FINAL ORDER/JUDGMENT
SMT. SUKLA SENGUPTA, PRESIDENT
This is an application filed by the complainant U/s 35 of the CP Act 2019.
The fact of the case in brief is that the complainants Sri Arup Kr. Khemka and Smt. Kusum Khema are senior citizen.
The representative of the OP insurance Company approached the complainants for having health insurance policy from their company being agreed and convinced with the approach of the OP Insurance Company. The complainant No. 1 being a senior corporate executive intends to purchase health insurance certificate from the OP Insurance Company and submitted the medical papers of himself and his wife for last 10 years including his own Angiogram Report dated 18.06.2009, to the said Manager/Representative/Agent of the OP Insurance Company. The complainants filed up the application form with that effect.
It is further stated that one Mr. Somnath Chatterjee being the representative of the OP Insurance Company deliberately misrepresented the complainants that since the complainant No. 1 neither the actually suffered from any disease nor taken any medication, therefore, this was not a material issue to be mentioned. Accordingly, the OP Insurance Company being covered with the medical paper of the complainants issued the health insurance certificate in favour of the complainant.
The photocopy of the original health policy dated 06.11.2014 with terms and conditions is enclosed herewith as Annexure-A.
It is the further case of the complainant that they tried to get original health policy. The representative of the OP Company filed up the application form of the complainants. Thereafter the complainants signed the claim on payment of the total premium of more than Rs. 6,00,000/- during last six years towards premium both for them but made no claim at all except cashless request for himself for an amount of Rs. 45,000/- in Nov, 2019. It is alleged that such claim of the complainant No.1 was declined by the OP Insurance Company on the ground of non- compliance of duty of disclosure as per clause VIII.I as per terms and conditions and also cancelled the health insurance policy in question of the complainants on same self ground on 28.09.2020 I.e. after 10 months from date of their knowledge about the said ground.
As a result, the complainants being the senior citizen was threw out by the OP Insurance Company without having any health insurance cover in the time of covid pandemic which they did illegally and wrongfully. They also snatched away the health insurance cover of the complainant No. 2 Smt. Kusum Khemka at the time who was about 75 years old.
It is alleged by the complainant No. 1 that he was misguided by the agent of the OP and compelled to sign the application form written and filed up by the agent of the OP. So, the ground of non-compliance of duty of disclosure had been actively caused by the representative of the OP. Thus, the responsibility should be borne by the OP (the complainant No. 1) made several contacts by emails and letters with the OP vide letters dated 03.01.2020, 17.08.2020, 01.10.2020,12.01.2020 and 11.03.2020 are enclosed herewith as Annexure 2a, 2b, 2c, 2d, 2e and 2f collectively.
It is further alleged by the complainants that once the OPs declined the cashless claim of Rs. 45,000/- vide their email dated 16.01.2020 and again they sent email asking the complainant No. 1 to resubmit the same as “a reimbursement claim for further evaluation”. The photocopy of said email dated 16.01.2020 is annexed herewith as aneuxre-3 and they informed the complainant that the health Insurance Company in question of the complainants was active and valid on 16.01.2020. So, question of termination of insurance policy by the OPs after having declared it to be valid is a clear illegal act amounting to unfair trade practice and serious deficiency in service. So, the sudden termination of the insurance policy dated 28.09.2020 is unlawful that which must have been done by the OP with ulterior motive. The email dated 28.09.2020 as herewith as Annexure-6.
The complainant on several times made contact with the OP-1 on 28.02.2021 by email with a request to review, consider and to continue the health insurance cover of the complainant-2 Mrs. Kusum Khemka.
The photocopy of email dated 28.02.2021 is annexed as Annexure-7.
The OPs even on receipt of said email did not take any further step. Hence, without having any other alternative, the complainants have filed this case with a prayer to give direction to the OPs to offer an unconditional apology admitting their unlawful acts in respect of both complainant and also prayed for giving direction to the OP to pay a sum of Rs. 1,00,00,000/- each to the complainant as compensation for harassment, mental pain and agony along with Rs.1,00,000/- as litigation cost.
The OPs have contested the claim application by filing a WV denying all the material allegation leveled against them.
It is stated by the OPs in the WV that the petition of complaint is false malicious and incorrect. The complainants have filed petition of complaint with malafide intention which is nothing but the abuse of process of law.
