Punjab

Ludhiana

CC/20/93

Kanwal Kumar - Complainant(s)

Versus

Manipal Cigma health Insurance Co.Ltd - Opp.Party(s)

B.S.Rampal Adv.

04 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:93 dated 22.06.2020.                                                 Date of decision: 04.09.2023.

 

Sh. Kanwal Kumar Malhotra S/o. Sh. Harbans Lal Malhotra, R/o. H. No.57, PHB Colony, Jamalpur, Ludhiana now deceased through his L.Rs:-

  1. Reetu Malhotra (wife)
  2. Neha Malhotra (daughter)
  3. Pulkit Malhotra (minor son) through his mother, next friend and natural guardian Smt. Reetu Malhotra W/o. Late Sh. Kanwal Kumar Malhotra,

All R/o. H. No.57, PHB Colony, Jamalpur, Ludhiana.                                                                                                                      ..…Complainant

                                                Versus

  1. Manipal Cigna Health Insurance Co. Ltd., Ist Floor, Sandhu Tower-I, Gurdev Nagar, Ferozepur Road, Ludhiana-141001 through its Branch Manager.
  2.  Manipal Cigna Health Insurance co. Ltd. (formerly known as Cigna TTK Health Insurance Co. Ltd.) Reg. Office 401/402, 4th Floor, Rajan Titanium Off. Western Express Highway, Goregaon (East), Mumbai-400063 through its Director.                                                                                                                                       …..Opposite parties 

Complaint Under section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Manoj Kumar, Advocate for legal heirs of                                             complainant.

For OPs                         :         Sh. Vyom Bansal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Succinctly put, the facts of the case are that complainant Sh. Kanwal Kumar Malhotra (now deceased) along with his family members purchased a medi-claim policy bearing No.P/161114/01/2014/004329 from Star Health and Allied Insurance Company Ltd. for the period from 14.11.2013 to 13.11.2014, which was renewed from 14.11.2014 to 13.11.2015, 17.11.2015 to 16.11.2016, 22.11.2016 to 21.11.2017. The said policy was taken over by the opposite parties and was renewed from 24.11.2017 to 23.11.2018 vide policy No.PROHLR010458663. The representatives of opposite parties obtained signatures of the complainant on unfilled forms and blank papers at the time of issuing the policy. The opposite parties also got medically examined the complainant and his family from their authorized doctors and after completing all the legal formalities, opposite parties issued the policy. The complainant got his policy transferred with the opposite parties on their assurance that the policy will be considered from 14.11.2013 and all the benefits of previous policy will be given to him. The policy with opposite parties was further renewed from 24.11.2018 to 23.11.2019 after proper medical checkup and which was further got renewed from 24.11.2019 to 23.11.2020. The policy was for a sum insured of Rs.5,50,000/- per person.  According to the complainant, in the month of July 2018, Sh. Kanwal Kumar Malhtora got operated his left eye from Chugh Eye Surgery Centre, Ludhiana for which he lodged a medi-claim with the opposite parties and the claim was passed by the opposite parties without any hindrance. Further on 17.11.2019, Sh. Kanwal Kumar Malhotra was got admitted in SPS Hospital, Ludhiana where he was operated on his right foot and was discharged on 22.11.2019. The complainant spent Rs.1,15,671/- on his treatment and he also spent Rs.40,000/- for his further treatment and medicines. The complainant was further admitted in SPS Hospital, Ludhiana on 02.12.2019 and was operated and his right knee was amputated on 03.12.2019 and he was discharged on 04.12.2019. The complainant paid a sum of Rs.57,385/- for his treatment besides Rs.30,000/- for his further treatment and medicine. Sh. Kanwal Kumar Malhotra lodged two claims bearing No.21187217 and 21187352 and submitted the necessary documents as required by the opposite parties but the claims were rejected without any legal reason. The rejection of the claims has been made on the basis of condition which was never communicated to the complainant at the time of insurance policy. The complainant many times visited and requested the opposite parties to look into the matter but all in vain. The complainant served legal notice dated 10.02.2020 through registered post on 17.02.2020 to the opposite parties but to no avail. Hence this complaint whereby the complainant has prayed for issuing directions to the opposite parties to pay the claim of Rs.1,15,671/-, 57,385/-, Rs.40,000/- and Rs.30,000/- spent on medical treatment and also to pay compensation of Rs.1,00,000/- besides litigation expenses of Rs.25,000/-.

