District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.009/2020.
Date of Institution: 06.01.2020.
Date of Order: 29.07.2022.
Pradeep Kumar Aggarwal S/o Dev Raj Aggarwal r/o H.No. 998, Sector-14, Escorts Nagar, Faridabad (HR.)
…….Complainant……..
Versus
1. Ms/s. Manipal Cigna Health Insurance company Limited Limited (formerly known as Cigna TTK Health Insurance Company ), 32-B, 3rd floor, Rajinder Nagar, Pusa Road, Near Pillar No.1 22 of Metro Station Karol Bagh, New Delhi – 110 005 through its Branch Manager.
2. P.K.Bansal Authorised Agent, M/s. Manipal Cigna Health Insurance company Limited, Shop No. 7, Second floor, Rama Palace Ajronda, Sector 20 B, Faridabad – 121001.
3. Medi Assist Insurance TPA Private Limited, No. 8b, Tej Building, 2nd floor, Bahadur Shah Zafar Marg, ITI, Delhi –110002.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
PRESENT: Sh. D.K.Gosain, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite party No.1.
Opposite parties Nos.2 & 3 exparte vide order dated 4.05.2022.
ORDER:
The facts in brief of the complaint are that the complainant was obtaining mediclaim policy form National Insurance Company Limited continuously since the year 2006 for himself, his wife and children. Last policy obtained by the complainant form National Insurance Company Limited was bearing policy NO. 361102501710002421 valid for the period 10.07.2017 to 09.07.2018 for a sum insured of Rs.8 lakh and it was a floater cover policy and apart from the complainant, his wife Leena Agarwal, daughter Priya Aggarwal and son Mayank Agarwal were also insured. The complainant ported the said policy about 10 days prior to the expiry of the previous policy obtained from National Insurance Company Limited and obtained the mediclaim policy from opposite party No.1 Cigna TTK health Insurance Company Limited (Now known as M/s. Manipal Cigna Health Insurance company Limited) through their agent opposite party N o.2 at Faridabad bearing Pro health insurance policy No. PROHLR010710654. Customer ID-1000842018 valid for the period 10.07.2018 to 09.07.2019 thereby insuring himself, Leena Agarwal and Mayank Agarwal and the sum insured was Rs.7.50 lakh. AT the time of porting the said policy, opposite party No.2 the representative of the opposite party No.1 assured that all the benefits of the previous policy obtained from national Insurance Company Limited should be made available to the complainant and to his wife Leena Agarwal and son Mayank Agarwal and the said policy was in continuation of the last policy obtained from national Insurance Company Limited bearing policy No. 3611025001710002421 effective of the period 10.07.2017 to 09.07.2018. Firstly the complainant was hospitalized due to pain in abdomen in Ghai Hospital, Sector-9, Faridabad on 23.08.2018 and was discharge don 25.08.2018 and paid the hospital bill of about Rs.14,200/- and other medicine bills total amounting to Rs.18,000/-. Prior to the hospitalization in Metro Heart In statute with Multispecialty, Sector-16A, Faridabad request was sent to opposite party No.3 by the hospital for cashless calim in respect of the complainant however the cashless facility was denied by Medi Assist Insurance TPA Private Limited vide letter dated 24.11.2018 and it was stated that the insured might resubmit the claim with complete set of documents for possible reconsideration after discharge. Further the doctor’s recommendation was also submitted to Medi Assist Insurance TPA Private Limited. On 27.11.2018, the complainant was admitted in Metro Heart Institute with Multispecialty, Sector-16A, Faridabd and was discharged on 28.11.2018 and diagnosis was made umbilical Hernia and left upper Ureteric Stone and was treated in the said hospital and the procedure done – Laparoscopy Mesh hernia repair done under G.A on 27.11.2018 as well left URS + DJ Stenting under GA on 27.11.2018 and at the time of discharge, medicines were prescribed. The complainant paid a sum of Rs.1,51,050/- to Metro Heart Institute with Multispecialty, Sector-16, Faridabad vide bill No.1B1802400 dated 28.11.2018 and thereafter also incurred post hospitalization medicine expenses. After discharge form Metro heart Institute, the complainant submitted all the treatment record as well as bills amounting to Rs.1,55,613/- and copy of insurance policy with the office of opposite party No.1 for reimbursement of the mediclaim of the complainant. Further the complainant had also submitted the treatment record and bills of Rs.18,000/- of Ghai Hospital for reimbursement. Opposite party No.1 sent the message to the complainant that they had received the reimbursement claim of the complainant on 15.12.2018 and would process the claim of the complainant. Further the complainant submitted all the relevant documents and reply to the query made by opposite party No.1 and thereafter the complainant had been approaching the opposite party No.1 time and again and asked to settle the genuine claim of the complainant but the opposite party No.1 kept on putting the complainant on one pretext or the other. The repudiation of the mediclaim of the complainant was totally, arbitrary and illegal because the complainant was holding the policy since 2006 continuously and it was ported to the opposite party No.1 w.e.f 10.07.2018 to 09.07.2019 and only 1 page policy schedule was supplied and the terms and conditions of the policy were never supplied to the complainant and never disclosed to the complainant. Further the policy a sported to the opposite party No.1 company on the assurance of representative of the opposite party company that all the benefits available to the complainant in respect of last medicalim policy obtained from national Insurance company Limited would be available under the policy of the opposite party No.1. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of the aforesaid bills amount of Rs.1,73,613/- alongwith upto date interest @ 18% p.a. till the payment..
