Haryana

Karnal

CC/162/2020

Kamal Shukla - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

R.K. Chauhaan

07 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 162 of 2020

                                                        Date of instt.16.03.2020

                                                        Date of Decision:07.07.2022

 

Kamal Shukla son of Shri O.P. Shukla, resident of house no.384, Kalandri Gate, Karnal.

                                               …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. through its Branch Manager, Karnal.

2.     Managing Director Star Health and Allied Insurance Company Ltd. Registered and Corporate Office, 1 New Tank Street Valluvar Kottam High Road, Nungambakkam, Chennai-600034.

 

                                                                      …..Opposite Parties.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Sh. Vineet Kaushik……Member 

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri R.K. Chauhan, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the opposite parties.

 

                    (Jaswant Singh President)

ORDER:   

                

                 The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant is holder of a Health Insurance policy bearing no.P/161219/01/2020/000015, which he had purchased in the year 2015 through his employer, while complainant was serving in Haier Appliances India Pvt. Ltd. The premium was paid by the employer of the complainant in time, which was part of salary and perks of complainant was given to him from the side of his employer. The said policy includes the risk of life of the total 5 members of family of the complainant, in case of any health problem during the time. It is further averred that after more than four years the complainant on 02.11.2019 had resigned from the abovesaid company and OP company duly intimated in this regard. The complainant is very much entitled to continue the abovesaid policy taken by him independently as per Rule of the Company. The complainant has given timely intimation for request to OPs on 20.11.2019 to continue the abovesaid policy, but OPs failed to intimate the complainant in time and in the meantime Grace period to continue the abovesaid health insurance policy was passed due to failure on the part of the OPs. For that reason the OPs have discontinued the abovesaid policy without any fault on the part of the complainant. The complainant was/is ready and willing to keep and continuing the abovesaid health policy on payment of its premium independently, but OPs  have refused to continue the abovesaid policy by giving intimation through email dated 23.12.2019. The complainant has requested the OP so many times to continue his policy, but OP did not pay any heed to the request of complainant. Then complainant sent a legal notice dated 01.10.2020 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that OPs earlier issued Group Insurance Plan by his employer Haier Appliances India Private Ltd, vide policy no.P/161219/01/2020/000015 alongwith his family and dependent mother for a floater SL of Rs. 6 lakhs for the period 08.07.2019 to 07.07.2020. The complainant has resigned his job on 02.11.2019 and the Group Insurance cover got expired on the same day, since the insured cease to be an employee. The insured approached the opponent to avail Family Health Optima with the continuity benefit, however on receipt of the records, it is noted that the insured Mr. Kamal Shukla has earlier through the Group Health Insurance Policy claimed for the treatment of Squamous Cell Carcinoma left buccal mucosa vide claim no.CLI/2018/161124/0280551 and the same was authorized and settled for Rs.5,00,000/-. Since the insured was treated with cancer prior to the porting, the OP advised the complainant to avail Cancer Care Policy for himself. However, complainant till date has not approached with the premium amount for availing cancer care policy. Thereafter, the insured approached the OPs to avail a Senior Citizen Red Carpet Policy, vide policy no.P/211114/01/2020/010905 for the period 08.07.2019 to 07.07.2020. The complainant has never informed about the previous group insurance policy to OPs. The proposal, declaration given by the Proposer (insured) forms the basis of the contract between the Proposer and the company. The proposer, in the proposal has not mentioned the previous insurance details, which could be gathered from the following:-

Existing insurance coverage with this company and any other company-given details-

