Haryana

Panchkula

cc/538/2019

SMT.RANJANA SAINI - Complainant(s)

Versus

THE CHIEF MANAGER/MANAGER,MANIPAL CIGNA HEALTH INSURANCE LTD. - Opp.Party(s)

25 Apr 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,  PANCHKULA

                                                      

Consumer Complaint No	:	540 of 2019
Date of Institution	:	13.09.2019
Date of Decision	:	25.04.2022

 

 

Smt. Ranjana Saini wife of Sh. D.D.Saini, now residing at House No.345, Sector-45, Panchkula Permanent resident of Flat No.117, Dream Homes Kishanpura, Dhakoli, Tehsil Zirakpur, District S.A.S. Nagar, Punjab.

 

                                                                           ….Complainant

Versus

1.     The Chief Manager/Manager, Manipal Cigna Health Insurance Limited, 401/402, Raheja, Titanium, Western Express Highway, Goregaon(East), Mumbai-400063.

2.     The Branch Manager, Manipal Cigna Health Insurance Company Limited, Ist Floor, SCO 149/150, Sector-9-C, Next to Yes Bank Madhya Marg, Chandigarh-160009.                                                                                                                                  ….Opposite Parties

COMPLAINT UNDER SECTION 35 OF THE CONSUMER PROTECTION ACT, 2019.

 

Before:              Sh. Satpal, President.

Dr. Pawan Kumar Saini, Member.

Dr. Sushma Garg, Member.

 

For the Parties:   Ms. Anju Saini, Advocate for the  complainant.    

                        Sh. Inderjit Singh, Advocate for OPs No.1 & 2. 

 

                                        ORDER

(Satpal, President)

1.             The brief facts of the present complaint are that husband of the complainant took a Family Floater Policy no.30193236201300 of Max Bupa Health Insurance Company Ltd. on 13.03.2013. The sum insured was Rs.2,00,000/-. On 23.03.2017, the complainant ported the above mentioned policy to Manipal Cigna Health Insurance Ltd. vide policy no.PROHCR010089426 and the sum insured was Rs.3,50,000/- under the same family Floater Plan. As per the guidelines of IRDA i.e. Insurance Regulatory and Development Authority, after four years of issuance of the policy, all disease pre-existing as well as post existing are covered in all policies of any company. The complainant used to have backache whenever she exerted more, off and on for the last 3-4 years but she always became fine and normal just after taking rest for half an hour and so no medical advise was ever taken for the backache. On 12.11.2018 the complainant first visited to Orthopedic Specialist in Alchemist Hospital, Sector-21, Panchkula due to numbness and increased back pain. The doctor prescribed some medicines for three months and also advice MRI etc. The MRI was done on 12.11.2018, the doctor also recommended the need of surgery if the medicine do not work for three months. On 25.02.2019 the complainant visited the Neurosurgeon for the same problem who after perusing the MRI report dated 12.11.2018 recommended the need of surgery. All the investigations as advised by the doctor which are mandatory and required before the surgery, were carried out including the cardiography tested. Prior to the admission for surgery, the complainant approached the TPA team available in the hospital and she applied for cashless facility on 26.02.2019. On 28.02.2019 the complainant got an email from the OPs in which they had refused the cashless facility on the ground that policy is issued on 23.03.2017 and patient is suffering from numbness and backache since last 6 years and due to the pre-existing disease, they cannot cover till four years from issuance of the policy.  Thereafter, the complainant was admitted in the Alchemist hospital on 13.03.2019 for Neurosurgery and was operated on same day i.e. 13.03.2019. She was discharged on 17.03.2019. The total expenses incurred upon the surgery, investigation, medicines etc. amounted to Rs.2,12,052/-. As per the discharge summary, she underwent L3 to L5 pedical Screw fixation. Apart from the surgery amount, she herself bore the pre-hospitalization charges amounting to Rs.9,427/- and post hospitalization charges amounting to Rs.2,458/-. On 20.03.2019 the complainant sent the claim documents for reimbursement with original documents. On 25.03.2019 the Ops refused the claim by observing that the patient was suffering from numbness and backache since last 6 years and the policy was issued on 23.03.2017 and also declared the policy null and void due to misrepresentation of facts. On 25.03.2019, the complainant again sent an e-mail to the higher authority i.e. Head Customer Services for reconsideration of the claim. On 05.04.2019 received the e-mail from the OPs vide which OPs denied the claim of the complainant. She requested through various emails, but all in vain.  Thereafter, the complainant had also sent a legal notice through registered post on 08.07.2019 to the OPs but the OPs have failed to comply the notice. Due to the above said act and conduct on the part of the OPs, the complainant has suffered mental and physical agony, financial loss and harassment. The OPs have also committed deficiency in service and unfair trade practice; hence, the present complaint.  

