Chandigarh

DF-I

CC/950/2022

MANMOHAN SINGH CHADHA - Complainant(s)

Versus

MANIPALCIGNA HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

ADS JATTANA

02 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/950/2022
Date of Institution	:	01/12/2022
Date of Decision	:	02/05/2024

 

1. Manmohan Singh Chadha, aged 66 years son of Sh. Kirpal Singh;

2. Sukhbir Kaur, aged 65 years wife of Sh. Manmohan Singh Chadha;

    both residents of house No.222, Sector 9-C, Chandigarh.

… Complainants

VERSUS

Manipal Cigna Health Insurance Company Limited (formerly known as Cigna TTK Health Insurance Company Limited) having its registered office at Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai;

Local address:-

SCO No.149/150, 1^st Floor, Sector 9-C, Chandigarh.

… Opposite Party

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. A.D.S. Jattana, Advocate for complainants.
	:	Sh. J.P. Nahar, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Manmohan Singh Chadha and Smt.Sukhbir Kaur, complainants against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainants were approached by the agent of the OP and were informed about the benefits of medical insurance policy.  Accordingly, proposal form was filled and on the basis of disclosure with regard to the complainants suffering from pre-existing diseases, the OP vide letter dated 23.1.2017 (Annexure C-1) advised them for medical tests to be conducted from the company’s authorised medical centre at the cost of the OP.  Accordingly, the tests were undertaken and the report was directly submitted to the OP and the complainants were informed by the OP vide letter dated 8.2.2017 (Annexure C-2) that due to pre-existing medical condition, they were required to pay additional cost of ₹5,459.89 apart from the regular payment and the same was accepted by the complainants on 15.2.2017. Accordingly, additional payment of ₹5,460/-, as demanded by the OP, was paid by the complainants. Thereafter the medical policy was periodically renewed by the complainants every year till 2022 on payment of requisite premium, as demanded by OP.  In the year 2022, complainants got the aforesaid health insurance policy renewed w.e.f. 18.2.2022 to 17.2.2024 (Annexure C-7) on payment of requisite premium under the plan “ProHealth – Protect” (hereinafter referred to as “subject policy”) with sum insured of ₹5,50,000/- each as reflected in the policy schedule (Annexure C-8). Thereafter complainant No.2 (hereinafter referred to as “insured patient”) suffered issue of knee pain and approached the Fortis Hospital, Mohali (hereinafter referred to as “Treating Hospital”), which was empaneled for cashless payment of the insurance amount, and after consulting the doctor, complainants had informed the OP regarding the diagnosis received from the doctor.  The Treating Hospital had advised the insured patient for replacement of the knee and for that purpose x-ray was taken and the report dated 24.8.2022 is Annexure C-9. Accordingly, information was given to the OP about the diagnosis and in response, letter dated 13.10.2022 (Annexure C-10) was received through which the cashless claim of the complainants was denied as the insured patient was known case of HTN (hypertension) since 10 to 12 years and DM (diabetes mellitus) since 20-25 years, which fact was not disclosed at the time of inception of the policy.  The complainants responded to the aforesaid letter vide letter (Annexure C-11).   The Treating Hospital informed the OP regarding the diagnosis and filled up and stamped the claim form.   The complainant No.2 was admitted in the Treating Hospital on 14.10.2022 and was discharged on 19.10.2022 and after surgery inpatient bill (Annexure C-13) to the tune of ₹2,61,159/- was raised by it and complainants paid ₹2,60,000/- vide receipt (Annexure C-14).  However, vide letter dated 7.11.2022 (Annexure C-15), OP illegally terminated the subject policy due to non-disclosure of long standing diabetes of complainant No.2 and forfeited the premium paid, despite of the fact that the OP had received higher premium on account of pre-existing ailments.  In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, admitting that the subject policy was issued to the complainants, but, denied that the claim of the complainants was illegally and wrongly rejected by further alleging that, in fact, the insured patient/complainant No.2 was having hypertension for 10-12 years and diabetes mellitus for 20-25 years and also suffering from allergic bronchitis since many years regarding which reference has also been made in the investigation report (Ex.OP-2) of the TPA. The claim of the complainants was denied as the same was in breach of the terms and conditions of the subject policy for non-disclosure of the material facts by the complainant at the time of inception of the policy. It is also admitted that earlier the answering OP was named as ‘Cigna TTK Health Insurance Company Limited’. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. The complainants chose not to file rejoinder 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 earlier the health insurance policy was issued to the complainants by Cigna TTK Health Insurance Company Limited after getting them medically examined through its authorised medical centre by issuing letter (Annexure C-1) and also by charging higher premium, as is also evident from the copies of letter dated 8.2.2017 (Annexure C-2) and cheque dated 15.2.2017 (Annexure C-3) and the same was got periodically renewed by paying requisite premium to the OP and finally the subject policy (Annexure C-7) was issued on payment of premium of ₹90,681/- which was valid w.e.f. 18.2.2022 to 17.2.2024, as is also evident from Annexure C-7, and the cashless request of Osteoarthritis left knee, raised by the Treating Hospital, for the insured patient/ complainant No.2 was denied vide letter (Annexure C-10) and the subject policy was terminated due to non-disclosure and concealment of facts, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in denying/ rejecting the genuine claim of the complainants and cancelling the subject policy and the complainants are entitled to the reliefs prayed for in the consumer complaint, as is the case of complainants or if the OP has rightly denied/rejected the claim and cancelled the subject policy and the consumer complaint of the complainants, being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   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 subject policy, investigation report, having been relied upon by the OP and claim denial/rejection letter as well as policy cancellation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of copy of subject policy as well as Policy schedule (Annexure C-7 & C-8) clearly indicates that the same was valid w.e.f. 18.2.2022 to 17.2.2024 and the Policy category was mentioned as “Renewal_04” meaning thereby it was renewed for the fourth time.  The policy schedule also clearly mentioned the pre-existing disease of the insured patient/complainant No.2 as “Diabetes Mellitus” as well as the medication followed by her.  It is further mentioned that PED (Pre-Existing Diseases) were covered after 48 months of continuous coverage.
   4. Annexure C-10 is copy of letter dated 13.10.2022 whereby the cashless facility for the claim of insured patient/complainant No.2 was rejected on the ground of non-disclosure and concealment of facts. The relevant portion of the said letter is reproduced below for ready reference :-

