Judgment : Dt.5.12.2017
Shri S. K. Verma, President.
This is a complaint made by one Smt. Lily Halim, wife of Shri Biplab Halim, Ramkrishna Mission Pally, P.O.-Sonarpur,P.S.-Sonarpur, South 24-Parganas, PIN- 700 150 against Senior Divisional Manager, United India Insurance Company Ltd., Division VIII, CIT Complex, Gariahat Road South, 2nd Annex Building, P.S.-Lake, Kolkata-700 068, OP No.1, Regional Manager, Kolkata Regional Office, United India Insurance Company Ltd., Himalaya House, 38, B 2 Jawaharlal Nehuru Road, P.S.-Shakespear Sarani, Kolkata-700 071, OP No.2, Manager, Claim, Heritage Health TPA Ltd., Nicco House, 2, Hare Street, P.S.-Hare Street, Kolkata-700 001, OP No.3 and Shri Debkumar Das, Development Officer, United India Insurance Company Ltd., Division VIII, CIT Complex, Gariahat Road South, 2nd Annex Building, P.S.-Lake, Kolkata-700 068, Proforma OP No.4 praying for releasing Rs.19,796.50, cost of hospitalized treatment of insured No.2 along with interest @ 10% p.a. from the date of submission of the reimbursement claim and to pay Rs.30,000/- as compensation for harassment and Rs.50,000/- as damage for harassing the Complainant and Rs.10,000/- as litigation cost.
Facts in brief are that Complainant being a senior citizen of about 67 years along with her wife aged about 66 years is under coverage of individual health insurance of OP No.1 & 2 for Rs.2,00,000/- each and the policy used to be renewed year by year continually within the time stipulated through Debkumar Das, proforma OP No.4. On 16.4.2015 insured Shri Biplab Halim was hospitalized for treatment and after recovery preferred a claim on 27.4.2015 for reimbursement of cost of his hospitalized treatment Rs.48,466/- through OP No.3, designated TPA of insurer. OP No.3 vide his letter dt.4.6.2015 after one month and 9 days acknowledged the receipt of the reimbursement claim of the insured No.2 that the claim has been processed and duly approved for reimbursement of Rs.19,796.50, but declined to pay the said amount taking with the ground that there is discrepancy in age of insured No.2 in the policy and the case was forwarded to insurer named with the advice to collect extra premium of Rs.22,991/-. OP No.2 advised Complainant to arrange refund the amount of Rs.3,194.50. On 26.6.2015, Complainant addressed a self contained letter to OP No.1 referring to letter dt.4.6.2015 of OP No.3 with the request for clarification of certain points. After repeated reminders dt. July,13, 2015 and July 24, 2015 insurer wrote to the Complainant after more than one month’s time vide letter dt.31st July acknowledging the receipt of the communications as it will appear from the documents filed herein.
OP replied that at the time of inception of the policy the discrepancy in the age of insured No.2 was detected from the claim documents and as such the amount of sanctioned or approved claim is adjusted against the due deficit premium and further advised to pay Rs.3,194.50. The Complainant approached the NGO in the month of September, 2015. Meanwhile the renewal of the health insurance policy became due. Even after repeated persuasion OP No.1 did not agree to accept the renewal of the policy.
Thereafter, OP No.1 agreed to accept the renewal of the policy on condition of subject to the payment of the amount of Rs.3,194/- to TPA by cheque and OP No.1 compelled to communicate the same in writing on a blank sheet of paper. So, Complainant was compelled to deposit the renewal premium vide cheque No.151608 d.19.8.2015 annexing the same to her letter dt.19.8.2015.
Further, Complainant has stated that at the time of inception of the policy the copy of passport of insurer No.2 was submitted as proof of his age. But in spite of that for reasons best known to insurer it did not mention the date of birth of the insured no.2 in the policy certificate the copy of the passport of the insured No.2 is filed as annexure H. At the time of inception of the policy the insured No.2 was 6 days less than that of 50 years. But insurer purportedly recorded the age of her as 50 years. Further, from Annexure H it will appear that he was 49+. Complainant has further submitted that insurer collected excess premium from the insured No.2 but on receipt of the alleged claim for reimbursement of cost of medical treatment all the OPs unequivocally declined to pay the legitimate claim of the Complainant on the plea of discrepancy in the recorded age of insured No.2.
