District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.556/2021.
Date of Institution: 27.10.2021.
Date of Order: 14.09.2022.
Mr. Pardeep Kumar s/o Sh. Ram Gopal,
R/o. Village Mahawatpur, P.O. Bhaskola, Tehsil and District Faridabad, Haryana
….Complainant..
Versus
1. Principal Officer/ Branch Manager, Manipal Cigna Health Insurance Company Limited,(Earlier M/s Cigna TTK ProHealth Insurance Company Limited) E-75, 7th floor, Himalaya House, 23 KG Marg, Connaught Place, New Delhi – 110 001.
2. Manipal Cigna Health Insurance Company Limited, (Earlier M/s. Cigna TTK ProHealth Insurance Company Limited) 401/402, Raheja Titanium, Western Highway, Goregaon (East), Mumbai - 400 063
…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.
Indira Bhadana………..Member
PRESENT: Sh. Inderjeet Singh Tanwar, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant
Pardeep Chauhan and his family members namely Mrs. Sangeeta Kumari, sons
Ravi Raj & Gaurav were insured with M/s Star Health And Allied Insurance
Company Ltd. since 2012. After going through the medical Insurance plan of the
opposite party/ company, the complainant decided to port the policy in question
with the opposite party/ company and requested to port the policy on 27.9.2016
and obtained policy No. PROHLR010198183 valid from 17.10.2016 to 16.10.2017
through Mr.Ashok Tyagi, Health insurance agent, having office at 2657, Sector
7A, Faridabad. The sum insured in the said policy was Rs. 3,50,000/- According to the porting policy, continuous coverage will be considered from the first day of the policy's start date. On 31.7.2017 the wife of complainant namely Sangeeta Kumari @ Sangeeta Chauhan got admitted in Artemis Hospital, Sector-51, Gurgaon, due to severe back pain. The pain was so severe that she was unable to move or walk. After thorough examination by doctors, diagnosis of Disc Bulge at L5-S1 for Decompression and Fixation LS-SI was found. The wife of the complainant was admitted for the treatment at a cashless facility. The various clinical and laboratory tests/examinations were conducted upon the patient/wife of the complainant and was given treatment in the said Hospital on 31.7.2017 and she was discharged on 4.8.2017 from the said Hospital. The complainant spent a sum of Rs. 2,06,979.39 on the treatment of his wife. Complainant duly submitted his claim papers with respondent company for the above stated expenses incurred by the complainant on the treatment of his wife. The opposite party/ company denied the reimbursement of cash less medical expenses on the pretext that the medical treatment of complainant's wife cannot be covered stating the clause that the problem of 'Disc Bulge at L5-S1 for Decompression and Fixation LS-SI' is coming under the Pre-Existing Disease Clause. One day, the complainant made another personal visit to the office of the opposite parties/ company to enquire about the status of his wife's medical treatment claim processing and to his utter surprise opposite parties/ company informed that his claim has been rejected on the grounds mentioned in the letter already posted at his correspondence address. The complainant received the medical claim rejection letter dated 22/07/2017, stating the reason that "History of Disc Bulge since20/03/2016 as per MRI report which is pre-existing to the Policy inception with Cigna TTK, which is non-disclosure of material facts. The opposite parties/ company also terminated the Family Floater Policy on this pretext. After the termination of the Family Floater Policy done by opposite parties/ company, the complainant made several visits to opposite parties/ company's office to get his medical claim approved by the concerned officials, but all went in vain. The medical policy of the complainant is more than four years old and the disease/medical complication of the complainant's wife is not at all a pre-existing disease. Opposite parties/ company had arbitrarily rejected the medical claim of the complainant, just to avoid making payments, on false and frivolous grounds. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) Reimburse the cost of Rs.2,06,979.39 already spent by the complainant in medical treatment of his wife alongwith the pendente lite and future interest @ 18% p.a.
b) reinsate the Family Floater medical policy of the complainant which had been illegally and arbitrarily terminated by the opposite partiies.
c) pay Rs.2,00,000/- as compensation for causing mental agony and harassment .
d) pay Rs. 50,000 /-as litigation expenses.
