Haryana

Ambala

CC/209/2022

Braj Kishore Mishra - Complainant(s)

Versus

Manipal Cigna Health Insurance Co Ltd - Opp.Party(s)

Pawan Yadav

25 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	209 of 2022
Date of Institution	:	13.06.2022
Date of decision	:	25.04.2024

Braj Kishore Mishra resident of House No.300, Prem Nagar, Ambala City.

……. Complainant

Versus

Manipal Cigna Health Insurance Company Limited (formerly known as Cigna TTK Health Insurance Company Limited), Regd. Office: 401/402, 4th Floor, Raheja Titanium, Western Express Highway, Guregoan (East), Mumbai-400063 through its Authorized Signatory/Managing Director.

….…. Opposite Party

 Before:       Smt. Neena Sandhu, President.

                      Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Pawan Yadav, Advocate, counsel for the complainant

                     Shri Sunil Sharma, Advocate, counsel for the OP.     

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘OP’), praying for issuance of following directions to it:-

1. To refund the amount of Rs.71,871/- alongwith interest @24% p.a.
2. To pay compensation of Rs.4,00,000/- causing mental agony, harassment to the complainant.
3. To pay Rs.22,000/- as litigation expenses.
382.  

Grant any other relief which this Hon’ble Commission may deems fit.

 

