[The Post review incidents: dated 20-09-2016, included in the end portion, signifies this review]
The policyholder, in his Good Faith, maintained paying premium amounts on or before the due dates against the Renewal Notices issued by the Company, for a policy no HC00018224000100, since the last nine years and until date.
The policy’s Sales Brochure insisted the policyholder to enter into the policy agreement concerned. Where a contractual agreement irrecoverable in nature, cannot change post implementation.
Recently, the said policyholder received a renewal notice for his medical insurance policy that asked the policyholder to pay an exorbitant premium amount for renewal before a certain date.
Therefore, the exorbitant amount raised a doubt in his mind that insisted him to verify copy of the policy documents and the policy’s Sales Brochure, where he found abnormalities.
The premium slabs mentioned in the policy Sales Brochure reflect(91 Days-18 Yrs) Rs. 1141.00, (19-45 Yrs.) Rs. 1745.00, (46-60 Yrs.) Rs. 2568.00, and(61-75 Yrs.) Rs. 3487.00.
The policyholder, on condition the company address his notice for refund reasonably, remitted the demanded amount, as per said Renewal Notice, so that said policy renewed before the due date,
Unfortunately, the premium amount claimed by Royal Sundaram does not commensurate with the age groups specific premium amounts mentioned in the Sales Brochure of the policy, where the brochure itself insisted the policyholder to enter into said policy agreement.
Royal Sundaram never intimated any change in premium amount but acted cleverly with a motive not reasonable for a company. As per receipts of premium payments, the Royal Sundaram Alliance Insurance Co. Ltd, has taken more amount than the company should have taken; there is a positive difference between the total premiums claimed and paid by the policyholder in his good faith and the total premium payable as per said agreement.
The act of claiming and receiving exorbitant amount by Royal Sundaram Alliance Insurance not only violates a consumer’s right, also those claims violate the interests of this policyholder - as described by the Insurance Regulatory and Development Authority of India(IRDA).
A demand notice, for refunding the excess amounts total, served upon Royal Sundaram, for the Company to refund the excess amounts to the said policy-holding customer within 30 days from the date of notice. Now, the policyholder is waiting for a reasonable action from the Company.
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24-Sep-2015: The consumer(policyholder) did not receive or, could not find a reasonable/acceptable reply from Royal Sundaram Alliance Insurance Co. Ltd, till date, as such, before visiting his lawyer for taking further action, said consumer called Royal Sundaram to confirm unavailability of the desired reply said, while Royal Sundaram assured the customer to send the reply today. The customer, postponed his visit to his lawyer for 3 more days against the assurance of Royal Sundaram.
26-Sep-2015: Instead of their said assurance, dated 24-Sep-2015, to send reply to the policyholder's notice, Royal Sundaram Alliance Insurance Co. Ltd. has not given any heed to said notice. Therefore, the policyholder confirmed Royal Sundaram today that there is no constrain for the policyholder to seek appropriate remedy or legal shelter now, against the relevant injury caused to him.
18:31 Hrs. 26-Sep-2015:
The reply of Royal Sundaram Alliance Insurance Co. Ltd. dated 22-08-2015 but received by the policyholder on 26-09-2016 at 17:21 Hrs. not accepted by him.
The policyholder therefore, constrained to challenge your decision in the premium charged, claiming it to be correct and your indifference to rework on the same, besides policy coverage is not increasing that caused policyholder's irreparable injury.
28 September 2015 at 05:40. Aggrieved by the unreasonable act and impugned reply of the insurer, the policyholder escalated the matter by making a complaint before the Office of the Insurance Ombudsman, Kolkata.
Additional information of the complaint follows:(1) Since the inception of the said Policy dated 23-08-2006 and till date, the policyholder maintained paying premiums amounts within the due dates, as per age group specific premium slabs mentioned in the sales brochure.
(2) A renewal notice dated 15-07-2015 asked the policyholder to pay an abnormal premium amount of Rs. 3251 that does not commensurate with said age group specific premium slabs.
(3) As such, the policyholder has sent a demand notice dated 20-08-2015 for refund of the excessive premium to the Insurer, prior making notified premium amount said.
(4) On condition, the Insurer refunds the portion of excessive premium stated above, the policyholder has made the notified premium amount on 21-08-15 against payment receipt.
(5) Later, the Insurer refused to refund excessive premium portion demanded by the policyholder, rather mentioned unreasonable statements in their favour.
(6) Such unreasonable act of the Insurer and corresponding violation of mutual understanding caused injury to the policyholder on the following grounds, besides others.
(a) For that, the insurer’s arbitrary intent to increase the premium amount has made the policy unpredictably risky, at present and in its future course.
(b) For that, the insurer ruled in own favour, unreasonably, by stating the premium charged for the policy is correct, but they ruled against the policyholder's will or honouring his demand notice dated 20-08-2015.
(c) For that, the insurer should not have accepted last premium amount before addressing the demand notice of the policyholder, dated 20-08-2015, reasonably.
(d) For that, the a contractual agreement is irrecoverable in nature and that cannot change post implementation, but arbitrary, the insurer increased the premium amount in violation age group specific premium slabs mentioned in the policy’s Sales Brochure.
(e) For that, the Sales Brochure of the policy that the insurer provided to assure the policyholder, insisted him to enter into the policy agreement,
(f) For that, the Sales Brochure of the policy reflects yearly premium 91Days-18Yrs Rs.1141.00, 19-45 Yrs. Rs. 1745.00, 46-60 Yrs. Rs. 2568.00, and 61-75 Yrs. Rs. 3487.00, but the recent increase in premium slabs injured the policyholder, and in his understanding about the policy's maintenance.