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs.11,000/ - as litigation expenses .
2. Opposite party No.1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant on 22.06.2018 had submitted a proposal for porting his existing health insurance policy from the opposite party. Based on the documents submitted and information provided by the complainant, the opposite party had issued a health insurance coverage to the complainant form 10.07.2018 to 09.07.2019.. The complainant on 29.08.2018 had submitted a reimbursement claim of Rs.18,741/- for his hospitalization at Ghai Hospital from 23.08.2018 to 15.08.2018. as per the medical documents the complainant was admitted with C/o pain in abdomen. Upon assessment of the claim documents the opposite party had rejected the claim of the complainant stating that the expenses on stones in the urinary uro-genital and biliary systems including calculus diseases were not admissible for two years from the date of inception of the policy. Hence, the claim was repudiated by the company under clause V3 of policy terms and conditions. Opposite party later in November 2018 had received a cashless request from the complainant for his admission at Metro Heart Institute, for diagnosis of ‘umblical hernia. However, the said cashless request was also rejected by the opposite party stating that “expenses related to renal calculus and herenia were not payable for 24 months from the inception of the policy and the requisite waiting period is not complete…” it was respectfully submitted before the Hon’ble Forum that the claim of the complainant had taken the policy from the company in July 2018 and the claim was lodged in November 2018,, which was within the waiting period of 2 years. The complainant in December 2018 had lodged a reimbursement claim of Rs.1,55,613/- for his hospitalization at Metro Heart Institute from 27.11.2018 to 28.11.2018. The said reimbursement claim was also rejected by the company reiterating the reason provided in the rejection of cashless claim. It was further submitted that the claim was also rejected for the reason that “….As per the pre auth claim form, it was found that the patient was having diabetes since 6 months. Since the said ailment was not disclosed at the time of policy inception….”. The fact was of utmost importance that the complainant had not disclosed the said fact at the time of proposal, thus amounting to breach of policy terms & conditions. The complainant was communicated about the reason of repudiation of claim vide rejection letter dated 25.01.2019. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that it was admitted that the complainant ported the mediclaim policy from national Insurance Company Limited to Cigna TTK Health Insurance company Limited (now known as M/s. Manipal Cigna Health Insurance Company Limited) through him being the agent of opposite party No.1 at Faridabad and the said policy was bearing No. PRO Health Insurance Policy No. PROHLR010710654 effective 10.07.2018 to 9.7.2019 and by way of said policy the complainant insured himself, Leena Agarwal – his wife and Mayank Aggarwal – his son. The sum insured was Rs.7,50,000/-. As the policy was ported from National Insurance Company limited, with whom the complainant was having continuous mediclaim policies for several years therefore on asking by the complainant opposite party NO.2 told him that all the benefits of the previous policy taken from previous insurance company i.e. National Insurance Company Limited would be made available to the insured persons as the policy was in continuation of earlier policy No. 361102501710002421 period 10.07.2017 to 9.7.2018. