Chandigarh

DF-I

CC/225/2023

Sh. SANJEEV RASTOGI - Complainant(s)

Versus

MANIPAL CIGNA HEALTH INSURANCE Company - Opp.Party(s)

ANKIT PARTI

09 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/225/2023
Date of Institution	:	1/5/2023
Date of Decision	:	9/1/2024

 

Sh Sanjeev Rastogi S/o Late Sh. Mahendra Kumar Rastogi R/o House No. 1161, Sector 21-B Chandigarh

 

......Complainant

 

Versus

 

1. Manipal Cigna Health Insurance Company, SCO 149-150, 1st Floor, Sector 9-C. Chandigarh through Its Branch Manager/Authorized Signatory

 

2. Sh Prasun Sikdar Managing Director & CEO Manipal Cigna Health Insurance Company O/o 401-402, 4th Floor, Raheja Titamum, Western Express Highway, Goregaon (East)

 

....... Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

                       

ARGUED BY	:	Sh. Ankit Parti, Advocate for complainant.
	:	Sh. Krishan Kant, Advocate for OPs.

Per SURJEET KAUR, Member

     Briefly stated the complainant availed a health policy from the OPs for him and his family   effective from 3.4.2019 and the complainant had been paying premium regularly.  The son of the complainant admitted in Government Medical College &  Hospital, Sector 32, Chandigarh on 11.11.2022 to 17.11.2022 with complaints of post traumatic right distal femur epiphyseal arrest with RT genu valgum and thus was operated by the doctors. The complainant filed medical claim documents for a sum of Rs.1,18,408/-   with the OPs vide Annexure C-6.  However  the Ops vide letter dated 31.12.2022 repudiated the claim of the complainant on the ground that  complainant’s son had history of injury by bike knee joint 6 years before and pain since 4 years with genu  valgum deformity changes, which is material to the policy decision and the same was not disclosed in the proposal form at the time of policy inception. It is stated that in fact the son of the complainant got hit by bike 6 years back following which he developed pain which was managed by crepe bandage and pain killer  and at that time also the complainant covered for medical health and an outward bending of right leg at knee was noticed recently when the complainant’s son started gaining height and there was no misrepresentation. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Parties in their reply while admitting factual matrix of the case stated that the son of the complainant Sanyog Rastogi was a case of Outward Bending of right leg at knee joint since 4

years and  as per  discharge summary the patient was having a past medical condition before he was admitted on 11-11-2022 at GMCH Sector 32, Chandigarh and the said medical condition was concealed by the complainant while obtaining the insurance coverage from the OPs. Had the Complainant disclosed this history truly and correctly at the time of porting the policy, the answering opposite party would not have accepted the proposal for porting and would have requested the Complainant to continue with the previous insurer.  Thus the claim of the complainant was rightly repudiated due to non disclosure of the material facts. All other allegations made in the complaint has been denied being wrong.

3. Rejoinder was filed and averments made in the consumer complaint were reiterated.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The sole grouse of the complainant through the present complaint is that the OPs illegally and arbitrarily repudiated the  genuine claim of the complainant in respect of his son despite being covered under the policy. It has also been alleged that the Ops have illegally terminated the policy in question without any valid reason.
7. The stand taken by OPs  is that the complainant did not disclose  about the pre-existing disease of his son while obtaining the policy in question from the Ops. Had the complainant been disclosed the past history truly and correctly at the time of porting the policy the OPs would not have accepted the proposal for porting and would have requested the complainant to continue with the previous insurer. Hence, they rightly repudiated the claim of the complainant due to non-disclosure of the material facts.
8. After going through  the documents on record  and as per contention of the complainant  that the policy in question is in existence since the time of birth of his son and he is continuously paying the premium for  the same without any breakage.  The above fact is very much clear from page 37 of the complaint which shows  the existence of the policy for year 2006 and the complainant’s son  was duly covered under the policy even then. Admittedly, the complainant is paying premiums since the beginning and the policy was ported with the OPs w.e.f. 3.4.2019 and had been regularly and continuously being renewed time and again without any breakage. The policy issued by OP No.2 is annexed as Annexure C-2 and perusal of the same reveals that for roll over portability cases continuous coverage will be considered from first policy inception. 
9. So far as the allegation of OPs with regard to history of knee pain is concerned,  as per Annexure C-5 there is no chronic illness mentioned in the discharge summary issued by Government Medical College and Hospital, Chandigarh UT, Sector 32B, Chandigarh but it is mentioned that pain and swelling in right knee, managed by crepe bandage application and pain killers. There is no such like mention that it was a pre- existing disease. In our opinion as and when the problem was disclosed by the doctors  the complainant rightly took treatment and lodged the claim with the OP being duly covered under the policy. There is no cogent evidence on record placed by the OPs which proves that the son of the complainant had ever being hospitalized or taken any treatment except the  advice of the doctor  for crepe bandage and pain killers. Thus there is no misrepresentation or concealment by the complainant.  In our opinion it was the duty of the OPs to conduct thorough enquiry about the previous treatment of the present problem of the son of the complainant and no such enquiry was conducted and so merely charges of past history mentioned in the discharge summary prepared by the hospital cannot be held that the insured was suffering with pre-exiting disease at the time of taking the policy and intentionally concealed the material fact.
10. Our view is supported with the principle of law laid down in case titled as Asha Garg and Ors. Vs. United India Insurance Co. Ltd. and Ors. 2005(4) CPJ 269 ,  New India Assurance Co. Ltd. vs. B.Y. Srikanta 2015(4)CPJ 380 both decided by the Hon’ble National Commission and in case titled as Manish Goyal vs. Max Bupa Health Insurance Company Limited  decided on 22.3.2018 by  the Hon’ble State Commission, Chandigarh.
11. Thus, in view of the forgoing  discussion it is proved that the OPs arbitrarily terminated the policy thereby wasted the whole exercise of the complainant of paying continuous premiums since  beginning of the policy.  Thus the act of the Ops repudiating the claim of the complainant and  terminating the policy amounts to deficiency in service.
12. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

 

1. to pay Rs.1,18,408/- with interest @9 P.A.from the date of filing of claim i.e. 27.12.2022 till onwards.
2. to restore the policy in the question immediately.
3. to pay Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
4. to pay Rs.10,000/- to the complainant as costs of litigation.

 

13.      This order be complied with by the OPs within 45 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) & (iii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(ii)&(iv) above.
14. Pending miscellaneous application(s), if any, also stands disposed off.
15.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member