Date of filing: 21.04.2018

                                                               Date of Disposal:16.03.2023

 BEFORE THE III ADDITIONAL BANGALORE URBAN

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

                               BENGALURU – 560 027.

DATED THIS THE 16^th DAY OF MARCH, 2023

CONSUMER COMPLAINT NO.714/2018

PRESENT:

SRI.RAJU K.S,

SMT.REKHA SAYANNAVAR,:MEMBER

Shri. Chandrashekar C S,

S/o. Srinivasa Shetty,

Aged About 34 years,

Occupation: Business,

R/at: No.6, Ruthvik Nilaya,

Bangalore-560 300.

Rep by Sri.Sharanagouda S. Patil, Advocate

1) M/s. Reliance General Insurance

Company Limited, Unnati Arcade,

No.5/111 & 6/112, 1^st Floor, 1^st Block,

Dr. Rajkumar Road, (1^st Main Road),

Rajajinagar, Bangalore-560 010.

2) M/s. Reliance General Insurance

Company Limited, Reg. Office: No.19,

Reliance Centre, Walchand Hirachand

Marg, Ballard Estate, Mubai-400001.

Rep by Sri.B.C.Shivannegowda, Advocate

//JUDGEMENT//

BY SRI.SHIVARAMA K, PRESIDENT

The complainant has filed this complaint under Section-12 of Consumer Protection Act, 1986 seeking for direction to the opposite parties to refund the entire amount paid towards premium along with interest at the rate of 18% per annum with an amount of Rs.6,00,000/- as compensation and such other relief as this Commission deems fit in the circumstances of the case. 

02.    It is not in dispute that, opposite party No.2 is the Head Office of opposite party No.1.  Further the complainant had obtained Reliance Health Gain Policy from the opposite party and the first policy was for the period from 31.03.2015 to 30.03.2016 and the subsequent policies are from 01.04.2016 to 31.03.2017, 01.04.2017 to 31.03.2018 and 01.04.2017 to 31.03.2018.  The complainant sought pre-authorization request from opposite party with regard to the treatment and going to admit in Chord Road Hospital on 13.03.2018.  Further it is not in dispute that, the request of the hospital has been denied by the opposite party for the reason that, the second year policy date of inception was 01.04.2016.  Hence as per policy Clause 3.1.2 expenses incurred for management of cysts, nodules polyps falls under 2^nd year waiting period, thereby repudiated the claim.

03.    It is the further case of the complainant that, the opposite parties played fraud and considered inception period as 01.04.2016 and not at all considered the first premium paid against inception period on 31.03.2015.  Further the complainant is eligible for entitlement to get benefit under the policy.  Policy base sum assured was Rs.3,00,000/- plus other benefits.  Further the opposite parties did not verify the documents and rejected the claim.  Hence the complaint came to be filed.

04.    It is the further case of the opposite parties that, the first policy taken by the complainant has expired on 30.03.2016 and the complainant did not renew the policy in time and on submission of the fresh proposal, the opposite party had issued the fresh policy covering the risk from 01.04.22016 to 31.03.2017 and it was renewed further from 01.04.2017 to 31.03.2018.  As per the policy Clause 3.1.2 the complainant is not entitled for the claim made and sought to dismiss the complaint.

05.    To prove the case, the complainant (PW1) has filed affidavit in the form of his evidence in chief and got marked EX.P1 to P10 documents.   The opposite parties have filed affidavit in the form of their evidence in chief and got marked EX.R1 to R2 documents.

06. Counsels for the complainant and opposite party Nos.1 & 2 have filed their respective written arguments.

         07. The points that would arise for consideration are as under:

  (1) Whether there is deficiency of service on the part of the opposite party No.1 & 2?

  (2) Whether the complainant is entitle for the 

    relief sought ?

       (3) What order ?

  08.  Our findings on the aforesaid points are as follows:

Point No.1 :  In affirmative

Point No.2 :  Partly in affirmative

Point No.3 :  As per the final order for the following;

REASONS

09. POINT NO.1:- The complainant (PW1) and OP Nos. 1 & 2 have reiterated the fact stated in their respective pleadings, in the affidavits filed in the form of their evidence in chief.  There is no dispute with regard to the purchase of Reliance Health Gain Policy by the complainant from opposite parties.  Further it is not in dispute that, the first year policy was for the period from 31.03.2015 to 30.03.3016 and the same expires on 30.03.2016.  Further the complainant obtained second year policy from 01.04.2016 to 31.03.2017.  Hence there was one day gap.  That means, there was no policy in force on the day on 31.03.2016.  Hence it is contended by the learned counsel for the opposite parties that, the policy issued for the second year was a fresh policy.  It is the contention of the learned counsel for the complainant that, the policy obtained in the second year was of a continuation one and the said policy was a renewed policy.  The complainant has also produced the policy vide EX.P.1 to P.3.

10. The complainant claimed the hospital expenses going to be incurred on the admission to the hospital on 13.03.2018.  EX.P.4 is the letter of repudiation.  It is only in EX.P.4 that, since two years have not been completed after the second year policy being obtained, the complainant was not entitled for the claim.  EX.R.1 is the copy of the policy.  In which in Clause 3.1.2, it is stated that, the policy shall not be covered during the first two consecutive years of coverage by the company from the first policy period start date, with regard to the illness i.e., cysts, nodules, polyps. 

