Delhi

North East

RBT/CC/159/2022

KEWAL SINGH - Complainant(s)

Versus

ADITYA BIRLA HEALTH INS.CO.LTD. - Opp.Party(s)

17 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

RBT/Complaint Case No.159/22

In the matter of:

 

	Kewal Singh, R/o D-105, West Upper Ground Floor, Nawada Housing Complex, Delhi 110059	Complainant
	Versus
1.               2.           3.               4.	Aditya Birla Health Insurance Co. Ltd., Through its Chairman Ist Floor, HDFC House, 10th Floor, R-Tech Park, Nirion Compound Next To HUB Mall Off, Western Express Highway, Goregaon East, Mumbai 400063   Aditya Birla Health Insurance Co. Ltd., Though its Manager Office No. 103 & 105, HB Twin Tower 1, 1st Floor, Above Starbucks Coffee, Near D Mall, Pitampura Delhi 110034   Aditya Birla Health Insurance Co. Ltd., Through its Manager 605, 6th Floor, Mahatta Tower B1, Janakpuri, C-Block, Janakpuri, C-Block Community Center, Janakpuri, New Delhi 110058   Royal Sundram General Insurance Co. Ltd., Through its Manager 21, Patullos Road, Chennai 600002	Opposite Parties

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

14.11.2018 11.08.2023 17.10.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

 

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant has taken a policy from the Opposite Party No. 4 vide policy       no. HLSBIL0013 which was valid from 19.02.2008 to 30.03.2018. On 31.03.2018, Complainant got ported his policy from Opposite Party No. 4 to Opposite Party No. 1 and paid a premium of Rs. 21,717/-. Opposite Party No. 1 and Opposite Party No. 2 issued a policy no. 13-17-0017205-00 which was valid from 30.03.2018 to 30.03.2019. On 13.07.2018, Complainant was admitted in Mata Roop Rani Maggo & Mahindru Hospital Pvt. Ltd., Delhi for feeling Chest pain on the left side with radiating to left shoulder with Ghabrahat with palpitation with profuse sweating with vomiting plus with nausea and pain for 2-3 days. It is his case that after final diagnosis, it was found that Complainant was suffering from ACS with Cad with DM with HTN. Complainant was discharged on 14.07.2018. It is his case that on the same day of admission to the hospital, the hospital authorities had sent an intimation letter through e-mail to Opposite Party No. 1 and Opposite Party No. 2 about the cashless hospitalization of the Complainant. On 20.07.2018, Complainant submitted his claim of Rs. 24,250/- to the Opposite Party No. 3 along with all the original documents. After submission of the claim papers, the Complainant received a claim repudiation letter dated 01.08.2018 in which the claim was rejected on the ground that the Complainant was a patient of diabetes and hypertension since 5 years which was not disclosed on proposal form. In the month of August, 2018, the Complainant received an e-mail by the Opposite Party No. 1 regarding repudiation claim and forfeited his policy amount due to presumed misrepresentation, mis-description or non-disclosure of any material fact that had not been specifically mentioned. It is his case that again on 24.07.2018, Complainant felt chest pain and he was taken to the Safdarjung Hospital, New Delhi for the treatment where he was advised to purchase two stents. Complainant had paid Rs. 72,074/- for the stents and Rs. 1,944/- for tests and other charges i.e. total Rs. 74,018/-. It is his case that after repudiation of the genuine claim vide letter dated 06.08.2018, the Complainant sent an e-mail on 10.08.2018 to the Opposite Party No. 1 to return his documents which were submitted by him for reimbursement and Opposite Party No. 1 sent the original documents through courier. After discharge from the hospital, Complainant submitted his claim documents to Opposite Party No. 2 for reimbursement. After that the Complainant visited the office of Opposite Party No. 2 and they stated that on 26.09.2018, they sent an email and stating that regarding investigation of the concern would be informed in next 48 hours in case any additional clarification are required but the Opposite Party No. 1 did not confirm. On 15.10.2018, Complainant received third time e-mail from the Opposite Party No. 1 stating that the Complainant would receive a call within 48 hours about the current status but they did not give any reply. Hence, this shows the deficiency of service on the part of Opposite Parties. Complainant has prayed to direct the Opposite Party No. 1 to restore and continue the health insurance policy from 2008 and to bear the amount claimed for treatment during the pendency of the complaint. Complainant also prayed for Rs. 98,268/- along with interest @ 24% p.a. w.e.f 04.09.2018, Rs. 2,00,000/- on account of mental harassment and    Rs. 1,00,000/- on account of litigation expenses.

