FINAL ORDER/JUDGEMENT

  SHRI ASHOKE KUMAR GANGULY, MEMBER

This is an application U/s.12 of the C.P. Act, 1986.

The complainant was having a family health optima Insurance Policy with Star Health and Allied Insurance Company Ltd., from the year 2012. Being inspired and allured  by the agent of the OP the complainant ported the existing policy to Cigma TTK Insurance Health Insurance Company being the OPs. on 29.01.2018. The date of inception was rectified as 24.12.2012 instead of 29.01.2016 by the OPs vide letter dated 23.08.2018. The complainant thereafter was admitted to Ruby Hospital, Kolkata on 03.02.2018 after being referred by G.D. Hospital & Diabetes Institute for treatment of his chest pain. The TPA being the OP No. 3 & 4 met the complainant on 09.02.2018 and on 12.02.2018 the OPs sanctioned Rs.1,50,000/- and on 14.02.2018 the OPs further sanctioned Rs.50,000/-  as cashless amount but the same was not disbursed by the OPs arbitrarily which tantamount to deficiency in service  and unfair trade practice. The complainant had no earlier occasion of chest pain before 03.02.2018. However the complainant submitted claim to the OPs through TPA on 13.04.2018 which was rejected by flouting the enrollment date with the reason of pre existing disease on the basis of discharge summary of Ruby General Hospital where it is mentioned that the patient has history of occasional exertional chest pain.  But thereafter the treating doctor Sri S.B. Bhattacharyay vide letter dated 05.11.2018 clearly certified that the complainant had no occasional exertional chest pain. After submission of initial papers the complainant was further asked to submit additional documents which was submitted by the complainant on 12.07.2018. But the OP Nos.1 & 2 repudiated the claim on 11.10.2018 without considering the fact that the policy was ported on 24.12.2012 which was affirmed by the OP No. 1 & 2 vide letter dated 23.08.2018. The total expenses incurred was Rs.3,28,011.74. But the maximum sum assured was Rs.2,50,000/- . As such the complainant is entitled to Rs.2,50,000/-. Legal notice was served upon   the OPs on 11.03.2019  but the OPs did not consider the claim. Finding no alternative, the complainant has approached the Commission for justice with relief as mentioned in the complaint petition.

The OP Nos. 1 & 2 have contested the case by filing W/V contending interalia that the complaint is false, malicious and incorrect and the same is nothing but the abuse of the process of law and deserves to be dismissed with costs.

The complainant had taken an Insurance Policy from the OPs bearing No.PROHLR010619638 for the period from 29.01.2018 to 28.01.2019 under certain terms and conditions. The complainant filled up the proposal form with “All No” regarding his previous ailments. The complainant deliberately suppressed his previous ailments in the proposal papers for which the OPs did not have the opportunity to conduct medical test on that line. The complainant was admitted to Ruby Hospital on 03.02.2018 with anteroseptal wall myocardial infarction, Coronary Artery Disease (CAD), heart failure, pneumonia and underwent coronary angiography and PTCA. The cashless request was denied by the OPs on the ground of non disclosure of the material information. It is admitted that the complainant lodged claim for reimbursement to the tune of Rs.2,50,000/- against his expenses of Rs.3,28,011.74 incurred by him for the hospitalization for acute myocardial infarction. The complainant has breached the most fundamental principle of insurance namely UTMOST GOOD FAITH. Since expenses on pre existing diseases and related complications are not admissible under the policy for a period of 48 months under policy Clause VIII.1 the claim of the complainant was repudiated.

  The complainant should have disclosed the material information before taking the policy and by not providing the information relating to his medical history the complainant has transgressed not only the terms and conditions of the policy but the basic principles of Insurance also.

The OP no-3 has not submitted their W/V as they are the processing authority of the OP No-1&2 only.

The OP no-4 has also filed W/V wherein they have stated that the complainant had no heart disease even for a single day as claimed is not true from the medical point of view since a damaged heart with ‘anteroseptal wall myocardial infarction’ and ‘single vessel coronary artery disease both of which were diagnosed in the patient cannot set in on a single day. The history of occasional exertional chest pain was briefed by the patient and no part of it was manipulated by the OP no- 4. The concerned Doctor S.B. Bhattacharya described the procedure of the treatment and the happening as on fact while in admission at the hospital and has never stated anything about any medical history of the patient. Other allegations against the OP No- 4 are denied.