2.             Brief facts of this case are that the complainant was exploring for a health insurance for him and his family member. On recommendation from one of his relatives, who has obtained Health Insurance from the OP. The complainant had accessed web site on www.manipalcigna.com for a suitable Health Insurance for him and his family members and had provided his detail credentials required. The representative of the OP namely, Vipin had called the complainant from his office landline number and made an interaction and provided the policy Boucher on the email of the complainant: braj.ambalal@gmail.com. On 28.2.2022, the complainant got a call from Mr. Vipin and he had arranged a discussion with his senior regarding few queries. During the course of discussion, the complainant had given his family medical/health details and told that his wife had gone a peri-cardial effusion which is simplified that it was not a surgery; further all lab reports founds normal, therefore, she was prescribed no medical test/medicines and asked to lead a normal life by the doctor. Ultimately, the complainant paid premium amount of Rs.71871/- to the OP through Net Banking for obtaining the  health insurance policy.  However, the complainant had made a typo error in his primary email ID 'braj.mshra@ril.com', but the correct e-mail ID is 'braj.mishra@ril.com'. He came to know about this only on 16.4.2022 after receiving the policy papers over e-mail. However, the complainant had also given his alternate e-mail ID in the online application' braj.ambala1@gmail.com but was astonished that his email get bounce back with a message can't deliver to recipient mail ID/recipient mail ID not found etc. On 16.03.2022 the complainant had received a call from the company and a lady doctor had inquired about the health history of complainant and his family health. The details were shared point by point with the questions, she had put regarding existing and past illness history for self and family. Peri-cardinal effusion of wife of the complainant was also intimated along with diabetic medicines of complainant, work profile, Covid-19 status etc. and the complainant has received a message that your service request is processed and he will receive call from their customer service support team by 21.3.2022. On 19.3.2022 the complainant has received a SMS to pay additional amount of Rs.4253.23 through the link sent in the email of complainant. As the primary email ID was incorrect, the complainant could not made any payment. Till 12.4.2022 the complainant has not received the Health Insurance copy nor any inputs collected and as such he contacted the OP in the matter.   On 16.4.2022 the company sent Policy No. PROHL V050098959 of plan named ProHealth-Profect, T & C and stated that this policy was terminated on 19.3.2022 due to no disclosure of Peri-Cardinal Effusion of his wife Rita Rath and the premium paid is forfeited with any refund. On receipt of the email from the OP, the complainant informed the OP that he has not hidden any fact regarding family health history and requested not to terminate the policy. However, on 19.4.2022 the OP again replied that the policy is terminated owing to non discloser of peri-cardinal effusion and the premium paid is forfeited. Thereafter, the complainant contacted the OP through every possible means for redressal of his grievance but to no avail. Hence, the present complaint.
3.           Upon notice, OP appeared and filed written version wherein while admitting the factual matrix of the case regarding receipt of payment of Rs.71871/- as premium from the complainant for purchase of the policy in question and also its termination by it, raised preliminary objections to the effect that this complaint is not maintainable; the complainant has suppressed material facts from this Commission etc. On merits, it has been stated that on 28.02.2022, the complainant has submitted online proposal from through website of the OP, for purchasing the policy in question for himself, his daughter and his wife. At the time of submitting the said proposal form, under Section 5 (Medical and Life style Information), the complainant has answered “NO” to all the questions. However, thereafter, when the OP contacted the complainant to conduct tele-medical for all the proposers, the complainant disclosed that his wife-Rita has a history of Pericardial Effusion in 2021, yet, the same was not disclosed by him in the proposal form. Under those circumstances, since there was disclosure of medical history of the proposed insured, the policy in question was cancelled by the OP. The proposal made by the complainant was not accepted by the company and the same became an unconcluded contract. A contract will come into existence only upon the acceptance by the offeree and because in the present case, the proposal of the insurance contract was not acceptable to the company, the same was terminated.   Rest of the averments of the complainant were denied by the OP and prayed for dismissal of the present complaint with exemplary costs.
4.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-8 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OP tendered affidavit of Jaswinder Singh Shekhawat, working as Senior Manager-Legal and Authorized Representative of OP i.e Manipal Cigna Health Insurance Company Limited, having its corporate office at 4^th Floor, Raheja Titanium, Off Western Express Highway, Goregaon East, Mumbai-400 063 as Annexure OP-1/A alongwith documents as Annexure R-1 to R-3 and closed the evidence on behalf of OP.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.  
6.           Learned counsel for the complainant submitted that by terminating the proposal of the insurance in question illegally despite the fact that the complainant has informed the OP that his wife has a history of Pericardial Effusion in 2021 and at the same time, not refunding the premium amount of Rs.71871/- after terminating the said proposal of insurance, the OP is deficient in providing service and indulged into unfair trade practice.
7.           On the other hand, learned counsel for OP while reiterating the objections and contentions raised in the written version submitted that since there was fresh disclosure of medical history of the proposed insured i.e. the wife of the complainant had history of Pericardia Effusion in 2021. The insurance company evaluated the proposal and cancelled the policy. He further submitted that the proposal made by the complainant was not accepted by the company and the same became an unconcluded contract. He further submitted that a contract will come into existence only upon the acceptance by the offeree and because in the present case, the proposal of the insurance contract was not acceptable to the company, the same was terminated.  
8.           The moot question which falls for consideration is as to whether the complainant is entitled to get any relief in this case or not. It may be stated here that it is not in dispute that the complainant has filled proposal form for obtaining the health insurance policy from the OP, through online from the website of the OP, for himself, his wife and daughter, on making payment of premium of Rs.71871/-. The receipt of premium of Rs.71871/- from the complainant on 28.02.2022 has been admitted by the OP vide premium certificate, Annexure C-5. It is also not in dispute that though in the proposal form, the complainant has mentioned that they are not suffering from any disease, yet, when before issuance of the policy in question, the OP contacted the complainant to conduct tele-medical for all the proposers, the complainant himself has disclosed that his wife-Rita has a history of Pericardial Effusion in 2021. However, on this ground only, the OP decided to terminate the proposal of the complainant. It is significant to mention here that it was the own case of the OP since there was disclosure of medical history of the proposed insured i.e. the wife of the complainant had a history of Pericardial Effusion in 2021, the proposal made by the complainant was not accepted by the company, on the ground that the same became an unconcluded contract; that a contract will come into existence only upon the acceptance by the offeree and because in the present case, the proposal of the insurance contract was not acceptable to the company, the same was terminated. Thus, once it was the own case of the OP that the proposal of the complainant was not accepted by the company and was terminated because of the reason that the complainant himself has informed it that his wife-Rita has a history of Pericardial Effusion in 2021, then, it has not been clarified by the OP as to why it retained the premium amount of Rs.71871/-. Once no services were provided by the OP and it, itself did not accept the proposal, it was legally bound to refund the premium amount received from the complainant but it miserably failed to do so and dragged the complainant in this unwanted litigation. The complainant is therefore held entitled to get back his premium amount of Rs.71,871/- from the OP alongwith interest and compensation for mental agony and harassment and also litigation expenses.

9. In view of the aforesaid discussion, we hereby allow the present complaint and direct the OP, in the following manner:-  

•   To refund the amount of Rs.71,871/- alongwith interest @6% p.a. from 28.02.2022, i.e the date of receipt of the premium amount, till its realization.
•   To pay Rs.3,000/-, as compensation for the mental agony and physical harassment suffered by the complainant.
•   To pay Rs.2,000/- as litigation expenses.  

 

The OP is further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OP shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 25.04.2024.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President