Delhi

North East

RBT/CC/221/2022

NAMIT KOHLI - Complainant(s)

Versus

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

21 Aug 2024

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.221/22

 

In the matter of:

	Sh. Namit Kohli, S/o Sh. Anil Kohli, R/o 1715, 1st Floor, Outram Lines, Kingsway Camp, Delhi 110009	Complainant
	Versus
	Aditya Birla Health Insurance Co. Ltd., Through its Directors, Office At: 104, PP Tower, Lala Jagat Narayan Marg, Netaji Subhash Place, Wazirpur, Delhi 110034   Also at: 9th Floor, One Indiabulls Centre Tower 1 Jupiter Mill Compound, S.B. Marg, Elphinstone Road, Mumbai,  Maharashtra 400013	Opposite Party

 

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

06.12.2018 05.06.2024 21.08.2024

 

 

 

CORAM:

Surinder Kumar Sharma, President

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 he had a health insurance policy from Bajaj Allianz Health Insurance which was a family floater policy which covered the Complainant, his wife and his minor son. The same was expired in the month of June 2018. Complainant stated that in the month of May 2018 an employee of Opposite Party approached him and offered him for portability of his policy from Bajaj Allianz Health Insurance to Aditya Birla Health Insurance Co. Ltd. Complainant stated that he was ready to port out his policy. Complainant stated that Opposite Party asked him for some relevant documents and subsequently Complainant shared all the requisite demanded documents with the Opposite Party through e-mail and whatsapp. Complainant stated that Opposite Party directed him to make the payment of Rs. 16,901/- for completion of the process of policy. Thereafter, Opposite Party told the Complainant that the process of the policy had been completed and after couple of days he would receive the policy document through e-mail and within a week hard copy was also received. Complainant stated that on 11.07.2018 the wife of the Complainant suddenly felt pain and after checkup the doctor diagnosed fibrosdenoma breast and advised for a surgery. Complainant stated that his wife got admitted in Max Hospital Shalimar Bagh where the surgery was done by the doctors on 20.08.2018. Complainant stated that as per the policy term he informed the Opposite Party 48 hours prior to the surgery on its customer care and provided all the details of his policy as well as the surgery and hospital. Complainant stated that at the time of admission a proposal of Rs. 1,27,000/- approx. was sent to the Opposite Party through TPA desk of the Hospital. Complainant stated that he received a call from the Opposite Party just after the surgery in which the executive of Opposite Party informed that his claim was rejected with the reason “Non- Disclosure or False Information”. The wife of the Complainant was discharged on 21.08.2018 and he paid an amount of Rs. 1,08,351/- as the expenses incurred on the surgery. Complainant stated that he approached several times to the Opposite Party through e-mails but Opposite Party had failed to satisfy the claim. Complainant stated that he provided all the relevant documents and information to the Opposite Party at the time of porting the policy and hard copy of the policy reveals that all the details in the policy form and even signatures on the policy form were done by the executive of the Opposite Party. Complainant stated that he also lodged a criminal complaint dated 22.08.2018 to the police station Mukherjee Nagar, and also filed a criminal complaint against the Opposite Party and its employees at Delhi. Complainant stated that Opposite Party deliberately confirmed the termination of the policy vide email dated 17.09.2018 to save itself from its liability. Hence, this shows the deficiency of service on the part of Opposite Party. Complainant has prayed for an amount of Rs. 1,08,351/- incurred by him on surgery along with interest @ 24 % p.a. Complainant also prayed for an amount of Rs. 10,00,000/- on account of mental harassment and Rs. 55,000/- on account of litigation expenses.

Case of the Opposite Party

2. Opposite Party contested the case and filed its written statement. It is stated that the complaint is without any merit. It is alleged that the Complainant at the time of purchasing the policy in question had furnished false information and concealed the material facts. Thus, the Complainant has violated the terms and conditions of the policy. It is alleged that the Complainant has played fraud with the Opposite Party by mis-representing and non-disclosure of pervious ailments and medical history of his wife. It is prayed that the complaint may be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Partyand has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his case filed his affidavit wherein he has supported the assertions made in the complaint.

 

Evidence of the Opposite Party

5. Despite grant of opportunities Opposite Party did not file the evidence. Therefore, the evidence of the Opposite Party was closed vide order dated 31.05.2023.

Arguments & Conclusion

6. We have heard the Ld. Counsel for the Complainant. None has appeared on behalf of the Opposite Party to address the arguments despite grant of opportunities. We have also perused the file and written arguments filed by the Complainant. The case of the Complainant is that he had purchased a health policy from the Opposite Party. The said policy covered the Complainant, his wife and his minor son. As per the case of the Complainant, the wife of the Complainant had undergone some surgery and the said surgery was performed in Max Hospital. The intimation in this regard was given to the Opposite Party through the TPA desk of the hospital. The claim of the Complainant was rejected by the Opposite Party with the reason “Non-Disclosure or False Information”. The case of the Opposite Party is that the Complainant has concealed material facts and has not disclosed the previous ailments and medical history of his wife and thus the Complainant has violated the terms and conditions of the policy. It is important to note that the Opposite Party did not lead any evidence to prove the fact that the Complainant had concealed the previous ailments and medical history of his wife. Therefore, the plea of the Opposite Party that the Complainant had not given correct information or that the Complainant had concealed the previous ailments or medical history of his wife cannot be believed.
7. Admittedly, the Complainant had purchased a health policy from Opposite Party and the said policy also covered his wife. Complainant has placed on record the copy of the bill of Max Hospital showing the total bill of Rs. 1,08,351/-.
8. In view of the above discussion, we are of the considered opinion that there is deficiency of service on the part of the Opposite Party. Hence, the complaint is allowed. The Opposite Party is directed to pay an amount of Rs. 1,08,351/- to the Complainant along with interest @ 9 % p.a. from the date of filing the complaint till recovery. The Opposite Party is also directed to pay an amount of Rs. 25,000/- on account of mental harassment and Rs. 25,000/- on account of litigation expenses to the Complainant along with interest @ 9 % p.a. from the date of this order till recovery.
9. Order announced on 21.08.2024.

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

File be consigned to Record Room.

 

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