Chandigarh

DF-II

CC/1/2020

Shuban Ji Yecho - Complainant(s)

Versus

Manipal Cigna TTK Health Insurance Company Limited - Opp.Party(s)

A.K. Tripathi Adv.

17 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	CC/1/2020
Date of Institution	:	31/12/2019
Date of Decision	:	17/09/2024

       

                                       

                       

 

 

 

Shuban Ji Yecho, aged about 74 years, resident of Flat No.5135/2, Category 1, Modern Housing Complex, Manimajra, Chandigarh.

                                ...  Complainant

Versus

1.     Manipal Cigna TTK Health Insurance Company Limited through its Manager, SCO No. 149- 150, First Floor, Sector 9-C, Next to Yes Bank, Madhya Marg, Chandigarh.

2.     Manipal Cigna TTK Health Insurance Company Limited through its authorized signatory, 404/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai-400063.

3.     The New India Assurance Company Limited through its authorized signatory, SCO No. 804, NAC, Manimajra, Chandigarh.

 

…. Opposite Parties

 

BEFORE:
	SHRI AMRINDER SINGH SIDHU	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

ARGUED BY:-
	Ms. Mahima, Adv. Proxy for Sh. A.K. Tripathi, Counsel for complainant
	Sh. Vikramjit Singh, Adv. Proxy for Sh. Inderjit Singh, Counsel for OPs 1 & 2
	Sh. J.P. Nahar, Counsel for OP-2

       

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.        The complainant, who is a senior citizen, has filed the present consumer complaint alleging that he and his wife were insured with OP-3 since 2005-06 to 2013-14 by paying the requisite premium. In August, 2008 complainant suffered from pituitary adenoma for which he had undergone operation at PGIMER, Lucknow (UP) and upon submission of claim, the same was reimbursed by OP-3.   In the year 2013, OPs 1 & 2/insurer took over the aforesaid policy. At that time complainant had orally disclosed to the officials of OPs 1 & 2 that he had already undergone operation in the year 2008 and they assured that they have no concern with his past medical history.  OPs 1 & 2 insured the complainant and his wife vide policy (Annexure C-4) which was valid w.e.f. 14.11.2018 to 13.11.2019 and the complainant paid huge amount of premium.  In the month of July 2019, complainant started feeling trouble in his body and went to Fortis Memorial Search Institute, Gurgaon and got himself medically examined. Thereafter, the complainant came to Chandigarh and got himself medically examined from PGIMER, Chandigarh where various tests were conducted and he was informed that he required operation for Benign Neoplasm of pituitary gland which was operated on 9.9.2019.  Though the complainant had spent total sum of Rs.95,000/- (approx.) upon his treatment, but, he could retain medical bills of Rs.92,768/- only, which were duly submitted by him with OPs 1 & 2 for reimbursement.  However, OPs 1 & 2/insurer repudiated the claim of the complainant vide letter dated 3.10.2019 (Annexure C-8) on the pretext that there was past medical history of pituitary adenoma.  On 1.10.2019 complainant received policy renewal intimation letter from OPs 1 & 2 and in pursuance to the same he issued cheque dated 24.10.2019 amounting to Rs.53,589/- for renewal of the policy.  However, vide letter dated 8.11.2019 (Annexure C-11), OPs 1 & 2 terminated the policy due to non disclosure of past history of pituitary adenoma. Alleging that the aforesaid acts of omission and commission on the part of OPs amount to deficiency in service and unfair trade practice, complainant has filed the instant consumer complaint.
2.        In their written version, OPs 1 & 2 admitted that previously the complainant and his wife were insured with OP-3 and thereafter ported the policy with the answering OPs.  However, it is averred that the policy was obtained by the complainant after understanding all the terms and conditions as well as exclusions and limitations.  It is also admitted that the complainant lodged claim for his hospitalization. However, it is alleged that as complainant had past history of operation of pituitary adenoma in 2008, which was not disclosed by him at the time of proposal, the claim was rightly repudiated vide letter dated 3.10.2019. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, OPs prayed for dismissal of the consumer complaint.
3.        In its separate written version OP-3, inter alia, averred that as the claim occurred under the policy period 2018-19 and the complainant was insured with OPs 1 & 2, OP-3 has no concern with the claim and if any amount is payable to complainant, same has to be paid by OPs 1 & 2 as they had received the premium for insuring the complainant.
4.        The parties filed their respective affidavits and documents in support of their case.
5.        In replication, complainant controverted the stand of the OPs and reiterated his own.
6.        We have heard the learned Counsel for the parties and have gone through the documents on record, including written arguments.
7.        The main question involved for determination in the present consumer complaint is whether OPs 1 & 2/ insurer have repudiated the claim of the complainant on just and fair grounds or wrongly and arbitrarily?

