Tamil Nadu

StateCommission

CC/33/2017

Naintara Sawhney - Complainant(s)

Versus

M/s. Cigna TTK Health Insurance Company Ltd. ,Rep. by its Chairman Cum Managing Director - Opp.Party(s)

Bader Sayeed

10 Feb 2023

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present:  Hon’ble THIRU. JUSTICE R. SUBBIAH  : PRESIDENT

                             Thiru R  VENKATESAPERUMAL : MEMBER

 

 

C.C.No.33 of 2017

Monday, the 10th day of February 2023

Mrs. Naintara Sawhney

1A Jains Venus Garden

No.41/17, 2nd Street

Venus Colony, Alwarpet

Chennai  600 018.                                              .. Complainant

                                            

                                             Vs 

M/s. Cigna TTK Health Insurance Co. Ltd.,

Rep. by its

Chairman cum Managing Director

New No.104, Old No.90

Ganesha Tower

Dr.Radhakrishnan Salai

Mylapore,  Chennai 600 004.                              .. Opposite Party

       

 

Counsel for the Complainant            :  M/s. Bader Sayed

Counsel for the Opposite party        :  M/s. R.Nandakumar

 

This complaint has come before us for final hearing today i.e., on 10.02.2023 and on hearing the arguments of the counsel for the complainant, and on perusing the material records, this Commission made the following :-

O R D E R

 

 R.SUBBIAH J., PRESIDENT [Open Court]

       This complaint has been filed by the Complainant under Sections 17 of the Consumer Protection Act, 1986 praying for the following directions to the opposite party:

1. To disburse the medical expenses borne by the complainant being a sum of Rs.3,61,414/- along with interest;
2. To pay a sum of Rs.20,00,000/- for deficiency of service, damages for physical strain and mental agony caused to the complainant ; and
3. To pay the cost of the complaint.

 

     2.  The case of the complainant, in brief, is as follows:

     The complainant is in possession of Mediclaim Policy with the National Insurance Company Limited, for the past 20 years and was paying the premium amount without any break.  Whileso, the complainant was suffering from 'Osteroarthritis' in her legs for two years and was taking treatment for the same.  Since the illness of the complainant got worse, she was forced to go for advanced treatment for her illness and went to Apollo Hospital, Chennai for further treatment.  She was under a bonafide belief that her medical expenses would be borne by the National Insurance Company Limited, from whom she has taken hospitalisation insurance policy.  The complainant had renewed the mediclaim insurance policy for the past 20 years, without any break and hence the policy was intact with all benefits.  While she was undergoing treatment, one Ms.Sujatha of Landmark Insurance Brokers Pvt. Ltd, came in contact with the complainant and informed her that Public Sector Units (PSU) will not offer cashless facility for taking treatment and advised the complainant to initiate portability feature that is available in the market so that she can enjoy cashless facility for her medical treatment expenses, along with all benefits of her old policy in the new company.  Believing the words of the said Sujatha, the complainant changed her Insurance Policy from National Insurance Company Limited to that of M/s.Cigna TTK Health Insurance, the opposite party herein, with portability transfer.  On taking portability transfer, the complainant paid the premium amount and the opposite party assigned Insurance Policy No. PROHLR 050001249.  In the policy details, it has been clearly stated that pre-existing disease waiting period will be covered after 48 months of continuous coverage.  As the complainant was having the policy right from the year 2005 without any break up and it is a portable transfer, she was assured that there will not be any difficulty in claiming the insurance coverage.  The main reason for switch over from National Insurance Company to the opposite party is that they will be affording her with cashless facility, to undergo treatment in the Apollo Hospital. With the belief that the treatment cost will be taken care by the opposite party, she went to Apollo Hospital and got admitted on 14.07.2016, where she was diagnosed for 'Osteoarthritis' in her right knee and as per Doctor's advise she underwent surgery for the same on 15.07.2016 and was finally discharged from the hospital on 19.07.2016.  At the time of discharge, to the shock and surprise of the complainant, the hospital authorities asked the complainant to pay the hospital expenses being a sum of Rs.3,61,414/-.  The complainant was speechless and shocked to hear that she has to pay the above amount, in spite of her taking insurance coverage and only after due enquiry with the opposite party she underwent surgery for her illness.  When she contacted the opposite party and enquired about her insurance coverage and the reason for non-payment of the medical expenses, she did not get any proper reply from them.  Therefore, she was forced to arrange money through her son with great difficulty and heavy heart and paid the same to the hospital.  The complainant after getting discharged, contacted the opposite party to reimburse the medial expenses, so that she can repay her dues.  Inspite of their best efforts, till this time, the opposite party has not paid the medical expenses to the complainant.  Though the surgery was done in the month of July, the opposite party is evading from making the payment to the complainant.  The complainant and her son had visited the office of the opposite party number of times, but all ended in vain, as there was no positive response from the opposite party.  The complainant being an old lady, the opposite party had exploited her innocence and made her to run from pillar to post for her claim.  Therefore, alleging deficiency of service on the part of the opposite party, the complaint has been filed, for the relief stated supra.

