Chandigarh

DF-I

CC/167/2023

POOJA NARULA - Complainant(s)

Versus

ADITYA BIRLA HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

06 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/167/2023
Date of Institution	:	05/04/2023
Date of Decision	:	06/09/2023

Pooja Narula wife of Sh. Varinder Kumar, aged about 38 years, r/o H.No.1234-B, Meeramalli Mohalla, Near Ram Lila Ground Floor Derabassi, District Mohali.

… Complainant

V E R S U S

1. Aditya Birla Health Insurance Company Limited, SCO No.2473-2474, First Floor, Sector 22-C, Chandigarh through its Branch Manager.
2. Aditya Birla Health Insurance Company Limited, 7^th Floor, Modi Business Centre, Kasarvadavali, Thane (W) 400615 through its Managing Director.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate for complainant
	:	Ms. Archana Sharma, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Pooja Narula, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that in the year 2019, the agent of the OPs approached the complainant and explained the features of health insurance policy. By relying upon the assurances of the agent of the OPs, complainant paid the premium to the OPs, who issued a medical health policy to the complainant, covering the complainant, her husband - Varinder Kumar and son - Aarav Shandilya.  Before providing the said policy to the complainant, OP-1 had completed all the formalities qua conducting the proper medical test of her husband at Amcare Hospital, Zirakpur. Thereafter the complainant continuously got the said policy renewed from the OPs by paying premium and the subject policy (Annexure C-1) was issued by the OPs by receiving premium of ₹23,505/- from the complainant and the same was valid w.e.f.  28.10.2022 to 27.10.2023.  In the month of March 2022, husband of complainant – Varinder Kumar had suffered severe pain in the gluteal region which was having swelling and accordingly he was brought to the Fortis Hospital, Mohali, where he was diagnosed to be gluteal abscess and was advised for operation. Accordingly, operation was performed in the aforesaid hospital and finally he was diagnosed as “RIGHT ISCHO-RECTAL ABSCESS”. The husband of the complainant was admitted in the said hospital on 16.3.2023 and was discharged on 19.3.2023. For his treatment, Fortis Hospital made request (Annexure C-3) to the OPs for cashless hospitalities, but, they denied the cashless pre-authorization claim vide letter dated 17.3.2023 (Annexure C-4) on the ground of non-disclosure of hypertension since 15 years by the insured. The complainant had spent an amount of ₹2,74,343/- for the treatment of her husband vide payment receipts (Annexure C-5 Colly.), but, despite of the fact that the complainant was assured that cashless facility will be provided to her in case of medical problem to the insureds, OPs have wrongly denied the claim of the complainant as well as cashless facility at the time when the insured i.e. her husband had undergone medical treatment in the hospital. Not only this, even the OPs had also issued cancellation notice (Annexure C-7) to the complainant intimating that the policy will be cancelled on account of concealment of material facts by her. The aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.  OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of material facts and cause of action.  It is alleged that, in fact, complainant had concealed material fact qua the disease of her husband i.e. hypertension at the time of taking the policy and as the aforesaid non-disclosure of pre-existing disease by the complainant at the time of obtaining the policy is in violation of the terms and conditions of the subject policy, the cashless request made by the complainant was declined. On merits, facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant alongwith her husband, Varinder Kumar and son, Aarav Shandilya were insured under the subject medical policy (Annexure C-1) by the OPs and during the subsistence of the subject policy, husband of the complainant Varinder Kumar had been admitted in Fortis Hospital on 16.3.2023 where surgery was performed for “RIGHT ISCHO-RECTAL ABSCESS” and he was discharged on 19.3.2023, as is also evident from the discharge summary (Annexure C-2), the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in denying the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly denied the claim of the complainant on the ground of non-disclosure of pre-existing disease, having been suffered by her husband before obtaining the subject policy, and there is no deficiency in service or unfair trade practice on their part, as is the defence of the OPs.
   2. It has been contended on behalf of the complainant that as it stands proved on record that the alleged pre-existing disease of hypertension has no connection with the disease for which her husband had taken the treatment at the Fortis Hospital, OPs have wrongly denied the cashless facility and thereby impliedly repudiated the claim of the complainant and the consumer complaint be allowed.
   3. On the other hand, it has been contended with vehemence on behalf of the OPs that as it stands proved on record that the complainant had concealed material fact qua the pre-existing disease from which her husband was suffering i.e. hypertension for the last 15 years, which fact has also been opined by the medical officer, OPs have rightly denied the cashless facility and the consumer complaint be dismissed.
   4. There is no force in the contention of the OPs as the medical record i.e. the discharge summary (Annexure C-2) of the insured, Varinder Kumar clearly indicates that he was diagnosed with “RIGHT ISCHO-RECTAL ABSCESS” and for that surgery was performed in the Fortis Hospital and he was treated for the said disease only.  The discharge summary also shows that the patient – Varinder Kumar had history of hypertension (since 15 years) on medication. The defence of the OPs is only based on the aforesaid medical record where the medical officer has mentioned about hypertension regarding which reference has also been made by the OPs in the letter dated 17.3.2023 (Ex.OP/3) issued by them to the complainant denying the pre-authorisation request for cashless facility by mentioning the ground as under :-

       “On scrutiny of the documents it was observed that Cashless denial on non-disclosure of Hypertension since 15 years as per policy t & c, and hence we are unable to approve your preauthorization request.”

Thus, one thing is clear on record that OPs have only denied the claim of complainant for non-disclosure of hypertension. 

5. It has been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) as under :-

“Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

6. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

15. In RP No.4461 of 2012, Neelam Chopra v. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it
was held that:

"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal v. Oriental Insurance Co. Ltd., (supra)."

16. Based on the above discussion, I am of the opinion that the Insurance Company had not been able to prove beyond doubt that the Complainant was suffering from diabetes before filing of the proposal form. It is also to be noted that the Insurance Company had given Insurance to a person of 66 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. It is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim also because the chances of death of such persons are more during the currency of the Policy.”

7. In view of the foregoing and ratio of law laid down in the aforesaid judgments, it is safe to hold that complainant has not withheld information of such diseases which were otherwise required to be disclosed and further hypertension and diabetes are otherwise held to be common lifestyle diseases. Hence, it is safe to hold that OPs were unjustified in denying/repudiating the claim of complainant and the said act amounts to deficiency in service on their part and, therefore, the present consumer complaint deserves to succeed against them.
8. Now coming to the quantum of relief to be awarded to the complainant, since the complainant has proved the bills (Annexure C-5 colly.) totaling to ₹2,74,343/-, it is safe to hold that OPs are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by her.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹2,74,343/- to the complainant alongwith interest @ 9% per annum from the date of denial of cashless pre-authorisation of claim i.e. 17.3.2023 onwards.
2. to pay an amount of ₹20,000/- to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till payment, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 06/09/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member