Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.130/13.07.2018
Mr. Kamlesh Singh s/o Sh. Omprakash Singh
R/o Flat No. 116, Personal Service Apartment
Omaxe Heights, Sector-86
Faridabad, Haryana-121001 ...Complainant
Versus
OP-1- Cigna TTK Health Insurance Company Ltd.
(through its Chairman)
OP-2- Mr. Sandeep Patel, Managing Director & CEO
Cigna TTK Health Insurance Company Ltd.
OP-3-Mrs. Jyoti Punja, Chief Customer Officer
Cigna TTK Health Insurance Company Ltd.
Address for all : (1) to (3)
Cigna TTK Health Insurance Company Ltd.
Corporate Office, 401/402, Raheja Titanium
Western Express Highway
Goregaon (East), Mumbai-400063
OP-4- Branch Head
Cigna TTK Health Insurance Company Ltd.
Branch Office, 32-B, 3rd Floor Rajender Nagar
Pusa Road, Near Karol Bagh Metro Station
New Delhi-110005 ...Opposite Parties
Date of filing: 13.07.2018
Order Reserved on: 10.02.2023
Date of Order: 22.05.2023
Quorum: Shri Inder Jeet Singh, President
Shri Vyas Muni Rai, Member
Ms. Shahina, Member -Female
Ms. Shahina, Member (Female) ORDER
1. Sh. Kamlesh Singh S/o Shri Om Prakash Singh (insured/complainant) has filed the instant complaint against the Cigna TTK Health Insurance Company Ltd. through its Chairman (insurer/OP1), Mr. Sandeep Patel is its Managing Director and CEO Cigna TTK Health Insurance Company Ltd. (OP2), Ms. Jyoti Punja, is its Chief Customer Officer (OP3), Cigna TTK Health Insurance Company Ltd. and their Branch Head is OP4 is Cigna TTK Health Insurance Company Ltd., u/s 12 of Consumer Protection Act, 1986. In the present complaint, the complainant bought for him and his family a health insurance policy from ICICI Lombard Health Care in the year 2011 vide policy no. 41281/IH/92203029/02/000 and the inception date was 23.07.2011. The complainant states that he has never failed to renew the policy. After maintaining the policy for 6 years by the complainant, the Executive of the opposite parties contacted the complainant in 2017 and OPs requested complainant to port his policy to the opposite parties from ICICI Lombard. The complainant further states that the Executive of OP had assured to the complainant “that no documentation required as the policy is six years old and the policy has to be ported”. And also assured by the OPs’ executive; that there will be no waiting period and all diseases will be covered cashless since first date of inception of the policy with the opposite parties as the policy of the complainant was six years old (copy of the policy with ICICI Lombord is annexed-A on record). The opposite parties provided new port policy to the complainant bearing no. PROHLR150015572 valid from 30.07.2017 under Pro-Health Protection Plan and policy type was Family Floater Plan and the complainant paid Rs. 11,236/- as a premium for one year to the opposite parties and sum insured was Rs. 4,20,000/- (as per the opposite parties Original Sum Insured and ‘Cumulative bonus.
2. The complainant, his wife namely Ms. Bindu Singh (but inadvertently Bindhu mentioned in policy schedule) and his two sons, namely Naman Kumar Singh and Aarth Singh (but inadvertently Earth mentioned in policy schedule) got insured. It is also pertinent to mention that on policy schedule “For Roll Over/Portability cases continuous coverage will be considered from first policy inception date with us or other insurer” (copy of policy schedule is annexed-B, from Cigna TTK ProHealth Insurance Company Ltd.)
3. That after sometimes, on 06.11.2017 wife of the complainant who is also insured fallen ill and admitted to the hospital and the charges incurred was Rs. 32,929/- at the time of the hospitalization. Complainant informed the hospital about policy and hospital informed the OPs for approving cashless facility; but the opposite party did not provide approval for cashless facility; however, on 08.11.2017 the TPA sent rejection letter to the complainant citing reason as “ the liability cannot be ascertained at this juncture, as the patient has history of DM since two years, which is pre-existing to the policy with Cigna TTK, which is non-disclosure of material facts; hence cashless is denied. (Copy of medical documents of the wife of the complainant alongwith the receipts are annexed herewith as Annexure-C and the rejection letter sent by TPA is annexed as Annexure-D on record.)
