FINAL ORDER/JUDGEMENT

SHRI REYAZUDDIN KHAN,MEMBER

This is an application U/S.34 read with 35 of the C.P Act  of 2019. The case of the complainant in brief is that the complainant took a family Health Insurance Plan,being “Group Active Health” (Mediclaim) from the OPs.The Policy no is GHI-22-2611358-V2.Earlier the complainant had the same mediclaim policy with one Bajaj Alliance Company.Later,the insurance policy was changed from Bajaj Allaince to the OPs company ie,Aditya Birla Health Insurance Company Limited without the consent and information to the complainant.The complainant stated that the pre-existing waiting period was 2 years,commencing from 2020.The complainant had fulfilled the said waiting period and had also paid extra premium for such pre-existing diseases after which the complainant has undergone the said surgery.

The complainant stated that upon medically diagnosed with Cholelithiasis- Gal Bladder stones the complainant selected Apollo Gleneagles Hospital,Kolkata for surgery.Before the surgery the aforesaid Hospital had forwarded the OPs company a pre-approval claim on 16.11.2022.and Rs,80,000 was initially approved the OPs.The complainant was finally discharged on 22.11.2022 after surgery. The total bill amount by Apollo Gleneagles Hospital was Rs,3,83,489/ out of which Rs,3,65,399/ , Hospitalization expenses and Rs,18,040/ pre-Hospitalization expenses and Rs,50/ Post Hospitalization expenses.The complainant further stated that the OPs have repudiated  the entire hospital expenses  claim on 21.11.2022 on the ground that the complainant had been suffering from Hypertension for the past 16 years and furthermore state that the same was not disclosed at the time of policy inception. The complainant was compelled to pay in cash the entire hospital expenses at the time of discharge.on 28.02.2023 the complainant through Ld.Advocate sent a letter to the OPs too conveying all the grievances but the OPs company has not taken any steps.Finally,the complainant knocked the door of the commission to get justice and prayed before the commission to direct the OPs to pay Rs,3,83,489/ the hospital bill,Rs,50,000/ for mental agony and harassment,Rs,2,00,000/ for damage cost  with Rs,1,00,000/ as litigation cost.

The OPs have not entered into appearance .No WV has been filed by the OPs.It also appears that the stipulated period for filling WV by the OPs have already been elapsed and as such the case do proceed ex-parte against the OPs.

Points for Determination

In the light of the above pleadings, the following points necessarily have come up for determination.

1)  Whether the OPs are deficient in rendering proper service to the Complainant?
            2)  Whether the OPs have indulged in unfair trade practice?

           3)  Whether the complainant is entitled to get relief or reliefs as prayed for?

Decision with Reasons

Point Nos. 1 to 3 :-

The above mentioned points are taken up together for the sake of convenience and brevity in discussion.

We have travelled over the documents placed on record. Upon perusal of the consumer complaint coupled with evidence of the complainants we find that the complainant took a family Health Insurance Plan “Group Active Health” (Mediclaim)from the OP Insurance company.The same mediclaim policy with one Bajaj Alliance Company.The policy no.GHI-22-2611358-V2.Due to the age of the complainant, the waiting period for pre-existing diseases was fixed to be three years and for this the complainant had paid extra premium duly acknowledge by the OPs.The complainant stated that she undergone surgery for Cholelithiasis.The total billed was Rs,3,83,489/-.The OPs company repudiated the claim of the hospital bill against medical expenses of the complainant on the ground that the complainant  had been suffering from Hypertension for past 16 years and the same was not disclosed at the time of policy inception.

Now let us focus on the chronology of the happenings of the said case.The complainant alleged that without consent and information to the client the OP company ported from earlier Bajaj Alliance to present OPs ie,Aditya Birla Health Insurance Company.This must be intimated and explained the entire terms and conditions to each and every client who were the beneficiary of the Insurance company.This lead to negligence of responsibility  on the part of the OPs company.

The OPs company issued an initial approval of Rs,80,000/-and in such approval it was clearly mentioned that in case of deviation,discrepancy,and manipulation of  documents the approval would stand null and void.so,by giving such pre-approval it is accepted by the OPs company that the complainant has met all the said conditions and she should be covered for her medical expenses.The complainant had a legitimate expectation that her medical expenses would be covered and thus, the complainant proceeded to undergo surgery in Apollo Gleneagles Hospital.

On perusal of the copy of Doctor’s report of the complainant dated 01.11.2022 issued by Dr.Syamal Kumar Sarkar addressed to Ms Tapti Pal mentioned in the Past medical history column “Hypertensive disorder-01.11.2022 12.12 pm” and also in the discharge summery dated 22.11.2022 where it is mentioned in the diagnosis that of Cholelithiasis with Mucocele of Gall Bladder,Hypertension,Hypothyroid,Hyperurciemia.

The claim of the complainant has repudiated dated 21.11.2022 by the OPs on the ground that the patient has not disclosed history of Hypertension during policy inception.So the claim rejected under non disclosure of fact.

Here the complainant repeatedly denied the statement of non disclosure of hypertension during inception of the project and communicated to the OPs company through mails on different dates and asked to share the documents proving the statement of non disclosure of the pre-existing diseases of Hypertension but the OPs company outridely neglected the request and without any proper justification and supporting documents the OPs company rejected the claim.The OPs company failed to lead evidence to show that the claim of the complainant in respect of the treatment taken for a pre-existing diseases of hypertension.

A judgement passed by NCDRC on 10.11.2020 for Oriental Insurance Company Ltd Vs Sunil Dutt Singla & Ors in which it mentioned that “Hypertension is a common disease which is required to be referred in proposal form-Hypertension is a common disease and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.Therefore,ground that complainant suffering from hypertension not corroborated on basis of evidence on record.Further as per terms and conditions of policy,OPs failed to prove on record that complainant before taking policy was suffering from any pre-existing disease which concealed by him at the time of time of taking policy”    

So,the commission opined that there is no merit in the contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary a person suffering from hypertension would always suffer a heart attack.Therefore the letter of repudiation issued by the OPs company  is rejected and as such the consumer complaint succeeds.        

Hence,

                                                         ORDERED

        That the Complaint Case be and the same is disposed of on ex-parte against OPs

1.OPs Insurance company  is directed  to refund Rs,3,83,489/ (Rupees Three lakh eighty three thousand four hundred eighty nine)only to the complainant within 45 days from the date of  passing of this order.

2.OPs insurance company is further directed to pay Rs,10,000 as compensation for harassment and mental agony.

The complainant is at liberty to put the matter into execution if the OPs transgress to comply the order of this commission.