District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.47/2021.
Date of Institution: 25.01.2021.
Date of Order: 18.10.2022.
Sudhir Chandila son of Sh. Shree Chand, resident of H.NO. 371, Block No. 12, Fatehpur Chandila, Faridabad.
…….Complainant……..
Versus
Aditya Birla Health Insurance Co. Ltd., Office No. 104 and 105, H.B.Twin Tower I, Ist floor, above Starbucks Coffee, Near D Mall, Pitampura, New Delhi – 110 034, through its Branch Manager/Manager Claim.
…Opposite party……
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. Rajpal Singh, counsel for the complainant.
Sh. Parveen Gupta, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that previously complainant was having mediclaim policy under Bajaj Allianz General Insurance Company Limited in the name of the complainant, his family members. The policy No. was OG-16-1124-8421-00000256 since 3.2.2016 and the same was renewed time to time. Previously the policy in question was renewed form 11.3.2019 to 10.3.2020 under Bajaj Allianz General Insurance Co. Ltd. Bearing policy No. OG-20-1124-8421-000058. The representative of the opposite party contacted to the complainant and told that the opposite party was the sister concern of Bajaj Allianz and issued the policy under opposite party bearing policy No. 13-19-0150615-00. All the insurance policies were taken by the representative of the opposite party. The representative also enquire about the benefit taken under the previous policies. The complainant handed over the documents to the opposite party as the complainant had taken the claim for his wife once in the year of 2017 as she fallen ill. The representative of the opposite party issued the cover note of the policy and the previous number was mentioned in the policy issued by the opposite party, thus the opposite party issued the policy after enquiry and perusing all the documents of claim taken by the complainant and the policy was valid from 12.3.2020 to 11.3.2021. Unfortunately the wife of the complainant had a pain in abdominal and ghabarahat and due to that the complainant got admitted his wife Mrs. Anju in Asian Institute of Medical Science, Sector-21A, Faridabad on 17.6.2020 where she remained admitted. At the time of investigation and medical checkup this fact was intimated immediately the opposite party. The complainant’s wife Mrs. Anju was discharged from the above noted hospital where required treatment was given. The complainant had spent Rs.50,827/- on the said treatment. The complainant asked the opposite party for cashless treatment for the mediclaim of the treatment of his wife but the opposite party denied the clai
m of the complainant by saying that ailment being pre-existing to policy thus cashless cannot be accorded. Inspite of repeated request the opposite party did not pay heed to the request of the complainant and did not approve the claim on the ground, non-disclosure of hypertension and diabetes mellitus. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay Rs.44,000/- to the complainant which was spent by him in repairing of the vehicle alongwith interest @ 24% per annum.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the insurance company was in receipt of duly filled and signed proposal form from complainant for issuance of insurance policy on health of Mr. Ashish Kumar Singh (the complainant) alongwith his wife and 4 dependent kids. Specific questions were asked in the proposal form with respect to medical history of all the insured including complainant and all the questions were responded in negative by the proposal form. Believing the details given by the complainant to be true correct and complete, insurance company issued the subject policy as per the details mentioned below:
Policy No. : 13.19-0150615-00
Product : Active Assure
Policy Plan : Active Assure Diamond
Life assured : Mr. Sudhir Chandila
Mrs. Anju
Mr. Gautam
Miss. Bhavya
Miss. Aarti
Miss. Bharti
Policy start date : 12.03.2020
Expiry date : 11.03.2021.
