Mumbai: The Mumbai Suburban Additional District Consumer Dispute Redressal Commission has held Aditya Birla Health Insurance Company guilty for wrongly repudiating a legitimate medical bill claim of a Kandivali-based consumer, despite the complainant making timely premium payments.

The Commission directed the insurance company to release the medical bill amount of Rs. 3,17,286 along with 9% interest from March 2023. Additionally, the complainant was awarded Rs. 1,20,000 for mental agony and litigation charges.

The insurance company was also instructed to restore the insurance policy by collecting the legitimate premium after notifying the complainant within 45 days of the order, ensuring the policy continues with all benefits.

Mihir Vora had purchased the “Active Assure Diamond Plan” mediclaim policy from Aditya Birla Health Insurance on February 4, 2019, by porting his existing health insurance policy from another insurer. Vora had held the original policy with some other insurance company since 2006 and renewed it annually before switching to Aditya Birla.

On January 31, 2019, Vora underwent medical tests and disclosed that he had been taking medication for diabetes for the past nine months. The complete medical examination reports, shared with Vora, showed no adverse findings regarding his medical condition. Based on Vora’s disclosure, the insurance company charged a 20% premium loading for covering diabetes and collected the additional premium. The policy was active from February 4, 2023, to February 3, 2024, for which Vora paid Rs. 32,855, providing an insured amount of Rs. 24 lakhs.

On March 22, 2023, Vora experienced discomfort on the left side of his body and consulted a doctor, who, after conducting tests, diagnosed arterial blockages. He underwent angioplasty, incurring medical expenses of Rs. 3,17,286. Vora believed the medical bill would be covered under his mediclaim policy.

However, the insurance firm rejected the claim, alleging non-disclosure of hypertension since 2012. Subsequently, the insurer refunded the premium amount of Rs. 32,855 on April 15, 2023.

The Commission, after reviewing the evidence, asked the insurance firm to file its reply, but the firm failed to do so. Consequently, the Commission passed an ex parte decision.

The Commission found that the insurer had arbitrarily raised a baseless defense to avoid liability. It ruled that the repudiation order was unwarranted and highlighted the insurer’s failure to prove the allegations. The Commission deemed the insurer’s actions as arbitrary, high-handed, and an example of deficiency in service and unfair trade practices.

The Commission also justified the complainant’s demand for restoring the policy, directing the insurer to collect the appropriate premium and provide continuous coverage.