Chandigarh

DF-I

CC/555/2022

Mrs. Nidhi Gupta - Complainant(s)

Versus

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

Sudhir Gupta

12 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

 

Consumer Complaint No.	:	CC/555/2022
Date of Institution	:	30/05/2022
Date of Decision	:	12/04/2023

 

 

Mrs. Nidhi Gupta, aged 36 years, resident of Flat No.304, GHS 39, Sector 20, Panchkula-134116.

… Complainant

V E R S U S

1. Manipal Cigna Health Insurance Company Limited (formerly known as Cigna TTK Health Insurance Company), SCO 149-150, 1^st Floor, Sector 9-C, Next to Yes Bank, Chandigarh 160009.
2. Manipal Cigna Health Insurance Company Limited (formerly known as Cigna TTK Health Insurance Company), Registered and Corporate Office 401/402, Raheja Titanium, Western Express High Way, Goregaon, East Mumbai 400063 (Maharashtra).

… Opposite Parties

 

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

                                                                               

ARGUED BY	:	Sh. Sudhir Gupta, Counsel for complainant
	:	Sh. Inderjit Singh, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Mrs.Nidhi Gupta, complainant against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the complainant took a Family Floater Mediclaim Insurance Policy (hereinafter referred to as “subject policy”) from the OPs for self, her husband and two minor sons, having sum insured of ₹25.00 lacs, by paying premium of ₹35,636/- and the same was valid from 25.5.2020 to 24.5.2021 (Annexure C-1). On account of pandemic situation worldwide due to COVID-19 disease, many people got infected, including the husband of complainant.  In the month of September, 2020, complainant also got infected and thereafter she consulted the doctors who advised her on 10.9.2020 to get RAT done as her husband was already corona positive.  Thereafter, on 11.9.2020, RAT of the complainant for COVID was done at Government Dispensary, Sector 20, Panchkula and she was found positive. The complainant was also advised x-ray chest which was got conducted by her from Mirchia Diagnosis Centre, Manimajra, Chandigarh on 12.9.2020. After going through x-ray and RAT report (Annexure C-2 & C-3), the medical officer advised the complainant to take all COVID medicines which were taken by her by spending an amount of ₹5,521/-. The complainant was also advised home isolation/quarantine for 17 days by the doctor.  Intimation qua the disease from which the complainant was suffering as well as medical treatment and home isolation was given to the OPs.  Thereafter, complainant submitted the claim form alongwith all the required documents with the OPs.  However, the complainant was shocked when she received information from the OPs that her claim has been repudiated by the OPs vide letter dated 3.5.2021 (Annexure C-6) as she was never hospitalized.  Thereafter the complainant issued a legal notice dated 25.1.2022 (Annexure C-7) to the OPs, but, with no result. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and also that the complainant has filed a false complaint against the OPs.  However, it is admitted that the complainant alongwith her husband and children were insured with the OPs under the subject policy at the relevant time, but, denied that her claim was repudiated on wrong grounds by alleging that in fact the complainant was not entitled for any treatment as an outpatient/OPD since the same is not covered under the policy. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant alongwith her husband and two children were covered under the subject policy which was valid w.e.f. 25.5.2020 to 24.5.2021, and she had suffered from COVID-19 and remained under home isolation/ quarantine for 17 days, as advised by the doctor, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the claim of the complainant on the ground that she being an outdoor patient is not covered under the subject policy and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant or if the OPs are justified in repudiating the claim of the complainant on the ground that any treatment in an outpatient department/OPD was not covered under the subject policy and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy and for that purpose, the relevant portion/clauses of the same are required to be scanned carefully. 
   3. OPs have resisted the claim of the complainant by alleging that clause II.4 of the subject policy does not cover any treatment in an outpatient department/OPD and as it is the case of the complainant that she was never hospitalized and remained in home isolation, she is not entitled for any claim.  Clause II.4 of the subject policy is reproduced below for ready reference :-

        “II.4 Day Care Treatment :

        We will cover payment of Medical Expenses of an Insured Person in case of Medically Necessary Day Care Treatment or Surgery that requires less than 24 hours Hospitalization due to advancement in technology and which is undertaken in a Hospital/nursing home/Day Care Centre on the recommendation of a Medical Practitioner. Any treatment in an outpatient department/OPD is not covered. For list of Day Care Treatments refer Annexure II of the Policy.