Policy Tenure : 1 year
Sum insured : 5,00,000
It was pertinent to bring to the notice of this Hon;ble Complainant that complainant retained policy documents and did not raise any objection towards the policy during the said period for cancellation with any grievance regarding the policy or its terms and conditions, meaning thereby that complainant had agreed to the policy and its terms and conditions. As per the terms and conditions of subject policy as well as settled principles of law the subject policy contract continued on its implied acceptance by complainant. Thereafter insurance company was in receipt of pre-authorization form for cashless claim under subject policy in respect of treatment of the complainant at Asian Institute Of Medical Sciences for hospitalization from 17.06.2020 from the hospital under subject policy alongwith medical documents for claiming Rs.88,000/-. The opposite party was having right to investigate the truthfulness of the claim and to conduct the verification process for claim as the insurance laws. During the verification process, the opposite party came to know about the suppression of material facts as to medical history complainant. It was revealed that there was non-disclosure of hypertension and diabetes mellitus. Complaints since 2-2.5 years as per proposer’s declaration. Thus insurance company was unable to process the claim of the complainant and hence the same was rejected by letter dated 19.06.2020. In view of above fraud came to knowledge of the opposite party within the three years from the date of policy hence the active concealment of fact on the part f the insured renders the claim liable to be repudiated on the ground of fraud as the action of the insured action were fitted to deceive the opposite party for the purpose of procuring the policy from the opposite party hence the act of omission and commission of insured for claiming the fraudulent insurance claim clearly falls under the ambit and scope of fraud as specifically defined under the Insurance Act. It was further stated that onus to proof that there was no fraud while procuring the policy lies on the shoulder of the insured/complainant. In view of provision and law settled under the Insurance Act claim of insurance was rightly repudiated by the company in view of provision of Section 45 of Insurance Act. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Aditya Birla Health Insurance co. Ltd. with the prayer to: a) pay Rs.44,000/- to the complainant which was spent by him in repairing of the vehicle alongwith interest @ 24% per annum. b)pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Sudhir Chandila,, Ex.C-1 – Star Package Policy, from 02.02.2016 to 01.02.2017,, Ex.C-2 – 22.2.2017 to 21.2.2018, Ex.C-3 – 22.2.2018 to 21.02.2019, Ex.C-4 –11.03.2019 to 10.03.2020, Ex.C-5 - policy from 12.03.2020 to 11.3.2021, Ex.C-6 – letter dated 12.03.2020, Ex.C-7 – repudiation letter dated June, 19,2020, Ex.C-8 – letter regarding additional information needed, Ex.C-9 – discharge summary, Ex.C-10 – final bill summary
Shri Parveen Gupta, counsel for opposite party has made a statement
that written statement filed by opposite party may be read as evidence on behalf
of opposite party and closed the same vide order dated6.9.2022. As per evidence of opposite party, Annexure 1 - Active Assure Diamond Proposal Form – online, Annexure -2 – letter dated 19.06.2020,
6. In this case, previously complainant was having mediclaim policy under Bajaj Allianz General Insurance Company Limited in the name of the complainant, his family members. The policy No. was OG-16-1124-8421-00000256 since 3.2.2016 and the same was renewed time to time. Previously the policy in question was renewed form 11.3.2019 to 10.3.2020 under Bajaj Allianz General Insurance Co. Ltd. Bearing policy No. OG-20-1124-8421-000058. The representative of the opposite party contacted to the complainant and told that the opposite party was the sister concern of Bajaj Allianz and issued the policy under opposite party bearing policy No. 13-19-0150615-00. All the insurance policies were taken by the representative of the opposite party. The representative also enquire about the benefit taken under the previous policies. The complainant handed over the documents to the opposite party as the complainant had taken the claim for his wife once in the year of 2017 as she fallen ill. The representative of the opposite party issued the cover note of the policy and the previous number was mentioned in the policy issued by the opposite party, thus the opposite party issued the policy after enquiry and perusing all the documents of claim taken by the complainant and the policy was valid from 12.3.2020 to 11.3.2021. Unfortunately the wife of the complainant had a pain in abdominal and ghabarahat and due to that the complainant got admitted his wife Mrs. Anju in Asian Institute of Medical Science, Sector-21A, Faridabad on 17.6.2020 where she remained admitted. At the time of investigation and medical checkup this fact was intimated immediately the opposite party. The complainant’s wife Mrs. Anju was discharged from the above noted hospital where required treatment was given. The complainant had spent Rs.50,827/- on the said treatment. The complainant asked the opposite party for cashless treatment for the mediclaim of the treatment of his wife but the opposite party denied the claim of the complainant by saying that ailment being pre-existing to policy thus cashless cannot be accorded. Inspite of repeated request the opposite party did not pay heed to the request of the complainant and did not approve the claim on the ground, non-disclosure of hypertension and diabetes mellitus.
7. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 18.10.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
