Delhi

North East

CC/157/2021

Mohit Kumar - Complainant(s)

Versus

Manipal Cigna Health Insurance Co. Ltd. - Opp.Party(s)

17 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 157/21

 

 

In the matter of:

 

		Sh. Mohit Kumar S/o Sh. Mange Ram R/o D 906 A, St. No. 13, Ashok Nagar, Shahdara, Delhi 110093		Complainant
		Versus
		Manipal Cigna Health Insurance Co. Ltd. Through Its Manager/AR Office at:- 401/402, Fourth Floor Raheja Titanium Off. Western Express Highway, Goregaon (East) Mumbai 400063   Also at:- Plot No.1, Block 204, Second Floor, ZygonSquare H 1 A, Sector 63 Noida UP		Opposite Party
			DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                           DATE OF ORDER:		22.10.21 29.08.24 17.12.24

 

CORAM:

Surinder Kumar Sharma, President

Ms. Adarsh Nain, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against Opposite Party.

 

Case of the Complainant                                                                 

1. The case of the Complainant as revealed from the record is that Complainant purchased an online insurance policy from Opposite Party the policy named Corona Rakshak Policy, bearing policy no. CORRAK 150034760 w.e.f. 22.10.20 to 05.05.21, Plan Type Individual having policy term of 195 days. The policy had initial waiting period of 15 days, commencing from the date of policy i.e. 22.10.20 ending on 06.11.20, hence effective policy inception date being 07.11.20. The sum insured under aforesaid policy is Rs. 2,50,000/- for which the Complainant had paid a premium of Rs. 3,627/-. Thereafter for several months the Opposite Party did not dispatched/email policy bond or card to the Complainant. Thereafter Opposite Party issued a back dated policy bond and same was received by Complainant on 02.02.21. The Opposite Party had issued the policy bond on 24.10.20 (received on 28.01.21) and detailed claim process was given on page 10 of the said bond. On 06.02.21 the Complainant was diagnosed positive for Covid 19 and a report was issued by Rajiv Gandhi Super Specialty Hospital Tahirpur Delhi-93, vide SRF no. 767100382580 and he was advised to get admitted.  The Complainant had Corona Rakshak Policy and therefore Complainant was admitted to Makkar Medical Centre from 09.02.21 to 13.02.21 and after post discharge Complainant submitted hard copies of all relevant documents for claim to Opposite Party at their Noida branch and total amount paid by Complainant was Rs. 84,752/-.Thereafter on 28.02.21 Complainant received an email seeking some additional documents and vide email dated 28.02.21 Complainant informed Opposite Party that he does not have any document related to CT Scan as there was no CT scan done ever, and remaining documents were duly submitted to them. Complainant has submitted his claim form and same was duly rejected by Opposite Party on 25.03.21. Complainant had approached Opposite Party several times through personal visits and email but all in vain. Thereafter Complainant sent various emails on different dates and received by Opposite Party and again on 30.03.21 Opposite Party gave vague and ambiguous statement that the claim of Complainant is rejected and later vide email dated 25.03.21 rejection reason was attributed. Thereafter having no other option the Complainant sent legal notice dated 05.04.21 to Opposite Party through speed post and served to Opposite Party on 07.04.21 but Opposite Party neither gave reply nor paid the insurance amount. Hence, this shows deficiency in service on behalf of Opposite Party. The Complainant has prayed for a sum of Rs. 2,50,000/- with interest @ 24 % p.a. w.e.f 23.03.21 and for Rs. 2,00,000/- towards mental harassment. He further prayed for Rs. 75,000/- for litigation expenses.

Case of the Opposite Party

2. The Opposite Party contested the case and filed written statement. It is stated that there is no deficiency of service on the part of Opposite Party. It is stated that in this case the same treating doctor has different handwriting and there are some notes where there are no signatures or stamps etc. There is some variation regarding time of admission of patient in the hospital. It is stated that the complaint is without any merit and the same may be dismissed.

Rejoinder to the written statement of Opposite Party

3. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

4. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party

5. In order to prove its case, Opposite Party filed affidavit of Ms. Swetha Nair, Deputy Manager Legal of Opposite Party,wherein the averments made in the written statement of Opposite Party have been supported.

Arguments & Conclusion

6. We have heard the Ld. Counsels for the parties. We have also perused the file and the written arguments filed by the parties. The case of the Complainant is that he has obtained a Health Insurance Policy from the Opposite Party and it also covered the corona disease. It is his case that during the validity of the said policy he was diagnosed as corona positive and he was advised to be admitted in hospital accordingly he got admitted in Makkar Medical Centre from 09.02.21 to 13.02.21. His case is that he has spent Rs. 84,752/- on his treatment but his claim was rejected by the Opposite Party without any valid reason.
7. On the other hand, the case of the Opposite Party is that the claim of the Complainant was rejected under clause 8.8 of the insurance policy.  The said clause is reproduced under:

“If any claim made by the insured period, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy shall be forfeited.”

8. However, the Opposite Party has not led any evidence and has failed to prove that how the claim was fraudulent or what was the false statement or declaration made by the Complainant in support of his case. Therefore, the pleas raised by the Opposite Party cannot be accepted.
9. Admittedly, Complainant was having a valid insurance policy and the said insurance policy also covered the treatment regarding the corona disease. Admittedly, Complainant was diagnosed as corona positive by Rajiv Gandhi Super Specialty Hospital (An Autonomous Body under Govt. of NCT of Delhi) Tahirpur, Delhi 110093. The Complainant was advised to get admitted in the hospital. Admittedly the Complainant had Corona Rakshak Policy and the Complainant remained admitted in Makkar Medical Centre from 09.02.21 to 13.02.21.
10. In view of the above discussion, we are of the opinion that there is deficiency of service on the part of the Opposite Party. The complaint is allowed. The Opposite Party is directed to pay an amount of Rs. 84,752/- to the Complainant along with interest @ 9 % p.a. from the date of filing the complaint till recovery. The Opposite Party is further directed to pay an amount of Rs. 50,000/- on account of mental harassment and litigation expenses to the Complainant along with interest @ 9 % p.a. from the date of this order till recovery.
11. Order announced on 17.12.24.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Adarsh Nain)      Member

(Surinder Kumar Sharma) President