District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.15/2022.
Date of Institution: .05.01.2022.
Date of Order: .09.11.2022.
Ajay Sharma, aged about 50 years son of Shri Mahendar Pal Sharma, resident of H.No.112, Sector -18, Faridabad, Haryana – 121001 Aadhaar No. 5271 8886 9458, mobile No. 9716243429.
…….Complainants……..
Versus
1. M/s. Aditya Birla Health Insurance Co. Ltd., 9th floor, Tower 1, One Indiabulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg ,Elphinstone Road, Mumbai – 400 013. Email:care.healthinsurance@adityabirlacapital.com through its Principal Officer/Director/Managing Director/Authorized Signatory.
Also at:
10th floor, R-Tech Park, Nirlon compound, Next to HUB Mall,Off Western Express Highway, Goregaon East Mumbai -400 063.
Also at:
Ist floor, SCO NO. 24, Sector-14, Gurgaon, Haryana – 122002.
2. Mr. Vivek, C/o Axis Bank Ltd., BK Chowk Branch, Faridabad, Haryana Mobile 9891506739.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana…………Member.
PRESENT: Sh. Sunil Kumar Jain, counsel for the complainant.
Opposite party No.1 exparte vide order dated 21.02.2022.
Opposite party No.2 exparte vide order dated 22.03.2022.
ORDER:
The facts in brief of the complaint are that the complainant had obtained a Family Medaicare Policy on dated 28.12.2010 in his own name, jointly with his wife Smt. Nidhi Sharma and his son namely Ansh Sharma form M/s. United India Insurance company Ltd., having its office at C-1, Suchita Complex, Ambedkar Marg, Ghaziabad and registered office at 24, Whites road, Chennai bearing policy No. 222000/48/11/06/00003058 for a total sum insured of Rs.1,00,000/- having premium of Rs.2195/-. The said policy was further renewed form time to time. The complainant was not suffering from any ailment or disease at the time of taking the said mediclaim policy, renewal and enhancement thereof from time to time. The complainant was not suffering from any ailment or disease at the time of taking the said nmediclaim policy, renewal and enhancement thereof from time to time. In the month of Feb. 2021, the opposite party No.2 being he representative of the opposite party No.1 had approached the complainant and induced him to port aforesaid policy into the policy being provided by the company “Aditya Birla Health Insurance co. Ltd. The opposie parties disclosed countless benefits about the policy and said that the policy of the opposite party company was the “King” in the market. At that time, the complainant was not suffering from any disease and upon receiving this fact, the opposite party No.2 assured that this policy was a fit policy to him and his family members. Upon believing the assurance given by opposite party No.2, complainant agreed to port his policy into the policy of opposite party No.1. After knowing the answers to some questions, the opposite party No.2 Had obtained complainant’s signature on a blank form and told him that he would complete the rest of the formalities on his own. Thereafter the opposite parties ported the complainant’s previous policy with the opposite party No.1 company and issued a policy bearing No. 23-20 0086542-00 in the name of the complainant “Mr. Ajay Sharma” under “Active Assure – Diamond” Plan, type “Family Floater” valid for a period from 27.02.2021 to 26.02.2022 for a sum insured amounting to Rs.5,00,000/-. At the time of porting the policy by enhancing the sum insured amounting to Rs.5,00,000/-, the complainant was not suffering any type of diabetes/disease. The complainant before porting the said policy with opposite party No.1 had not taken any benefit of claim with the previous insurance company since he was in well health. On 17.05.2021, the complainant was admitted to “Sarvodaya Hospital and Research Centre”, Gopi colony, Sector-19, Faridabad due to feeling shortness of breath and some cough and subsequently shifted to “Sarvodaya Hospital and Research Centre, Sectora-8, Faridabad for his treatment. The complainant discharged on 24.05.2021 in stable condition from the hospital. A sum of Rs.2,52,110/- had been claimed by the complainant as expenses incurred on his treatment. The complainant submitted a claim for Rs.2,52,110/- plus medical expenses of Rs.14,964/- total amounting to Rs.2,67,074/- by filing the claim on dated 31.05.2021. On 15.08.2021, a sudden medical health check was also conducted on the complainant by the authorized team of doctors of the opposite party No.1, at Health Life Medical Care Clinic,, 331, Sector-49, Gate NO.3, Sainik Colony, Faridabad. In the said check up, the diabetes level of the complainant was also found normal had been mentioned by the doctors at the [;ace of policy number of the complainant for the reasons best known to them. Vide letter dated 23.08.2021 addressed to the complainant, the opposite parties informed that they were unable to approve the reimbursement of claim on the ground that the complainant was admitted for treatment post covid status, pulmonary embolism and diabetes. The opposite party’s had arbitrary concluded that the complainant was suffering from diabetes Meletus for the last one year. The complainant had neither been diagnosed with diabetes in past nor he was permanent patient of diabetes. At the time of rejecting the genuine claim of the complainant through repudiation letter, opposite party No.1 had failed to reveal any documents prior to the date of the proposal, showing any treatment record of the complainant for diabetes. The disease of diabetes was a disease of normal life style. The decision of the opposite parties of inability to approve reimbursement of claim submitted by the complainant was an arbitrary and baseless decision, which proves that the opposite parties were engaged in the business of unfair trade practice and deficiency in service. The opposite party No.1 had not given any reference of any other document, either a treatment prescription or any other admission details, or any other hospital where the complainant was treated for diabetes during the past one year in their repudiation letter while rejecting the genuine claim of the complainant. In the absence of any sold proof or evidence to support the version of the opposite party No.1, the claim of the complainant could not be repudiated. The repudiation of claim was therefore arbitrary and untenable in the eyes of law. The complainant sent a legal notice dated 21.09.2021 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) reimbursement the claim of the complainant amounting to Rs.2,67,074/- with interest @ 18% p.a. to the complainant forthwith;
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 33,000 /-as litigation expenses.
2. Notice to opposite party No.1 not received back either served or unserved. Tracking details filed in which it had been mentioned that “Item Delivery confirmed”. Therefore, opposite party No.1 was hereby proceeded against ex-parte vide order dated 21.02.2022.
3. Case called several times since morning but none appeared on behalf of opposite party No.2. It was already 2.30p.m. Waited sufficiently. No more wait was justified. Hence, opposite party No.2 was hereby proceeded against ex-parte vide dated 22.3.2022.
4. The complainant led evidence in support of his respective version.
4 We have heard learned counsel for the complainant and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties – M/s. Aditya Birla Health Insurance Co. Ltd.with the prayer to: a) reimbursement the claim of the complainant amounting to Rs.2,67,074/- with interest @ 18% p.a. to the complainant forthwith; b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 33,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence Ex.CW1-A – affidavit of Ajay Sharma,, Ex.C-1 (colly) - insurance policy for the period 30.12.2011 to 29.12.2012, Ex.C-2 – Activ Assure Policy Schedule valid from 27.02.2021 to 26.02.2022, Ex.C-3 – Discharge summary, Ex.C-4 – Application Form, Ex.C-5 (colly) – Provisional Bill, Ex.C-6 – Health Assessment,, Ex.C-7 - letter dated 23.08.2021 , Ex.C-8 (colly) - legal notice, Ex.C-9 – lab test.
6. Opposite parties Nos.1 & 2, jointly & severally, are directed to:
a) pay the paid amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization.
b) pay Rs.2200/- as compensation on account of mental tension, agony and harassment.
c) pay Rs.2200/- as litigation expenses to the complainant.
Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 09.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