It is the practice of the insurer in the health insurance business that while scrutinizing the claim of the insured, if any discrepancy and suppression of the fact in the policy is felt they repudiate the claim as a whole. Further, it is astonishing to note that the concerned insurer and TPA at first admitted and approved the claim of the insured No.2 and thereafter declined to reimburse the same taking the age discrepancy. That apart insurer did not agree to accept the renewal of the policy. The insurer did not reimburse the claim. So, Complainant filed this case.
United India Insurance Co., OP No.1 & 2 filed written objection and denied the allegation of the complaint. Further, this OP has stated that the complaint petition is liable to be dismissed with cost.
OP No.3 & 4 did not file written version to contest the complaint and so the case is heard ex-parte against them.
Decision with reasons
Complainant filed affidavit-in-chief against which OP No.1 filed questionnaire to which Complainant filed affidavit-in-reply. Similarly, OP No.1 filed evidence to which Complainant filed questionnaire to which OP No.1 filed affidavit-in-reply.
Main point for determination is whether Complainant is entitled to the reliefs as prayed for.
On perusal of the prayer portion, it appears that the Complainant has prayed for payment of Rs.19,796.50 approved cost of hospitalized treatment of insured No.2 along with interest @ 10%p.a.
In this regard, a copy of insurance policy is filed, which reveals that Lily Halim and Biplab Halim purchased insurance from United India Insurance Co. Ltd., OP No.1, and the period is from 8.9.1997 to 7.9.1998. Further, copies of the correspondences between the Complainant and the insurer have been filed. In the present case, Smt. Lily Halim wife of Sri Biplab Halim has filed this complaint through Consumers’ and Elderlys’ Rights Protection Society. In annexure C, it is mentioned a total claim of Rs.48,466.50 was incurred for the hospitalization to which TPA informed that Rs.19,796.50 is to be paid against the claim of Rs.48,468.50. Again the correspondence took place between the insurer and the Complainant in annexure D, OP No.1 has stated that the policy since inception was renewed on the basis of the age proof as submitted at the time of taking the policy in the year 1997 and the contract of insurance is made on the utmost good faith. The discrepancy in age was detected in the claimed document and the due premium amount since inception is Rs.22,991/-. So, Complainant is required to pay another Rs.3,194.50. Now, the question is whether an insurer has right to adjust the premium amount on the basis of the detection of age discrepancy after a lapse of about 17 years.
In our view the fault which was detected is of the insurer to a larger extent than the Complainant. It is because the insurer went on renewing the policy. On the basis of that premium received by it and after 17 years when the insured got hospitalized instead of paying the amount spent; they are showing that the fault is of the insured.
The principle of estoppel is very much clear that if a person acts on the representation of some other person; he or she cannot go back on that declaration. In the present case the insurer went on issuing policies in favour of the Complainant and suddenly when the Complainant/insured No.2 made an application for reimbursement then the insurer detected a discrepancy. So, it can be presumed as to how far negligent are our insurance companies and in what manner the insurers are discharging their obligations towards the insured.
So, we are of the view that the plea which has been taken by the OP cannot be accepted. At best they can refuse to renew the premium unless the enhanced premium is paid but they cannot charge premium retrospectively where the contract is only for one year. The moment the policy is not renewed the policy contract comes to an end. Every year there takes place a fresh contract between the insurer and the insured.
As such, we are of the view that Complainant is entitled to the prayer for payment of Rs.19,796.50p. Further, Complainant is also entitled to compensation of Rs.10,000/- and litigation cost of Rs.5,000/-.
Hence,
ordered
CC/100/2015 and the same is allowed on contest against OP No.1 and ex-parte against OP No.2, 3 & 4 in part. OP No.1, 2 & 3 are directed to pay Rs.19,796.50 with compensation of Rs.10,000/- and litigation cost ofRs.5,000/- to the Complainant within two months of this order, in default the total amount shall carry interest @ 10% p.a., provided original policy is filed.