Case of the Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3

2. The Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 contested the case and filed their common written statement. It is stated that the complaint is without any merit. It is alleged that the Complainant has concealed the material facts at the time of purchasing the health insurance policy. It is alleged that the Complainant had a history of diabetes and hypertension since 5 years but this fact was not disclosed by him in the proposal form. It is stated that due to high blood pressure i.e. hypertension, health problems occur such as heart disease etc. It is admitted that at the relevant time the Complainant had a valid insurance policy issued by them. It is stated that as the Complainant has concealed his previous ailment so there was a violation of terms and conditions of the health insurance policy and accordingly his claim was repudiated.

Case of the Opposite Party No. 4

3. The Opposite Party No. 4 contested the case and filed its written statement. It is stated that the Complainant was issued health insurance policy in his name by it and the same was affected from 19.02.2008 to 18.02.2009 and thereafter the same was renewed every year and it was lastly renewed from 31.03.2017 to 30.03.2018. It is stated that the said health insurance policy was subject to the terms and conditions of the policy. It is stated that subsequently, the Complainant has obtained health insurance policy from Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3. It is prayed that the complaint be dismissed.

Rejoinder to the written statement of Opposite Parties

4. The Complainant filed rejoinder to the written statement of Opposite Party No. 1, Opposite Party No. 2, Opposite Party No. 3 and Opposite Party No. 4, wherein the Complainant has denied the pleas raised by the Opposite Party No. 1, Opposite Party No. 2, Opposite Party No. 3 and Opposite Party No. 4 and has reiterated the assertion made in the complaint.

Evidence of the Complainant

5. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3

6. To support their case Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 have filed affidavit of Shri Vikram Jain, wherein, he has supported the case of the Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 as mentioned in the written statement.

Evidence of the Opposite Party No. 4

7. To support its case Opposite Party No. 4 has filed his affidavit of Shri V. Harishankar, wherein, he has supported thecase of Opposite Party No. 4 as mentioned in the written statement.

Arguments & Conclusion

8. We have heard the Ld. Counsels for the Parties. We have also perused the file and written arguments filed by the Complainant and Opposite Parties. The case of the Complainant is that at the relevant time he was having a valid health insurance policy issued by Opposite Party No. 1, Opposite Party No. 2 and Opposite Party   No. 3. His case is that he was admitted in hospital for treatment of chest pain on the left side with radiating to left shoulder with ghabrahat with palpitation with profuse sweating with vomiting plus with nausea and pain for 2-3 days. It is his case that his claim was wrongly rejected by the Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 and therefore there is deficiency of service on their part. On the other hand, the case of Opposite Party No. 1, Opposite Party No. 2 and Opposite Party No. 3 is that at the time of obtaining the health insurance policy, the Complainant has concealed his previous ailment i.e. diabetes and hypertension. It is their case that the said concealment of the previous ailment is violation of the terms and conditions of the health insurance policy and therefore, the Complainant is not entitled to claim any amount from them. It is their case that as the Complainant was suffering from high blood pressure and if a person suffers from high blood pressure for a considerable time then it causes heart ailments etc. The case of the Opposite Party No. 4 is that the complaint is not maintainable against it and therefore, the complaint deserves dismissal.
9. The Complainant has filed the copy of treatment card/record of Mata Roop Rani Maggo & Mahindru Hospital. The perusal of the same shows that it mentions about the past medical history of the Complainant which is hypertension and diabetes mellitus and was on regular treatment. The Complainant has also filed the copy of discharge summary of Mata Roop Rani Maggo & Mahindru Hospital and perusal of the same shows that the Complainant was a known case of hypertension and diabetes and he was on regular treatment. The final diagnosis which was made by the said hospital is ACS with Cad with DM with Hypertension. The Opposite Party No. 1 and Opposite Party No. 2 have argued that the hypertension can lead to heart problem. This is a well known fact that in the present case the Complainant was treated and diagnosed as ACS with Cad with DM with Hypertension. The Complainant has not led any evidence that he was not having any previous ailment of diabetes and hypertension as alleged by the Opposite Parties and reflected in the medical record of Mata Roop Rani Maggo & Mahindru Hospital. Therefore, it is clear that the Complainant has concealed his previous ailments of diabetes and hypertension in the proposal form which amounts to violation of terms and conditions of the health insurance policy. Therefore, the Complainant is not entitled for any relief. Hence, the complaint is dismissed.
10. Order announced on 17.10.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)