Chandigarh

DF-I

CC/755/2022

RUPESH KUMAR KHOSLA - Complainant(s)

Versus

MANIPAL CIGNA HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

YOGINDER NAGPAL

01 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/755/2022
Date of Institution	:	23/08/2022
Date of Decision	:	01/11/2023

Mr. Rupesh Kumar Khosla r/o H.No.234, Near Well, Village Kansal, Kharar, SAS Nagar, Mohali.

… 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, 4th Floor, Raheja Titanium, Western Express Highway Goregaon (East) Mumbai-400063.
2. Manipal Cigna Health Insurance Company Limited, 32-B, Pusa Road, Rajinder Nagar, Opp. Pillar No.122 of Metro Station, Karol Bagh, New Delhi-110005.
3. Manipal Cigna Health Insurance Company Limited, First Floor, SCO 149/150 Sector-9-C Madhya Marg Chandigarh-160009.
4. Medi Assist I TPA Pvt. Ltd, Tower-D, 4th Floor, 1 BC Knowledge Park, 4/1, Bannerghatta Road, Bengaluru-560029.

… Opposite Parties

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

                                                                               

ARGUED BY	:	Sh. Yoginder Nagpal, Advocate for complainant
	:	Sh. J.P. Nahar, Advocate for OPs 1 to 3
	:	Sh. Bhupender Singh, Advocate for OP-4

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Rupesh Kumar Khosla, complainant against the aforesaid 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 purchased a health insurance policy namely “Manipal Cigna ProHealth Insurance” from the OPs/insurer for himself and his family members by paying premium of ₹11,512.08 valid w.e.f. 17.8.2017 to 16.8.2018 and the same was renewed annually till 2023 w.e.f. 17.8.2022 to 16.8.2023 vide the subject policy (Ex.C-1). In the month of July 2022, the complainant was reeling under enormous and unbearable pain of stones in kidney and on the morning of 16.7.2022 at around 9:51 a.m., the complainant was admitted for surgical management at Healing Super Speciality Hospital, Sector 34, Chandigarh (hereinafter referred to as “treating hospital”). The complainant remained admitted in the treating hospital w.e.f 16.7.2022 to 18.7.2022 and the discharge summary is Ex.C-2. The cashless claim was also raised by the complainant with the OPs and thereafter all the documents i.e. medical record etc. were also submitted to the OPs for settlement of the claim. However, the complainant was shocked to see that the OPs had repudiated his genuine claim vide letter dated 27.7.2022 (Ex.C-7) on the ground that the complainant is a known case of disc problem since 2008 which is material to policy decision and was not disclosed by him in the proposal form.  Thereafter complainant had issued legal notice (Ex.C-8) to the OPs, but, with no result.  In this manner, aforesaid acts of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written versions.
3. In their written version, OPs 1 to 3 admitted that the complainant had purchased the subject policy from the complainant, but, the claim of the complainant was repudiated on the ground that the complainant had not disclosed that he was suffering from pain related to problem of slip disc since 2008, which fact came to the notice during the TPA claim verification. It is further alleged that as the complainant has not disclosed material information at the time of taking the subject policy by mis-stating details in the proposal form, the claim was rightly repudiated by the OPs. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. OP-4 in its separate written version, inter alia, took preliminary objections of maintainability and cause of action.  On merits, admitted that the complainant had purchased the subject policy and also that it was found that the complainant had taken the treatment from the treating hospital, but, during the scrutiny of the hospital documents, it was found that the complainant was suffering from disc problem since 2008 and as he had not disclosed the said fact at the time of purchasing the subject policy, he has violated the terms and conditions of the subject policy and his claim was recommended to be repudiated.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
5. Complainant chose not to file rejoinder.

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, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had initially purchased the subject policy w.e.f. 17.8.2017 to 16.8.2018 and the same was annually renewed by him by paying premium to the OPs, covering the complainant and his family members, and the last policy i.e. the subject policy was renewed w.e.f. 17.8.2022 to 16.8.2023 (Ex.C-1) and further that the complainant had undergone treatment for kidney related ailment at the treating hospital and remained admitted there w.e.f. 16.7.2022 to 18.7.2022, as is evident from the discharge summary (Ex.C-3), the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant on the ground that he had not disclosed about the disc problem having been suffered by him since the year 2008, and the complainant is entitled to 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 and the instant consumer complaint 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, medical record and the repudiation letter, having been relied upon by both the parties, and the same are required to be scanned carefully.
   3. Perusal of the terms and conditions of the subject policy (Ex.OP 1-3/1) clearly indicate that insured has to disclose about the previous ailment, if any, in the proposal form. Discharge summary [Ex.C-3] clearly indicates that the complainant was admitted in the treating hospital for surgical management and was diagnosed with Bladder/VUJ (Left) Calculus with Bilateral RSD and the chief complaints and reason for admission were as under :-

“CHIEF COMPLAINTS & REASON FOR ADMISSION :-

38 years old make patient presented with chief complaint of flank pain, difficulty in passing urine. After investigations done patient diagnosed with Bladder/VUJ (Left) Calculus with Bilateral RSD. Now patient admitted for surgical management.”

 

4. Ex.C-7 is the repudiation letter dated 31.7.2022 which clearly indicates that the claim of the complainant was repudiated on the ground that the insured had failed to disclose in the proposal form, at the time of inception of the first policy, that he was a known case of Disc Problem since 2008.  The relevant portion of the repudiation letter is reproduced below :-

        “The Company has received cashless claim request for yourself admitted at for B/L renal calculi. Post assessment of the documents, it is noted that you have a history and known case of Disc Problem since 2008 which is material to policy decision and was not disclosed in the proposal form at the time of policy inception.   Hence, the claim stands rejected.”

 

5. As per the defence of the OPs, as the complainant has not disclosed about the pre-existing disease i.e. the disc problem from which he has been suffering since the year 2008, which fact was also disclosed by the complainant in the TPA claim form (Ex.1-3/3) but not in the proposal form (Ex.1-3/2), the complainant has concealed about the same, the claim of the complainant was rightly repudiated.
6. However, there is no force in the contention of OPs as it is clear from the discharge summary (Ex.C-3) that the treatment taken by the complainant in the year 2022 was for “Bladder/VUJ (Left) calculus with bilateral RSD” whereas the alleged ailment of 2008, as per the own case of the OPs, pertained to disc problem.  Hence, OPs have wrongly repudiated the claim of the complainant on the ground that the complainant had not disclosed about the pre-existing disease in the proposal form at the time of policy inception, knowing fully well that the present ailment for which the complainant has taken the treatment has no nexus/connection with the previous ailment of the year 2008 and also that alleged concealment was not of such a nature as would disentitle the complainant from getting his life insured.  Here we are strengthened by the order passed by the Hon’ble National Commission in Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) and the operative part of the same reads as under :-

                12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

 

7. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs have not been able to connect the previous ailment, as mentioned in the repudiation letter, with the present ailment and the present consumer complaint deserves to succeed. 
8. Now coming to the quantum of relief to be awarded to the complainant, since the complainant has proved the bill (Ex.C-4) amounting to ₹2,08,237/-, it is safe to hold that OPs are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

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 ₹2,08,237/- to the complainant alongwith interest @ 9% per annum from the date of repudiation/rejection of the claim i.e. 31.7.2022 onwards.
2. to pay an amount of ₹20,000/- 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 forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/11/2023 hg		Sd/- [Pawanjit Singh] President
		Sd/- [Surjeet Kaur] Member
		Sd/- [Suresh Kumar Sardana] Member