Chandigarh

DF-II

CC/207/2021

Suman - Complainant(s)

Versus

Cigna - Opp.Party(s)

Adv. Randhir Singh Manhas

28 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	207/2021
Date of Institution	:	24.03.2021
Date of Decision	:	28.02.2024

 

                     

            

Suman wife of Radhey Shyam, resident of House No.1507/1, Sector 43-B, Chandigarh

...Complainant

Versus

1. Cigna T.T.K. Health Insurance Co. Ltd. having its registered and cooperative Office 401/402, Titanium Raheja Western at Express Highway, Goregoan (East Mumbai) through its Managing Director

2. Cigna T.T.K. Health Insurance Co. Ltd. having its Branch Office at SCO No.149/150, First Floor, Sector 9-C, Chandigarh, through its Branch Manager

3. Medi Assist Insurance TPA Pvt. Ltd., Tower-D, Fourth Floor, IBC Knowledge Bannerghatta Road, Bangalore Park, 4/1

...Opposite Parties

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI S.K.SARDANA	MEMBER
PRESENT:-
	Sh.Randhir Singh Manhas, Counsel for the complainant  along with complainant Proxy Counsel for Sh.Sachin Ohri, Counsel for OPs No.1 and 2 OP No.3 exparte.

   

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

1.     The complainant has filed the present complaint alleging therein that on completion of the previous insurance policy, she and her husband took the health insurance policy bearing No.PROHLN00018770 known as Pro Health Protect of the OPs commencing from 03.04.2019 to 02.04.2021 against the premium of Rs.1,18,982.53P for sum assured of Rs.10 lacs (Annexure C-3).  In the month of January, 2021, the complainant complained of knee pain and diagnosed to be Ostio Apprentice knee and she was advised total left knee replacement by the doctors after clinical tests.  She got the treatment from Paras Hospital, Panchkula and requested the OPs to make the payment of the surgery as the policy was cashless. In pursuance to the request of the complainant, OP No.3 sought additional information from the hospital vide letter dated 18.02.2021(Annexure C-6) and the same was furnished. However, the claim was repudiated by the OPs vide letter dated 19.02.2021  on the ground that in the proposal form, she did not disclose the fact that she had history of chest pain since 2012 as the same was material to policy decision.  It has been averred that she admitted in the hospital on 19.02.2021 and after operation discharged on 23.02.2021 and she had no option but to pay the hospital bills.  It has been stated that in the year 2012, she was examined by Dr.Anurag Sharma who certified that the complainant underwent coronary angiography in 2012 which revealed normal coronaries and also issued certificate that the medi claim cannot be denied. The complainant again requested the OPs for cashless claim but the same was again rejected stating that as per Clause VIII.1 of the policy, they are enable to admit the liability under the policy. The claim was stated to be wrongly and illegally rejected by the OPs. 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 refund the treatment expenses of Rs.2,75,000/- along with interest, compensation for mental agony and physical harassment as well as litigation expenses.
2.     After service of notice upon OPs No.1 and 2, they filed written version stating that the husband of the complainant had submitted the proposal form dated 30.03.2019 for porting his existing health policy and he was required to answer various questions pertaining to his & other insured members medical and lifestyle information.  The policy holder in response to the said questions had answered in negative, implying that none of the proposed insured members were suffering from any medical illness. Basis the information & declaration provided in the proposal form, the policy "Pro Health Protect bearing policy No.PROHLN000187002 valid from 03.04.2019 to until 02.04.2021 was issued, which was subject to the terms and conditions of the policy.  However, on receipt of the cashless claim request along with the various medical documents, they evaluated the medical documents received along with the cashless request and it was found that the complainant had complaints of chest pain in 2012 and had undergone Coronary Artery Angiography (CAG) in 2012 at Max Healthcare Super Speciality Hospital, Mohali but the said fact has not been disclosed in the proposal form. Had the complainant disclosed the same, the proposal would have been duly evaluated and decision would have been taken. Hence, the cashless claim was declined vide rejection letter dated 19.02.2021 stating as under:-

    "We have received Cashless request of Mr. Suman admitted at Paras Hospitals Panchkula (Unit Of Paras Healthcare Pvt Ltd) Panchkula for Osteoarthritis Left Knee. Claimant is covered under Manipal Cigna Health Insurance Prohealth (Protect V3) policy since 03 Apr 2019. & Ported since 31 Mar 2017. As per the available documents patient had History Chest Pain since 2012 which is material to policy decision and was not disclosed in proposal form at the time of policy inception. Hence the claim stands repudiated under Clause VIII. 1. We regret our inability to admit this liability under the present policy conditions."

        The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, OPs No.1 and 2 prayed for dismissal of the complaint.

3.     Despite due service, OP No.3 failed to put in appearance and as a result thereof it was ordered to be proceeded against exparte vide order dated 21.09.2022.
4.     Parties filed their respective affidavits and documents in support of their case.
5.     The complainant filed replication to the written reply of Opposite Parties No.1 and 2 and controverted their stand and reiterating her own.
6.     We have heard the Counsel for the contesting parties  and have gone through the documents on record including written submissions.
7.     Now the main question to be decided is as to whether the claim of the complainant was rightly repudiated by OPs No.1 and 2 vide its letter dated 19.02.2021 or not?
8.     In order to find out answer to this question, it is observed from the documents placed on record that OPs No.1 and 2-Insurance Company repudiated the claim of the complainant vide letter dated 19.02.2021 (Annexure R-4) on the ground that the patient had history of chest pain since 2012 which is material to policy decision but the same was not disclosed in the proposal form. However, the complainant had undergone surgery for left knee replacement during the existence of the said insurance policy and incurred a sum of Rs.2.75 lakhs upon her treatment. The disease of chest pain has no nexus whatsoever with the knee replacement of the complainant. In addition to this, OPs No.1 and 2 have further not led any evidence that the disease of chest had any connection or nexus with the knee replacement of the complainant. In the absence of any evidence of nexus with the chest, the claim for treatment of knee replacement cannot be said to have been rightly repudiated on the ground of non-disclosure of the material facts by the policy holder.
9.      It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.
10.     In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

    “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

11.     In view of the above discussion, it can be safely concluded that OP Nos.1 & 2-Insurance Company have committed deficiency in service by wrongly and illegally rejecting the genuine claim of the complainant.
12.     Consequently, the present complaint deserves to be partly allowed and the same is accordingly allowed qua OP Nos.1 & 2-Insurance Company. The OP Nos.1 & 2-Insurance Company are directed to pay Rs.2,75,000/- towards the medical expenses to the complainant  along with interest @ 9% per annum from the date of its repudiation i.e. 19.02.2021 till the date of its actual realization to the complainant.  The OPs No.1 and 2 shall also pay a sum of Rs.11,000/- to the complainant towards compensation for mental agony and physical harassment as well as litigation expenses.
13.     This order be complied with by OP Nos.1 & 2-Insurance Company  within 90 days from the date of receipt of its certified copy.
14.     The complaint qua OP No.3 stands dismissed.
15.     The pending application(s), if any, stands disposed of accordingly.
16.     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 28.02.2024
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(S.K.SARDANA) MEMBER