        Coverage will also include pre-post hospitalisation expenses as available under the Plan opted.

        All claims under this benefit can be made as per the process defined under Section VII 4 & 5.”

 

4. On the other hand, learned counsel for the complainant contended that even otherwise, claim of complainant is covered under clause II.5 of the subject policy which covers domiciliary treatment. Clause II.5 of the subject policy is reproduced below for ready reference :-

       “II.5. Domiciliary Treatment:

We will cover Medical Expenses of an Insured Person which are towards a Disease/Illness or Injury which in the normal course would otherwise have been covered for Hospitalisation under the policy but is taken at home on the advice of the attending Medical Practitioner, under the following circumstances:

i.      The condition of the Insured Person does not allow a Hospital transfer; or

ii.     A Hospital bed was unavailable;

Provided that, the treatment of the Insured Person continues for at least 3 days, in which case the reasonable cost of any Medically Necessary treatment for the entire period shall be payable.

1. We will pay for Pre-hospitalisation and Post-hospitalisation Medical Expenses up to 30 days each.
2. We shall not be liable under this Policy for any Claim in connection with or in respect of the following :

1. Asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and pharyngitis, cough and cold, influenza,
2. Arthritis, gout and rheumatism.
3. Chronic nephritis and nephritic syndrome
4. Diarrhoea and all type of dysenteries, including gastroenteritis
5. Diabetes mellitus and Insipidus
6. Epilepsy
7. Hypertension
8. Psychiatric or psychosomatic disorders of all kinds.
9. Pyrexia of unknown origin.

All claims under this benefit can be made as per the process defined under Section VII 5.”

 

5. From the pleadings/allegations as set out by the parties and the evidence led by them, one thing is clear on record that as the complainant remained under home isolation for 17 days as per the advice of the doctor of the Govt. Hospital, on being diagnosed as COVID positive case, as is also evident from the prescription slip (Annexure C-5), and she remained in home isolation for the said period, and she had spent an amount of ₹5,521/-, as is also evident from the medical record (Annexure C-2 & C-3) and further that though she was not covered under clause II.4 of the subject policy, but, her case was covered under clause II.5 i.e. domiciliary treatment which specifically provides that the insured person is covered for medical expenses which are towards a disease/illness or injury which  in the normal course would otherwise have been covered for hospitalisation under the policy, but, is taken at home on the advice of the attending medical practitioner under the circumstances that the condition of the insured does not allow hospital transfer.  In the case in hand, as it stands proved on record that the complainant was found COVID positive and she was advised home isolation by the medical practitioner vide Annexure C-5 and for her treatment she had spent an amount of ₹5,521/- i.e. for medicines only, she is certainly entitled for the same as she got the treatment by keeping herself in home isolation on the advice of the medical officer and not on her own. 
6. Moreover, OPs cannot repudiate the claim of the complainant on technical grounds i.e. due to non hospitalisation of the insured especially when the situation in the year 2020 due to COVID-19 pandemic was so serious that even beds in the hospitals were not available and majority of the patients were advised by the medical officers for home isolation and to take the medicines at their homes.  Hence, it is safe to hold that the act of OPs in repudiating the genuine claim of the complainant certainly amounts to deficiency in service on their part and the present consumer complaint deserves to succeed.
7. Now coming to the quantum of compensation, though the complainant in the prayer clause has claimed an amount of ₹35,636/-, but, since in para 4 of the consumer complaint she has averred that she spent an amount of ₹5,521/-, which fact has also been endorsed by the learned counsel for the complainant at the time of arguments, it is safe to hold that the complainant is entitled for the claim amount to the extent of ₹5,521/- only (and not ₹35,636/- as claimed in the prayer clause) alongwith interest and compensation etc. for the harassment suffered by her.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹5,521/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 3.5.2021 till realization of the same.
2. to pay an amount of ₹10,000 to the complainant as compensation for causing mental agony and harassment to her;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs 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) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 12/04/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member