Haryana

Panchkula

CC/514/2021

VIJAY ARORA. - Complainant(s)

Versus

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

SATYAJEET SINGH & ANUJ SHARMA

18 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

 

                                                       

Consumer Complaint No	:	514 of 2021
Date of Institution	:	13.12.2021
Date of Decision	:	18.04.2024

 

 

1.     Vijay Arora @ Vijay Kumar son of Sh. Kashmir Lal;

2.     Shivam Arora son of Sh. Vijay Kumar

 

        Both residents of House No.342, Sector-2, Panchkula, Haryana.

 

 

                                                                ….Complainants

Versus

ManipalCigna Health Insurance Company Limited, through its authorized person, Registered office of 401/402, 4^th Floor, Raheja Titanium, off Western Express Highway, Gogegoan(East), Mumbai-400063.                                                                                                                                                                                                                                                                                                                                                  ….Opposite Party

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019

 

Before:              Sh. Satpal, President.

Dr. Sushma Garg, Member.

Dr. Barhm Parkash Yadav, Member

 

 

For the Parties:   Sh. Satyajeet Singh, Advocate for the complainant alongwith complainant No.1.    

                        Sh. J.P.Nahar, Advocate for OP.

                       

ORDER

(Satpal, President)

1.             The brief facts, as alleged, in the present complaint, are, that the wife of complainant no.1, namely Mrs. Manju Arora had purchased a health insurance policy from the opposite party(hereinafter referred to as OP) vide policy no. PROHL980074430 having “ProHealth-Plus” plan and policy type as “Family Floater” on 18.05.2018, for herself and her son, namely, Sh.Shivam Arora(complainant no.2) and that the said policy was valid w.e.f. 28.05.2018 to 27.05.2019, wherein the sum insured was Rs.10,00,000/- and the said policy was got renewed again in the year 2019 and lastly, the same was got renewed for the period from 28.05.2020 to 27.0.2021. It is averred that the said insured Mrs.Manju Arora approached the Gokul Surgical Hospital, Panchkula on 16.02.2019 and as per advice, she got the biopsy done from Kap’s Diagnoscan Centre on 03.01.2020, wherein she was diagnosed having Papilloma. It is stated that as per histopathology/Cytopathology of Malhotra Medical Laboratories Pvt. Ltd, Chandigarh on 03.03.2020, a resolving Hematoma was diagnosed on 04.05.2020. It is averred that Mrs.Manju Arora was diagnosed with “Metastatic Malignant Melanoma”, which is a type of skin cancer in its advanced stage, after the excision biopsy of the skin, by the Paras HIMRI Hospital, Panchkula. It is averred that, after the diagnosis said, Mrs.Manju Arora approached the Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab for her checkup as also her treatment for the “Metastatic malignant melanoma”, wherein, the chemotherapy treatment was advised for her skin cancer. It is averred that Mrs.Manju Arora, having health insurance from the OP, applied for cashless treatment from OP but the same was not provided; thus, Mrs.Manju Arora paid for her treatment at Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab. The insured said Mrs. Manju Arora was given the chemotherapy treatment on 11.05.2020 at the Max Hospital and thereafter, she approached the IVY Hospital, SAS Nagar, Mohali, Punjab and continued her further chemotherapy treatment from there. It is stated that Mrs. Manju Arora was given the chemotherapy treatment on various dates from the period between June, 2020 to September, 2020 at IVY Hospital also.  It is stated that an amount of Rs.14,00,000/- approximately was incurred on the treatment on Mrs.Manju Arora for the period till September 2020 and the bills were raised by the respective hospitals. Mrs. Manu Arora applied to OP for the reimbursement of the bills qua her treatment till September 2020. All the original bills along with the claim form and other documents, as per the requirement of the OP, were submitted with OP and the receipt of the same was acknowledged by OP vide email dated 04.12.2020. The claim of Mrs.Manju Arora was registered on 03.12.2020 with claim no.23361992. It is stated that on 15.01.2021, the OP refused to approve the reimbursement claim filed by Mrs. Manju Arora citing the clause no.Vlll(l) i.e. the duty of disclosure. The OP, while rejecting the reimbursement claim of Mrs.Manju Arora, stated that on the scrutiny of her documents had shown history of skin nodules on her left breast since childhood, which was material information to policy decision and was not disclosed in proposal form at the time of policy inception; hence the claim was repudiated vide clause no.Vlll(1). It is stated that an email was sent on 27.01.2021 by insured Mrs.Manju Arora to the OP alongwith the report of Dr.Sachin Gupta of Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab in support of her reimbursement claim, which stated that “in our initial workup, it was written that she had childhood nodule in breast-which was erroneously written as nodule-it should have been documented as nevus or mole”. Dr. Sachin Gupta further wrote that “Any nevus or mole cannot be considered as pre-existing disease, neither it is recommended to do biopsy(without symptoms) or before enrolling for any insurance schemes. It is stated that the OP again repudiated the claim of Mrs. Manju Arora vide email dated 15.02.2021 without any further justification. It is stated that Mrs. Manju Arora again vide email dated 13.04.2021 requested to reconsider her claim on the basis of report and clarification provided by Dr.Sachin Gupta but no response was received from the OP. Unfortunately, Mrs.Manju Arora has expired on 11.07.2021, leaving behind complainants as her legal heirs. Mrs.Manju Arora has spent Rs. 31,00,000/-  approximately on her treatment from the period from 04.05.2020 till her death i.e. 11.07.2021. A legal notice was served upon the OP on 27.08.2021 by the complainant no.1 for sanctioning the claim but to no avail. It is averred that the Op has wrongly rejected the reimbursement claim filed by Mrs. Manju Arora(now deceased). Due to the act and conduct of the OP, the complainant has suffered financial loss as well as mental agony & physical harassment; hence the present complaint.

