Chandigarh

DF-II

CC/1130/2019

Rupnarayan Yadav - Complainant(s)

Versus

Cigna TTK Health Insurance Company Limited - Opp.Party(s)

Adv.M.S.Gorsi & Rakesh Gupta

24 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

 

Consumer Complaint No.	:	1130/2019
Date of Institution	:	21.11.2019
Date of Decision	:	24.04.2023

 

                     

            

 

1. Rupnarayan Yadav aged 35 years son of Sh.Barahmdev Yadav r/o H.No.1681, F-Block, Adarsh Nagar, Naya Gaon, Mohali.

 

2. Govind Yadav aged 18 years s/o Rupnarayan Yadav r/o H.No.1681, F-Block, Adarsh Nagar, Naya Gaon, Mohali.

                 ...  Complainants.

Versus

 

1. Cigna TTK Health Insurance Company Ltd., having office at 401/402, Raheja Western Express Highway, Goregan (East), Mumbai-400063 through its Managing Director/Authorized Signatory.

 

2. Cigna TTK Health Insurance Company Ltd., 1^st Floor, SCO No.149/150, Sector 9-C (Next to Yes Bank), Madhya Marg, Chandigarh through its Branch Manager/Authorized Signatory.

 

…. Opposite Parties

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI S.K.SARDANA	MEMBER
Present:-
	Sh.M.S.Gorsi, Counsel of complainant Sh.Vishal Sharma, Counsel of OPs.

   

 

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.     The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986, as amended up-to-date alleging therein that on 28.02.2018 complainant No.1 purcahsed health insurance policy covering himself, his wife and both the children including complainant No.2 and Keshav Yadav, commencing from 28.02.2018 to 27.02.2019 by paying premium of Rs.11,533.32P. The complainant No.2 was admitted in the PGIMER, Chandigarh for the treatment of bone marrow transplant from 04.08.2018 to 15.09.2018. The complainant No.1 informed the OPs regarding the same through email. The complainant No.1 incurred a sum of Rs.4,20,597/- on the treatment of complainant No.2. The complainants submitted the requisite documents (Annexure C-6 (colly.) for release of the claim of medical reimbursement on 10.10.2018.  However, the OPs rejected the claim vide letter dated 07.01.2019 under Clause VI (Permanent Exclusions) of the policy on the ground that DOI 28.02.2018, as per policy conditions, genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cell excluded under the policy. The complainants again represented to the OPs for settlement of the claim but the OPs again rejected the claim on 08.02.2019.  It has been alleged that as per the medical report /opinions, the treatment under gone by the complainant No.2 was not a genetically disease. The complainants further averred that a special blood test-cytogenetic of complainant No.2 was conducted by the PGI on 19.03.2018 (Annexure C-10) which stated that spontaneous breaks-absent and under the column diagnosis it is stated aplastic anemia –non-FA meaning thereby the treatment for which the complainant NO.2 was operated was not a genetic in nature.  Therefore, the repudiation of the claim is illegal and unjustified.  The Medical Consultant of PGI who conducted the bone marrow transplant gave a certificate on 29.01.2019 and 26.02.2019 that the disease is not a genetic but acquired in nature (Annexures C-12 and C-13). Subsequently, the complainant served a legal notice dated 29.05.2019 upon the OPs but to no effect. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to pay the claim amount along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
2.     In their written version, the OPs while admitting the factual matrix of the case have submitted that on receipt of the claim, the same was analyzed by the house doctors and after going the medical documents, it was found that as per Clause (Permanent Exclusion) sub Clause 1, genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cell are not covered under the policy.  It has further been submitted that the claim of the complainants was rightly repudiated as per the terms and conditions of the insurance policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, the OPs prayed for dismissal of the complaint.
3.     The complainant filed replication to the written reply of the Opposite Parties controverting their stand and reiterated the contents of the complaint.
4.     The parties filed their respective affidavits and documents in support of their case.
5.     We have heard the Counsel for the parties and have gone through the documents on record, including written submissions.
6.     The only question to be determined in the present complaint in this case is whether the claim of the complainants was rightly repudiated by the OPs vide letter dated 07.01.2019 or not?.
7.     It is an admitted fact that complainants took the Family Floater Policy No.PROHLR1500118206 effective  from 28.02.2018 to 27.02.2019 with sum assured of Rs.5.50 lakhs by paying premium of Rs.11,533.32P. The complainant No.2 admitted in PGIMER, Chandigarh  from 04.08.2018 to 15.09.2018 for the treatment of bone marrow transplant and stem cell implantation/surgery. The claim for reimbursement of the expenses incurred on the treatment was lodged with the OPs. The claim was analyzed by in house doctors of the OPs and after going through the medical documents submitted by the complainants, it was found that as per Clause 6 (permanent exclusions) Sub Clause 1, genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cell are not covered under the policy, therefore, the claim was repudiated as per terms and conditions of the policy because the claim falls under the exclusion clause of the policy. The OPs placed on record repudiation letter dated 07.01.2019 as Annexure R-2 which reveals that the claim stood repudiated under the policy Clause VI. Permanent Exclusions(1):