2. Opposite parties Nos.1 & 2 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the Complainant on 13-10-2016 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 from 17-10-2016 to 16-10-2017. Policy details are provided herein below for your easy reference:
Policy No. : PROHLR010198183
Policyholder : Mr Pradeep Kumar
Plan : ProHealth- Protect
Policy period : 17-10-2016 to 16-10-2017
Insured Members : Mr. Pradeep Kumar (Self)
Mr. Ravi Raj (Son)
Mr. Gaurav (Son)
Mrs. Sangeeta Kumari (Wife)
Sum insured : Rs. 3,50,000/-
The complainant had neither any cause of action nor locus standi in lodging of the present complaint before this Hon'ble Commission, reason being, the complainant had submitted cashless claim with the Company, it is submitted that the complainant had submitted the cashless claim alongwith relied upon documents with regards to his treatment. After scrutiny of the claim papers, from the perusal of MRI 20/3/2016. However, the same was not disclosed by the Complainant at the proposal stage and suppressed this material information. Since, it has was established from the medical documents that there was suppression of material information and had the Complainant disclosed this fact at the proposal stage, the Company would have rejected the proposal. Hence, the claim was accordingly rejected under clause No. VIII 1 of the policy terms & conditions. Opposite parties Nos. 1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– Mahipal Cigna Health Insurance Co. Ltd. & Ors. with the prayer to: a) Reimburse the cost of Rs.2,06,979.39 already spent by the complainant in medical treatment of his wife alongwith the pendente lite and future interest @ 18% p.a. b) reinsate the Family Floater medical policy of the complainant which had been illegally and arbitrarily terminated by the opposite parties. c)pay Rs.2,00,000/- as compensation for causing mental agony and harassment . d) pay Rs. 50,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, affidavit of Pardeep Kumar, Annexure-1 – Cash receipt, Annexure-II – Rejection letter dated 22.07.2017, Annexure-III – email , Annexure-V - Report of claim submission, Annexure -IV - order dated 14.01.2021 passed by DCDRC, Faridabad, Annexure – Vi – email.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri JaswindEr Singh Shekhawat, Senior Manager (Legal), M/s. Manipal Cigna Health Insurance Company Limited, 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), MumbAI, Ex.R-1 – Insurance policy, Ex.R-2 - Artemis Joints and Spine Institute, Ex.R-3 – MRI Lumbosacral Spine,. Ex/R-4 – Claim Form A, Ex.R-5 – certificate regarding reimbursement claim request for your Manipal Cigna Pro-Health Insurance Protect Floater policy number PROHLR010198183 2016, Ex.R-6 – Termination Schedule.
6. The complainant has filed the complaint with the prayer to reimburse the cost of Rs.2,06,979.39 already spent by the complainant in medical treatment of his wife alongwith the pendente lite and future interest @ 18% p.a. and reinsate the Family Floater medical policy of the complainant which had been illegally and
arbitrarily terminated by the opposite parties.
7. During the course of arguments, counsel for the opposite party agitated at length. As per Ex.R-1 i.e. Cigna TTK Prohealth Insurance Proposal Form in column i.e. Medical And Lifestyle Information which was duly signed by the proposer i.e. Prapeep on 13.10.2016 and received by the Cigna TTK Health Insurance Company Limited on 13.10.2016 duly stamp in coloumn No.2 i.e.
b) Diabetes or pre-diabetic condition
c) Arthritis/Gout, Spondykutusm, Joint Pain, SlipDisc., Spinal Disorder Chronic Backache or any other disorder of the muscle/borne/joint.
d) Tuberculosis, Asthma, Bronchilis or any other lung/rspiratory or ENT disorder
There is no tick mark or cross by the complainant in above said YES or NO Column but it was also the duty of the insurance company seller to explain everything to the complainant. This issue goes in favour of the complainant because this policy is since 2012 and not of 2016. This policy was ported from different companies to opposite party company i.e. Manipal Cigna Health Insurance Company. As per the report of Focus Diagnostics vide Ex.R-3 opposite party has repudiated the claim of the complainant vide rejection letter dated 22.07.2017 (Annexure - II).
8. After going through the evidence led by the parties, the Commission is of the opinion that the complainant has got the policy since 2012 and the report of Focus Diagnostics is of 20.03.2016. As per repudiation letter dated 22.07.2017 vide Annexure-II, the claim of the complainant was repudiated on this ground only.. The Commission is also of the opinion that that after 48 months of the policy it was the duty of opposite party to verify everything from the complainant before issuing the policy. Hence, the complaint is allowed.
9. 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:14.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