2.             Upon notice, the OP appeared through counsel and filed written statement by raising preliminary objection that the complainant has not approached the Commission with clean hands. It is submitted that the insured Mrs. Manju Arora had obtained the insurance policy by concealing the material facts in the proposal form i.e. the skin nodules in left her breast since childhood.  

                On merits, it is submitted that  the insurance policy bearing no.PROHLR980074430, valid from 28.05.2018 to 27.05.2019, was issued  to Mrs. Manju Arora for an assured sum of Rs.10,00,000/- and the said policy was renewed and finally, the policy was issued valid from 28.05.2020 to 27.05.2021, for assured sum of Rs.10,00,000/-. It is submitted that the insured Mrs. Manju Arora was having a complaint of skin cancer even prior to 04.05.2020. It is submitted that the said insured Mrs.Manu Arora was taken to Gokul Surgical Hospital, Panchkula on 16.02.2019 and the complainant no.1, being husband of Mrs.Manju Arora, had given his consent for her biopsy on 17.05.2019, which means that she was having problems much prior to even 16.02.2019. As per TPA Medi Assist Insurance TPA Pvt. Ltd. investigation report dated 23.12.2020, Mrs.Manju Arora was advised for first biopsy papilloma on 17.05.2019 but the biopsy report was not provided. It is submitted that the decease/aliment was treated within the Ist year of policy, though the same was pre existing and not disclosed in the proposal form as well as medical examination test report. It is submitted that Dr. Ashrani on the basis of report of Kap’s Diagnoscan Centre dated 03.01.2020, Report dated 17.02.2020 of Mirchia’s Diagnostics Centre, Chandigarh and 03.03.2020 of Malhotra Medical Laboratories Pvt. Ltd, Chandigarh has opined that the complainant had concealed the pre-existing disease of nodules. It is submitted that the claim lodged by the complainants was rightly repudiated vide letter dated 15.01.2021 by invoking the clause Vlll(i) of the insurance policy. Rest of the allegations alleged by the complainant have been denied and it has been prayed that there is no deficiency in service on the part of the OP and as such, the complaint is liable to be dismissed.