2.             Upon notice, OPs No.1 & 2 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable being baseless and false; the complainant does not fall within the definition of a consumer; not come with clean hands; suppressed the material facts; no cause of action and no territorial jurisdiction. On merits, it is stated that the present complaint is pertaining the medical treatment of the wife of the proposer i.e. Ranjana Saini(insured 2). It is stated that at the time of taking the policy the proposer represented the insured-2 i.e. Ranjana Saini to be not suffering from any illness or condition at the time of proposing to purchase the policy. However, the complainant did not disclose any pre-existing illness/disease for the complainant. It is also submitted that in the pre-policy medical examination form also, the complainant was asked specific questions regarding her medical history based on which the medical examination was conducted. However, she did not disclose any previous medical history. It is submitted that if the complainant had disclosed her medical history truly and correctly, the medical tests would have been conducted accordingly. It is alleged that the complainant registered a cashless request for hospitalization in Alchemist Hospital on 13.03.2019 due to numbness in lower limb. The OPs after scrutiny of the claim documents requested the treating doctor to confirm the etiology and duration of the present ailment and the relevant past history and to share the first consultation note. In response to the same the doctor confirmed vide his letter that the complainant has been suffering from numbness and backache since the last 5-6 years. Therefore, the Ops denied the cashless request for non-disclosure of material information and repudiated the claim under Clause Vlll.1 of the terms and conditions and duly informed the complainant vide repudiation letter dated 25.03.2019. So, there is no deficiency in service and unfair trade of practice on the part of OPs No.1 & 2 and prayed for dismissal of the present complaint

3.             To prove her case, the complainant has tendered affidavit as Annexure C-A along with documents Annexure C-1 to C-27 in evidence and closed the evidence by making a separate statement. On the other hand, the ld. counsel for the OPs No.1 & 2 has tendered affidavit Annexure R/A alongwith documents as Annexure R-1 to R-8 and closed the evidence.

4.             We have heard the learned counsels for the parties, considered the written arguments filed by the learned counsel for complainant and gone through the record minutely and carefully.

 5.            Admittedly, the complainant was hospitalized in Alchemist Hospital, Panchkula w.e.f. 13.3.2019 to 17.03.2019 in connection with surgical operation of L3 to L5 pedicle screw fixation. The complainant lodged the claim bearing no.19233319 for the reimbursement of the expenses incurred by her during her hospitalization and treatment, which has been repudiated by the OPs stating that the complainant was suffering from the pre-existing disease of numbness and backache prior to the policy inception. The only issue for adjudication is whether the repudiation of the claim no.19233319 by the OPs vide its letter dated 25.03.2019(Annexure R-8) is legally valid and justified. The claim has been repudiated on the ground that the complainant did not disclose her pre-existing disease to OPs while obtaining the health policy in question.

                As per complainant, nothing was concealed from the OPs as she was not suffering from any pre-existing disease as alleged by the OPs. During the arguments, the learned counsel for the complainant reiterated the facts and contentions as contained in the complaint and supporting documents.

6.             On the other hand, the learned counsel for the OPs while reiterating the facts and contentions as contained in the written statement as well as supporting documents justified the repudiation of the claim in question on the ground that the complainant was suffering from numbness and backache since last 5-6 years as confirmed by the treating doctor vide his letter dated and consultation note dated 12.11.2018. It is contended that the complainant was suffering from the said ailment prior to the policy inception, which was not disclosed at the time of purchasing of the policy. It is vehemently contended that the history of previous ailment/disease/ illness was material to the issuance of the policy and ought to have been disclosed by the insured. It is further argued that if the complainant had disclosed the said material factum of previous aliment to the OP at the time of issuance then the OPs would not have issued the insurance policy. Reliance has been placed following case laws:-

          i.        Reliance Life Insurance Co. Ltd. Vs. Rekhaben Nareshbhai Rathod 2019 (2) RCR CIVIL 909

          ii.       TATA AIG Life Insurance Co.Ltd. Vs. Orissa State Co-operative   Bank & anr.” 2012(IV) CPJ 310(NC).

          iii.       Life Insurance Corporation of India & Anr. Vs. Mandava Geetha, 2012(lll)  CPJ 644(NC)

          iv.      Sandanand Bag Vs. Life Insurance Corporation of India & Anr.,   2012(lll) CPJ 398(NC).

          v.       LIC of India Vs. Rukma, 2012(ll) CPJ 44(NC).

          vi.      Life Insurance Corporation of India Vs. Francis Antony D’souza, 2012(2) CLT 176(NC)

          vii.      LIC of India Vs. Premlata Aggarwal, 2012(2) CLT 182(NC)

          viii.     Meenaben Ashok Kumar Patel Vs. Life Insurance Corporation of India,  2012(2) CLT 415(NC)

          ix.      Sunita Goyal Vs. Bajaj Allianz Life Insurance 2017(4) CPJ 54.

