Date of filing:- 28/07/2023.
Date of Order:-16/07/2024.
DISTRICT CONSUMER DISPUTE REDRESSAL COMMISSION
B A R G A R H (ODISHA).
Consumer Complaint No. 106 of 2023.
- Dr. Arun Kumar Sharma, Aged about 45(forty five) years, S/o Paramanda Sharma.
- Mrs. Jyoti Kiran Sharma, Aged about 45(forty five) years, W/o Dr. Arun kumar Sharma.
Both residents of Po. Kodobahal Attabira, Bargarh, Odisha-768102 Email: Complainant.
-: V e r s u s :-
- Aditya Birla Health Insurance Co. ltd., through its Managing Director, having Registered Office At: 9th Floor, Tower-1, One World Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400615, Email: th Floor, Tower-1, One World Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400615, Email: st Floor, Harichitra Tower, Plot No. 1792/3923, Unit No. 5, Near AIR Colony, VSS Marg, Sakhigopinath, Sambalpur-768001, Odisha.
- Mr. Manas Mahapatra, Officer of M/s Aditya Birla Health Insurance Co. ltd. Working at: 1st Floor, Harichitra Tower, Plot No. 1792/3923, Unit No. 5, Near AIR Colony, VSS Marg, Sakhigopinath, Samblapur-768001, Odisha.
- Mr. Vikram Pradhan, Officer of M/s Aditya Birla Health Insurance Co. Ltd. Working at: 1st Floor, Harichitra Tower, Plot No. 1792/3923, Unit No. 5, Near AIR Colony, VSS Marg, Sakhigopinath, Sambalpur-768001, Odisha. ..... ..... ..... Opposite Parties.
Counsel for the Parties:-
For the Complainant :- Sri A.K.Dash, Advocate with associates.
For the Opposite Parties :- Miss Nitu Roy, Advocate with associates.
-: P R E S E N T :-
Smt. Jigeesha Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Smt. Anju Agrawal ..... ..... ..... ..... ..... M e m b e r (W).
Dt.16/07/2024. -: J U D G E M E N T:-
Presented by Smt. Jigeesha Mishra, President:-
1) The case of the Complainants is that Complainant No.1(one) and No.2(two) are the member of the same family and took a family health insurance policy “Family Floater Scheme” from the Opposite Party No.1(one). In the year 2019, the Complainants took a heath policy from a company namely Apollo Munich Health Insurance Co. Ltd. now known as “HDFC” Ergo and later switched to another policy namely Active Health-Family Floater Policy from Opposite Party No.1(one) for availing better benefits and coverage. From onwards the year 2019, the Complainant No.1(one) has been regularly paying the premium towards renewal of the health policy. The Complainant No.1(one) had paid premium of ₹ 14,698/-(Rupees fourteen thousand six hundred ninety eight)only towards the policy for the financial year ending 2021, further an amount of ₹17,112/-(Rupees seventeen thousand one hundred twelve)only was paid as premium towards renewal of the policy for the financial year 2020 and an amount of ₹ 19,533/-(Rupees nineteen thousand five hundred thirty three)only was paid for the financial year 2023. Unfortunately on 09-12-2022, the Complainant No.2(two) namely Mrs Jyoti Kiran Sharma, wife of the Complainant No.1(one) got diagnosed with cancer disease at Ramakrishna Care Hospital, Raipur. Thereafter on 17-12-2022 the Complainant No.2(two) was consulted and admitted on 19-12-2022 at Rajiv Gandhi Cancer Institute and Research Centre for her treatment. The Complainant No.1(one) informed the Opposite Parties about hospitalization of the Complainant No.2(two) and applied for cashless facility on 20-12-2022. On 22-12-2022 the Opposite Parties acknowledged the request for cashless facility but the Opposite Parties neither made payment nor came forward for settlement of the bills of medical expenses which ultimately had to be borne by the Complainant No.1(one) solely out of his own pocket. Subsequently the Complainant No.1(one) applied for reimbursement of medical expenditure by submitting all original medical bills physically at their Sambalpur branch office i.e. Opposite Party No.3(three) which was also denied by the Opposite Parties. On 10-01-2023 the Opposite Parties had asked the Complainants to re-submit the claim along with supporting documents of hospitalization and medical expenses at Sambalpur branch, but the Opposite Parties vide letter dated 11-01-2023 denied/repudiated the claim on reason of “non-disclosure”. The Opposite Parties rejected the claim that the Complainant No.2(two) had not disclosed that she is having Asthma for 18(eighteen) years. On 30-03-2023 the Complainants through their advocate issued a legal notice to the Opposite Parties for payment of an amount of ₹ 18,43,351/-(Rupees eighteen lakh forty three thousand three hundred fifty one)only towards medical expenses. Despite receipt of the legal notice the Opposite Parties have neither paid any amount nor had given any response. Hence the Complainant filed this case before this Commission.