4. It is case of the complainant that as per the policy brochure provided by the opposite party, it has been clearly mentioned that “as discussed with you that we will cover as per the condition in Cigna TTK ProHealth Plus and Protect Plan and by the time you are porting your policy from ICICI Lombard policy in Cigna TTK, then as per the IRDA portability condition there will be no waiting period in this policy upto the sum insured you are holding in the previous policy. And your insured members are going to be covered from day one in Cigna TTK. (Copy of the policy is annexed as Annexure-E). The complainant submitted all the required and necessary documents to the OPs for reimbursement; the OPs kept harassing to the complainant and to asked the complainant to send his specimen signature attested by his banker, the complainant sent the same to the opposite parties within time given by OPs. Subsequently, after submitting all the required documents to the opposite parties, the complainant many times wrote letter to the opposite parties for reimbursement but they did not pay claim amount and refused to reimburse the amount on the ground of the suppression of fact about Diabetes to the wife of the complainant. However, the complainant states that neither at the time of porting the policy nor before claim. OPs asked anything from the complainant as the policy was 6 years older and waiting period was over. That is why complainant subjected to undergo severe mental torture and harassment, it is severe deficiency in service on the part of the OPs, and due to negligent and inhuman behavior of the opposite parties; the complainant had to suffered hardship during the stay of his wife in the hospital.
5. The case of the complainant is that his wife had fallen ill again, after sometime and had got admitted in the hospital on 23.05.2018 and the opposite parties again refused to either give cashless facility or reimbursement the amount spent by the complainant on the treatment of his wife. The complainant spent again Rs. 94,044/- on the treatment of his wife. The complainant had spent total Rs. 1,26,973/-, on treatment of his wife. The complainant contacted the opposite parties and sent number of e-mails to them but they neither paid any heed nor even bothered to reply properly to the complainant. Further, the complainant shocked and surprised; when he received the e-mail dated 01.06.2018 sent by the opposite parties informing that his policy has been terminated in view of non-disclosure of history of Diabetes since two years. The complainant submits even on 29.05.2018; Senior Executive, namely Ms. Dipti Shah wrote to him that “we wish to inform you that we are working on your claim reconsideration request and shall assist you with the status shortly”. (Copy of e-mail showing termination is annexed as Annexure-F and e-mail dated 29.05.2018 is at ‘Annexure-G’ on record). The complainant further submits that he has been harassed by the opposite parties; the complainant sent legal notice dated 11.06.2018 to the opposite parties but no reply was received, (copy of legal notice is annexed as Annexure-H; postal receipts and copy of delivery report is annexed as Annexure-I).
6. Hence, the complaint for deficiency in service and unfair trade practice against OPs, complainant alleges that the acts of opposite parties are fraud with the complainant by raising false and frivolous grounds for termination of policy and has sought for directions as under:
- To direct the opposite parties to jointly and severely refund total bill amount i.e. Rs. 1,26,973/- along with appropriate payable interest accrued in time to come;
- Direct the opposite parties to reframe from unfair and negligent trade practice;
- Direct the opposite parties, jointly and severely to pay sum of Rs. 05 lac along with interest @ 18% p.a. from the date of complaint towards compensation for mental agony, loss of pregnancy, loss of reputation, cost of litigation expenses, loss and injury and damages, etc;
7. OPs have and filed their joint written statements dated 24.9.2018 stating therein, inter-alia, that the complainant ported his policy from ICICI Lombard to Cigna TTK Health Insurance Company Ltd. and was issued policy no. PROHLR15005572 on 30.07.2017 for a tenure of one year. The complainant at the time of the porting the policy made a PLVC (Pre Loging Verification Call) to ensure that the complainant has clear understanding of the terms and conditions of the policy; OPs have further stated that in the PLVC recordings; the company’s executive has asked the complainant about the pre-existing disease and health condition of all the insured persons, the complainant clearly stated that there has not been any pre-existing disease and that there is no condition with which the insured persons were diagnosed with, at the time of the porting of policy (Annexure-A to reply).
8. OPs have further alleged that at the time of porting the policy; the complainant has filled the proposal form and the portability form, in which he has not disclosed any pre-existing disease, he has written “NO” in the pre-existing column of the proposal form (Annexure-B to reply).