 

      3.   Resisting the complaint, the opposite party has filed their version stating that the amount claimed by the complainant towards medical expenses is Rs.3,61,414/-, but the amount claimed towards deficiency of service is Rs.20,00,000/-, which is solely meant to exaggerate the claim amount, so as to reach pecuniary jurisdiction of this Commission.  The opposite party had denied all the allegations made in the complaint.  The complainant availed the said health insurance policy named as Pro-Health Protect with the opposite party under Policy No.PROHLR050001249 for the policy period from 29.06.2016 to 28.06.2017 subject to terms, conditions, exceptions and limitations thereof.  It is also specifically mentioned in the policy schedule that for any pre-existing disease, the waiting period is 48 months of continuous coverage, since the policy start date.  The complainant has admitted in the proposal form that she is suffering from Cholelithiasis Gouty Arthritis.  Therefore, the cashless access under the policy commencing from 29.06.2016, was rejected by the letter dated 08.07.2016 of the opposite party stating that, “Policy since 29.06.2016.  Cashless denied as per the policy sub limits, two year waiting period is applicable for Knee Replacement Surgery (other than caused by an accident), Non-infectious Arthritis, Gout, Rheumatism, Osteoarthritis and Osteoporosis”.  The said rejection is only for the cashless access under the policy and such rejection neither means nor is equivalent to rejection/ repudiation of the claim in toto.  The rejection letter clearly bears the following instructions :-

“2.  The denial of cashless access shall not be construed to mean that the patient cannot claim under the terms and conditions of the policy.

 3.  The patient can send a claim for consideration of reimbursement.

4.  The claims should be submitted within 15 days from the date of discharge of the patient”

 

But the opposite party has not received any claim for such reimbursement of the medical expenses.  The Opposite party has never evaded from answering the complainant.  Absolutely, there is no deficiency of service on the part of the opposite party.  The fictitious complaint before this Commission is based on wrong reasoning and logic, that do not have any merit and has to be dismissed.         

 

      4.  In order to prove the case, the complainant, along with proof affidavit, has filed 20 documents and the same were marked as Ex.A1 to A20.  On the side of the opposite party, neither proof affidavit nor documents were filed.

 

     5.  Considered the submissions of the counsel for the complainant and carefully perused the materials available on record.  

 

     6.  It is the case of the complainant that originally she had taken Mediclaim Insurance policy with National Insurance Co. Ltd., and the same was renewed for more than 20 years without any break.  The policies were marked as Ex.A1 series.  When the said policy was in force, the complainant developed a degenerative joint pain called Osteroarthritis.  She was suffering for a period of 2 years with the said ailment.  Since the pain aggravated severely, during June/July 2016, she was advised by her Doctors at Apollo, to undergo a surgery.  During this time she was approached by an Agent of the opposite party informing that the Public Sector Undertakings will not provide cashless facility and that if she takes insurance policy with the opposite party they will settle the hospital bills directly to the hospital instead of reimbursing the medical expenses to the insured.  Further, the companies such as the opposite party would provide portability transfer facility and change the insurance policy with the opposite party.  Hence, the complainant availed the said portability transfer option and migrated her insurance policy to the opposite party.  The new policy No.PROHLR050001249 was also assigned by the opposite party.  Thereafter, the complainant had undergone surgery at Apollo Hospital.  The Health Insurance portability was introduced by the Insurance Regulatory and Development Authority’s (IRDA) in the year 2011 under their circular No.IRDA/HLT/MISC/CIR/ 030/02/2011 dated 10.02.2011.  Portability makes it possible for the policy holder to transfer the credit gained for pre-existing conditions and time bound exclusions when switching from one plan to another of the same insurer, or from one insurer to another.  Therefore, the insured would be entitled to all continuity benefits like no claim bonus and free medical check-ups, which gets accumulated during the previous policy.  Further, the phrase ‘from the date of inception of policy’ will only mean the original date of inception with the National Insurance Company.  But, at the time of discharge, the hospital has served the complainant with a bill for a sum of Rs.3,61,414/- and had instructed them that the discharge summary could be prepared only on payment of the bill.  When the complainant contacted the opposite party for clarification on payment of the bill, they gave an evasive reply and refused to provide any explanation.  Hence, the complainant’s son was forced to undergo an immense ordeal to arrange for the money to pay the bills.  Thus, there is deficiency of service on the part of the opposite party and that they are also guilty of unfair trade practice for having promised a benefit while marketing their service and denying it to them at the time of claim.  Hence, the complainant is well within the eligibility criteria for availing the insurance claim from the opposite party and repudiation of the claim by the opposite party is unjust.

