PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint No.- 157/2024

Present-Dr. Ramakanta Satapathy, President,

  Sri. SadanandaTripathy, Member,

Satrughna Khamari, Aged About 42 Years

S/O- Ramesh Khamari

At- Hatpada, Po-Jamankira,

Dist- Sambalpur, Pin- 768212                                            ..…………..Complainant

Versus

1. Aditya Birla Health Insurance Company Ltd

10^thfloor, R-Tech Park, Nirlon Compound

Goregaon East, Mumbai - 400063

2. Aditya Birla Health Insurance Company Ltd

Corporate Office 9^th Floor Tower-1, One India Bulls Centre, Jupiter Mills Compound- 841,  SenapatiBapat Marg Mumbai 400013

3. Axis Bank Limited, Rengali Branch

Near Post Office, Rengali, Sambalpur, Odisha

Pin-Branch Code-4338, Pin- 768212

4. Vikash Hospital

Near Central Honda Panchgachaia Sambalpur, Pin- 768006, Odisha

5. Apollo Hospital Interprise Limited, Apollo Health City Campus 

Film Nagar Jubli Hills Hydrabad, Pin- 500096

E-Mail- Apollohealthcity@Apollohospitals.Com

                                                                                    ……………………………... Opp. Parties

Counsels:-

1. For the Complainant         :- Sri. R.Gupta & Associates
2. For the O.P.No.1 & 2         :- Miss Nitu Roy & Associates
3. For the O.P. No. 3              :- Ex-parte
4. For the O.P.No.4                :- Sri. S. Dash & Associates
5. For the O.P.No.5                :- Sri. S.S. Panda & Associates

Date of Filing:03.05.2024,  Date of Hearing :21.10.2024,  Date of Judgement :03.12.2024

Presented by Dr. Ramakanta Satapathy, PRESIDENT

1. The case of the Complaint is that the Complainant is having a health policy No. 000556143601 dated 13.08.2020 obtained through O.P.No.3 from O.P.No.1 & 2. The master policy is 61-20-00054-00-00. Premium of Rs. 8000/- was given and sum assured is Rs. 5.00 lakhs. On regular basis insurance premium was given till 2023. On 03.08.2022 the Complainant visited Katarbaga P.H.C. for health check up and found blood pressure high. Doctor prescribed some medicines and Complainant became normal.

On 22.09.2023 the Complainant suffered from discomfort and tiredness, visited VIMSAR, Burla, ECG was done and suggested for surgical intervention. On 09.11.2023 the Complainant was admitted in O.P.No.4 hospital. The admission staff wrongly mentioned that he was suffering from hypertension since last 6 years. The Complainant paid Rs. 32,960/- to O.P.No.4. Thereafter admitted in O.P.No.5 hospital on 02.12.2023 for treatment under supervision of Dr. Vijay Dikshit, Dr. Sanjay Ku. Khulbey and P.C. Rath. The team performed the Aortic Surgical replacement with 21mm X mechanical valveand discharged on 13.12.2023 with normal health condition.

Claim No. 1222385144201 dated 22.11.2023 was made, pre-authorisation was rejected. Again on 30.11.2023 when O.P.No.1 & 2 were requested, the O.Ps rejected the claim.

Being aggrieved complaint has been filed.

2. The O.P.No.1 & 2 during judgement stage filed version through their advocate without serving copy to Complainant. However the version is taken into consideration. The insurer submitted that certificate of insurance submitted that certificate of insurance No. GHI-CM-22-2012556-004 for the period 07.10.2023 to 06.10.2024 was issued to the Complainant as part of Group Active Health insurance. Premium paid Rs. 7458/- and S.A. is Rs. 5.00 lakhs.

On 15.11.2023 claim No. 1222385144201 was received. The Complainant diagnoses hypertension for last six years and Acute Febrile illness severe Arotic stenosis psoriasis since 2 years and suppressed the fact. The company repudiated the claim vide letter dated 22.11.2023. The Complainant violated the terms and conditions of the policy and repudiation of claim is proper.

3. The O.P.No.3 is set ex-parte. The O.P.No.4 appeared and not filed any version. The O.P.No.5 submitted that the Complainant admitted in hospital on 02.12.2023 at 6.08.55PM under Dr. Vijay Dikshit, Dr. Sanjeev Ku. Khulbey and P.C. Rath with complaint of chest discomfort on extertion from 15 days. On evaluation the Complainant was diagnosed Severe Aortic Stenosis and suggested for surgical intervention. Using Del Nido Cardioplegia was done on 05.12.2023. Complainant submitted insurance policy and it was forwarded to insurer for cashless treatment on 28.11.2023 through hospital portal. The insurer denied cashless on the ground of non-disclosure of hypertension of 6 years and accordingly, the Complainant was admitted in O.P.No.5 as a cash patient.