 

                Since the controversy revolves around the repudiation letter dated 25.03.2019(Annexure R-8) hence it is deemed proper to reproduce the same for the sake of convenience and clarity as under:-

                “On scrutiny of the documents it has been observed that on perusal of the claim documents-claimant admitted at Alchemist Hospital on 13.03.2019 with, C/o numbness in lower limb & underwent L3 to L5 pedical screw fixation and discharged on 17.03.2019. The beneficiary is covered under Cigna TTK     Health Insurance Company Ltd policy since 23.03.2017. As per treating doctor justification letter, the patient is having numbness in lower limb & backache since 5-6 years on treatment same is not disclosed in the proposal form; hence the claim stands repudiated under non-disclosure clause. We regret out inability to admit this liability under the present policy conditions. We also reserve the right to repudiate the claim under any other ground/s available to us subsequently”. 

7.             From a bare perusal of repudiation letter as reproduced above, it is found that the OPs has treated the date of inception of the policy as 23.03.2017, which is contrary to actual facts. It is not disputed that the complainant as well as her husband were duly insured with health policy of Max Bupa Health Insurance Company Ltd. w.e.f. 13.03.2013 as per Annexure C-5 & C-7. The policy schedule issued by the OPs which is available on record as Annexure C-5 & C-7 clearly states that for Roll over/Portability cases continuous coverage will be considered from first policy inception date with us or other insurer. Since it is a case of portability from Max Bupa Health Insurance Company Ltd. to Cigna TTK Pro Health Insurance Policy i.e. OPs, the coverage of the complainant under health policy was continuous w.e.f. 13.03.2013. As per terms and conditions of the insurance policy as well as well settled legal proposition, no claim can be denied after the expiry of four years. In the present case, the policy was continuous w.e.f. 13.03.2013 and not from 23.03.2017 as alleged by the OPs, so after the expiry of four years w.e.f. 13.03.2013, the OPs cannot be permitted to take the excuse of pre existing disease. Thus, the repudiation of the claim by the OP is not legally valid and justified.

8.             Moreover, except the initial assessment OPD record which is available on record as Annexure R-6, the OPs have not produced any other medical record of the complainant to prove that the complainant was taking the treatment for the disease of numbness and problem of backache, prior to taking the policy in question. It is not proved on record as to who had disclosed that complainant was suffering from the said disease of numbness and backache. Further, affidavit of the treating doctor, who had recorded the patient history, at the time of admission, has not been produced on record. In the absence of any such treatment record, which proves that the complainant was suffering from the disease of numbness and backache, it cannot be said that the complainant was suffering from the problem of pre-existing disease i.e. numbness and backache, prior to taking the policy in question. It is well settled proposition of law that the burden of proving the pre-existing disease lies upon the insurance company i.e. OPs and the same has to be proved by it by way of adducing adequate, cogent and credible evidence relating to the treatment of pre-existing disease. In the present case, the OPs have utterly failed to adduce any evidence much less cogent and adequate to prove that the complainant was suffering from the numbness and backache. Therefore, the repudiation of the claim was not valid and thus, the Ops have been found deficient while rendering service to the complainant; hence, the complainant is entitled to relief.

9.             Coming to the relief, it is found that the complainant has claimed a sum of Rs.2,23,937/-as expenses incurred by her prior to the hospitalization, during the hospitalization and post hospitalization whereas sum insured is Rs.3,50,000/-. The copy of hospitalization bills are available on record as Annexure C-14 to 25. The OPs have not disputed the correctness/genuineness of the said bills and thus, she is entitled to the reimbursement of Rs.223,937/-. Apart from it she is also entitled to be duly compensated on account of mental agony and physical harassment suffered by her. Further, she is also entitled to be compensated on account of litigations charges.  

10.            As a result of the above discussion, we partly allow the present complaint and dispose of with the following directions to the OPs No.1 & 2:-

1. To refund a sum of Rs.2,23,937/- to the complainant along with interest @ 9% per annum w.e.f. the date of filing of this complaint till realization.

2. To pay an amount of Rs.15,000/-to the complainant on account of mental agony and harassment.

3. To pay an amount of Rs.5,500/- to the complainant on account of litigation charges.

               

11.            The OPs No.1 & 2 shall comply with the order within a period of 45 days from the date of communication of copy of this order failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71/72 of CP Act, against the OPs No.1 & 2. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.

Announced:25.04.2022

Dr.Sushma Garg           Dr. Pawan Kumar Saini         Satpal

                 Member                   Member                      President

 

Note: Each and every page of this order has been duly signed by me.

 

   Satpal                                                

  President