Further in Clause 5.13 of the policy with regard to Renewal Notice, it is stated under clause “c” that, “the policy may be renewed by mutual consent and in such event the renewal premium shall be paid to the Company on or before the date of expiry of this policy and in any case not later than the expiry of the Grace Period.  Grace Period refers to a period of 30 days immediately following the premium due date during which a payment can be made to renew this Policy without loss of continuity benefits such as waiting periods and coverage of Pre-existing Disease.  Coverage is not available for the period for which premium is not received by the company and the company shall not be liable for any claims incurred during such period.”

12.        Hence we feel the opposite parties ought not to have rejected the claim, but it has liberty to exclude the claim for the period not renewed.  Further the learned counsel for the complainant contends that, the opposite parties should have entertained the claim of the complainant.  In support of the contention counsel relies the Judgment rendered by Hon’ble Apex Court in Civil Appeal No.6778 OF 2013.  In the said judgment nothing is stated about the grace period and continuity of the policy during the period it was not renewed.  The facts of the said judgment are entirely different from the facts of the case on hand.  Hence the same is not applicable.  We feel for the reasons stated, above as per Clause 5.13 of the policy vide EX.R.1 the opposite party was wrong in repudiating the claim.  Therefore there is deficiency of service on the part of the opposite parties.  Accordingly we answer this Point in affirmative.

13.        POINT NO.2:- The complainant claimed a sum of Rs.6,00,000/- and refund the entire amount paid towards premium.  The learned counsel for the complainant did not point out any provisions available for refund of the premium paid.  It appears to us that, by issuing the policy the opposite party had covered the health risk of the complainant.  Therefore the complainant can avail the benefits covered in the policy.  It is not forthcoming as to whether the complainant got treatment in the hospital during the period in between 01.04.2016 to 31.03.2017.  However, the complainant is entitled for the hospital expenses incurred if any for the period from 01.04.2016 to 31.03.2017 and the complainant is at liberty to claim the hospital expenses incurred if any on 13.03.2018.  It is not the case of the complainant that, since the opposite party denied to provide pre-authorization for the claim, the complainant was deprived of to obtain treatment and consequently he was put in to untold hardship.    

14.        Further we feel since because of the repudiation by the opposite parties the complainant has suffered mental agony and hardship.  Hence the complainant is entitled for a sum of Rs.20,000/- towards mental agony.  Further the act of the opposite parties made the complainant to issue notice vide EX.P.5 to the opposite parties claiming compensation for the deficiency of service and to approach this Commission.  Hence the complainant is entitled for a sum of Rs.10,000/- towards litigation expenses.  Hence we answer this Point partly in affirmative.

15.        POINT NO.3:- In view of the discussion made above, we proceed to pass the following:

ORDER

The complaint is allowed in part.

The opposite party Nos.1 & 2 are directed to renew the policy taken by the complainant for the period from 01.04.2016 to 31.03.2017 without loss of continuity benefits such as, waiting period and coverage of pre-existing disease.  It is made clear that, coverage is not available for the period for which premium is not received by the opposite party and the opposite party shall not be liable for any claims incurred during such period. 

Further opposite party Nos.1 & 2 are directed to pay a sum of Rs.20,000/- towards mental agony and a sum of Rs.10,000/- towards litigation expenses to the complainant.

The opposite party No.1 & 2 shall comply the order within 30 days.   In case, they fail to comply the order within the said period, the above said amount of Rs.30,000/- carries interest at the rate of 9% p.a. from the date of order till realization.

Supply free copy of this order to both the parties and return extra copies of the pleading and evidence to the parties.

Applications pending, if any, stands disposed-of in terms of the aforesaid judgment.

  (Dictated to the Stenographer, typed by her, the transcript corrected, revised and then pronounced in the open Commission on 16^th Day of March, 2023)                                            

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA. K)    
•  

//ANNEXURE//

Witness examined for the complainants side:

Sri. Chandrashekhar C.S, the complainant (PW-1) has filed his affidavit.

Documents marked for the complainant side:

1. Copy of the Insurance policy from 31.03.2015 to 30.03.2016 – EX.P.1
2. Copy of the policy schedule – EX.P.2
3. Copy of the policy schedule – EX.P.3
4. Copy of the repudiation letter – EX.P.4
5. Copy of the Legal Notice – EX.P.5
6. Postal acknowledgment & postal receipts – EX.P.5(a) to P.5(d)
7. Copy of the cheque bearing No.538498, dated: 30.03.2016 for making payment to the Reliance General Insurance Company to the tune of Rs.7,099/- - EX.P.6
8. Copy of the Reliance Health Gain Policy schedule dt.30.03.2017 – EX.P.7.
9. 03 Bank statements in respect of complainant’s SB Account from 29.03.2017 to 10.04.2017 – EX.P.8 to P.10.

Witness examined for the opposite party Nos.1 & 2 side: 

Sri. Pradeep D.S, Manager Legal (RW-1) has filed affidavit in the form of his evidence in chief. 

Documents marked for the Opposite Party side:

1. Policy with terms and conditions – EX.R.1

2. Repudiation letter – EX.R.2

• REKHA SAYANNAVAR)    (RAJU K.S)         (SHIVARAMA. K)    
•