Chandigarh

DF-I

CC/398/2020

Pawan Kumar - Complainant(s)

Versus

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

Rakesh K. Kaundal

01 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/398/2020
Date of Institution	:	22/09/2020
Date of Decision	:	01/02/2023

 

Pawan Kumar, aged 50 yrs son of Kartara Ram resident of House No.565, Sector 19, Panchkula presently residing at #126, Hem Vihar, Baltana, Tehsil Derabassi, District SAS Nagar.

… Complainant

V E R S U S

1. Manipal Cigna Health Insurance Company Limited (formerly known as Cigna TTK Health Insurance Company Limited Regd. Office 401-402, 4^th Floor, Raheja Titanium Off., Western Express Highway, Goregaon (East) Mumbai 400063, through its authorized person.
2. Manipal Cigna Health Insurance Company Limited, 1^st Floor, SCO 149-150, Sector 9-C, Madhya Marg, Chandigarh 160009 through its authorized person.

… Opposite Parties

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

 

                                                                               

ARGUED BY	:	Sh. Rakesh K. Kaundal, Counsel for complainant
	:	Sh. Hoshiar Chand, Vice Counsel for Sh. Inderjit Singh, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh.Pawan Kumar,  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 had obtained a pro health protect plan from the OPs for himself and his wife namely, Smt. Suneha Devi vide policy (Annexure C-1) valid w.e.f. 16.10.2019 to 15.10.2020 for sum insured of ₹4,50,000/- each by paying premium of ₹15,360.13.  At the time of filling up the proposal form, all information regarding health, which were true and correct to the best of their knowledge, were given by the insured and after verifying facts from the insured, OPs had issued the subject policy. Complainant was well aware that he was not suffering from any disease. However, on 2.6.2020, he suffered chest pain and was admitted to Alchemist Hospital, Sector 21, Panchkula and on the same day he was shifted to Coronary Care Unit (CCU) and was diagnosed with cardio problem and was advised for coronoary angiography. During coronary angiography of the complainant, the doctor on duty advised for coronary angioplasty.  The complainant applied for cashless facility through TPA i.e. Mediclaim Assist Insurance TPA Pvt. Ltd., but, it showed its inability to extend the same on the ground that documents submitted by the complainant showed he was known case of hypertension which amounts to pre-existing disease and the claim submitted by the complainant cannot be reimbursed and the same was conveyed to the complainant vide prescription and rejection of cashless facility (Annexure C-3).  As a result, the family of the complainant was compelled to deposit the amount in the hospital for his treatment. The complainant was admitted in the hospital on 2.6.2020 and was discharged on 4.6.2020 and during this period, he had undergone coronary angiography and coronary angioplasty and had spent an amount of approximately ₹2,00,000/- for the treatment as per copies of discharge summary and medical record (Annexure C-4 and C-5).  After discharge from the hospital, complainant had submitted claim with the OPs and after receiving the said documents, OPs asked him to submit additional documents which were also submitted by him.  However, the OPs finally rejected the claim of the complainant vide letter 27.8.2020 (Annexure C-11) by ignoring the documents submitted by him including the certificate (Annexure C-10) issued by the Medical officer in which he had specifically opined that etiology of the CAD is not known as history of diabetes mellitus or smoking.  Thus, despite of the mediclaim policy issued by the OPs in favour of the complainant, OPs had wrongly repudiated the claim of complainant on the ground of pre-existing disease and this act of the OPs amounts to deficiency in service on their part.  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 statement, inter alia, taking preliminary objections of maintainability and concealment of facts, though it is admitted that the subject policy was issued in favour of the complainant and his wife, who were asked to submit the proposal form and the same was submitted by them.  It is further alleged that in fact the complainant had concealed material facts while filling up the proposal form by not disclosing that he was having past history of pre-existing disease since 4-5 years and was a chronic smoker since 1991.  Submission of the claim form by the complainant has also not been disputed, but, it is alleged that the claim of the complainant was not considered by the OPs as he had not given material information qua the pre-existing disease which he was having prior to the purchase of the subject policy.  The complainant had also admitted in his own statement dated 17.8.2020 that he is a smoker which fact has also been endorsed by the doctor and due to concealment of material information by the complainant, OPs were left with no other option except to repudiate the claim of the complainant.  On merits, complainant reasserted the facts as stated in the preliminary objections and denied the cause of action set up by the complainant. The consumer complaint is sought to be contested.
3. Despite grant of numerous opportunities, no rejoinder was filed by the complainant to rebut the stand of the OPs.