9. OPs have further alleged that the wife of the complainant was suffering from Diabetes Mellitus from two years before porting the policy to Cigna TTK Health Insurance Company Ltd., which the complainant has not disclosed in the proposal form nor in the portability form. OPs have submitted that the insurance contract is based on principle of utmost good faith. Hence, both the parties are bound by the contract. OPs have further submitted that when the wife of the complainant was admitted on 06.11.2017 in Metro Heart Institute with Multi Specialty Hospital, Faridabad and the hospital expenses incurred was Rs. 32,929/- the company at the time of the evaluating the documents for claim submitted by the complainant, it was concluded that the insured/complainant’s wife was suffering from Diabetes Mellitus from past two years and hence on the basis of such non-disclosure of the pre-existing disease by the complainant at the time of the porting the policy, the claim was rejected; the complainant applied for cashless claim with our TPA bearing claim no. BLR-CG,00000-000-0194162 which was rejected as per terms and conditions of the policy; the complainant, then filed for reimbursement of claim bearing claim no. BLR-1117-CL-0009854 which was also rejected as per the terms and conditions of the policy. The clause VIII-I of the policy, which reads as under:-
VIII-1 Duty of Disclosure:
“The Policy shall be null and avoid and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statement, declaration, claim form declaration, medical history on the claim form and connected documents, or any material information having been withheld by you any one acting on your behalf, under this policy. You further understand and agree that we may at our sole discretion cancel the policy and the premium paid shall be forfeited to us.”
10. OPs further assorts that there is no deficiency in service on the part of opposite parties in rejecting the claim of the complainant and terminating the insurance policy in question and the present complaint is liable to be dismissed on this ground, (policy terms and conditions are annexed as Annexure-B on record).
11. Rejoinder of complainant: The complainant filed rejoinder to the reply of OPs, he reaffirms his complaint as correct. The complainant has submitted in his rejoinder that the complainant never signed any of the documents annexed with the reply filed by the opposite parties and it appears that the officials of the opposite parties have forged the signature of the complainant on the aforesaid documents; the complainant has further pleaded in complaint in para no. 10 that after submission of documents; opposite parties kept, harassing the complainant on one pretext to other and after much delay, opposite parties had been asked the complainant to send attested signature by his banker and the complainant did so within time given by OPs. The copy of the banker’s cheque filled with complainant signature has been filed on record, in rejoinder, complainant has also denied allegations in reply of OPs as well as explanation to certain allegations of the reply, the complainant has suffered heavy financial loss, mental torture, pain and agony and undue harassment. Rest of the submission in rejoinder are the repetition of pleadings of the complaint.
12. The complainant has cited The State Consumer Disputes Redressal Commission, Punjab in The New India Assurance Co. vs Sanjeev Jain (First Appeal No. 477 of 2013) “Appellants/OPs are only interested to get the premiums and when it comes the preposition to make the payment then they go to the clauses of the policy despite the fact that they know that the persons were suffering from pre-existing disease but they are issuing the policy, which shows that they are resorting to unfair trade practice and genuine claims of the consumers are not being settled by the insurance companies and they repudiated the same on flimsy grounds.” Thus the complainant is entitled to reimburse the full amount as claimed, there was no pre-existing disease at the time of taking medical claim policy from opposite parties.
Complainant further refers the Hon’ble Delhi High Court in Hariom Aggarwal Vs. Oriental Insurance Company Limited, AIR 2008 Delhi 29 observed that :
“22. If the rule indicated in the preceding paragraph were kept in mind, it would be apparent that the object of the insurance policy is to cater to medical expenses incurred by the insured. That is the “main purpose” of the contract of insurance. The object of the exclusion clause is to except the liability of the insurer. In a sense this is at variance with the object of the policy. Nevertheless, it is a part of the contract; the court should firstly seek to harmonize the all the clauses, and attempt to give effect to it. If one proceeds on this premise, the concept of “pre-existing condition” has to be understood. Clause 4.1 defines it as any injury which existed prior to the effective date of the insurance; and any sickness or its symptoms which existed prior to the effective date of the insurance, whether or not the insured had knowledge that the symptoms were relating to the sickness. It is apparent that even if there were known diseases or conditions, which were disclosed and for which there was a likelihood of complications arising in the future, the insurer sought to distance itself from the liability. There is no dispute here that diabetes was a condition at the time of submission of proposal; so was hyper tension. In a sense these were “old ailments” the petitioner was advised to undergo ECG, which he did. The insurer accepted the proposal and issued the cover, One may ask, what then was the cover for. It is not an accident cover policy, or a life policy. Now, it is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications, etc, depending upon varied factors. That implies that there is probability of such ailments; equally they can arise in non-diabetics or those without hypertension. Unless the insurer spelt out with sufficient clarity, the purport of its clauses, or charged a higher premium, at the time of accepting the proposal, the insured would assume and perhaps, reasonably that later, unforeseen ailments would be covered. Thus, it would be apparent that giving a textual effect to Clause 4.1 would in most such cases render the medical claim cover meaningless; the policy would be reduced to a contract with no content, in the event of the happening of the contingency. Therefore, I am of the opinion that Clause 4.1 cannot be allowed to override the insurer’s primary liability; the main purpose “rule would have to be pressed into service”.
