District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 225/2021.
Date of Institution:13.04.2021.
Date of Order:01.03.2023.
Mr. Boby S/o Shri Hargovind, V.P.O. – Badarpur Said, Faridabad, Haryana – 121101.
…….Complainant……..
Versus
1. Aditya Birla Health Insurance Co. Ltd. Through its Executive Officer, R Tech Park, 10th floor, Nirlon Compound, Next to HUB Mall, Off Western Express Highway, Goregaon East, Mumbai – 400 063.
2. Aditya Birla Health Insurance Co. Ltd., Nehru Place Branch, through its Branch Manager, Ist floor, 107-108, Aggarwal Bhawan, 35-36, Nehru Place, New Delhi – 110 048.
3. Aditya Birla Health Insurance Co. Ltd., Gurgaon Branch through its Branch Manager, Ist Floor, SCO NO. 24, Sector-14, Goregaon, Haryana – 122001.
…Opposite parties.
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. J.S.Sorout counsel for the complainant.
Sh. Sachin Parashar, counsel for opposite parties Nos. 1 to 3.
ORDER:
The facts in brief of the complaint are that complainant bought Health Insurance Policy No. 11-20-0011665-00 from opposite parties from himself and his family members by paying a premium of amount of Rs.21821/- valid from 15.06.2020 to 14.06.2021. On 08.09.2020, complainant critically fell ill and his family members admitted him in Asian Institute of Medical Sciences Hospital, Sector -21A, Faridabad, wherein diagnosis complainant was found suffering from Covid-19 Type II Diabetes Mellitus, Thrombocytopenia, Dengue, accordingly his treatment was started. The complainant was eligible under policy for cashless treatment, accordingly his family members applied for cashless treatment with concerned TPA in hospital for complainant’s treatment on day of his admission in hospital but opposite parties wrongly and with malafide intention did not approve cashless treatment of complainant and created unexpected financial crisis for complainant. As such put critically ill complainant and his family members under great mental trauma and stress in such a time when complainant was struggling for life in hospital. The treatment expenses amounting to Rs.1,71,786/- was paid by the complainant’s family on their own after borrowing from relatives. The Complainant eligible for reimbursement of aforesaid treatment expenses filed reimbursement claim with defendant via email dated 28.09.2020 by submitting all requisite documents and also submitted all other documents as and when requested by the opposite parties but till date opposite parties had not reimbursed the claim of the complainant. The opposite party agent personally conducted enquiry by visiting house of the complainant for making enquiries about the previous health
history of the complainant and also took an authorization from the complainant to check all relevant hospital records. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay to the complainant treatment expenses amounting to Rs.1,71,786/- with interest @ 18% p.a. from the date of its due till realization of whole amount.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 25,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the present complaint was not maintainable as the claim of the complainant was in violation of the terms and conditions of the policy. The insurance policy was a legal contract between insured and the insurer and they both were bound by its terms and conditions. In the present case, the terms and conditions of the policy clearly laid down the claim documentation that was required ad the process of claim under the policy. The insurer raised query with regards to below documents which were not duly submitted by the insured:
“The following documents need to be submitted:
1. First consultation paper all previous treatment records of Asian Hospital since 2017.
2. Misc.(free Text) Clear duration of DM (from treating physician) and very first diagnostic documents and consultation.”
Therefore, it was submitted that the complainant was bound by the terms and conditions of the policy while submitting the claim to submit all the documents
sought by the insurance company. However, the complainant failed to submit the requisite documents as per the terms and conditions of the policy. Hence, the opposite parties rightfully acted and rejected the claim of the complainant on non receipt of the documents. It was further submitted that it was a stttled principle of law that if any person signs any documents, it wa presumed that she had made true disclosures for the questions sought and signed the same after reading and understanding it properly. In the instant case the proposalform was signed by the complainant and it could be presumed that the complainan t made full & fair disclosures to questionnaire and was well aware of the terms and conditions of the policy. Presuming that even if he was unable to understand any of the terms and conditions, he had an option to approach the opposite parties within the stipulated free look period but the complainant chose not to avail the free look period and did not approach the opposite parties within free look period. Opposite parties 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 parties– Aditya Birla Health Insurance Company Ltd. with the prayer to: a) pay to the complainant treatment expenses amounting to Rs.1,71,786/- with interest @ 18% p.a. from the date of its due till realization of whole amount. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .c) pay Rs. 25,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence,
Ex.CW1/A – affidavit of Boby, Ex.C-1 – policy, Ex.C-2 – Discharge summary, Ex.C-3 – Covid-19 Test, Ex.C-4 – Final Bill Summary Pkg,, Ex.C-5 to 8 – Deposit receipts, Ex.C-9 – Retail invoice/bill/cash memo, Ex.C-10 – Bill Cum Receipt, Ex.C-11 – Consolidated invoice,Ex.C-12 & 13– emails, Ex.C-14 – Claim Form-Part A,, Ex.C-15 – Questionnaire,, Ex.C-16 – legal notice,, Ex.C-17 – postal receipt. Ex.C-18 – track consignment, C-19 to 23– emails.
Counsel for the opposite party has made a statement that written statement already filed on behalf of the opposite party be read as evidenc of opposite party vide order dated 27.02.2023.
6. During the course of arguments, complainant has filed an affidavit in which it has been stated that the complainant was diagnosed suffering from diabetes at the time of purchase of policy NO.11-20-0011665 dated 15.06.2021 or earlier. The complainant was diagnosed first time suffering from diabetes only on 08.09.2020 at Asian Institute of Medical Sciences Hospital, Sector-21A, Fakirabad. It has been further that that the complainant did not take treatment earlier from Asian Institute of Medical Sciences Hospital, Sector-21A, Faridabad. It was first time that the complainant was admitted in Asian Hospital on dated 08.09.2020 with symptoms of Covid-19. On the other hand, Shri Sachin Parashar, counsel for opposite party stated at Bar that they are ready for process the claim of the complainant, subject to submission of some documents i.e. original bills and claim form which shows the bonfafidy of the opposite party.
7. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties Nos.1 to 3, jointly & severally, are directed to process the claim of the complainant, subject to submission of documents mentioned above within 30 days from the date of receipt
of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. There are no order as to costs. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 01.03.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