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 and his wife had obtained the subject policy from the OPs which was valid w.e.f. 16.10.2019 to 15.10.2020 with sum insured of ₹4,50,000/- for each, as is also evident from the policy schedule (Ex.OP-2) and also that the complainant had undergone treatment for Coronary Artery Disease, acute anterior wall myocardial infarction, CAG-PTCA and CAG and was treated upon for coronary angiography and coronary angioplasty at Alchemist Hospital and he remained admitted there from 2.6.2020 to 4.6.2020 and thereafter the complainant had submitted claim for his medical treatment with the OPs, which was repudiated by the OPs on the ground that he was having pre-existing disease prior to obtaining the policy i.e. he had history of hypertension since 4-5 years and was chronic smoker, which fact, was not disclosed by him in the proposal form, 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 the complainant was suffering from hypertension and was a chronic smoker and there is deficiency in service on the part of the OPs 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 he was suffering from pre-existing disease i.e. hypertension since 4-5 years and was a chronic smoker, which fact was concealed by him in the proposal form and the consumer complaint of the complainant 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 terms of the policy as the same are interpreted by the complainant in the manner which is beneficial for him whereas the OPs have interpreted the same in the manner which is beneficial to them.
   3. The learned counsel for the complainant contended with vehemence that as hypertension has no connection with the disease for which the complainant had taken treatment from the aforesaid Alchemist Hospital for Coronary Artery Disease, acute anterior wall myocardial infarction, CAG-PTCA and CAG and further when it has been held in various judgments passed by the Hon’ble Apex Court as well as Hon’ble High Courts that diabetes and hypertension are lifestyle diseases and repudiation of the claim of the complainant is not justified under law, complainant is entitled for the claim as prayed for.
   4. On the other hand, learned counsel for the OPs has contended with vehemence that as the complainant, while purchasing the policy in question, has filled the declaration form where he had disclosed that he was not suffering from hypertension and it has also been proved by the OPs through medical record issued by Alchemist Hospital that complainant was suffering from hypertension since 4-5 years and was a chronic smoker, non-disclosure of pre-existing disease by the complainant is fundamental breach of the policy and the claim of complainant was rightly repudiated by the OPs.  However, there is no force in the contention of learned counsel for OPs as proposal form (Ex.OP-1) does not bear the signature of the complainant or his wife, rather the same is simply showing that the columns of information have been typed without having signature of any of the insured.  As it has come on record that the said proposal form does not bear the signatures of both the insured and the OPs have not proved the same in accordance with law, same has no evidential value in the present case. 
   5. As it is not disputed by the OPs that the aforesaid disease, from which the complainant was suffering, has not been covered under the policy, rather the complaint has been resisted by the OPs on the ground that the complainant had been suffering from hypertension 4-5 years prior to obtaining the subject policy, which proves that the complainant was suffering from pre-existing disease, the same can be decided in the light of various judgments passed by the Hon’ble Apex Court and various Hon’ble High Courts.
   6. It has recently been held by the Hon’ble State Commission Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) as under :-

“Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

 

7. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“10.   We further deem it appropriate to refer to Revision Petition No.3557 of 2013 titled as Sunil Kumar Sharma vs. TATA AIG Life Insurance Company and Ors., decided on 01.03.2021, wherein the Hon’ble National Commission has dealt the issue of pre existing disease and held as follows:

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

15. In RP No.4461 of 2012, Neelam Chopra v. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it
was held that:

"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal v. Oriental Insurance Co. Ltd., (supra)."

16. Based on the above discussion, I am of the opinion that the Insurance Company had not been able to prove beyond doubt that the Complainant was suffering from diabetes before filing of the proposal form. It is also to be noted that the Insurance Company had given Insurance to a person of 66 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. It is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim also because the chances of death of such persons are more during the currency of the Policy.”

8. As it is an admitted case of the parties that the complainant was diagnosed with Coronary Artery Disease, acute anterior wall myocardial infarction, CAG-PTCA and CAG, in view of the ratio laid down in the aforesaid judgments, it is to be further determined if hypertension, with which as per the defence of the OPs, complainant was suffering for the last 4-5 years of the inception of the subject policy, is the cause for the said disease.  However, it is evident from the history and physical examination form and the chronic illness form that the doctor has only opined hypertension from which complainant had been suffering for 4-5 years and nothing has been disclosed in the said form if the patient (complainant) was having any pre-existing heart disease.  Even the discharge summary (Annexure C-4) further makes it clear that the patient or any of his family member had not past history of the disease for which he was diagnosed and was treated upon in the said hospital making it further clear that nothing was concealed by the complainant or his wife or the insured before purchasing the subject policy and the OPs had repudiated the claim of the complainant on flimsy ground that the patient was having history of pre-existing disease. Moreover, in the certificate (Annexure C-10), issued by the medical officer of the Alchemist Hospital, he has opined that the patient (complainant) was diagnosed with CAD, Acute anterior wall MI and he underwent CAG followed by PTCA stenting to LAD on 2.6.2020 and there is no significant past medical history and further that etiology of CAD is not known as history of Diabetes Mellitus or smoking. 
9. Thus, one thing is clear from the above discussion that the disease for which the complainant was suffering and he had taken treatment from Alchemist Hospital, has no connection with hypertension or complainant being a smoker and the OPs had wrongly repudiated the claim of the complainant.  Hence, the act of the 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 be allowed.  The final bill proved by the complainant having been issued by the Alchemist Hospital (Annexure C-5) clearly indicate that he had spent an amount of ₹1,78,952/-  + ₹10,000 = ₹1,88,952/-  for his treatment and the OPs are liable to pay the same alongwith interest and compensation etc.

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 to the complainant ₹1,88,952/- alongwith interest @ 9% per annum w.e.f the date of repudiation of the claim i.e. 27.8.2020 till realization of the same.
2. to pay an amount of ₹30,000/- to the complainant as compensation for causing mental agony and harassment to him;
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 01/02/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member