3 weeks ago
Insurer must restore policy, pay Rs 1.10 lakh over hypertension
A 67-year-old man in Hyderabad had a health insurance policy for himself and his wife.
He paid his insurance money every year without missing a payment.
In December 2023, he felt chest pain and had trouble breathing.
He went to the hospital and stayed there for three days.
His hospital bill was Rs 93,000.
When he asked the insurance company to pay, it said no.
The company cancelled his policy and said he had hidden a health problem called hypertension.
But the man said he had told them about his health during a check-up.
The court said the insurance company was wrong because it showed no proof.
It ordered the company to pay the bill, give him extra money, and bring back his policy.
A Hyderabad consumer commission held Aditya Birla Health Insurance officials guilty of deficiency of service for rejecting a senior citizen's claim and cancelling his policy over alleged non-disclosure of hypertension.
The commission directed the insurer to reimburse Rs 93,000 in hospitalisation expenses, pay Rs 10,000 for mental agony and Rs 5,000 towards costs, and reinstate the policy.
The 67-year-old complainant had a family policy from September 2018, paid premiums regularly until 2024, and was hospitalised for chest pain and shortness of breath on December 13, 2023.
The commission noted the insurer produced no documentary evidence to support the rejection and called the unilateral cancellation 'highly objectionable'.
The insurer's branch managers defended the action, calling the complaint false, frivolous and vexatious and arguing the complainant had no locus standi.
- Who
- A 67-year-old senior citizen from Hyderabad against officials of Aditya Birla Health Insurance, decided by commission President Vakkanti Narasimha Rao and member P V T R Jawahar Babu.
- What
- The commission found the insurer guilty of deficiency of service and ordered reimbursement of a rejected claim, reinstatement of the policy, and compensation.
- Where
- Hyderabad (Telangana, India), at the consumer commission.
- When
- The order was dated July 10; the policyholder was hospitalised on December 13, 2023, under a policy held from September 2018 to 2024.
- Why
- The insurer rejected the claim and cancelled the policy alleging non-disclosure of hypertension without producing supporting evidence, despite the policy being in force over five years with regular premiums.
Consumer's position
Insurer's position
Non-disclosure of hypertension
Consumer's position
The policyholder said he disclosed hypertension as a possible condition during his pre-policy medical check-up and had informed the insurer of his use of Stamlo 5 mg for a temporary high blood pressure issue.
Insurer's position
The insurer rejected the claim and cancelled the policy, alleging non-disclosure of hypertension and arguing the policy was a contract binding both parties to its agreed terms and conditions.
Evidence and standing of the complaint
Consumer's position
The commission found the insurer did not file a single piece of paper to support the rejection and called the unilateral cancellation 'highly objectionable', noting the policy had been in force for over five years with regular premiums.
Insurer's position
The insurer's branch managers claimed the complaint was false, frivolous and vexatious, not maintainable in law or on facts, and that the complainant had no locus standi.
Key facts
- Commission
- Hyderabad Consumer Commission
- Insurance company
- Aditya Birla Health Insurance
- Complainant
- 67-year-old senior citizen
- Reimbursement ordered
- Rs 93,000 (hospitalisation expenses)
- Compensation ordered
- Rs 10,000 for mental agony and Rs 5,000 towards costs
- Policy period
- September 2018 to 2024 (over five years, premiums paid regularly)
- Hospitalisation
- December 13, 2023, for chest pain and shortness of breath
- Order date
- July 10
Quotes
Judge in the Hyderabad consumer commission
Judge presiding over the case
“As the treatment has been taken for hypertension during the subsistence of the policy, the complainant approached the opposite party ( Aditya Birla Health Insurance officials) for reimbursement of claim for the expenses incurred for treatment wherein the claim was rejected by the opposite parties without assigning any substantial reason for which acts upon their part is amounts to deficiency of service, that leads adoption of unfair practice”
indianexpress.com
Sources
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