It is stated by the OPs that the complainant Arun Kr. Khemka the primary insured of the policy in question approached the OP Insurance Company for purchasing a health insurance company and submitted in proposal form bearing no. PROHLT020000532 on 21 Oct, 2014 (Annexure-A).
It is alleged that there was no disclosure of medical history U/s 5 of the “Proposal Form “ therefore, the OP after evaluation of the given information requested the complainant to under go Pre-policy Medical Examination which included a set of medical test based on their age and the policy holders undergoing the medical Pre-policy Medical Examination. The primary policy holder Mr. Khemka and his wife Smt. Kusum Khemka filed up and singed the medical policy form dated 30.10.2014 (Annexure-2) where in their medical history sought and based on the ground of information submitted therein. The medical examination was carried out. It is further alleged by the OP that no medical history was disclosed for the primary insured in the pre-policy medical information form. The complainant-2 disclosed her health profile and accordingly, the insured was requested to pay additional premium and provide consent to cover the said illness as preexisting disease. Upon receiving the consent, additional premium of insured health insurance policy being No. PROHLT020000532 was issued to the complainants. The policy documents along with a copy of proposal form and the terms and conditions were duly delivered to the complainants in their registered address.
The copy of policy documents along with terms and conditions are filed as Annexure-3 and 4.
It is further stated by the OPs that the policy holders or the insured had always the option to approach the Insurance Company about their medical history within free look period but they did not raise the same within the free look period nor beyond the free look period and they enjoyed the cover under the policy through the policy period until its termination as per terms and conditions of the policy in question and also enjoyed the policy benefits. i.e. health maintenance benefits.
It is the further case of the OPs that they received the cashless claim No. 21128518 by the complainant under the above named policy for the estimated amount of Rs. 45,000/- for the hospitalization of the complainant No. 1 due to Ischemic Heart Disease and Coronary Angiogram on and from 02.12.2019 to 12.12.2019.
The OPs further stated that during evaluation of the claim, it was come to their notice that the complainant -1 had a history of Coronary Angiogram in the year, 2009 and have 60 % LAD. This event was noted to be prior to the purchase of the policy and hence, identified to be material of non- disclosure at the time of the purchasing the policy in question. Hence, the claim of cashless is declined as per clause No. VIII.I of the terms and conditions of the policy in question. After termination of the claim, the complainants again approached the insurance policy with a request for reconsideration of their claim application. He was already discharged from the hospital then the OP had requested him to submit reimburse claim request but no such claim as filed by the primary insured despite several request. Hence, admittedly the insurance policy in question was terminated by the OPs. The insured No. 1 repeatedly requested for recover the policy termination but the company was not yet in a position to reconsider the same and repudiated the claim of the complainants. It is alleged by the OP Insurance company and other that the claim was repudiated and the policy was terminated only because of non disclosure of pre existing disease of the insurd-1. So, question of deficiency in service on the part of the OPs does not arise at all.
Hence,
The complainant has no cause of action to file the case and the case is liable to be dismissed with exemplary cost.
In view of the above fact and circumstances, the points of consideration are as follows.
- Is the case maintainable in its present form?
- Have the complainants any cause of action to file the case?
- Are the complainants a consumer?
- Is there any deficiency in service on the part of the OPs?
- Are the complainants entitled to get relief as prayed for?
- To what other relief or reliefs is the complainants entitled to get?
Decision with reasons
All the points of considerations are taken up together for convenience of discussion and to avoid unnecessary repetition.
On a close scrutiny of materials fact and circumstances of the case as well as evidence on record, it is revealed that the case is well within the territorial and pecuniary jurisdiction of this commission and the complainants have filed this case within the period of limitation. It is also revealed that admittedly, the complainants have purchased the health insurance policy being policy No. PROHLT020000532 in question from the OP M/s Manipal Cigna Health Insurance Company Ltd. and Anr. on payment of required premium for both the complainants for the period from 06.11.2014 to 05.11.2015, 06.11.2015 to 04.11.2016, 05.11.2016 to 04.11.2017, 05.11.2017 to 04.11.2018, 05.11.2018 to 04.11.2019 and 05.11.2019 to 04.11.2020 and subsequently, when the complainants claimed the cashless benefits for the treatment of complainant No. 1. for a sum of Rs. 45,000/- in the month of 2019. The OP Health Insurance Company repudiated the claim and then the complainants have filed this case that means admittedly, the complainants are the consumers within the ambit of CP Act, 2019 and there is/was sufficient cause of action for the complainants to file this case.