3.             Rejoinder to the written statement of the OPs No.1 to 3 was filed by the complainant reiterating the contents of the complaint while controverting the contentions of the OPs.

 4.            To prove the case, the learned counsel for the complainant has tendered affidavits Annexure C-A & C-B along with documents Annexure C-1 to C-13 in evidence and closed the evidence by making a separate statement. On the other hand, the learned counsel for the OP has tendered affidavits as Annexure R-A & R-B along with documents as Annexure R-1 to R-10 and closed the evidence.

                During the arguments, the learned counsel for the complainant has placed on record the details of the bills showing the date, hospital and the period qua the expenses incurred during the hospitalization of Mrs. Manju Arora, which is taken on record as Mark ‘A’ for the proper adjudication of the complaint.

5.             We have heard the learned counsels for the complainant as well as OP and gone through the record available on the file including the written arguments/synopsis filed by the complainant as well as OP minutely and carefully.

6.             During arguments, the learned counsel on behalf of the complainants have reiterated the averments as made in the complaint as also in the affidavits(Annexure C-A & C-B) and contended that the repudiation of the claim no.23361992 by the OP on 15.01.2021 qua the reimbursement of the expenses as incurred during the hospitalization of insured Mrs. Manju Arora(now deceased), was made on erroneous and invalid grounds because nothing material was concealed by said Mrs. Manju Arora(now deceased), while taking the policy no. PROHL980074430 first time on 18.05.2018. It was argued that Mrs. Manju Arora(now deceased) had answered all the questions as per  her knowledge, which were asked from her vide proposal form(Annexure R-2) and medical examination form(Annexure C-3). It was argued that Mrs.Manju Arora never faced any problem or trouble from the mole on her left breast and that no symptoms like change in the size or colour of the mole had appeared during the period of about 50 years, prior to taking of the policy in question by her from OP and thus, there was no occasion for her to disclose about the presence of benign mole on her left breast. Further, it was argued that there was no specific question in the proposal form(Annexure R-2) and medical examination report (Annexure R-3) qua the presence of the mole on the body of the insured. Concluding the arguments, the learned counsel contended that the Metastatic malignant melanoma, which is one type of cancer, was first time diagnosed on 04.05.2020/11.05.2020 i.e. after a period of 2 years from the purchasing of the policy on 18.05.2018; thus, the complaint is liable to be accepted by granting the relief as claimed for in the complaint.

7.             On the other hand, the learned counsel on behalf of OPs reiterated the averments as made in the written statement as also in the affidavit(Annexure R-A & R-B) and contended that  the repudiation of the claim no.23361992 vide  letter dated 15.01.2021(Annexure R-10) was made as per the terms and conditions of the insurance policy. It was argued that Mrs.Manju Arora(now deceased) had availed the insurance policy in question from the OP by concealing the skin nodules on her left breast since childhood as she had not disclosed, in response to the queries as raised vide proposal form(Annexure R-2) and medical examination  form (Annexure R-3) about the same. It was argued that the nodules on the left breast whether Malignant or benign was required to be disclosed, while taking the insurance policy but the insured Mrs. Manju Arora(now deceased) had concealed the same and thus, the policy had become null and void ab initio. In this regard, the learned counsel relied upon the opinion(Annexure R-9) given by Dr.K.H. Ashrani. It was argued that the insurance contracts being contract of absolute good faith (Ubermma fide), the duty of disclosure applies both to the insured and insurance company and that both the parties to the insurance contract are bound by the terms and conditions as contained in the policy. The learned counsel argued that the certificate dated 22.01.2021(Annexure C-6) issued by Dr.Sachin, Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab and the certificate(Annexure C-13) issued by Dr. Jatin Sarin, IVY Hospital, in support of complainant’s  contentions, carry no weight for want of affidavits of the said doctors and thus, the complaint is liable to be dismissed being frivolous, baseless and meritless.

8.             After hearing the learned counsels for the parties, the question that arises for adjudication, before the Commission, is, whether the repudiation of the claim no.23361992, as lodged by the insured Mrs.Manju Arora(now deceased) on 03.12.2020 qua the expenses incurred during her hospitalization, by the OP vide its letter dated 15.01.2021(Annexure R-10), is based on valid and justified grounds.          