(g) For that, with recent increase of said premium amount, the policy coverage amount did not increase, making the whole episode unreasonable.
The policyholder therefore, challenges insurer decision to charge the excess premium, for that the same action caused policyholder's injury. The policyholder prays for the refund of the excess premium from the insurer and a direction to the policyholder to keep the premium slabs of the policy unchanged during its lifetime.
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30-09-2015: Registration of complaint –
The policyholder maintained paying premiums as per age group specific premium slabs mentioned in the sales brochure. The insurer should not have accepted last premium amount before addressing the demand notice of the policyholder dated 20-08-2015 reasonably. On condition, the Insurer refunds the portion of excessive premium; the policyholder has made the notified premium amount on 21-08-15 against payment receipt. Concerning the rate revision of the premium, the insurer did not issue any intimation to the policyholder until the time of the last premium paid for the policy, making premium charged for the policy incorrect. Later, the Insurer refused to refund excessive premium portion as demanded by the policyholder, rather mentioned unreasonable statements in their own favour.
IRDA Token Number: 09-15-021689.
Entity Reference Number: RSA/20151001/00020500:
The insurer did not attend specific instruction of the policyholder. Such unreasonable acts of the Insurer and corresponding violation of mutual understanding caused injury of the policyholder on relevant grounds.
As such, the policyholder used the Integrated Grievance Management System(IGMS) for Registration of the complaint to IRDA. The policyholder prayed for the direction to the insurer for the refund of the excess premium as per demand notice dated 20-08-2015. And a direction to the insurer to keep the premium slabs of the policy unchanged during its lifetime as mentioned in said sales brochure. And/or, any other order/s or direction as IRDA deems fit and proper for the ends of Justice.
01-10-2015: Insurer acknowledged the above complaint.
07-10-2015: The insurer replied the increase in renewal premium is due to medical inflation in India. As a result, we are constrained to revise the premium by 17.50% and 22.50% for up to 45 years and more than 45 years respectively for the Health Forever product chosen by you and the changes in policy terms and conditions and the revised premium will be effective on your renewal falling due on or after 1st August 2015.
We understand from our records that the soft copy of the rate revision letter has been sent to your email address by our customer service officer on August 21, 2015. Hence, the premium charged for your policy is correct and we will be unable to rework on the same.
On the other hand, the policyholder stated, “He maintained paying premiums as per age group specific premium slabs mentioned in the sales brochure. He has made the notified premium amount on 21-08-15 on condition that the Insurer refunds the portion of excessive premium, also the insurer did not issue any intimation to the policyholder until the time of the last premium paid for the policy.”
13-10-2015: Escalated to IRDA:
The policyholder stated, “Instant complaint remained unresolved. Policyholder cannot reach a consensus with the insurer until date for the reason the insurer ignored and failed to consider and address whole of the policyholder's statements, grounds and prayers made in the instant complaint. The insurer repeated same, disputed and incomplete statements they made earlier and before IRDA complaint made, making insurer reply irrelevant. Further, not all the reference numbers 787287, 787662, 801858 considered by the insurer in instant complaint. In response to the insurer letter, the policyholder replied a letter dated 12-Oct-2015, and sent today through registered post. Policyholders, prayers remained unresolved and remained injured as per description of consumer protection act 1996. The case needs to be escalated / acted upon.
15-10-2015: The insurer made Closure Request to the complaint:
Repeats the same irrelevant, impugned statement, “customer has been informed, we understand from our records that our officer has responded to him with the clarification through their e-mail dated October 07, 2015 for the query raised from his end.”
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20-09-2016 Post review incidents:
The Office of the Insurance Ombudsman sends me its first and the only communication dated 15-Oct-2015, that decides that my complaint cannot be considered by this forum for the reason, " . deduction or non deduction of premium ., " . are not falling within the preview of Insurance Ombudsman adjudication.
The said communication also mentions that as per RPG Rules 1998 a complaint is decided by the forum.
The Office of the Insurance Ombudsman awards me an order that stipulates, " You may take up the matter with the Insurance Company or any other court/forum for the resolution of you grievance as you may deem fit."
However, on receipt of said communication, I felt that the decision of the Office of the Insurance Ombudsman was not based on correct interpretation of my complaint made, since the cause of action, as the forum has decided, should not be the same the forum has interpreted but others.
However, said communication reflects information that mentions, ". if you feel the complaint admissible, you may represent referring specific section of RPG Rules with your justification for our further consideration." – This is where I regained my strength to justify my complaint.
Accordingly, as per RPG Rules, I have appealed before the forum and sent my justification for the complaint to be accepted. But there was a delay in reply to my appeal. And my personal visit to the forum could not trace out my appeal but my verbal submission before an official, about admittance of my complaint appealed, correctly interpreted by said official even without seeing the application sent, and said official agreed to admit my complaint with the suggestion that said insurance company sold the policy in cheap price and now they cannot manage hence increasing the renewal amount. He also suggested porting the policy to another insurer.
Therefore, though I was confident enough and is in a good position to sue the Royal Sundaram before the Insurance Ombudsman or, before the Consumer Forum, but I have dropped the idea of suing Royal Sundaram considering its contingent situation and high cost of premium if ported to other Insurer.
The End.