The surgery was uneventful and the Complainant was stable and discharged on 13.12.2023 with a total bill of Rs. 4,41,760/- which was paid by Complainant. The O.P.No.5 is a proforma O.P.

4. Perused the documents filed by the parties. The Complainant submitted following documents:-

1. Aadhar Card No. 8833-7264-1777
2. Axis Bank A/C No. 919010072302873
3. Insurance Certificate No. GHI-CM-202008638
4. P.H.C. Katarbaga OPD ticket of 03.08.2022
5. VIMSAR, Burla OPD No. 42555 of 22.09.2023.
6. IPD Receipt 1931 of 09.11.2023 for Rs. 32,960/- of Vikash Hospital.
7. Appolo Hospital receipts of payment and discharge summary.
8. Rejection letter dated 22.11.2023.
9. Letter dated 29.11.2023 of insurer.
10. Letter dated 30.11.2023 if insurer.

The O.P.No.5 submitted detail bills payment of Rs. 4,41,760/-.

5. From the certificate of insurance it revealed that Master Policy No. 61-20-00054-00-00 and certificate No. GHI-CM-20-2008638 was issued by O.P.No.1 & 2 insurer for the period 13.08.2020 to 12.08.2021. Likewise Master policy No. 71-21-00044-00-00 certificate No. GHI-CM-21-2009218-V₂  was issued for the period 13.08.2021 to 12.08.2022. The policy was lastly renewed for the period 13.08.2021 to 12.08.2022. The policy was lastly renewed for the period 13.08.2023 to 12.08.2024 vide certofocate No. HGI-CM-22-2012556-004. The policy was valid during the period of surgical intervention at Appolo Hospital.

For the first time as an outdoor patient the Complainant went for check up on 03.08.2022 then in VSSIMSAR Burla on 22.09.2023 then in Vikash Hospital from 6.11.23 to 9.11.23 the expert diagnosed ‘ACUTE FEBRILE ILLNESS, SEVERE AORTIC STENOSIS and PSORIASIS. The Complainant then moved to Appolo Hospital, Hyderabad and admitted on 02.12.2023, undergone operation on 05.12.2023 and discharged on 13.12.2023 The patient was diagnosed “Bicuspid Aortic valve, severe Aortic stenosis, Trivial Tricusped Regurgitation and Normal LV function.

6. The Complainant applied for claim through ID No..1222385-144201 but it was rejected on 22.11.2023. The reconsideration request was also denied vide Letter dated 29.11.23. The pre- authorisation request-was also denied vide letter dated 30.11.2023. The insurer repudiated the claim on the ground of pre-existing disease like Hypertension since 6 years and acute febrile illness severe Aortic stenosis psoriasis since 2 years. For non-disclosure of information the claim was repudiated.

On what basis the O.Ps came to the conclusion that the complainant was Suffering since6 years due to hypertension acute febrile illness severe Aortic stenosis psoriasis since 2 years have not been disclosed. Further the O.Ps have not examined any witnesses nor any documents prove that the complainant was Suffering from alleged pre-existing disease. Here question arises the O.Ps continucing the policy since 13.8.2020 and every year the complainant hes been examined and the insurer failed to identify the alleged pre-existing disease. The insurer not applied their mind properly and repudiated the claim which amounts to deficiency in service.

Health policies are obtained by the ensured to meet the emergency situation and as discussed supra the complainant moving to one hospital from another since 03.08.2022. The insurer not provided the pre-authorisation request nor the final claim simply saying that due to pre-existing disease and Suppression of material information claim is rejected The ensures failed to establish the pre-existing disease and non dis-closure part Accordingly, rejection of claim is not proper.

7. Taking in to consideration the circumstances of the case the complainant is entitled for the relief claimed.

The Complainant paid/spent following amount to-wards his treatment.

9.11.2023             Rs. 32,960.00                                    Vikash Hospital.

13.12.2023           Rs 4,41,760.00                                  Appollo Hospital

                             Total Rs. 4,74,720.00

Accordingly, following order is passed:

ORDER.

The Complaint is allowed and O.P No..1 & 2 and dismissed against O.P.No.3,4 & 5. The O.P.No.1 & 2 are directed to pay Rs 4,74,720/ within one month of this order to the complainant, failing which the amount will carry 12% interest P.A. w.e.f. 13.12.2023 till realisation. The O.P.No.1 & 2 are directed to pay Compensation of Rs 50,000/- and litigation expenses of Rs 20,000/-.

Order pronounced in the open court on 3^rd day of Dec. 2024.

Supplied free copies to the parties.