 

     7.  We find from the version filed by the opposite party that their rejection is only for cashless facility under the policy and not for reimbursement of the medical expenses.  The specific stand of the opposite party is that had the claim been submitted within 15 days from the date of discharge of the complainant, they would have reimbursed the medical expenses.  Therefore, we find that the opposite party is not denying payment of the medical expenses. But, it is the assertive submission of the complainant that only based on the assurance given by an agent of the opposite party that the public sector undertakings will not provide cashless facility and that only the companies like the opposite party will settle the hospital bills directly to the hospital instead of reimbursing the medical expenses to the insured, the complainant availed the portability transfer option and migrated her insurance policy to the opposite party.  But, to substantiate the same no tangible evidence was produced before this Commission.  Therefore, we are unable to appreciate the case projected by the complainant.   Further, we find in the version the opposite party had not denied the treatment undergone by the complainant and the medical expenses incurred by the complainant thereon.  The only contention is that they have rejected the claim for cashless payment not for reimbursement of the medical expenses.  Therefore, now there cannot be any impediment for the opposite party in reimbursing the medical expenses incurred by the complainant. 

 

      8.   In the result, the complaint is allowed in part.  The opposite party is directed to pay a sum of Rs.3,61,414/- being the medical expenses incurred by the complainant, within a period of two months from the date of receipt of a copy of this order, failing which, the amount mentioned above shall carry interest at the rate of 6% per annum from the date of default till the date of realisation.   However, considering the factual background of the case, we are not inclined to grant any compensation, as prayed for by the complainant.    

 

   R  VENKATESAPERUMAL                                   R.SUBBIAH, J.

MEMBER                                                        PRESIDENT

 

 

 

LIST OF DOCUMENTS MARKED ON THE SIDE OF THE COMPLAINANT

 

Sl.No.       Date                 Description of Documents

 

Ex.A1        10.06.2008       Insurance Policy No.500411/48/08/

 8500000498 for the period of 29.06.2008

 To 28.06.2009 issued by National

 Insurance Company Limited

 

Ex.A2        12.06.2009       Insurance Policy No.500411/48/09/

 8500000372 for the period of 29.06.2009

 To 28.06.2010 issued by National

                                         Insurance Company Limited

 

Ex.A3        11.06.2010       Insurance Policy No.500411/48/10/

 8500000375 for the period of 29.06.2010

 To 28.06.2011 issued by National

                                         Insurance Company Limited

 

Ex.A4        24.06.2011       Insurance Policy No.500411/48/11/

 8500000368 for the period of 29.06.2011

 To 28.06.2012 issued by National

                                         Insurance Company Limited

 

Ex.A5        22.06.2012       Insurance Policy No.500411/48/12/

 8500000381 for the period of 29.06.2012

 To 28.06.2013 issued by National

                                         Insurance Company Limited

 

Ex.A6        07.06.2013       Insurance Policy No.500411/48/13/

 8500000152 for the period of 29.06.2013

 To 28.06.2014 issued by National

                                         Insurance Company Limited

 

Ex.A7        19.06.2014       Insurance Policy No.500411/48/14/

 8500000410 for the period of 29.06.2014

 To 28.06.2015 issued by National

                                         Insurance Company Limited

 

 

Ex.A8        02.06.2015       Insurance Policy No.500411/50/15/

 10000314 for the period of 29.06.2015

 To 28.06.2016 issued by National

                                         Insurance Company Limited

 

Ex.A9        05.07.2016       Health Insurance Policy No.PROHLR

050001249 issued by the opposite party

 

Ex.A10      08.07.2016       Email from opposite party for non-

                                         Approval

 

Ex.A11      19.07.2016       Final bill issued by Apollo Hospital

 

Ex.A12      19.07.2016       Discharge summary issued by Apollo

Hospital

 

Ex.A13      24.11.2016       Legal notice sent to opposite party

 

Ex.A14      26.11.2016       Acknowledgement card

 

Ex.A15      10.06.2008       Insurance Policies

 

Ex.A16      05.07.2016       Health Insurance Policy No. PROHLR

050001249 issued by the opposite party

 

Ex.A17      19.07.2016       Final bill issued by Apollo Hospital

 

Ex.A18      19.07.2016       Discharge summary issued by Apollo

Hospital

 

Ex.A20                              Email communication between complainant

                                        And opposite party

 

Ex.A21      24.11.2016       Legal notice sent to opposite party

 

 

 

 

 

LIST OF DOCUMENTS MARKED ON THE SIDE OF THE OPPOSITE PARTY

 

           

            NIL   

 

 

 

 

R  VENKATESAPERUMAL                                        R.SUBBIAH

         MEMBER                                                               PRESIDENT

 

 

 

Index :  Yes/ No

 

AVR/SCDRC/Chennai/Orders/February/2023

 

 

 

 

 

 

 

 

 

 

 

 

C.C.No. 33 of 2017

HON’BLE  JUSTICE

THIRU R.SUBBIAH, PRESIDENT

      

In the result, the complaint is allowed in part.  The opposite party is directed to pay a sum of Rs.3,61,414/- being the medical expenses incurred by the complainant, within a period of two months from the date of receipt of a copy of this order, failing which, the amount mentioned above shall carry interest at the rate of 6% per annum from the date of default till the date of realisation.   However, we are not inclined to grant any compensation as prayed for, by the complainant.    

 

 

 

MEMBER                   PRESIDENT              

                10.02.2023                   10.02.2023