract the Complainant has come up with such frivolous allegations, which is condemnable. Further the allegations that the terms and conditions of the policy cannot be read and it has to be read through magnified glass are not correct and denied by this Opposite Party. If at all if there is any grievance to the Complainant ought to have informed this Opposite Party or the insurer and feigning ignorance at later stage upon rejection of claim of the Complainant doesn't hold substance. The 2^nd Opposite Party is a Policy Holder of the 1^st  Opposite Party and the Master Policy is availed by the 2^nd Opposite Party for the benefits the members of their customers and hence it there is any repudiation of claim no liability can be fixed on this Opposite Party and it is also clearly stated in the policy terms. The duty of this Opposite Party is to receive the premium on behalf of members and to remit the same to 1^st  Opposite Party Insurance company and once the policy is issued the responsibility of 2^nd Opposite Party ends and this Opposite Party can be held responsible for any deficiency of service till payment of premium amount and issuance of policy but not thereafter. The discretion/consent of Complainant is used and exercised by him and after making himself fully understood about the future prospectus and coverage risk of the policy he chose to opt by making the requisite payment as per the plan. The Complainant after getting all the information made the payment in favour of the Opposite Party No.1 Insurance company. Once the policy is issued the role of the 2^nd Opposite Party ceases and as such herein the Complainant had unlawfully arrayed as a party for which the 2^nd  Opposite Party is not liable to any extent and the relationship of the Complainant with the Opposite Party No.1 is direct and if the Complainant has any grievance or dispute that can only lie with the Opposite Party No.1 and not with the 2^nd Opposite Party against them.  Hence the complaint is to be dismissed against them.

5.      The Complainant submitted his Proof Affidavit and Written Arguments. On the side of the Complainant, documents Ex.A-1 to Ex.A-7  were marked.   

The Opposite Parties 1 and 2 submitted their Proof Affidavit and Written Arguments. On the side of the 1^st Opposite Party, documents Ex.B-1 to Ex.B-5 were marked.

Points for Consideration

1. Whether there is deficiency in service on the part of the Opposite Party?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No.1:-

         It is not in dispute that the complainant had availed Insurance policy under plan- Group care (Scheme 2-11B) including his family members for a sum assured of Rs.6 Lakhs with the 1^st Opposite Party through the 2^nd Opposite Party.

The dispute arose when the cashless claim made by the complainant on 14.09.2015 for the treatment of his wife, Mrs.Kanchana Devi, was not registered by the 1^st Opposite party after receiving necessary records of treatment from the hospital, on the ground that for the surgery of Umbilical Hernia, waiting period of 24 months was a criteria under the terms and conditions of the policy and hence the cashless claim was not registered as per condition 3(1)(b)(i) & 3(1)(b)(Viii) of the policy.

The Contention of the Complainant is that he was not provided with the terms and conditions of the policy and even the printing of the policy document was also too small to read in bare eyes. Further  contended that he was not informed about the terms and conditions at the time of availing the said policy. Hence the rejection made is illegal. The contention of the 1^st Opposite party is that following the terms and conditions of the policy and as per condition no.3(1)b(i),3(1)(b)(viii) the cashless claim was rejected by the 1^st Opposite party. Further contended that the complainant was given option of free look period of 15 days, which clearly provides the Complainant to decide to continue with the policy availed if he accepts the terms and conditions of the policy, otherwise he was given option to return the policy within 15 days. Further contended that the surgery of umbilical hernia to be performed covers under condition No.3(1)(b)(i) in which specific waiting period of 24 months for illness or surgical procedure was listed and under condition no.3(1)(b)(viii) it is clearly mentioned as “All types of Hernia, Hydrocele”. Hence they have rightly rejected the claim of the complainant.        

On perusal of the Exhibits marked on both sides, it is clear that the surgery of umbilical hernia to be performed on Complainant’s wife, Mrs.Kanchana Devi is well within the waiting period of 24 months of the policy, as the policy was availed on 24.03.2015 and covered for the period 24.03.2015 to 23.03.2016, which disentitle the complainant to make a claim as per condition no.3(1)(b)(i) of the policy as found in  Ex.B-2.  Further the contention of the complainant that he has not provided with the terms and conditions of the policy, is not sustainable, as in Ex.A-4 and in Ex.B-2,  Page no.6, in point no.3 of Note column mentioned that

“Attached with this certificate of insurance are the key Terms and Conditions. Please ensure that these documents have been received, read and understood. If any of these documents have not been received. Please email at Hence, we hold that the rejection of Insurance Claim made by the 1^st Opposite Party is legally sustainable. Therefore, we are of the considered view that the 1^st Opposite party and 2^nd Opposite party had not committed any deficiency of service.

In the result this complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 26^th of August 2022. 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                 B.JIJAA

         MEMBER II                       MEMBER I                        PRESIDENT

 List of documents filed on the side of the Complainant:-

List of documents filed on the side of the 1^st Opposite Party:-

List of documents filed on the side of the 2^nd  Opposite Party:-

NIL

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT