Haryana

Ambala

CC/132/2022

Sh Mohinder Kumar - Complainant(s)

Versus

Aditya Birla Capital - Opp.Party(s)

C.M. Atri

04 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	132 of 2022
Date of Institution	:	28.04.2022
Date of decision	:	04.12.2024

Sh. Mohinder Kumar s/o Sh. Balak Ram R/o House No.175, Village Andheri Tehsil Naraingarh, District Ambala, Haryana (134203).

  ……. Complainant

                                                Versus

1. Aditya Birla Capital, Health Insurance Co. Ltd. 10^th Floor, R-Tech Park, Nirlon Compound, Goregaon East Mumbai-400063 through its Manager (Policy Issuance Office).
2. Aditya Birla Capital, health Insurance Co. Ltd. 7^th Floor, Modi Business Centre, Kasarvadavali, Thane (W) 400615 through its Manager (Policy Servicing Office).

                                                                                   ….…. Opposite Parties

Before:        Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Chander Mohan Atri, Advocate, counsel for the complainant.

                      None for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

a) To pay Rs.32,769/- i.e. the amount spent on treatment of wife of the complainant;

(b) To pay Rs.20,000/- as compensation on account of pain, mental agony  and physical harassment.

(c) To pay Rs. 20,000/- as cost of litigation.

                                      OR

Grant any other relief which this Hon’ble Commission may deems fit.

            

2.           Brief facts of the case are complainant is a businessman & by running his business & maintaining his family and he is having an account with Axis Bank, Branch Panjlasa, Naraingarh, District Ambala. Due to regular transactions/visiting terms, he was having good business terms with all staff members of said branch. On the suggestion of branch Manager of Axis Bank, complainant was convinced and allured to obtain a health policy of Aditya Birla Capital, Health Insurance Company Limited for coverage of his future illness as well as his family members. Suggestion and allurement given by the branch manager of Axis Bank, are accepted by complainant and he was introduced with Ms. Neha i.e agent of Aditya Birla Capital, Health Insurance Company Limited. On its first meeting Ms. Neha gave false assurance/allurement to complainant and considering the wrong/fake/false version as genuine, he was agreed to obtain a health policy from Aditya Birla Capital, Health Insurance Company. He paid an amount of Rs.17,500/- as premium and obtained a Health Insurance Policy vide policy No.61-20-00054-00-00, product Name Group Active Health, Certificate No.GHI-CM-20-2020260, unique identification number 414581931 for an amount of Rs.17,500/- including SGST & ICST from the period i.e 13.08.2020 to 12.08.2021, for sum insured Rs.15,00,000/- for himself as well as for his wife Smt. Kamlesh Devi. Up-till the fulfilling the complete period of above said policy everything was OK, however in the month of June/July, 2021 when wife of complainant had fallen ill due to fever, Complainant after discussion took his ill wife to Healing Touch Super Specialty Hospital, Sultanpur Chowk, Nr. Dhulkot Barrer, Ambala Chandigarh Expressway, Ambala, Haryana on 16.07.2021, as the same was a paneled hospital of Aditya Birla Capital Health Insurance Company & she was treated in the said hospital. She was admitted in the hospital and all the expenses of her treatment, admission, medicines etc. were to be borne by the insurance company i.e (Aditya Birla Sun Life) Aditya Birla Capital, Health Insurance Company Limited i.e OPs. To the utter surprises when Smt. Kamlesh Devi was discharged from said hospital on 18.07.2021, complainant was handed over a detailed bill of Rs.32,769/- to get his wife discharged from the said hospital,  he paid the said amount of Rs.32,769/-, from his own pocket. Healing Touch Super Specialty Hospital, Sultanpur Chowk, Nr. Dhulkot Barrer, Ambala Chandigarh Expressway, Ambala Haryana had forwarded a request letter to OPs to consider the claim  of complainant however a repudiation letter was received in this regard wherein claim was rejected on the ground that:- “On scrutiny of the documents it has been observed that Patient admitted for AFI with Mediastinal Lymphadenopathy which enlargement of the mediastinal lymph nodes has 2 years waiting period hence claim denied and hence we are unable to approve the claim”. As per clause IV Waivers and Discounts available for customization for the coverage Number Mentioned 42. Specified disease/procedure waiting period: (Code-Excl02) a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident. B) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase. C) If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply. D) The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion. E) If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage. F) List of specific diseases/procedures as mentioned in policy wordings if any of the Illness/conditions listed above are Pre-Existing Diseases, then they will be covered only after the completion of the pre-Existing Disease Waiting Period described under Section & It & IT;41 & gt; & gt;. It is further stated that cashless denial is not the complete final denial of claim. Complainant approached and requested to OPs several times to pay the amount of expenses incurred on account of admission, treatment, medicines etc. however till today no amount is being paid by the OPs and delaying/putting the matter on one pretext or the other, hence aggrieved from the same complainant had forwarded a regd. A.D. Notice to the OPs on 22^nd November 2021, which was duly served on the OPs. Complainant is legally entitled for the amount of expenses incurred on account of admission treatment, medicines etc. however unlawful denial at the end of OPs is an arbitrary act & conduct which is not accepted in the eyes of law. Hence the present complaint.

