Chandigarh

DF-I

CC/931/2022

SUSHIL KUMAR SHARMA - Complainant(s)

Versus

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

SUDHIR GUPTA

01 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/931/2022
Date of Institution	:	21/11/2022
Date of Decision	:	01/02/2024

 

Sushil Kumar Sharma, resident of Flat No.37 GH No.38, Sector 20, Panchkula-134112 (Haryana).

… Complainant

V E R S U S

1. Manipal Cigna Health Insurance Company Limited (Formerly known as Cigna TTK Health Insurance Company Limited), 1^st Floor, SCO 149/150, Sector 9-C, Next to Yes Bank, Madhya Marg, Chandigarh 160009 through its Branch Manager.
2. Manipal Cigna Health Insurance Company Limited (Formerly known as Cigna TTK Health Insurance Company Limited), Registered Office, 401/402, 4^th Floor, Raheja Titanium, Of Western Express Highway, Goregaon (East), Mumbai-400063.

… Opposite Parties

 

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

                                                                               

ARGUED BY	:	Sh. R.C. Gupta, Advocate for complainant
	:	Sh. Krishna Kant, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sushil Kumar Sharma, 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 on 30.3.2002, complainant had obtained a health insurance policy from United India Insurance Company Limited which was renewed annually upto 29.3.2017 (hereinafter referred to as “previous policy”). During the aforesaid period, complainant had availed claim for stenting done by Fortis Hospital in the year 2007 from the aforesaid insurance company. However, OP-1 through its agent approached the complainant for porting the earlier policy to OP-1 with the assurance of providing better services. Accordingly, complainant agreed to the porting of policy and OPs had issued medical claim policy under the plan namely “ProHealth – Plus” from the year 2017-18 which was annually renewed for the year 2018-19, 2019-20 and 2020-21 vide policies (Annexure C-1 to C-4) and for the year 2021-22 vide policy (Annexure C-5) valid w.e.f. 7.4.2021 to 6.4.2022 (hereinafter referred to as “subject policy”).  During the currency of the subject policy, complainant was hospitalized at OJAS Super Specialty Hospital for treatment on 26.4.2021 and the said hospital had raised bill to the tune of ₹1,75,462/-. However, despite of promises made by the OPs, when the request was sent by the said hospital through TPA for cashless claim, the same was rejected by the OPs vide letter dated 30.4.2021 (Annexure C-6). Though the OPs had raised queries about the previous history which was not relevant with the said claim, the reimbursement of the claim was repudiated by the OPs vide letter dated 8.6.2021 (Annexure C-7).  Aggrieved with the repudiation of the claim by the OPs, complainant approached the Insurance Ombudsman at Chandigarh and the said authority had allowed the complaint of the complainant vide award dated 24.1.2022 (Annexure C-8) and the OPs were directed to pay the admissible claim as per the terms and conditions of the policy within 30 days from the receipt of copy of award.  Accordingly, in compliance with the order of the Ombudsman, OPs had made payment of ₹1,75,462/- in favour of the complainant. however, instead of taking the order passed by the Ombudsman in right spirit, OPs vide letter dated 25.6.2021 (Annexure C-9) terminated the subject policy on flimsy grounds.  The complainant again approached the OPs to reconsider the decision, but, with no result.  In this manner, the aforesaid act of the OPs amount to deficiency in service and unfair trade practice, especially when the complainant was having insurance policy continuously for the last 14 years without raising any claim, except the present one, and only on the request of the OPs the complainant had agreed to port the policy from the previous insurer to OP-1. 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 objections of maintainability, concealment of facts and cause of action.  However, it is admitted that the complainant had obtained the subject insurance policy from the OPs by porting it from the previous insurer and the policy was firstly issued in favour of the complainant which was valid w.e.f. 30.3.2017 to 29.3.2018, subject to terms and conditions of the insurance policy.  It is further admitted that the complainant got the policy continuously renewed on annual basis.  However, the complainant deliberately concealed the correct and material facts from the OPs as a result of which the OPs were compelled to terminate the subject policy since the complainant had concealed about the previous ailment from which he was suffering as he was a known case of hypertension since 14 years and had also undergone coronary artery disease (CAD) stenting in 2007 and this information was material to the policy decision.  A copy of portability consent form is Ex.OP 1 & 2/2 which was duly signed by complainant and as the complainant had concealed aforesaid information about pre-existing disease, OPs decided to terminate the subject policy on the ground of non-disclosure of material facts while taking the insurance policy.  Not only this, complainant had not raised the said issue qua termination of the subject policy with the learned Ombudsman since the same had already been terminated and now the present consumer complaint is hit by the principle of res judicata and the same is not maintainable.  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.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