13. Evidence:- Complainant Sh. Kamlesh Singh S/o Shri Om Prakash filed detailed affidavit of evidence while relying upon the documentary record filed with the complaint. On the other hand, opposite parties filed affidavit of evidence of Sh. Akhil Kulhari, working as Assistant Vice President, Legal, of OPs company M/s Cigna TTK Health Insurance Company Ltd., coupled with record, it is on the lines of reply. It also reproduces exclusion clause no. VIII-1 of the policy to oppose the complaint and to establish their plea.
14. Submission of parties: Counsel for the complainant Sh Kaushikesh Kumar, Advocate filed written argument on behalf of complainant and also addressed orally. At the time of the argument the counsel for the complainant specifically mentioned that the signatures of the wife of the complainant are not matched in the instant complaint. On the other hand, the Counsel for the OPs Sh. Yuvraj Sharma, Advocate argued the matter, moreover, there is also written arguments filed by the opposite parties. Thus, the entire record will be considered.
15.1 The rival contention of both sides are considered, which are clear from their pleadings, affidavits and arguments.
The main controversy in the present complaint revolves around the issue as to whether the repudiation of claim of complainant was justified or not? OP1 rejected the claim on the allegations of non-disclosure of material facts, as the patient has history of DM since two years ‘which is pre-existing since inception with Cigna TTK, hence cashless denied’ (now Annexure-B to reply). However, the policy schedule from Cigna TTK filed by the complainant (as Annexure-B) is having details as under:-
Column-VI of the policy details:-
Pre-existing disease waiting period :-
- Covered after 48 months of continuous coverage.
- For roll over/portability cases continuous will be considered from first policy inception date with us or other insurer (as applicable). Moreover, it has placed on record the OP has also filed the proposal form (now as Annexure-B) of their WS which shows that the complainant has accepted the consent in the proposal form that there is no pre-existing disease; but on the other hand the complainant objected in his rejoinder that he never signed any of the document filed by the opposite parties; and it has pleaded that the official of the opposite parties have forged the signature of the complainant on the aforesaid documents. The complainant rely the judgment of Hon’ble Apex Court which has been cited above here. Although, the OPs not only denial the claim of the complainant’s wife treatment but also terminated the policy of the complainant.
- Keeping in view of the discussion as above, we are of the considered opinion that OPs have committed deficiency in service by not paying the legitimate claim of the complainant. It is the case of the complainant that neither the complainant nor any other members of his family (insured) had gone under any treatment in last 3-4 years at the time of porting the policy. However, the all pre-existing diseases are covered as the policy is more than 04 years old and waiting period is over. It is further submitted that even what is non-disclosure of disease of wife of the complainant as she neither undergone any disease treatment for Diabetes nor has prescribed any medicine for the same. It is also the negligence on the part of OPs that the policy of the complainant has been terminated. Although, the other two sons and the complainant are also the policy holder, the act of the opposite parties have been of negligence and not justified in termination the policy, however, the policy of the complainant is six years old.
15.2 After taking stock of all the materials, it is held that complainant has proved the complaint against OPs and the complaint is allowed for the following reasons:-
- Since parties does not dispute the previous policy contract between them and the complainant bought the policy from ICICI Lombard Health Care in the year 2011 vide policy no. 41281/IH/92203029/02/000, and the inception date was 23.07.2011, the sum insured is of Rs. 3,00,000/- and also covered the complainant, his wife namely Bindu Singh and his two sons, namely, Naman Kumar and Aarth Singh. The complainant maintained the policy and never failed to renew the policy as and when required to do so.