2.                During the pendency of the complaint, complainant Sh. Kanwal Kumar Malhotra expired and his legal heirs were ordered to be impleaded as party/complainant vide order dated 02.08.2022.  

3.                The opposite parties appeared and filed their joint written statement and by taking factual submissions/preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of cause of action; jurisdiction and suppression of material facts etc.  The opposite parties stated that stated that the complainant ported the health policy from previous insurer with them for the first policy period from 24.11.2017 to 23.11.2018 vide policy No.PROHLR010458663 and lastly renewed for the period 27.11.2020 to 26.11.2021. According to the opposite parties, the benefits under the policy are governed by its terms and conditions and their liability is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the policy. The condition of waiting period of continuous coverage of 48 months from first policy inception was applicable with the opposite parties. The opposite parties further averred that two reimbursement claims were received from the complainant vide claim No.21187217 and 21187352, which were assigned to Medi Assist Insurance TPA Pvt. Ltd. For investigation who submitted investigation report dated 02.01.2020, which is reproduced as under:-

          a. Claim No.21187217

i.        That complainant filed a re-imbursement claim for admission at SPS Hospitals from17.11.2019 go 22.11.2019 with the complaints of Type 2 Diabetes Mellitus (DM), Diabetic Foot abscess grade 4 with gangrene. As per ICP, the complainant had history of DM since 15 years.

ii.       As per statement of the Complainant, he was admitted in SPS Hospital, Ludhiana on 17.11.2019 with the complaints of pain and swelling in right foot and leg (diabetic foot) for last 10-20 days before admission. Further he consulted to Dr, Saini of Saini Clinic Ludhiana on dated 28.10.2019.

iii.      As per Statement of the complainant, he was suggested of blood investigation during hospitalization. Further as per Statement of the Complainant, he was suffering from diabetes since Oct. 2018 and diagnosed by Dr. Ramanbir Singh SPS Hospital, Ludhiana and he is on medication. The Complainant is having history of hospitalization in Chugh hospital Ludhiana in Feb 2018 for right eye surgery.

iv.      Previous Ailment:- As per OPD record of SPS hospital, Ludhiana dated 22.01.2018, Patient suffering from DM-II since 13 years and advised for oral medication, insulin therapy. Further as per OPD paper of Dr. Saini, Saini Clinic Ludhiana dated 04.10.2018, patient suffering from DM-II since 13-14 years and advised for oral medication and patient's BP level is 160/80. The Complainant took regular treatment for same from Dr. Saini from 04.10.2019. As per OPD record of SPS hospital, Ludhiana dated 22.01.2018, Patient suffering from DM-II since 13 years and advised for oral medication, insulin therapy.

b. CLAIM NO. 21187352

  1. That Complainant filed a re-imbursement claim for admission at Satguru Pratap singh Apollo Hospitals (SPS Apollo Hospitals) from 02.12.2019 to 04.12.2019 with the complaints of Type 2 DM, Right Diabetic foot. As per ICP documents Complainant had History of K/c/o DM since 15years.
  2. As per Statement of the Complainant, he was admitted in SPS Hospital, Ludhiana on 02.12.2019 with the complaints of pain and discharge from right foot for last one month and for surgery of right foot. Further he consulted to Dr, Saini of Saini Clinic Ludhiana on dated 28.10.2019.
  3. As per Statement of the complainant, he was suggested of blood investigation during hospitalization. Further as per Statement of the Complainant, he was suffering from diabetes since Oct. 2018 and diagnosed by Dr. Ramanbir Singh SPS Hospital, Ludhiana and he is on medication. The Complainant is having history of hospitalization in Chugh hospital Ludhiana in Feb 2018 for right eye surgery.
  4. Previous Ailment:- As per OPD record of SPS hospital, Ludhiana dated 22.01.2018, Patient suffering from DM-II since 13 years and advised for oral medication, insulin therapy. Further as per OPD paper of Dr. Saini, Saini Clinic Ludhiana dated 4/10/2018, patient suffering from DM-II since 13-14 years and advised for oral medication and patient’s BP is 160/80. The complainant took regular treatment for same from Dr. Saini from 04.10.2019. As per OPD record of SPS Hospital, Ludhiana dated 22.10.2018, patient suffering from DM-II since 13 years and advised for oral medication, insulin therapy.

