Chandigarh

DF-I

CC/252/2018

Dalip Kumar - Complainant(s)

Versus

Cigna TTK Health Insurance - Opp.Party(s)

Sh. Abhishek Singh

02 Aug 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/252/2018
Date of Institution	:	30/06/2018
Date of Decision	:	02/08/2019

 

Sh. Dalip Kumar, Shop No.23, Gupta Complex, Landmark Opp Hanuman Mandir Baddi Town, Solan, Himachal Pradesh.

… Complainant

V E R S U S

1.     Cigna TTK Health Insurance Company Limited, 401/402, Rahjea Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063, through its MD or Authorised Representative.

2.     Cigna TTK Health Insurance Company Limited, 1^st Floor, SCO 149/150, Sector 9-C, Chandigarh – 160009 through its Authorised representative.

3.     Fortis Hospital, Sector 62 VII, Mohali – 160062, through its MD or its Authorised representative.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                     

ARGUED BY	:	Sh. D.D. Taneja, Counsel for complainant
	:	Sh. Yugansh Siwach, Vice Counsel for Sh. Inderjit Singh, Counsel for OPs 1 & 2.
	:	Sh. Munish Kapila, Counsel for OP-3.

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, complainant had purchased a medical insurance plan under the name “ProHealth-Accumulate’ of OP-1 Insurance Company through OP-2 on payment of premium and the said policy was valid from 2.6.2017 to 1.6.2018.  Averred on 3.6.2017, complainant had felt pain in left side of chest radiating from left shoulder and arm and he got himself admitted with OP-3 for treatment and on improvement was discharged on the very next day on clearance of the bill of Rs.34,819/- to OP-3.  Claim was submitted to OPs 1 & 2 but it was not processed as OPs 1 & 2 repudiated it on the grounds that the complainant suffered DM diabetes and CAD, which were pre-existing and, therefore, it was not allowed.  The fact of the matter is, there was wrong medical report of OP-3 of complainant being patient of diabetes mellitus.  Later on he had also obtained a certificate from OP-3 of he was not suffering from any diabetic disease.  Legal notice was sent but it went unheard.  Hence, the complainant prayed for direction to OPs 1 & 2 to reimburse the claim amount of Rs.34,819/-, pay compensation of Rs.2.00 lakhs for mental and physical harassment; Rs.2.00 lakhs on account of unfair trade practice and cost of litigation of Rs.25,000/- alongwith any other relief which is deemed fit by this Forum.
2.         OPs 1 & 2 contested the consumer complaint and have put forth the facts of complainant had suffered pre-existing disease prior to the policy and he was having diabetes or pre-diabetes conditions for the last six months which facts were suppressed by him at the time of purchase of policy.  As such his case fell in exclusion clause and, therefore, the claim was repudiated.  The policy was given in good faith on reply to questions of the complainant having not suffered from any pre-existing disease as on the date of policy.  It was also claimed, this Forum has no territorial jurisdiction as cause of action has arisen at Mohali. On these lines, the cause is sought to be defended.
3.         OP-3 has also submitted separate reply and claimed complainant was admitted, treated and was discharged.  Bill was raised of Rs.34,819/- which was paid  by the complainant.  It is also claimed, OP-3 has no concern with the allegations made in the consumer complaint which were directed against OPs 1 & 2. On these lines, the cause is sought to be defended.
4.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
5.         Parties led evidence by way of affidavits and documents.
6.         We have heard the learned counsel for the parties and gone through the record of the case. After scanning of record, our findings are as under:-
7.         Per pleadings of the parties, issuance of the ProHealth-Accumulate policy by OPs 1 & 2 in favour of complainant valid from 2.6.2017   to 1.6.2018 is not in dispute before us.  Not only this, so much so, it is also admitted fact complainant fell ill on 3.6.2017 and was treated for a few hours and then was discharged and bill of Rs.34,819/- on being raised by OP-3 was paid by the complainant. There is no dispute about these averments made in the pleadings of the parties.
8.         The sole ground for repudiation of the claim by OPs 1 & 2 put forth based on diagnosis of OP-3 of complainant treated for HTN & DM type 2.  Their plea is complainant was admitted in the hospital in emergency under medical supervision of Dr. Karun Behal and discharged on 4.6.2017 on receipt of payment of Rs.34,819/-.  It is also deduced from Annexure OP-3/2. OP-3 had diagnosed the disease of the complainant for which he was treated.  Provisional diagnosis was chest pain evaluation UA k/c/o DM/UM and the diagnosis settled per Annexure OP-3/2 is chest pain, hyper tension, diabetes mellitus type 2 and had history of some surgery of fistula 10 years back.  From this Annexure OP-3/2 issued by OP-3, OPs 1 & 2 had come to know of complainant having history of diabetes mellitus for the last six months and for which disease the complainant was treated and suggested with diabetic diet.  It is on this opinion, OPs 1 & 2 held this pre-existing disease of diabetes mellitus type 2 was concealed by the complainant at the time of taking the policy on 3.6.2017. This is the only material available with OPs 1 & 2.
9.         We may refer here, in the averments made in the consumer complaint, the case of the complainant was he had no pre-existing disease and facts were wrongly mentioned by OP-3 and to this effect he had also taken a certificate from the own doctor of Fortis Hospital on 14.3.2018 vide which it was opined by Dr. Jasbir Kaur, Asstt. Medical Superintendent and Dr. K.P. Singh, MD (Med.) of Fortis Hospital that the complainant had never been a diabetic till date i.e. 14.3.2018. 
10.         The complainant even has made a reference after the aforesaid treatment other tests got done by him from the pathological lab which shows his sugar level was within normal limits. Hence, claimed he had not concealed any pre-existing disease. Even where OP-3 had mentioned complainant treated for chest pain and diabetes mellitus, it was nowhere disclosed it was as per past history disclosed by the complainant, but, it was their own diagnosis. 
11.         OP-3 in the reply furnished had asserted, diabetes mellitus was informed by the complainant himself while their own record shows, after their examination complainant was found to be patient of diabetes mellitus.  This is a contradictory reply.  From this record, we could only say since there was no concealment of pre-existing disease, therefore, the claim was wrongly repudiated by OPs 1 & 2 and they are liable to reimburse the amount of Rs.34,819/- to the complainant.  We hold so.
12.         In the consumer complaint, Fortis Hospital has been arrayed as OP-3.  It is nowhere mentioned of they were arrayed as proforma OP.  It is true, relief was prayed for against OPs 1 & 2 only, but, the fact remains, ground of repudiation complainant was treated for diabetes mellitus was on the disclosure of such record in the discharge slip etc. of OP-3.  At the cost of repetition, let it be taken note of here, per Annexure OP-3/2 final diagnosis of OP-3 was HTN DM type 2. This shows, it was the own diagnosis of OP-3 for which complainant was treated.  In order to escape from liability, OP-3 Fortis Hospital has taken inconsistent, contradictory and paradoxical stand that they were told so by the complainant at the time of admission, while their own record shows, it was their own diagnosis. The complainant had furnished the affidavit that he had not disclosed such disease to OP-3 and rightly so.
13.         OP-3 again subsequent to the treatment of disease on 14.3.2018 had issued a certificate (Annexure C-5), contents of which are reproduced below :-