1.     Name of the Insurance Company- No

2.     Period of Insurance                    - No

From the above mentioned facts, it is to be mentioned that the complainant has approached the OPs to avail a fresh policy, hence it is not possible for the OPs to consider the continuity benefit. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of email dated 22.04.2021 by complainant to OP Ex.C1 and closed the evidence on 22.04.2021 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of P.C.Tripathy Zonal Manager Ex.OPW1/A, copy of policy schedule Ex.OP1, copy of terms and conditions of the insurance policy Ex.OP2, copy of policy schedule Ex.OP3, copy of discharge summary Ex.OP4, copy of bill assessment sheet Ex.OP5, copy of proposal from Ex.OP6, copy of request for cashless hospitalization Ex.OP7 and closed the evidence on 17.03.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant is holder of a Health Insurance, which he had purchased in the year 2015 through his employer, while he was serving in Haier Appliances India Pvt. Ltd.  The said policy includes the risk of life of the total 5 members of family of the complainant, in case of any health problem during the time. He further argued that complainant on 02.11.2019 had resigned from the abovesaid company. The complainant is very much entitled to continue the abovesaid policy taken by him independently as per Rule of the Company. The complainant has given timely intimation for request to OPs on 20.11.2019 to continue the abovesaid policy, but OPs failed to intimate the complainant in time and in the meantime Grace period to continue the abovesaid health insurance policy was passed due to failure on the part of the OPs. For that reason the OPs have discontinued the abovesaid policy without any fault on the part of the complainant. The complainant was/is ready and willing to keep and continuing the abovesaid health policy on payment of its premium independently, but OPs have refused to continue the abovesaid policy and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of written version, has vehemently argued that complainant OPs earlier issued Group Insurance Plan by his employer Haier Appliances India Private Ltd. alongwith his family and dependent mother for a floater SL of Rs. 6 lakhs for the period 08.07.2019 to 07.07.2020. The complainant has resigned his job on 02.11.2019 and the Group Insurance cover got expired on the same day. The insured approached the OP is to avail Family Health Optima with the continuity benefit, however on receipt of the records, it is noted that the insured Mr. Kamal Shukla has earlier through the Group Health Insurance Policy claimed for the treatment of Squamous Cell Carcinoma left buccal mucosa and the same was authorized and settled for Rs.5,00,000/-. Since the insured was treated with cancer prior to the porting, the OP advised the complainant to avail Cancer Care Policy for himself. However, complainant till date has not approached with the premium amount for availing cancer care policy. Thereafter, the insured approached the OPs to avail a Senior Citizen Red Carpet Policy. The complainant has never informed about the previous group insurance policy to OPs. Complainant has approached the OPs to avail a fresh policy, hence it is not possible to the OPs to consider the continuity benefit and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, OPs had issued Group Insurance Plan to complainant by his employer Hair Appliances India Private Limited alongwith his family and dependent mother for floater SL of Rs.6 lakhs for the period 08.07.2019 to 07.07.2020. It is also admitted the complainant has resigned the job on 02.11.2019.

11.           As per the version of the complainant, after resigned from the company, he had duly intimated to the OPs and complainant is very much entitled to continue the abovesaid policy taken by him independently/individually as per the rule of the company.

12.           The onus to prove his version lies upon the complainant but complainant has miserably failed to prove his case by leading any cogent and convincing evidence. There is nothing on the file to prove that after resigning from the company the complainant had intimated the OPs in this regard. Complainant has relied upon only his affidavit Ex.CW1/A and email Ex.C1 dated 22.04.2021. In the said email complainant made request to company to regularize his cooperate policy as personal policy carrying the same benefits. Prior to this email there is no other correspondence between the complainant and OPs for believing the version of the complainant. Rather OPs have proved on record that insured Kamal Shukla (complainant) has earlier through the group health insurance policy, claimed for the treatment of Squamous Cell Carcinoma left buccal mucosa and the same was authorized and settled for Rs.5,00,000/-. As per the version of the OPs, insured (complainant) was treated with cancer prior to the porting, OPs advised the complainant to avail Cancer Care Policy, but complainant did not avail the same. Furthermore, as per the version of the OPs, complainant never informed about the previous group insurance policy.

13.           In the present complaint, complainant has prayed for continuing the abovesaid health policy on payment of necessary premium and compensation to the extent of Rs.30,000/-, but complainant has miserably failed to inform the OP with regard to his resignation from the company and to pay the premium with the OPs within stipulated time. Hence, present complaint is devoid of any merits and same deserves to be dismissed.

14.           Thus, as a sequel to abovesaid discussion, the present complaint is hereby dismissed. No order as to costs. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

Announced

Dated:07.07.2022.

                                                                      

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

       

           (Vineet Kaushik)                     (Dr. Rekha Chaudhary)      

                  Member                                Member