Denial Clause ID	Description
Clause VI Permanent Exclusions(1)	Genetic disorder and stem cell implantation/surgery, harvesting, storage or any kind of treatment using stem cells

 

        To rebut the stand of the OPs, the complainants stated that a Special Blood Test-Cytogenetic of the complainant No.2 was conducted by PGIMER, Chandigarh on 19.03.2018, which states spontaneous breaks-absent and under the column diagnosis it is stated aplastic anemia–non-FA.  To prove it Chromosomal Breakage Analysis, Report of Department of Hematology  of PGIMER, Chandigarh was placed on record as Annexure C-9 which reveals that the treatment for which complainant No.2 was admitted was not genetic in nature. Further Annexure C-10 which is a test conducted on 20.03.2018 for PNH-79/18 also reveals that treatment was not genetic in nature. The report states that the PNH clone of more than 50% on granulocyte population has been reported to be associated with a significant risk of thrombosis. Moreover, the complainants have also placed on record Certificate dated 26-02-2019 issued by Dr.Alka Khadwal, MD,  Additional Professor, (Bone Marrow Transplant) PGIMER, Chandigarh which reads as under:

“This is certify that Mr.Govind Yadav, 17 years old boy (CR No.201705570389) son of Rupnarayan Yadav, is a case of severe aplastic anaemia, which was not genetic but acquired in nature and he underwent matched sibling donor hematopoietic stem cell transplant on 04.09.2018 and is under regular post transplant follow-up. Hematopoietic stem cell transplant or bone Morrow transplant refers to same treatment procedure where the damaged bone marrow is replaced by healthy blood forming stem cells obtained from HLA- matched donor to cure underlying email back haematological disorder, as was done for Mr.Govind Yadav”.

        From The aforesaid certificate it is very clear that the complainant No.2 was not suffering from genetic disorder but disorder acquired in nature. From this certificate, it is evident that the OPs have wrongly and illegally repudiated the claim of the complainants which amounts to deficiency in service.

8.     In view of the above discussion, the present complaint deserves to be partly allowed and the same is accordingly partly allowed. The OPs are directed to :-

i)      to pay the mediclaim of Rs.4,20,597/- to the complainants along with interest @ 9% p.a. from the date of its repudiation i.e. 07.01.2019 till its actual realization.

ii)    pay Rs.7,500/- as compensation to the complainant on account of mental tension and harassment.

iii)   pay Rs.7,000/- as litigation expenses.

9.      This order be complied with by the OPs jointly and severally, within 60 days from the date of receipt of its certified copy, failing which the complainants shall be at liberty to get the order enforced through the indulgence of this Commission.
10.     The pending application(s) if any, stands disposed of accordingly.
11.     Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

 

Announced in open Commission 24/04/2023
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(S.K.SARDANA) MEMBER