Haryana

Karnal

CC/440/2022

Diwan Chand - Complainant(s)

Versus

Aditya Birla Health Insurance Company Limited - Opp.Party(s)

P.K. Mandi

17 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.440 of 2022

                                                        Date of instt.01.08.2022

                                                        Date of Decision: 17.09.2024

 

Diwan Chand son of Jati Singh, resident of 383 Kalwaheri, District Karnal, Haryana. Aadhar no.680660228922.

                                                                        …….Complainant.

                                              Versus

 

1. Aditya Birla Health Insurance Co. Limited through its Branch/Divisional Manager 9^th floor, tower 1, One Indiabulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400013.
2. Aditya Birla Health Insurance Co. Limited through its Branch/Divisional Manager, SCO no.220, 1^st floor, Sector-12, Karnal.

                                                                …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri P.K.Mandi, counsel for the complainant.

                    OPs exparte, vide order dated 23.01.2023.

       

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a health insurance policy i.e. Active Health Platinum Enhanced Plan, vide policy no.21-21-0063016-00 from OPs on 20.08.2021 with sum assured Rs.5,00,000/-, an amount of Rs.64,792/- was paid as the premium to the OPs for three years 2021-2022, 2022-2023 and 2023-2024. At the time of purchasing the policy, the complainant was asked to sign various blank and printed papers by the agent of the OPs. However, no  terms and conditions were ever explained to the complainant the agent of OPs at the time of signing of the abovesaid papers. In the month of December 2021, the complainant was having some cough and breathing problems, resulting which he was brought to the Artemis Hospital Sector 51, Gurugram, whereby  he was examined by the doctors of the said hospital. After necessary tests and investigations it was revealed that the patient was having Pulmonary TB Infection for which the complainant remained admitted in the hospital from 27.12.2021 to 28.12.2021. At the time of admission as well as during the hospitalization the complainant asked to sign the various blank/printed papers by the doctors and concerned staff of the hospital. At the time of admission the Artemis Hospital authorities applied for the pre-authorization to the OPs. But the OPs refused to allow the pre-authorization of the treatment of complainant. Complainant spent an amount of Rs.29,750/- on his treatment. Complainant again had some health problem including nasal bleeding for which the complainant was again admitted in My Hospital Amritdhara Karnal on 31.01.2022 and remained admitted upto 02.02.2022. Complainant applied for the pre-authorization to the OPs but OPs refused to allow the pre-authorization of the treatment of complainant. Complainant has spent an amount of Rs.36000/- on his treatment. Complainant applied online to the OPs for the reimbursement of the expenses spent on the treatment but OPs repudiated the claim of the complainant, vide letter dated 01.02.2022 on the ground that complainant has history of Diabetes since 6-7 months whereas the complainant never suffered from the disease of Diabetes at the time of purchasing the policy. Due to this act and conduct of OPs, complainant has suffered mental pain, agony, harassment as well as financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.70,000/- approximately as the expenses spent on his treatment, to pay Rs.70,000/- as the amount spent during pre and post hospitalization period and to pay Rs.3,00,000/- as damages for harassment etc. and Rs.25,000/- towards the litigation expenses.

2.             On notice, OPs did not appear despite service and opted to be proceeded against exparte, vide order dated 23.01.2023 of the Commission.

3.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of premium certificate Ex.C2, copy of letter dated 21.08.2021 Ex.C3, copy of denial letter of pre-authorization request Ex.C4, copy of medical bill/receipt Ex.C5, copy of discharge summary Ex.C6, copy of bills/tax invoice Ex.C7 to Ex.C12, copy of medical report Ex.C13, copy of final bill Ex.C14, copies of medical bills/cash memos Ex.C15 to Ex.C26 and closed the evidence on 21.02.2024 by suffering separate statement.

4.             We have heard the learned counsel for the complainant and also gone through the record available on the file carefully.

5.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from OPs. During the subsistence of the insurance policy, complainant admitted in Artemis Hospital Sector 51, Gurugram and Amritdhara, Hospital Karnal. The pre-authorization request was denied by the OPs. Complainant has spent an amount of Rs.70,000/- on his treatment. Complainant lodged the claim with the OPs and submitted all the required documents but OPs repudiated the claim of the complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

6.             The claim of the complainant has been repudiated by the OPs on the ground that complainant was suffering from Diabetes since 6-7 months from the date of purchasing of the policy whereas complainant never suffered from the Diabetes at the time of purchasing the policy. The onus to prove his version as relied upon the complainant. To prove his version, complainant has placed on file copy of insurance policy Ex.C1, copy of premium certificate Ex.C2, copy of letter dated 21.08.2021 Ex.C3, copy of denial letter of pre-authorization request Ex.C4, copy of medical bill/receipt Ex.C5, copy of discharge summary Ex.C6, copy of bills/tax invoice Ex.C7 to Ex.C12, copy of medical report Ex.C13, copy of final bill Ex.C14 and copies of medical bills/cash memos Ex.C15 to Ex.C26. To rebut the said evidence produced by the complainant, OPs did not appear and opted to be proceeded against exparte. Hence, the evidence produced by the complainant goes unchallenged and unrebutted and there is no reason to disbelieve the same.

 7.            For the sake of arguments, if it is presumed that the complainant was suffering from diabetes at the time of obtaining the insurance policy, in that case also the claim annot be repudiated on the said ground, because Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

“9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

 

8.             Further in United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it.

 9.            It is settled proposition of law that merely on the basis of presumption without any cogent and convincing evidence, it cannot be concluded that insured was suffering from any disease prior to taking the insurance policy. In this regard, we are also fortified from the observations of the Hon’ble National Commission made in judgment dated 31.05.2019 rendered in Rivision Petition No.2097 of 2017 case titled as Reliance Life Insurance Company Ltd. & Anr. Vs. Tarun Kumar Sudhir Halder in which it is observed as under:-

“12. From the above entry, it seems that either the doctor filling up this form has not clearly given the date or somebody has made cutting after the word ‘since’. Thus, no conclusion can be drawn in respect of the period since when the DLA was suffering from diabetes. From the entries in the Medical Attendant Certificate it is clear that the DLA first complained about illness only on 22.06.2021. This entry clearly denies pre existing disease of Diabetic Ketoacidosis. The insurance company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2021, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion.”

10.  

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

11.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one.           

12.           The complainant has spent Rs.70,000/-on his treatment and in this regard he has placed on file medical bills Ex.C5, Ex.C7 to Ex.C12, copy of final bill Ex.C14 and copy medical bills Ex.C15 to Ex.C26.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

13.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.70,000/- (Rs. seventy thousand only)  to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 17.09.2024   

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                      Member