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 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 been obtaining health insurance policy from the previous insurer namely United India Insurance Company Ltd. since the year 2002 and it is only in the year 2017, the health policy issued by the previous insurer was ported to OP-1 on the request of the OPs and the same was renewed annually by the OPs till 2021-22 i.e. the subject policy and further on 26.4.2021 when the complainant was hospitalized at OJAS Super Specialty Hospital due to corona and a bill of ₹1,75,462/- was raised by the said hospital and the same was denied by the OPs by firstly rejecting the cashless claim vide letter dated 30.4.2021 (Annexure C-6) and later on finally repudiated vide letter dated 8.6.2021 (Annexure C-7) and when the complainant approached the Insurance Ombudsman, with the intervention of aforesaid authority, who passed award dated 24.6.2022 (Annexure C-8) directing the OPs to settle the claim of the complainant, OPs had paid an amount of ₹1,75,462/- to the complainant and vide letter dated 25.6.2021 (Annexure C-9) OPs had terminated the subject policy against which the complainant is seeking relief through this consumer complaint against the OPs, the case is reduced to a narrow compass as it is to be determined if the act of the OPs terminating the subject policy amounts to deficiency in service and unfair trade practice and the same is illegal and arbitrary 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 terminating the subject policy and the instant consumer complaint, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of 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 as well as the previous policies, issued by the OPs and the previous insurer, and the termination letter (Annexure C-9) qua the subject policy and the same are required to be scanned carefully in order to determine the real controversy between the parties.
   3. Admittedly, complainant remained covered with the previous insurer w.e.f 30.3.2002 to 29.3.2017 and thereafter he got the policy ported with the OPs on 30.3.2017, as is evident from the copy of first policy issued by the OPs after porting (available at page 13 to 17 of Annexure C-1) and thereafter the same was continuously renewed by the complainant uptil the subject policy, which was renewed w.e.f. 7.4.2021 to 6.4.2022 (Annexure C-5).
   4. OPs had terminated the subject policy vide letter dated 25.6.2021 (Ex.OP 1 & 2/3) on the ground that the complainant had not disclosed about the pre-existing disease at the time of portability of the policy from the previous insurer and the relevant portion of the same is reproduced below :-

“We regret to inform you that your Manipal Cigna Health Insurance policy no. PROHLR010347235 has been terminated with effect from 23-06-2021 due to non-disclosure of History of Angioplasty, hypertension for MR SUSHIL KUMAR SHARMA

In view of the aforementioned reason, the premium paid by you shall be forfeited without any refund.”

5. Thus, one thing is clear on record that the OPs had terminated the subject policy w.e.f. 23.6.2021 knowing fully well that, at the time of porting of the policy from the previous insurer, complainant had taken treatment for CAD in the year 2007, especially when it was the duty of the insurer to check the previous claim history before accepting porting of the policy from the previous insurer to the new one. 
6. As it has come on record that the first policy was issued by the OPs w.e.f. 30.3.2017 to 29.3.2018 and the claim lodged by the complainant with the OPs qua his treatment on account of COVID-19, which was earlier denied by the OPs and the same was only settled after award passed by the learned Insurance Ombudsman, it is clear that the OPs had made up their mind to terminate the subject policy on the ground which otherwise had been disclosed by the complainant to the OPs at the time of porting of policy from the previous insurer with the OPs.  Moreover, subject policy was terminated by OPs for non-disclosure of history of angioplasty and hypertension.
7. So far as the defence of the OPs that the complainant was suffering from hypertension prior to the purchase of the subject policy is concerned, it has 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.) that 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. The relevant portion of the order is reproduced 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.”

8. Similarly, 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 issue of pre-existing disease, has held as under:-

“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."

9. Further defence of the OPs is that complainant had taken treatment for Coronary Artery Disease (CAD), which was otherwise admittedly taken in the year 2007 by the complainant.  However, it is also clear from the subject policy (Annexure C-5) that waiting period in the policy has specifically been mentioned with each category and the relevant portion of the same is reproduced below for ready reference :-

“Pre Existing Disease (PED) waiting period	Covered after 36 months of continuous coverage
Specific waiting period	24 months since inception of first policy with us”

      

10. As it is an admitted case of the parties that the first policy was taken by the complainant w.e.f. 30.3.2017 to 29.3.2018 after porting the same from the previous insurer to the present OPs and nothing has come on record if the complainant was treated with angioplasty since 24 months of the inception of the first policy with the OPs, rather it is an admitted case that angioplasty was done in the year 2007, it is clear that the OPs have illegally and arbitrarily terminated the subject policy on the ground of non disclosure of history of angioplasty and hypertension and the said act amounts to deficiency in service and unfair trade practice on their part.
11. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.

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 restore the subject policy in the name of the complainant, as per its terms & conditions, with upto date benefits on payment of requisite charges, if any;
2. to pay ₹7,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹7,000/- 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.

01/02/2024 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member