2) The case of the Opposite Parties is that Opposite Parties No.1(one) to No.5(five) Aditya Birla Health Insurance Company Limited filed its version. The Opposite Parties admitted that the Policy No. 11-19-004835-01-00 was issued by the Opposite Parties by receiving proposal from the Complainant No.1(one) for the period from 31-03-2020 to 30-03-2021. Further the policy was renewed vide Policy No. 21-19-0049835-01-00 for the period 31-03-2021 to 30-03-2022 and second renewal vide Policy No. 21-19-0049835-02 for the period from 31-03-2022 to 30-03-2023. The Opposite Parties submitted that after scrutiny it came to the knowledge of the Opposite Parties that the Complainant was known case of Chronic Obstructive Pulmonary Disease (COPD) before the inception of the policy i.e. these are the pre-existing disease/chronic conditions prior to policy inception which the Complainants had knowingly suppressed in the proposal form. Hence the Opposite Parties rejected the claim vide letter dated 10-03-2023. There is no any deficiency on the part of the Opposite Parties.
3) Perused the complaint petition, version and documents filed by the Parties and following issues are framed.
Issues
- Whether the Opposite Parties are deficient in service ?
- Whether the Complainant is entitled to get relief ?
Issue No.1(one)
4) The policy is admitted and the Complainant No.2(two) admitted in Rajiv Gandhi Cancer Institute and Research Centre, New Delhi during the currency of the policy on 19-12-2022 and discharged on 21-12-2022. The Complainant produced bills of treatment for the period from 19-12-2022 to 21-12-2022 for an amount of ₹7,33,339/-(Rupees seven lakh thirty three thousand three hundred thirty nine)only. But the Opposite Party denied the cashless request and subsequently on 11-11-2023 repudiated the claim on the ground that the Complainant did not disclose about the pre-existing disease during the time of policy inception. After perusal of record it reveals that the letter dated 31-03-2021 issued by the insurance company Aditya Birla Health Insurance Company Limited provides some of the important features of the policy. As per that letter the policy covers from day 1(one) for chronic illness like Asthma, high blood pressure, high cholesterol, diabetes and modern treatment method covered like stem cell therapy, robotic surgeries, oral chemotherapy and more. When the policy covers chronic illness from day one there is no need of repudiation on the ground of non-disclosure of chronic disease. Hence the repudiation is improper. When the policy is admitted and during the currency of the policy the Complainant No.2(two) admitted and produced bills of treatment, it was the duty of the Opposite Party to settle the claim. But the Opposite Parties did not settle the claim which amounts to deficiency in service on the part of the Opposite Parties. The issue is answered accordingly.
Issue No.2(two)
5) For deficiency in service of the Opposite Parties the Complainant is entitled to get relief. The issue is answered accordingly.
As per supra discussion the following order is passed.
O R D E R
6) The Complaint is allowed on contest against the Opposite Parties. The Opposite Parties are directed jointly and severally to pay ₹ 7,33,339/-(Rupees seven lakh thirty three thousand three hundred thirty nine)only to the Complainant within one month from the date of this Order. Further the Opposite Parties are directed to pay ₹ 40,000/-(Rupees forty thousand)only compensation for deficiency in service and ₹ 10,000/-(Rupees ten thousand)only for litigation expenses to the Complainant. Failing which the entire awarded amount shall carry 12%(twelve percent) interest per annum till realization.
7) Accordingly the order is pronounced in the open Commission to-day i.e. Dt.16/07/2024 and the case is allowed against the Opposite Parties and disposed off.
Typed to my dictation
and corrected by me.
I agree, ( Smt.Jigeesha Mishra)
P r e s i d e n t.
(Smt. Anju Agrawal)
M e m b e r(w).
