DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/290/2020

Date of Institution : 22.10.2020

Date of Decision : 30.03.2022

Karandeep Garg son of Sh. Madan Lal resident of Street No. 6, Tapa-148108 District Barnala, Punjab.  

…Complainant

Versus

1. HDFC Life Insurance Company Limited, Through its Branch Manager, C/o HDFC Bank Branch, Tapa-148108.

2. M/s HDFC Life Insurance Company Limited, H.O/Regd. Office, 11th Floor, Lodha Excellus, Apollo Mills Compound, NM Joshi Marg, Mahalakshmi Mumbai-400011 Through its Managing Director.

…Opposite Parties

Complaint under Section 35 of Consumer Protection Act, 2019

Present: Sh. NK Garg Adv counsel for complainant.

Sh. Anuj Mohan Adv counsel for opposite parties. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The complainant Karandeep Garg filed the present complaint under Section 35 of the Consumer Protection Act 2019 against HDFC Life Insurance Company Limited, Tapa and anoher. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased comprehensive policy bearing No. 90322132 on 26.7.2016  and Smt. Krishna Devi being dependent mother was also covered. Risk commenced is from 22.6.2016 to 21.6.2017 and paid premium through HDFC Bank Branch Tapa having Saving Account No. 50100026482287. Complainant paid 2nd and 3rd premium in time and policy was renewed from 22.6.2018 to 21.6.2019. The opposite parties enhanced the premium for the 4th year. The complainant contacted the agent of the company who assured to deposit the amount and policy would be renewed and continued as previous premium paid on 6.9.2019 through cheque and policy will continued for the 4th consecutive year. The complainant paid Rs. 19,499/- on 6.9.2019 and policy was renewed.

3. It is further alleged that on 14.11.2019 company refused the amount without any intimation. The complainant approached the opposite party who that some more charges be paid for continuation of the policy for 4th year and complainant paid Rs. 20,160/- on 6.12.2019. But they called telephonically to get medical of mother of the complainant. On this complainant got examined his mother on 6.1.2020 at Dr. Naresh Hospital of which payment of Rs. 3,000/- was paid by the complainant but as per terms and conditions company was to pay the expenses of medical but they did not pay. Complainant was called to have another medical on 21.1.2020 of which complainant paid Rs. 1,000/-. 

4. It is further alleged that due to sudden problem complainant got her mother admitted in Prem Eye and Maternity Hospital on 31.1.2020 and she was operated the right eye and lens were planted and paid Rs. 20,250/-. The complainant claimed the amount after giving all the original documents but opposite parties repudiated the claim vide letter dated 4.3.2020 without any reason that the policy started from 25.1.2020. The policy is continuing since June 2016. The complainant contacted through emails dated 17, 18 and 25 March 2020 but to no effect. He also sent notice dated 22.7.2020 but of no use. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay original claim of medical bill of Rs. 20,160/- alongwith interest at the rate of 12% per annum from 6.12.2019 to 5.10.2020 Rs. 2,016/-. 

2) To pay Rs. 20,000/- on account of compensation for mental agony and harassment and Rs. 10,000/- as litigation expenses. 

3) Any other fit relief may also be given. 

4) To recover interest at the rate of 12% per annum from 6.10.2020 till actual realization. 

5. Upon notice of this complaint, opposite parties filed written statement taking preliminary objections that the present complaint is not maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come to this Commission with clean hands. It is submitted that complainant Karandeep Garg submitted an Proposal form dated 22.6.2016 for the purchase of HDFC Life Health Assure Plan which included cover of his family i.e. Mother Smt. Krishna Devi. A policy was issued bearing No. 90322132 commencing from 22.6.2016 which was subsequently renewed in the year 2019. The complainant insured himself and his mother for sum assured of Rs. 5,00,000/-. All the terms and conditions and exclusions were explained to the complainant. In the year 2019 the complainant did not pay his premium due to which policy got lapsed. It is relevant to mention that the policy allows a grace period of 60 days and the complainant failed to pay the premium within the grace period as well due to which his policy was not revived. On 30.8.2019 the complainant chose to apply reinstatement. But he did not submit the medical tests and name of second life assured was missing and said details were required for revival of policy post grace period. The complainant reapplied on 16.10.2019 which was incomplete as height and weight were not mentioned. Then he reapplied on 5.12.2019 where again the medical documents were not submitted but later one submitted the same and policy was reinstated on 25.1.2020. On 31.1.2020 the mother of the complainant got admitted at Prem Eye and Maternity Hospital and insured was diagnosed with cataract right eye. On discharge of his mother the complainant claimed reimbursement with the answering opposite parties. The said claim was adjudicated by the claim team of the opposite parties and vide letter dated 4.3.2020 the opposite parties rejected the claim of the complainant as he had delayed in renewing the policy and the premium was received after the grace period of 60 days. As per policy terms and conditions post 60 days the policy shall be interpreted as a fresh policy and hence waiting period become applicable for the present claim. The opposite parties rightly rejected the claim of the complainant as policy was having a break and reinstatement was done on 25.1.2020 so 30 days waiting period and 2 years waiting period will apply. There is no deficiency in service on the part of the opposite parties. 

6. On merits, it is admitted that complainant Karandeep Garg purchased the policy from the opposite parties for sum assured of Rs. 5,00,000/-. Rest of the submissions mentioned on merits already mentioned in the preliminary objections of written statement so there is no need to repeat the same. However, the policy was not renewed on 6.9.2019 as the complainant did not submit the medical test results and documents which were necessary to revive the policy. Lastly, the opposite parties prayed for the dismissal of the present complaint with heavy costs.  