- In 2017 after maintaining the policy for six years by the complainant, the Executive of opposite parties assured the complainant that no documentation required as the policy is six years old and the policy has to be ported. The Executive of the opposite parties also assured the complainant that there will be no waiting period and all diseases will be covered cashless since first date of inception of the policy with the opposite parties, as the policy of the complainant was six years old. The ported policy bearing no. PROHLR150015572 was valid from 30.07.2017 under ProHealth Protect Plan and policy type Family Floater. The complainant had paid Rs. 11,236/- as a premium for one year to the opposites parties and the sum insured was Rs. 4,20,000/- and his wife namely Ms. Bindu Singh and two sons namely, Naman Kumar Singh and Aarth Singh got insured. It is clearly mentioned in policy schedule that “For Roll Over/Portability cases continuous coverage will be considered from first policy inception date with us or other insurer”.
- After some times, on 06.11.2017 wife of the complainant who was also insured; fallen ill and admitted to the hospital and the charge incurred was Rs. 32,929/-. Moreover, the opposite parties denied approval of cashless facility to the complainant;
- On 08.11.2017 the TPA sent rejection letter with reason as mentioned in Annexure-B. Complainant has submitted the required and all necessary documents asked by the opposite parties for reimbursement are placed on record.
- The wife of the complainant again fell ill after sometime and got admitted in the hospital on 23.05.2018 and the opposite parties again refused the claim of the complainant, although the treatment amount of Rs. 94,044/- also paid by the complainant to the hospital. The total amount has been spent Rs. 1,26,973/- when the wife of the complainant got admitted in the hospital, the opposite parties informed the complainant vide email dated 01.06.2018 that his policy has been terminated in view of non-disclosure of history of DM since two years.
- The opposite parties objected that the complainant has not disclosed the history of Diabetes since two years that is why the complaint may be dismissed as per the terms and conditions of the policy; instead the complainant rushed to the Commission. Further, the complainant also served legal notice dated 11.06.2018 upon the office of OPs’ but no reply was received.
- It is also submitted that even in the PLVC (Pre Loging Verification Call) it is clearly communicated to the complainant is an unequivocal term that there will be no waiting period for covering disease. The diseases will be covered from the date of inception of the policy. Whereas, as per record proved by the complainant, it was at the time of discharge, the complainant come to know that his wife was diagnosed Diabetes.
- So far as, pre-existing disease is concerned as alleged by OP to the effect that the wife of the complainant was suffering from pre-existing disease i.e DM since two years but the said fact was not disclosed by the complainant in his pleadings; however, perusal of the Cigna TTK ProHealth Insurance documents it is found that in the pre-existing disease waiting period ‘ it is mentioned that ‘covered after 48 months of continuous coverage, for rollover/portability cases continuous coverage will be considered from first policy inception date with us or other insurer (as applicable); meaning thereby after the portability all the coverage of the policy were to be continued since the inception of the first policy; if that is so, the allegation of OP about pre-existing disease does not hold good’ however; complainant has submitted in para-17 of the complaint that he also disclosed the same that his wife was not admitted for any disease earlier; which arose due to the side effect of Diabetes; in this regard he has referred the contents of the mail of the executive of OP dated 29.05.2018 mentioning therein that ‘we wish to inform you that we are working on your claim reconsideration request and shall assist you with the status shortly’ complainant further submitted that after admission in the hospital, he came to know at the time of discharge (page-39) wherein it was diagnosed that his wife is Diabetic; it was not known to complainant earlier.
- It is also case of complainant of difference in signatures of the complainant on the banker’s cheque and on the proposal form, (which is at page 47-56 annexed with the reply); whereas the complainant in para-10 of his complaint mention that the specimen signature attested by the Banker was sent to the OP as asked for; the complainant denies his signature at page-50-56 of the proposal form. The complainant contends that his signature on proposal form is manipulated by bare look at the signature on complaint and specimen attested by Banker by comparing with proposal form. It is appearing so.
So far as the hospital/treatment bills are concerned that is available at page-32-38, the total amount is of Rs. 1,26,973/- as mentioned in para-14 of the complaint.
16. Accordingly, the complaint is allowed in favour of complainant and against the OPs to pay jointly or severely a sum of Rs. 1,26,973/- simple interest at rate of 7% p.a. to the complainant. OPs are further directed to pay Rs. of 20,000/- as compensation for mental agony, loss of reputation and cost of litigation expenses Rs. 5000/- to be payable within 30 days from the date of receipt of this order.
17. In case, OPs do not pay the amount within 30 days from date of receipt of this order, then simple interest will @ 8% p.a. (in place of 7% p.a.) on the amount in period mentioned above.
18. Announced on this 22nd May, 2023. Copy of this order be sent/provided to the parties free of cost as per Regulations.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
