Only Pre-Informed T&C Can Be Binding On Insured, Kaushambi District Commission Holds Aditya Birla Health Insurance Liable

Brief Facts:

Mr Satish Kumar (“Complainant”) availed an 'Active Health' insurance policy from Aditya Birla Health Insurance Company Ltd. (“Insurance Company”). Approximately 9 months after the policy's inception, the Complainant was diagnosed with a non-hearing ulcer. On account of this disease, he was admitted to Medanta Hospital, Lucknow (“Hospital”). He incurred the total amount of Rs. 2,14,000/- for the entire stay at the Hospital and paid it by cheque. Subsequently, he submitted the claim, along with all the relevant receipts, to the Insurance Company. However, it was repudiated. The Complainant tried to contact the Insurance Company's representatives several times but the Insurance Company was hesitant to disburse the amount. Feeling aggrieved, the Complainant filed a consumer complaint in the District Consumer Disputes Redressal Commission, Kaushambi, Uttar Pradesh (“District Commission”).

The Insurance Company contended that as per the T&C of the policy, there is a waiting period of 24 months for chronic diseases after availing of the policy. In other words, the Complainant would have been able to claim the amount if the non-hearing ulcer was diagnosed 2 years after he availed of the policy.

Observations by the Commission:

The District Commission perused the evidence presented by both parties. It observed that while availing the insurance policy, the Complainant was not informed of any such T&C which entitled him to the amount only after 24 months after the inception of the policy. The District Commission also noted that the Complainant did not sign any such contract which mentioned this clause. Therefore, it held that at this stage, the Insurance Company could not cite a random condition to repudiate the amount claimed by the Complainant.

Consequently, the District Commission directed the Insurance Company to disburse Rs. 2,14,000/- for hospital expenses, pay Rs. 5,000/- as compensation and Rs. 3,000/- as legal costs to the Complainant.

Case Title: Satish Kumar vs Branch Head, Aditya Birla Health Insurance Co. Ltd.

Case No.: Complaint No. 99/2023

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