7. In support of his complaint, the complainant tendered into evidence his affidavit Ex.C-1, copy of letter dated 26.6.2016 Ex.C-2, copy of policy schedule Ex.C-3, copy of payment of Rs. 19,499/- dated 6.9.2019 Ex.C-4, copy of refund dated 14.11.2019 Ex.C-5, copy of payment of enhanced premium Ex.C-6, copy of medical appointment dated 5.1.2020 Ex.C-7, copy of medical appointment dated 20.1.2020 conducted on 21.1.2020 Ex.C-8, copy of bill of Rs. 20,250/- Ex.C-9, copy of discharge card dated 1.2.2020 Ex.C-10, copy of repudiation letter dated 4.3.2020 Ex.C-11, copy of email dated 17.6.2020 Ex.C-12, copy of email dated 17.6.2020 Ex.C-13, copy of legal notice Ex.C-14, copies of postal receipts Ex.C-15 and Ex.C-16, copy of statement of account from June 2019 to 31.3.2020 Ex.C-17, copy of receipt of premium dated 22.6.2020 Ex.C-18, copy of policy Ex.C-19, copy of receipt of premium dated 9.7.2021 Ex.C-20 and closed the evidence. 

8. To rebut the case of the complainant the opposite parties  tendered in evidence copy of resolution Ex.OPs-1, copy of proposal form Ex.OPs-2, copy of insurance alongwith terms and conditions Ex.OPs-3, copies of health revival form Ex.OPs- to Ex.OPs-6, copy of medical examination report alongwith medical documents Ex.OPs-7, copy of claim form Ex.OPs-8, copy of rejection letter Ex.OPs-9, affidavit of Arpit Higgins Ex.OPs-10 and closed the evidence. 

9. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments also filed by the opposite parties. 

10. The complainant had purchased the policy No. 90322132 in the year 2016 and the same policy was renewed from time to time till 21.6.2019 and thereafter in the year 2019 the policy was lapsed due to non depositing of premium amount. Later on the complainant had deposited the revival charges alongwith premium of the policy in question for continuation of the policy for 4th years. Ultimately, the policy was revived on 25.1.2020. The mother of the complainant namely Smt. Krishna Devi was got admitted in the hospital on 31.1.2020 and take the eye treatment and spent Rs. 20,250/- on the surgery. The complainant applied for the reimbursement of the said amount but the opposite parties repudiated the claim vide letter dated 4.3.2020. The opposite parties alleged in the written version that the said policy lapsed in the year of 2019 as the complainant did not pay the premium. The opposite parties further alleged that the complainant failed to deposit the premium amount even in grace period i.e. 60 days. The opposite parties mentioned in the written version that on 30.8.2019 the complainant chose to apply reinstatement of policy but did not submit the medical tests and name of the second life assured was missing and said details were required for the revival of the policy post grace period. Thereafter, after 2/3 times the complainant applied for the reinstatement of the policy. The opposite party alleged in the written version that ultimately the policy was reinstated on 25.1.2020. The opposite parties alleged in their written version that the complainant lodged the claim and said claim was rejected vide letter dated 4.3.2020 with the reason that the complainant had delayed in renewing the policy and the premium was received after the grace period of 60 days. As per policy terms and conditions post 60 days of the policy was interpreted as fresh policy and hence waiting period become applicable for the present claim. The opposite parties alleged that the claim was rightly rejected as policy was having a break and reinstatement was done on 25.1.2020 so 30 days waiting period and two years waiting period will apply. 

11. On the perusal of entire record it is established that the said policy was revived on 25.1.2020 and the mother of the complainant took the treatment on 31.1.2020 which is well within the period of policy schedule. The opposite party alleged in their written version that the complainant had made the request for reinstatement and after reinstate the policy shall be interpreted as fresh policy but the opposite parties produced the forms submitted by the complainant i.e. Ex.OPs-4, Ex.OPs-5 and Ex.OPs-6 which established that the complainant had requested for revival of the policy from the date of its first commencement. The opposite parties have taken the premium from the complainant from 2016 to 2020 and the opposite parties themselves revived the policy of the complainant and the policy number of the policy remained same after the revival of the policy. Therefore, it is established that the policy was continued without break as complainant purchased the same from the opposite parties in the year 2016. 

12. The complainant has produced the medical bill of Prem Eye and Maternity Hospital, Barnala of Rs. 20,250/- dated 31.1.2020 Ex.C-9 and discharge card dated 1.2.2020 Ex.C-10 which established that the mother of the complainant had taken the treatment and she was covered under the said policy. The claim repudiated by the insurance company on non valid grounds is clear cut deficiency in service.

13. The learned counsel for the opposite parties argued that the waiting period of 30 days is applied as it is mentioned in the exclusion clause of the terms and conditions of the policy but the policy in question is in continuity, therefore, the exclusion clause of 30 days is not applicable in the present case.

14. In view of above discussion, present complaint is partly allowed and opposite parties are directed to pay an amount of Rs. 20,160/- to the complainant alongwith interest at the rate of 7% per annum from the date of filing of present complaint till actual realization. The opposite parties are further directed to pay Rs. 7,500/- to the complainant as compensation for mental tension and harassment and Rs. 3,500/- as litigation expenses. Both the opposite parties jointly and severally liable to comply with this order. Compliance of this order be made within the period of 45 days from the date of receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance. ANNOUNCED IN THE OPEN COMMISSION:

        30th Day of March 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member