              In order to find out answer to the above mentioned question, it is necessary to discuss the following facts and circumstances.

8.        The complainant has filed his affidavit in support of his case to the effect that he and his wife were insured with OP-3 (i.e. the previous insurer) since the year 2005-06 to 2013-14 by paying the requisite premiums.  In the year 2013, OPs 1 & 2/insurer took over the said policy. At that time the complainant had orally disclosed to OPs 1 & 2 that he had already undergone operation in the year 2008 and they assured that they have no concern with the past medical history.  It was thereafter that OPs 1 & 2/insurer had insured the complainant and his wife vide policy (Annexure C-4) valid from 14.11.2018 to 13.11.2019 and the complainant had been regularly paying the premiums of the policies since the year 2005.  On 9.9.2019, operation for Benign Neoplasm of pituitary gland was performed on the complainant and he submitted mediclaim of Rs.92,768/- with OPs 1 & 2/insurer for reimbursement. However, OPs 1 & 2 repudiated the claim of the complainant on the pretext that there was past medical history of pituitary adenoma. 
9.        It is also observed that the complainant was continuously taking mediclaim policy since the year 2005 and OP-3 had cleared his claim in the year 2008.  As the complainant had ported his policy with OPs 1 & 2 in the year 2018, it was for OPs 1 & 2 to check and verify the record from the previous insurer i.e. OP-3 before issuing the insurance policy, especially when the insured were senior citizens and were aged 72 and 67 years respectively at that time.
10.        In M/s Max Bupa Health Insurance Co. Ltd. Vs Rakesh Walia, Appeal No.191 of 2016 decided on 18.8.2016 by our own Hon’ble State Commission, UT, Chandigarh, it has been held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to thorough medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.
11.        Further, it has been held by our own Hon’ble State Commission, Chandigarh in case SBI General Insurance Company Limited Vs. Balwinder Singh Jolly 2016(4) CLT 372 that if Insurance company failed to conduct thorough check up of the policy holder then Insurance company has no right to decline the insurance claim on non disclosure of the facts of pre existing disease when the policy was taken.
12.        Moreover, even there is nothing on record to prove that the terms and conditions, especially containing the exclusion clause were ever explained to the complainant. In M/s Modern Insulators Ltd. v. Oriental Insurance Co. Ltd., (2000) 2 SCC 734, it was held as under:-

        “(8) It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the facts which the parties know. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose all material facts in their knowledge since the obligation of good faith applies to both equally.

9. …….. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause…….”

As such, in the absence of signature of the insured/ complainant on the terms & conditions of the policy containing the exclusion clause, it cannot be said that the same were ever disclosed/informed to him and thus are of no help to the OPs.

13.        Not only this, it is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.
14.        In similar set of facts the Hon’ble Punjab & Haryana High Court, Chandigarh in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others, 2008(3) RCR (Civil) Page 111 went on to hold as under:-

       “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

 

15.        In view of the above discussion, it can be safely concluded that the act of OPs 1 & 2/insurer in rejecting the genuine claim of the complainant is not only wrong and arbitrary but the same certainly amounts to deficiency in service on their part.
16.        Consequently, the present consumer complaint deserves to succeed and the same is accordingly partly allowed. OPs 1 & 2 are directed to pay Rs.92,763/- alongwith interest @ 6% per annum from the date of order till the date of its actual realization to the complainant. 
17.        This order be complied with by OPs 1 & 2 within 60 days from the date of receipt of its certified copy.
18.        Since no deficiency in service or unfair trade practice has been proved against OP-3, the consumer complaint against it stands dismissed with no order as to costs. 
19.        The pending application(s) if any, stands disposed of accordingly.
20.        Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

Announced 17/09/2024 hg	[AMRINDER SINGH SIDHU] PRESIDENT
	[SURESH KUMAR SARDANA] MEMBER