                The relevant part of the repudiation letter dated 15.01.2021 (Annexure R-10), for the sake of clarity and convenience is reproduced as under:-

                On scrutiny of the documents it has been observed that we have received claim documents for, claimant Mrs.Manju Arora admitted at Max Health Care Super Speciality Hospital, Mohali from 19 May 2020 to 19 May 2020 with the complaints of metastatic malignant melanomia. Claimant is covered under Manipal Cigna Health Insurance Prohealth (plus) policy since 28 May2018. As per the available documents patient had history of Skin nodules left breast since Childhood which is material to policy decision and was not disclosed in proposal form at the time of policy inception. Hence the claim stands repudiated under Clause Vlll.1. We regret our inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other grounds/available to us subsequently.

                   With regards to the same, we request you to read the policy document and refer to the clause mention below:-

Denial Clause ID

Description

Vlll.1 Duty of Disclosure

The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statement, declaration, claim form declaration, medical history on the claim form and connected documents, or any material information having been withheld by You or any one acting on Your behalf, under this Policy. You further understand and agree that we may at our sole discretion cancel the policy and the premium paid shall be forfeited.

 

9.             A bare perusal of above would reveal that the repudiation of the claim was made by the OP, on 15.01.2021, invoking  the clause no.Vlll(l) of the insurance policy, only on the sole ground of non disclosure of the nodules on the left breast of Mrs.Manju Arora(now deceased), while taking  the policy by her.

10.            The complainants have totally refuted the contentions of the OP that the insured Mrs.Manju Arora(now deceased) was having nodules on her left breast since childhood. As per complainant’s version she was having “mole” on her left breast instead of nodules as alleged by the OP.

11.            Pertinently, the repudiation of the claim vide letter dated 15.01.2021(Annexure R-10) was based on the investigation report dated 24.12.2020(Annexure R-1) of Dr.Gurpreet Singh, Medi Assist Insurance TPA Pvt Ltd., which speaks “under the heading of conclusion” about the presence of mole also on the left breast of Smt. Manju Arora as per discharge summary and ICP of Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab. Further, we also find mention of black coloured mole on the left breast of Mrs.Manju Arora vide report dated 09.05.2020 of Paras Hospital; thus, the contentions of the OP qua the presence of skin nodule on the left breast of Mrs.Manju Arora(since deceased) stands contradicted and negated. Further, the certificate of Dr.Sachin Gupta of Max Super Specialty Hospital at SAS Nagar, Mohali, Punjab(Annexure C-6(colly)) and Dr.Jatin Sarin of IVY Hospital (Annexure C-13), under whom late Mrs.Manju Arora insured had got her treatment, has certified about the existence of “mole” instead of “nodules”.

12.            Without going into the rival contentions of both the parties qua the presence of the “Mole” or “nodules” on the left breast of Mrs. Manju Arora, the undisputed factual position as emerged out is that Mrs. Manju Arora insured(now deceased) did not face any kind of trouble or medical problem pertaining to the mole/nodules for more than 50 years.

13.            Admittedly, Mrs.Manju Arora was first time detected on 09.05.2020, with the ailment of Metastatic malignant melanoma. Prior to that, she was diagnosed having “pappiloma” on 03.01.2020 vide her histopathology examination (Annexure R-7) and thereafter, she was diagnosed having “enlarge lymphonode” vide report dated 17.02.2020 (Annexure R-8) of Mirchia Diagnostic Centre, Chandigarh. On 03.03.2020, she was diagnosed vide report dated 03.03.2020 of Malhotra Medical Laboratories Pvt. Ltd, Chandigarh (Annexure R-6) having a resolving Hematoma. Pertinently, none of the above i.e. Papilloma Lymphonde or a resolving hemadoma can be treated as malignant.