The opposite parties further stated that the complainant had not disclosed all the pre-existing diseases in the proposal form at the time of taking the insurance cover and the claim was repudiated under clause VII.1. Duty of Disclosure under the policy vide rejection letter dated 09.01.2020 which was duly informed to the complainant.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties have denied any deficiency in service on their part and in the end, prayed for dismissal of the complaint.

4.                In support of his claim, the complainant Kanwal Kumar Malhotra (now deceased) tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C4 are the copies of insurance policies from 14.11.2013 to 13.11.2014, 14.11.2014 to 13.11.2015, 17.11.2015 to 16.11.2016 and 22.11.2016 to 21.11.2017 respectively issued by Star Health and Allied Insurance Company Limited; Ex. C5 to Ex. C7 are the copies of insurance policies from 24.11.2017 to 23.11.2018, 24.11.2018 to 23.11.2019, 24.11.2019 to 23.11.2020 respectively issued by the opposite parties, Ex. C8 is the copy of  letter regard change of name of insurance company from Cigna TTK to Manipal Cigna, Ex. C9 to C33 are the copies of medical bills/receipts, Ex. C34 is the copy of legal notice dated 10.02.2020, Ex. C35 and Ex. C36 are the copies of postal receipts, Ex. C37 and Ex. C38 are the copies of rejection letters dated 09.01.2020 and closed the evidence.

5.                On the other hand, counsel for the opposite parties affidavit Ex. RA of Sh. Jaswinder Singh Shekhawat, Manager-Legal of the opposite parties along with documents Ex. R1 is the copy of policy documents, Ex. R2 is the copy of reimbursement claim file of Medi Assist Insurance TPA in claim No.21187217, Ex. R3 is the copy of reimbursement claim file of Medi Assist Insurance TPA in claim No.21187352, Ex. R4 is the copy of discharge summary dated 22.11.2019, Ex. C5 is the copy of discharge summary dated 04.12.2019, Ex. R6 is the copy of questionnaire in claim No.21187217, Ex. R7 is the copy of questionnaire in claim No.21187352, Ex. R8 and Ex. R9 are the copies of prescription slips of SPS Hospital, Ludhiana, Ex. R10 is the copy of investigation report in claim No.21187217, Ex. R11 is the copy of investigation report in claim No.21187352, Ex. R12 is the copy of repudiation letter dated 09.01.2020, Ex. R13 is the copy of proposal form and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

7.                In this case, the claims have been repudiated on the ground of non-disclosure of pre-existing disease which the complainant has been suffering from the disease such as type-2 diabetes mellitus  for the last about 13-14 years. It has also been pointed out that in the proposal form, all the questions pertaining to medical history have been answered in negative. It has also been pointed out by the counsel for the opposite parties that during investigation, it was found that the complainant was a known case of DM since 15 years. In this context, investigation report Ex. R10 and Ex. R11 wherein it has been mentioned that as per OPD paper of Dr. Saini, Saini Clinic, Ludhiana dated 04.10.2018, patient suffering from DM-II since 13-14 years and was on regular medicine.

8.                Now, it has to be seen whether repudiation of the claims on the ground of non-disclosure of pre-existing disease is justified or not. In the repudiation letters dated 09.01.2020 Ex. C37 and Ex. C38, the ground of the repudiation has simply been mentioned to be non-disclosure of pre-existing diseases as per clause VIII.1 Duty of Disclosure, which reads as under:-

          “VIII.1.       Duty of Disclosure

The Policy shall be null and void 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 or 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.”