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Opposite party No.3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that Mr. Pradeep Kumar Agarwal preferred a R-imbursement claim for a sum of Rs.19,276/-. The claim was processed vide claim No. 17774680 for Rs.19,726/-. On scrutinizing the claim document sby our team of doctors, it was found that edpenses on stones in the urinary uro-genital and biliary sytems including calculus diseases were not admissible for two eyhars from the date of inception of the policy. Hence the claim was repudiated under clause V.3 of the policy terms and conditions, As per the discharge summary, it ws found that the patient wa having diabetes mellitus since 6 months. Since the said ailment was not disclosed at the time of policy inception, hence the claim was repudiated under the policy clause Viii.1 Duty of disclosure, of the policy terms and conditions . Again the complainant had applied for cashless claim for a sum of Rs.1,50,000/- and the same was processed vide claim No. 18378002 and the same was denied under clause V 3 and V3 VII of the policy terms and conditions. Since the cashless claim was rejected as mentioned above, after getting discharged from the hospital, the complainant Mr. Pradeep Kumar Agarwal preferred a reimbursement claim for sum of Rs.1,55,613/-. The same was processed vide claim No. 18529073. On scrutinizing the claim documents it was found that complainant admitted for umbilical hernia with left upper ureteric stone, underwent lap mesh hernia repair with left URS with DJ Stenting. The beneficiary was covered under Cigna TTK Health Insurance company limited policy since 10.07.2018 (ported policy). As per the pre auth claim form, it was found that the patient was having diabetes since 6 months. Since the said ailment was not disclosed at the time of policy inception and also as per policy expenses related to treatment of Hernia and calculus were not payable for 24 months from policy inception. Hence, the claim stands repudiated under policy clause VIII.1.Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties – M/s. Manipal Cigna Health Insurance company Ltd. with the prayer to : a) make the payment of the aforesaid bills amount of Rs.1,73,613/- alongwith upto date interest @ 18% p.a. till the payment. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs.11,000/ - as litigation expenses .
To establish his case the complainant has led in his evidence Ex.CW1/A – affidavit of Pradeep Kumar Aggarwal, Ex.C-1 – Cigna TTK Pro Health Insurance for the period 10.07.2018 to 09.07.2019, Ex.C-2 – letter dated 24.11.2018, Ex.C-3 – Discharge summary,, Ex.C-4 – Final Bill, Ex.C-5 – legal notice,, Ex.C-6 – Policy of National Insurance Co. Ltd. Valid from 10.07.2016 to 09.07.2017,, Ex.C-7 – policy valid from 10.07.2017 to 09.07.2010,, Ex.C-8 – policy valid from 10.07.2015 to 09.07.2016,, Ex.C-9 – policy valid from 10.07.2013 to 09.07.2014, Ex.C-10 – policy valid from 10.07.2012 to 09.07.2013, Ex.C-11 – policy valid from 10.07.2019 to 09.07.2020, Ex. C-12 – Terms and conditions, Ex.C-13 – Discharge summary,, Ex.C-14 - bill dated 25.08.2018.
On the other hand counsel for the opposite party No.1strongly agitated and opposed. As per the evidence of the opposite party No.1 , Ex.RW1/A – affidavit of Shri Jaswinder Singh Shekhawat, manager (Legal), Manipal Cigna Health Insurance Co. Ltd., Mumbai, Ex.R-1 – insurance policy valid from 10.07.2018 to 09.07.2019, Ex.R2 – Emergency Assessment Form, Ex.R-3 - Ultra sound scan of whole abdomen, Ex.R-4 – certificate, Ex.R-5 – Discharge summary,, Ex.R-6 – bill dated 25.08.2018,, Ex.R-7 - prescription, Ex.R-8 – Reimbursement claim form, Ex.R-9 – prescription, Ex.R-10- letter dated 22.11.2018, Ex.R-11 – OPD card, Ex,R-12 – discharge summary, Ex.R-13 – Final bill, Ex.R-14 – Request for cashless hospitalization for medical insurance policy, Ex.R-15 – email, Ex.R-16 – claim form A, Ex.R-17 – claim form – part B, Ex.R-18 – Reimbursement claim reference No. 18529073,, Ex.R-19 – 25.01.2019 – reimbursement claim request for your Cigna TTK Pro-Health Insurance Protect Floater Policy.
8. Case called several times since morning but none appeared on behalf of opposite parties Nos.2 & 3. Hence, opposite parties Nos.2 & 3 were proceeded against ex-parte vide order atead 04.05.2022.