At this stage let us see whether there was any sort of deficiency in service on the part of the OPs or not.
Admittedly, the complainants purchased the health insurance policy from the OP insurance company after submitting their all the medical papers for last 10 years and the OPs being satisfied with the medical report and also even having angiogram report of the complaiantn-1 dated 18.06.2009. The complainants also undergo pre- policy medical examination on 30.10.2014 at the instance of the OP Insurance Company and being satisfied with the medical examination report of the complainants along with angiogram report of the complainant No. 1 dated 18.06.2009. The OPs issued the health insurance policy being No. PROHLT020000532 to the complainant dated 06.11.2014 with the terms and conditions (Annexure-1).
It is the case of the complainant that prior to Nov, 2019 when the complainant -1 claimed the cashless payment of Rs. 45,000/- for his hospitalization for coronary angiogram on 09.12.2019 to 12.12.2019 that time the OP Insurance Company repudiated the cashless request of the complaiantn-1 for an estimated expenditure of Rs 45,000/- on the ground of suppressing of pre-existing disease of complainant -1 because he had history of coronary angiogram in the year of 2009 and had 60 % LAD but from the evidence of record, it is palpably clear that at the instance of the OP, the complainants undergo pre-policy medical examination on 30.10.2014 and being satisfied with medical report of the complainants, the OP Insurance Company issued the original health policy dated 06.11.2014, if that the so then the OP Insurance Company is estopped for raising any question in respect of suppression of pre-existing disease of the complainant-1 and the other complainant. Moreover, from the evidence the material on record, it is also revealed that the OP Insurance Company reviewed the health policy of complainants on received of required premium and actually till the cashless claim the complainants have paid premium of Rs. 6,00,000/- in total in that case OP Insurance Company cannot repudiated the cashless claim of the complainant-1 when they issued the health policy to them after getting their 10 years medical report and also the pre–policy medical examination report and time to time they renewed the health policy insurance in question. From the evidence on record, it is established that the complainants on several time made contact with the OP to reconsider the matter and in spite of the same initially after getting the cashless claim of Rs. 45,000/- for the hospitalization of the Complainant -1. The OP Insurance Company repudiated the claim and subsequently, they stated to submit claim for consideration for the purpose of reimbursement.
Under such circumstances, after issuance insurance of policy in question to the complainant on 06.11.2014 being satisfied with their medical report, the OP cannot repudiated the same.
From the conduct of the OP Insurance Company, it is reflected that they used to issue the health Insurance to their insured only for the purpose of spreading their business but as and when the insured placed the claim before them they tried to repudiate the same on several plea mainly due to suppression of pre-existing disease which they did in the instant case with the senior citizen also. The complaints tried their level best to make contact with OP Insurance Company and to make understand about the matter. They also requested them on several occasion not to repudiate the claim and also to renew the health insurance policy but the OP Insurance Company did not pay any heed to their request rather they cancelled the health Insurance policy of the senior citizen complainants during the Covid Period. Such inhuman conduct of the OP Insurance Company should be consider as the deficiency in service because they harassed the old aged complainants and not only repudiated their cashless claim of Rs. 45,000/- but also cancelled the health policy of the complainants. This commission can not adore such conduct of the health Insurance Company like the present health Insurance Company M/s Manipal Cigna Health Insurance company Ltd. and Anr.
In view of discussion made above, this commission is of view that the complainants being consumer within the ambit of CP Act, 2019 could be able to prove this case against the OPs beyond the all reasonable doubt and are entitled to get relief as prayed for.
All the points are thus considered and decided in favour of the complainants.
The case is properly stamped.
Hence,
Ordered
That the case be and the same is decreed on contest against the OPs with cost of Rs. 5,000/-
The complainants do get the decree as prayed for.
The OPs are directed to renew the health insurance policy of both the complainants within 45 days from this date of order.
The OP are further directed to pay Rs. 5,00,000/- only as compensation to the complainants for harassment, mental pain and agony either jointly or severally within 45 days from this date of order along with litigation cost of Rs. 30,000/- only , id the complainant will be at liberty to execute the decree as per law.
Copy of the judgment be uploaded forthwith on the website of the commission for perusal.
