DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION ERNAKULAM

       Dated this the 30^th  day of September 2024

                      Filed on: 08/08/2023

PRESENT

Shri.D.B.Binu                                                                        President

Shri.V.Ramachandran                                                           Member Smt.Sreevidhia.T.N                                                           Member

C.C. No. 552/2023

COMPLAINANT

Sabura Ebrahim Karim, W/o.Ebrahim Karim, Chakkapilliyil House, Market P.O., Muvattupuzha-686 673

(By Adv.Tom Joseph, Court Road, Muvattupuzha-686 661)

VS

OPPOSITE PARTY

M/s.Aditya Birla Health Insurance Company Ltd., R Tech Park, 10^th Floor,                      Nirlon compound, Off Western Express Highway Gorgeon(E) Mumbai-400 063 Rep. by its Managing Director.

F I N A L   O R D E R

V.Ramachandran, Member

1. A brief statement of facts of this complaint is as stated below:

This complaint is filed under Section 35 of Consumer Protection Act 2019 stating that the complainant is the beneficiary of the Group active Health policy of the opposite party since 22.07.2021.  Her 2^nd year policy No. is GHI-HB-22-2010485-V2.  While so, the complainant was admitted in Aster Medicity, Kochi on 08.08.2022 with the complaint of severe breathlessness.  The disease was diagnosed as Acute Right Vestibulopathy, Chronic bronchitis, Seronogative Arthritis, Diabetes, mellitus with neuropathy, Diabetes Mellituswith retinopathy, peripheral Vasscular Disease, Intermediate tear in left Supraspinatus tendon, systemic hypertension.  She was discharged on 11.08.2022.  She spent Rs.55000/- towards treatment expenses.  The cashless claim was rejected by the opposite party by their letter dated 09.08.2022 stating the reason that two years waiting period is applicable for arthritis.  Subsequently, a claim was lodged with the opposite party, but no reply is received to it so far.  The reason given for the rejection of the cash claim is not sustainable due to the fact that the diagnosed disease was not arthritis.  On the other hand she received treatment for various other ailments such as Acute Vestibuopathy (sudden disorders of the inner ear), chronic bronchitis, seronegative arthritis, diabetes Mellitus, Peripheral vascular disease and Systemic hypertension as clearly mentioned in the discharge summary.  It is also pertinent to note that arthritis has not been mentioned in the policy document as a disease excluded from policy coverage.  Hence the repudiation of the claim by raising flimsy reasons amounts to deficiency in service.  The complainant has been put to severe hardships and financial loss due to the non-settlement of the claim.  The complainant is entitled for the claim amount Rs.49,375/- along with interest @ 12% p.a. from the date of claim till realization.  It is stated by the complainant that she is also entitled for compensation to the tune of Rs.20,000/- for the hardships, financial loss and mental agony suffered by her due to the non-payment of the claim amount.

2. Notice

Eventhough the notice was issued to the opposite party from this Commission, they appeared and not filed version and hence the opposite party set ex-parte.

3. Evidence

Evidence in this case consists of the documentary evidences produced by the complainant which were marked as Exbt.A1 to A4.

4)     The following are the main points to be analysed in this case:

(i)       Whether there is any deficiency in service or unfair trade practice from the side of the opposite parties to the complainant?

ii)       If so, whether the complainant is entitled to get any relief from the side of the opposite parties?

(iii)     Costs of the proceedings if any?

5)      Point No.(i)

          Exbt.A1 goes to show that the complainant had subscribed into a  Group active Health Policy with Aditya Birla Capital hospital under Health insurance scheme and the policy was live from 22.07.2021 1 hr to 21.07.2022  23.59 hrs.  The complainant was admitted in hospital for treatment for various ailments on 08.08.2021 and discharged on 11.08.2021.  The total amount of Rs.49,375/- has been charged by the hospital whereas the complainant state that she had spent an amount of Rs.55,000/- towards treatment expenses.  Exbt.A4 is a claim repudiation letter issued by the opposite party. 

The Commission upon going through the complaint, and other documents produced by the complainant, it seen that the complainant had subscribed the insurance policy on 01.05.2021 only.  The reason for repudiation as per Exbt.A4 is that the opposite party had issued specific definitions where in the Waiting period means a time bound exclusion period related to condition (s) specified in the Policy Schedule or Certificate of Insurance or Policy which shall be served before a claim related to such condition(s) became admissible. The cashless claim rejected by the opposite party stating the reason that two years waiting period applicable only for arthritis and hence unable to prove the claim. 

In this case, the opposite party had not stated that the 2 year waiting period is required for other ailments and also clearly stated that it is required only for arthritics. The notice was seen served to the opposite party by the Commission which is properly acknowledged by the opposite party.  The opposite party had not turn up before the Commission for filing version and made any defense.  Obviously, this reluctant attitude of the opposite party towards the complainant amounts to deficiency of service and unfair trade practice.  Herein the instant case, it can be seen that even the opposite party themselves agrees that the 2 year time period is required only for getting coverage for arthritis.  The opposite party had not considered Ext.A2 from which it can be seen that the complainant was treated not only for Arthritis but for other ailments also. 

In this case, the complainant very clearly proves her case on merit and therefore the Commission issues orders as follows:

1. The opposite parties shall pay an amount of Rs.49,375/- (Rupees Forty nine thousand Three hundred and seventy five only) to the complainant which is the amount paid by the complainant towards his treatment which is covered under policy.
2. An amount of Rs.10,000/-(Rupees ten thousand five hundred only) shall be paid by the opposite party to complainant as compensation.
3. The opposite parties shall pay an amount of Rs.5,000/- (Rupees five thousand only) as cost of the proceedings to the complainant.

4. The liability of the opposite parties shall be jointly and severally.

The above order shall be complied with within one month from the date of receipt of a copy of this order failing which amount ordered vide (1) and (2) above shall carry interest @7.25% from the date of order till the date of realization.

  Pronounced in the Open Commission on this 30^th day of September 2024.

                                                                                           Sd/-

                                                                       V.Ramachandran, Member

                                                                                      Sd/-

                                                                             D.B.Binu, President

                                                                                       Sd/-

                                                                             Sreevidhia.T.N, Member

                                                                             Forwarded by Order

                                                          Assistant Registrar

APPENDIX

Complainant’s evidence

Exbt.A1      - Copy of the 1^st year policy document

Exbt.A2    - Copy of the discharge summary issued by Aster Medicity, Kochi

Exbt.A3      - copy of the inpatient bills (summary)

Exbt.A4      - copy of the rejection letter dated 09.08.2022.

                                                                             Assistant Registrar

Date of Despatch          ::

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