9. In this case, the complainant was obtaining mediclaim policy form National Insurance Company Limited continuously since the year 2006 for himself, his wife and children. Last policy obtained by the complainant form National Insurance Company Limited was bearing policy NO. 361102501710002421 valid for the period 10.07.2017 to 09.07.2018 for a sum insured of Rs.8 lakh and it was a floater cover policy and apart from the complainant, his wife Leena Agarwal, daughter Priya Aggarwal and son Mayank Agarwal were also insured. The complainant ported the said policy about 10 days prior to the expiry of the previous policy obtained from National Insurance Company Limited and obtained the mediclaim policy from opposite party No.1 Cigna TTK health Insurance Company Limited (Now known as M/s. Manipal Cigna Health Insurance company Limited) through their agent opposite party N o.2 at Faridabad bearing Pro health insurance policy No. PROHLR010710654. Customer ID-1000842018 valid for the period 10.07.2018 to 09.07.2019 thereby insuring himself, Leena Agarwal and Mayank Agarwal and the sum insured was Rs.7.50 lakh. AT the time of porting the said policy, opposite party No.2 the representative of the opposite party No.1 assured that all the benefits of the previous policy obtained from national Insurance Company Limited should be made available to the complainant and to his wife Leena Agarwal and son Mayank Agarwal and the said policy was in continuation of the last policy obtained from national Insurance Company Limited bearing policy No. 3611025001710002421 effective of the period 10.07.2017 to 09.07.2018. Firstly the complainant was hospitalized due to pain in abdomen in Ghai Hospital, Sector-9, Faridabad on 23.08.2018 and was discharged on 25.08.2018 and paid the hospital bill of about Rs.14,200/- and other medicine bills total amounting to Rs.18,000/-. Prior to the hospitalization in Metro Heart In statute with Multispecialty, Sector-16A, Faridabad request was sent to opposite party No.3 by the hospital for cashless claim in respect of the complainant however the cashless facility was denied by Medi Assist Insurance TPA Private Limited vide letter dated 24.11.2018 and it was stated that the insured might resubmit the claim with complete set of documents for possible reconsideration after discharge. Further the doctor’s recommendation was also submitted to Medi Assist Insurance TPA Private Limited. On 27.11.2018, the complainant was admitted in Metro Heart Institute with Multispecialty, Sector-16A, Faridabad and was discharged on 28.11.2018 and diagnosis was made umbilical Hernia and left upper Ureteric Stone and was treated in the said hospital and the procedure done – Laparoscopy Mesh hernia repair done under G.A on 27.11.2018 as well left URS + DJ Stenting under GA on 27.11.2018 and at the time of discharge, medicines were prescribed. The complainant paid a sum of Rs.1,51,050/- to Metro Heart Institute with Multispecialty, Sector-16, Faridabad vide bill No.1B1802400 dated 28.11.2018 and thereafter also incurred post hospitalization medicine expenses. After discharge form Metro heart Institute, the complainant submitted all the treatment record as well as bills amounting to Rs.1,55,613/- and copy of insurance policy with the office of opposite party No.1 for reimbursement of the mediclaim of the complainant. Further the complainant had also submitted the treatment record and bills of Rs.18,000/- of Ghai Hospital for reimbursement.
9. Opposite party repudiated the claim of the complainant vide letter dated 25.01.2019 vide Ex.R-19 on the ground that “….As per the pre auth claim form, it was found that the patient was having diabetes since 6 months. Since the said ailment was not disclosed at the time of policy inception and also as per the policy expenses related to treatment of Hernia and calculus are not payable for 24 months from policy inception. Hence, the claim stands repudiated under policy clause VIII.1. Duty of disclosure and exclusion V.3. 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.”
On the other hand, as per terms & conditions of Manipal Cigna ProHealth Insurance policy vide Ex.C-12, it has been mentioned in clause V.1. Pre Existing Disease Waiting Period: All pre-existing disease/illness/injury/conditions as defined in the policy, until 24/36/48 (as specified in the schedule) months of continuous covers have elapsed since inception of the first policy with us. This exclusion doesn’t apply for insured person having any health insurance indemnity policy in India at least for a period of 12/24/36/48 months as applicable , prior to taking this policy and accepted under portability cover, as well as for subsequent Renewals with us without a break.
V.3. Two year waiting period.
10. After going through the evidence led by complainant, the Commission is of the opinion that this mediclaim policy is ported by the complainant from Ex.C1, Ex.C6 to C7 to C-11,Hence the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite parties are also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 29.07.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