Points for Determination

In the light of the above pleadings, the following  points necessarily have come up for determination.

1)  Whether the OPs are deficient in rendering proper service to the Complainant?
            2)  Whether the OPs have  indulged in unfair trade practice?

           3)  Whether the complainant is entitled to get relief or reliefs as prayed for?

Decision with Reasons

Point Nos. 1 to 3 :-

The above mentioned points are taken up together for the sake of convenience and brevity in discussion.

We have travelled over the documents placed on record. Both parties have submitted their evidence on affidavit and also their BNA The complainant and the OP No- 1&2 have filed replies to the questionnaire  set forth by their adversaries.

While perusing the records it is observed that the complainant Mr. Partha Sarathi Chatterjee had taken an insurance policy bearing no- PROHLR010619638 for the period from 29/01/2018 to 28/01/2019 from the OP no 1 & 2. This policy was ported from Star Health and Allied Insurance company Ltd. to CignaTTK Health Insurance Pvt. Ltd. with effect from 24/12/2012 being the Enrollment Date. This SignaTTK Health Insurance Pvt. Ltd. has been converted to  Manipal Signa Health Insurance Company LTD being the OP Nos 1 & 2. The porting of the earlier policy which was with Star Health and Allied Insurance company Ltd. has been confirmed by SignaTTK Health Insurance Co. Ltd. vide their letter dt 23/08/2018 as evident to us. By the said letter they have confirmed that this communication has become the part of the policy. In the said letter it has also been confirmed that the waiting period waived : 4 Years for 2 lakhs, 3 Years for additional 50k.Now let us consider the Repudiation Letter dated 11.10.2018 of the OP SignaTTK Health Insurance issued to the complainant where it is mentioned that  “ The beneficiary is covered under Cigna TTK Health Insurance Company Limited policy since 29.01.2018 (ported since 29.01.2016 ). On investigating  the case and as per initial assessment paper social history, it was found that the patient is having H/O Occasional exertion of chest pain 1 or 2 years. Since expenses on pre existing diseases and related complications are not admissible under the policy for a period of 48 months, hence the claim stands repudiated under the Policy Clause V.1. Pre existing Disease  Waiting Period.  Also the said ailment was not disclosed at the time of Policy inception, hence the claim stands repudiated under the Policy Clause VIII.1. Duty of Disclosure.”On further perusal of the said letter it is observed that this exclusion does not apply for the 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 subsequent renewals with us without a break. “   Since the policy has been ported with effect from 24.12.2012 and the complainant  was admitted on 03.02.2018  the bar of 48 months has already been crossed. Accordingly the Exclusion Clause of the said policy does not apply in the instant case. Moreover the OPs have erroneously probably deliberately  mentioned the portability date as 29.01.2016 instead of 24.12.2012 for the reason best known to them. They are contradicting their own letter dated 23.08.2018 where they have specifically mentioned that the policy has been ported from Star Health and Allied  Insurance co. Ltd. with Enrollment Date as 24.12.2012. The policy has been continued with them without any break. The existence of Pre existing Disease ha

time of hospitalization is not coming under the purview of concealment of pre-existing disease which has been clearly decided on 01.08.2008 vide Judgment of the Hon’ble NCDRC in the matter of Pradeep Kumar Garg V/S National Insurance Co. Ltd. Citation : 2008 Law Suit (CO) 378 where under Point No.5(iii) it has been mentioned that “ Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.

Point 5(iv) If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores like any other person and is not declared as a ‘diseased person’ as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months.”

In view of the above, we are of the opinion that, the OP Nos.1 and 2 were not correct in repudiating  the impugned Claim of the complainant.

All the points under determination are answered accordingly.

In the result, the Consumer Complaint succeeds.

Hence,

Ordered

That the Complaint Case be and the same is allowed on contest against the OP Nos.1&2 and dismissed against OP Nos .3&4  with the following directions.

1.The OP Nos.1&2 are directed to reimburse Rs.250000/- with Simple Interest@ 4% from the date of filing the complaint till the date of payment.

2. The OP Nos.1&2 are also directed to make payment of Rs.10000/- as litigation costs to the complainant.

The above order is to be complied by the OP Nos1&2 within 30 days from the date of the order, in default, the complainant will be at liberty to put the order into execution as per rules.

The Judgment be uploaded to the website of the Commission forthwith for perusal of the parties.