14.            From the above stated factual position, it is abundantly clear that Mrs.Manju Arora(now deceased) was having no symptoms, whatsoever, like the change in colour, increase in size and ulceration etc. qua mole on her left breast prior to taking of the policy in question on 18.05.2018.

                Had there been any cancerous nodules as alleged by the OP in the left breast of Mrs. Manju Arora since childhood, she would not have survived for more than 50 years. Moreover, she was having no trouble or medical problem emanating from the mole/nodules prior to the taking of the policy in question. Even it is not the version of the OP that she was taking any medical treatment qua the mole/nodules prior to taking of the policy in question. In the absence of any symptoms like the change in colour, increase in size or ulceration in the mole/nodules etc. no reasonable men/women of ordinary prudence, placed in similar situation as Mrs.Manju Arora (now deceased) was placed, would have acted differently.

15.            Moreover, no specific question was put up or asked vide medical examination report (Annexure R-3)/proposal form(Annexure R-2) qua the mole. As per well settled legal proposition, no benefit can be drawn out of the vague and ambiguous terms of the insurance policy.

16.            Furthermore, the fact of Metastatic Malignant Melanoma in the mole/nodules in the left breast of Mrs. Manju Arora had come into the knowledge of OP, while cashless request was made on 13.05.2020 but the insurance policy was renewed, by taking a premium of Rs.29,282.96 w.e.f. 28.05.2020 to 27.05.2021 and thus, the plea taken by OP qua non disclosure of nodules do not carry any weight.

17.            From the above stated facts, it is clear that the repudiation of the claim no. 23361992 was not made on valid and justified grounds. Therefore, we conclude that the OPs are liable, jointly and severally, to compensate the complainant.

18.            In relief, the complainants have claimed a sum of Rs. 30,49,952/-on account of expenses incurred during the hospitalization of Mrs. Manju Arora(now deceased), the details whereof have been given in the Mark ‘A’, which is appended with the brief synopsis. The details of the expenses as per Mark ‘A’ in tabular form are given as under:-

Sr. No.	Period	Amount
1	04.05.2020 to 28.05.2020	Rs.1,38,095.56
2	29.05.2020 to 28.05.2021	Rs.29,11,857
3	Total(Rs.138095.56+2911857)	Rs.30,49,952

 

                Apart from above, a sum of Rs.1,00,000/- & Rs.35,000/- have been claimed on account of mental agony, harassment and litigation charges.

19.            As per insurance policy schedule Annexure C-1, the sum insured was Rs.10,00,000/-  & with the addition of cumulative bonus @ 20%, it becomes Rs.12,00,000/-(Rs.Twelve lakhs),but the complainants have claimed the sum of Rs.29,11,857/-,  which is in excess of the sum insured + cumulative bonus. As such, the complainants are entitled to be indemnified to the extent of expenses up to Rs. 12,00,000/- only for the year 28.05.2020 to 27.05.2021. In addition to it, the complainants are also entitled to the payment of expenses amounting to Rs.1,38,095.56, which were incurred w.e.f 04.05.2020 to 28.05.2020. Thus, the complainants have been found entitled to the payment of the amount of Rs.1,38,095.56+ Rs.12,00,000= Total Rs.13,38,095.56.       

20.            As a sequel to above discussion, we partly allow the present complaint with the following directions to the OP:-

1. To make the payment of sum of Rs.13,38,095.56/- to the complainants along with interest @ 9% per annum (simple interest) w.e.f. 03.12.2020 i.e. the date when the claim was lodged till its actual realization.
2. To pay an amount of Rs.40,000/- to the complainants on account of mental agony and physical harassment suffered by them.
3. To pay an amount of Rs.7,500/- as litigation charges.

 

21.            The OP shall comply with the order within a period of 45 days from the date of communication of copy of this order failing which the complainants shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, against the OP. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.

Announced on:18.04.2024

 

 

 

Dr.Barhm Parkash Yadav      Dr.Sushma Garg             Satpal               

                Member                       Member                   President

 

Note: Each and every page of this order has been duly signed by me.

 

                                         Satpal                               

                                        President