3. Upon notice, the OPs appeared and filed written version and raised preliminary objections with regard to maintainability, no locus standi, estoppal, not come with clean hands and has concealed the true and material facts etc. On merits, it has been stated that at the time of purchase of the policy the complainant did not disclose the above mentioned medical history/health detail in the proposal form which amount to misrepresentation/non-disclosure of the material facts. Hence, as per the terms and conditions of the policy as mentioned above the claim of the complainant was not payable as there was a waiting period of 24 months from the inception of the first policy. Moreover had the complainant disclosed the above pre-existing diseases at the time of purchase of the policy the OPs would not have issued the policy. Keeping in view the above mentioned facts and violations of the terms and conditions of the policy the claim for the reimbursement of the amount was rejected by the OPs, in this regard the rejection was conveyed to the insured. It is pertinent to mention here that as per the terms and condition of the policy the complainant/insured is duty bound to disclose all material facts in proposal form while buying an insurance policy. Hence, the complainant intentionally and deliberately violated the cardinal principal of insurance and making the contract of insurance violable and enforceable. As per the contract of insurance it was the duty of the proposer to disclose all the material fact to the insurer, so that the insurer has opportunity to evaluate the material facts and to decide whether to accept to proposal or not and as per the health insurance contract it is the duty of the proposer to disclose all past medical history in the proposal form for which the complainant totally failed in this regard. It is further stated that there was no allurement on the part of the OPs for purchase of the present policy. The complainant himself purchased the policy from his free will. It is further stated that after admission of Smt. Kamlesh Devi in the above said hospital, documents regarding cashless facility were received by the answering OPs and after going through the same, it was opined that the illness suffered by Smt. Kamlesh Devi was not covered under the cashless scheme hence the cashless request was rejected by the complainant as per the rules, terms and conditions of the policy.It is further stated that the OPs received a letter issued from the above said hospital regarding the clarification of the disease of the complainant but after going through the letters as well as the documents produced by the complainant the claim of the complainant was not payable as earlier stated above. Hence the claim of the complainant was rejected. As earlier stated that as per the terms and condition of the policy there was a waiting period for 24 months for the treatment of above mentioned illness suffered by the complainant, hence the claim was repudiated by the answering OP. It is further stated that the OPs are always committed to serve their customers with all efforts under the legal obligations. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.