                        “This is to certify that Mr. Dilip Kumar was being observed by me for last 3 years.

                        He has never been diabetic (No diabetes till date).”

With the own document of OP-3, its diagnosis for the disease in the history chart is mentioned and the own doctors of OP-3 on 14.3.2018 had opined, complainant had never been a diabetic (no diabetes till date i.e. 14.3.2018). This falsifies own opinion of OP-3 wherein in the discharge chart as on 4.6.2017, it had diagnosed it a case of diabetes mellitus type 2.  Relevant opinion on OP-3/2 dated 4.6.2017 is reproduced below :-

                “Diagnosis :       -Chest pain

• HTN
• DM type 2

 

14.         The whole action of OP-3 becomes doubtful and we have noted per record of OP-3 complainant was admitted in the hospital on 3.6.2017 at about 8:15 p.m. and was discharged in the morning of 4.6.2017 and a bill of handsome amount of Rs.34,819/- was raised. Treatment as indoor patient lasted few hours.  We cannot comment upon raising of such an exorbitant bill as our hands are tied in the clutches of law as the rates had not been fixed by any legal/medical standard, but, OP-3 has definitely practiced unfair trade practice and firstly submitted the opinion that he was treated for diabetes also alongwith chest pain and hypertension and diabetes is such a disease which is not curable, but, can be controlled. If on 3.6.2017 complainant was a patient of diabetes, how the own doctor of OP-3 furnished a report on 14.3.2018 that he had never been a patient of diabetes.  It is ridiculous one. The claim of the complainant was denied by OPs 1 & 2 as per report of OP-3 which was not correct, therefore, any mental and physical harassment caused is to be put on the shoulders of OP-3/Fortis Hospital as we do not find in the title of the complaint OP-3 mentioned as proforma OP. Rather in the prayer clause, complainant lastly prayed for any other relief which this Hon’ble deems fit and in this scenario we are of the firm opinion, compensation amount and heavy cost is to be imposed to check the reckless behaviour of OP-3.  Such liability is to be burdened on OP-3 in the form of punitive damages.
15.         Per pleadings and evidence led the policy was taken through OP-2 whose office is situated at Chandigarh within the territorial jurisdiction of this Forum. Thus, this Forum retains jurisdiction to entertain and decide the consumer complaint.
16.         In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed.  OPs are directed as under :-

1. OPs 1 & 2 to pay the amount of Rs.34,819/-to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 29.7.2017 till realization.
2. OP-3 to pay an amount of Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. OP-3 to pay Rs.15,000/- to the complainant as costs of litigation.

The relief of complainant is complete. In view of observations made in order, OP-3 needs to be economically punished for its reckless behaviour, highlighted above.  Hence, OP-3 is further directed as under :-

4. OP-3 to also deposit an amount of Rs.1,00,000/- as punitive damages in the Consumer Legal Aid Fund account being maintained in the name of Secretary, State Consumer Disputes Redressal Commission, UT, Chandigarh for help of poor consumers who are in need of legal aid.

17.         This order be complied with by the OPs severally within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i), (ii) & (iv) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
18.         The certified copies of this order be sent to the parties free of charge.  A certified copy of this order be also sent to the Secretary, Hon’ble State Commission, UT, Chandigarh for filing an execution application for recovery of the aforesaid amount of Rs.1,00,000/-, as and when the order becomes final as amount to be deposited in legal aid fund for help of poor consumers.  The file be consigned.

	SD/-	SD/-	SD/-
02/08/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President