       “We regret to inform you, that we are unable to extend the cashless facility for this claim due to the following reasons:

1. We have received cashless request of Osteoarthritis left knee. Claimant is covered under ManipalCigna_ProHealth-Protect V4? Floater since 17 Feb 2017. As per the cashless form patient is k/c/o HTN since 10 to 12 yrs and DM since 20 to 25 yrs, which is material to policy decision and was not disclosed in proposal form at the time of policy inception. Hence, this claim also stands denied under policy condition VIII.1 duty of disclosure.”

5. Annexure C-15 is copy of letter dated 7.11.2022 whereby the subject policy was terminated due to non-disclosure of long standing diabetes of insured/ complainant No.2 and the premium paid was forfeited.
6. OP has proved the copy of investigation report dated 12.10.2022 (Ex.OP-2) issued by Medi Assist Insurance TPA Pvt. Ltd., based upon which the claim of the complainants was repudiated and the relevant portion of the same is reproduced as under :-

                “Conclusion

Overall findings during Verification: investigation of the case has been done and following are the findings noted down:-

• As per hospital record, patient had c/o of pain in left knee, difficulty in walking.
• Patient underwent relevant investigations and advised for the hospitalization on dated 13/10/2022 for the diagnosis of OA left knee.
• Patient advised for the planned surgical treatment of left TKR.
• Visit to the insured has been made, patient was non corporative. As per visit patient denied for providing the statement as she said they will provide statement after admission to the hospital.
• As per PAC record of dated 31/08/2022, patient has past history of HTN X 10-12 years, DM X 20-25 years, allergic bronchitis since many years, cataract B/L eyes.

Remarks:- claim may be repudiated for PED/ ND of HTN since 10-12 years as evident from hospital record.

 

7. It has been contended on behalf of the complainants that as it stands proved on record that the insured patient had taken treatment for knee replacement from the Treating Hospital and the same has no nexus with the earlier disease from which she was suffering i.e. diabetes mellitus, which had been duly disclosed by her and she had also paid the higher premium at the time of inception of the policy,  OP has wrongly denied/rejected the genuine claim of the complainants and cancelled the subject policy and the consumer complaint deserves to succeed.
8. On the other hand, it has been contended on behalf of the OP that as it stands proved on record that the pre-existing disease were to be covered after 48 months of continuous coverage and further that complainants, while obtaining the subject policy, did not disclose the factum of the insured patient suffering from hypertension since 10-12 years and Diabetes Mellitus since 20-25 years, the claim was rightly denied/rejected and policy was cancelled on the ground of non-disclosure and concealment of material facts as per the terms and conditions of the subject policy. 
9. However, there is no force in the contention of OP as it has come on record that the OP itself had issued letter dated 8.2.2017 (Annexure C-2) whereby it asked complainant No.1 to pay additional loading of ₹5,459.89 in view of pre-existing condition : Diabetes Mellitus for Mrs. Sukhbir Kaur, and the same was accepted by complainant No.1 on behalf of both the complainants on 15.2.2017. Further, while rejecting the claim of the complainants vide letter dated 13.10.2022 (Annexure C-10), for cashless facility, OP itself has admitted that “Claimant is covered under ManipalCigna_ProHealth-Protect V4? Floater since 17 Feb 2017”. Thus being the admitted position, it is unsafe to hold that the claim lodged by the complainants, for hospitalization and treatment of insured/complainant No.2, in the Treating Hospital in the month of October 2022 (i.e. after more than 60 months) falls within the period of ‘48 months of continuous coverage’.
10. Not only this, when it has also come on record, as is also evident from the investigation report (Ex.OP-2), that the insured patient/complainant No.2 had taken treatment from the Treating Hospital in the month of October 2022 for ‘left TKR’ (Total Knee Replacement) whereas earlier she was suffering from Diabetes Mellitus, there is no connection/nexus between the two diseases/ailments.
11. 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.”

12. Similarly, the 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 the 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."

13. The Hon’ble National Commission in case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC), while dealing with the question of suppression/non-disclosure of material facts, has held 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.”

14. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OP/insurer has not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured patient had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OP/insurer was justified in denying/rejecting the claim of the complainants as well as cancelling the subject policy and the present consumer complaint deserves to succeed.
15. Now coming to the quantum of amount to be awarded to the complainants, since complainants have proved the receipt dated 14.10.2022 (Annexure C-14) of ₹2,60,000/- towards the expenses spent on hospitalisation/treatment of the insured patient, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc. So far as the claim of complainants qua restoration of subject policy is concerned, since learned counsel for complainants, did not press the same at the time of arguments, therefore, the said claim of the complainants is disallowed, being not pressed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹2,60,000/- to the complainants alongwith interest @ 9% per annum from the date of denial/rejection of the claim i.e. 13.10.2022 onwards.
2. to pay ₹25,000/- to the complainants as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainants as costs of litigation.

5. This order be complied with by the OP 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.

02/05/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member