4.           Learned counsel for the complainant tendered affidavit of the complainant and affidavit of Kamlesh Devi wife of Shri Mohinder Kumar, R/o House No.175, Village Andheri, Tehsil Naraingarh, District Ambala, Haryana (134203) as Annexure CW1/A and CW2/A respectively alongwith documents as Annexure C-1 to C-11 and closed the evidence on behalf of complainant.  However, it is pertinent to mention here that the OPs failed to lead any evidence despite availing various opportunities, therefore, evidence of the OPs have been closed by the order of this Commission on 21.05.2024.
5.           On the date of arguments, none put in appearance on behalf of the OPs, therefore, we have heard the learned counsel for the complainant and have also carefully gone through the case file.
6.           Learned counsel for the Complainant submitted that by repudiating the genuine claim despite the fact that his wife took treatment under subsistence of the policy in question, the OPs have indulged into unfair trade practice and were also deficient in providing service.
7.           The issue which demands careful consideration of this Commission is whether the claim made by the complainant concerning the treatment received by his wife on 16.07.2021, during the valid term of the policy (from 13.08.2020 to 12.08.2021 as specified in Annexure C-3), was correctly rejected by the OPs or not. The OPs have categorically stated that the claim was denied because the complainant’s wife had received treatment at Healing Touch Hospital for Acute Febrile Illness (AFI) with Mediastinal Lymphadenopathy — a condition which, according to their policy, would only be covered after a waiting period of 2 years from the commencement of the policy. However, a careful review of the relevant medical documents paints a different picture.  The PLAN OF CARE document dated 16.07.2021, Annexure C-4, clearly outlines that Kamlesh Devi, the wife of the complainant, was admitted to the Healing Touch Hospital primarily due to fever that had been persistent for a month, along with other symptoms such as cough and exertion. The treatment she received was directly related to these issues, and she was billed Rs.32,769/- for the medical care/treatment, as per the bill presented in Annexure C-5, which was paid by the complainant only, as the OPs did not allow the same. Despite this, the OPs sent a letter dated 17.07.2021 (Annexure C-6), denying the claim on the grounds that the treatment was for Acute Febrile Illness (AFI) with Mediastinal Lymphadenopathy.
8.           According to the OPs, this condition was subject to a waiting period of 2 years under the policy terms. The OPs failed, however, to provide any solid evidence to support their claim that Kamlesh Devi was being treated for AFI with Mediastinal Lymphadenopathy, or that she was suffering from this condition at all. On the other hand, the complainant has submitted a certificate from the treating doctor at Healing Touch Hospital (Annexure C-7), which explicitly states that the treatment provided was for fever, and there was no mention of AFI with Mediastinal Lymphadenopathy as the underlying diagnosis. The doctor’s certificate further indicates that the hospital had requested the OPs to expedite the claim processing on priority.
9.           It is significant to note that the OPs did not offer any rebuttal or evidence challenging the validity of Annexure C-7, nor did they dispute the clear statement made by the attending physician therein. In the absence of any evidence from the OPs to contradict this document, it is reasonable to place full reliance on the statement made by the treating doctor, which directly refutes the OPs' claim that the treatment was for a condition subject to the waiting period.
10.           Given these facts, it is evident that the OPs' rejection of the complainant’s claim was arbitrary and without sufficient justification. Their failure to provide any supporting documentation or evidence in defense of their decision renders the rejection of the claim not only unjustified but also indicative of a deficiency in service and an unfair trade practice on their part.
11.           In conclusion, the OPs acted in a manner that is both legally and ethically indefensible. The decision to deny the claim, despite clear evidence to the contrary, reflects a failure to meet their obligations under the policy, and this act amounts to an unfair trade practice. Therefore, the rejection of the claim must be considered invalid, and the complainant is entitled to relief for the wrongful denial of his claim.
12.           In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-
    1. To pay/reimburse the amount of Rs.32,769/-, to the complainant alongwith interest @6% p.a.  w.e.f 17.07.2021, the date on which the claim was declined, till realization.  
    2. To pay Rs.5,000/-, as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.3,000/-, as litigation expenses.  

The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 04.12.2024

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President