In this context, it is relevant to point out that the policy was obtained by the complainant in the year 2013  from Star Health and Allied Insurance Company Ltd. and it has been renewed from time to time without any break. Thereafter, the policy was ported with the opposite parties vide policy having validity from 24.11.2017 to 23.11.2018  and the policy was renewed till 23.11.2020 for a sum assured of Rs.5,50,000/- per insured  for which the complainant paid  premium.

To be more specific, Kanwal Kumar Malhotra did not disclose that he was suffering from diabetes mellitus for 13-14 years and was on medication. Here it is pertinent to mention that in this case, the opposite parties have not invoked the major exclusions of the policy which provide for a waiting period of 48 months from the inception of the policy in respect of pre-existing diseases. The obvious reason for not invoking the said clause appears to be that the policy was obtained in the year 2013 and the period of 48 months had expired when the claim was lodged in the year 2019.

9.                No doubt that during the investigation, it has been found that Kanwal Kumar Malhotra was a known case of diabetes mellitus for the last 13-14 years. However, in our considered opinion, on the basis of the above stated so called history of Kanwal Kumar Malhotra, the claim could not have been rejected. In the treatment record of the patient i.e. discharge summary Ex. R4 dated 22.11.2019 and Ex. R5 dated 04.12.2019, in the column of diagnosis, it is simply mentioned that the complainant has diagnosed for Type-2 diabetes mellitus, but the period has not been mentioned. It is further pertinent to mention that when the policy was ported with the opposite parties, the complainant was got medically examined by the doctors of the opposite parties. In para No.2 of the complaint, it has been mentioned that health check of the complainant and his family were conducted by the authorized doctor of the opposite parties and after completing all the formalities, the opposite parties issued the health insurance policy.  Further even at the time of renewal of policy for the year 24.11.2018 to 23.11.2019, medical checkup was also conducted. This fact has not been denied by the opposite parties in the written statement. In para no.2 of the written statement, it has simply been mentioned that the complainant had ported his family health policy from previous insurer to them for the first policy period from 24.11.2017 to 23.11.2018 and lastly renewed the policy from 27.11.2020 to 26.11.2021 and further that the benefits under the policy are governed by the terms and conditions of the policy and one of the crucial condition of the policy a waiting period of continuous coverage of 48 months from first policy inception with the opposite parties is applicable. Strangely enough, no record of medical examination of the complainant and his family members which was admittedly conducted by the doctors of the opposite parties twice, one at the time of issuing the policy and second at the time of first renewal, has been placed on record and for that an adverse inference ahs to be drawn against the opposite parties.

10.              It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected. In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

11.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has held as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing diseases such as type-II diabetes mellitus could not have been made a ground to reject the claim and cancel the policy and the rejection of the claims on this ground cannot be sustained in the eyes of law. The complainant has staked the following claims for reimbursement:-

Claim No.21187217 for Rs.1,15,671/- + Rs.40,000/-

Hospitalization from 17.11.2019 to 22.11.2019

SPS Hospital, Ludhiana

Claim No.21187352 for Rs.57,385 + Rs.30,000/-

Hospitalization from 02.12.2019 to 04.12.2019

SPS Hospital, Ludhiana

 

12.              As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall settle and reimburse both the claims of the complainant Kanwal Kumar Malhotra (since deceased) in respect of his hospitalization 17.11.2019 to 22.11.2019 and further from 02.12.2019 to 04.12.2019 at SPS Hospital, Ludhiana in accordance with the terms and conditions of the policy in question within a period of 30 days from the date of receipt of copy of this order. The opposite parties shall further pay a composite compensation of Rs.10,000/- (Rupees Ten Thousand only) within 30 days from the date of receipt of copy of the order. All the amounts shall be paid to the legal heirs of the complainant in equal share. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                     (Sanjeev Batra)

Member                         Member                                       President         

 

Announced in Open Commission.

Dated:04.09.2023.

Gobind Ram.

 

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