Chandigarh

DF-II

CC/395/2022

Nimesh Lata through her Legal heir - Complainant(s)

Versus

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

Adv. GP Vashisht

08 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	395/2022
Date of Institution	:	29.04.2022
Date of Decision	:	08.05.2024

 

                                       

                       

Nimesh Lata (since deceased) w/o Late Jugal Kishore Chandan resident of House no. 2306 Golden Enclave Sector 49-C Chandigarh 160047 through his LRs Dheeraj Chandan (son)

....Complainant

Versus

1.     The Manipal Cigna Health Insurance Company Limited Regd. office 401/402,4th floor Raheja Titanium, Off, Western Express Highway, Goregaon (East) Mumbai, 400063 [GSTIN 27AAECC7904J1ZI]through its Authorized Signatory Provisional ID

2.     The Manipal Cigna Health Insurance Company Limitedits Branch office at Ist Floor, SCO 149/150, Sector 9-C, Next to Yes Bank Madhya Marg, Chandigarh-160009 [GSTIN Provisional ID 04AAECC790J1ZQ]

…. Opposite Parties.

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI B.M.SHARMA	MEMBER
PRESENT:-
	Sh.G.P.Vashisht, and Sh.Sh.Rohit Joshi, Advocates , Counsel for the complainant Sh.Vikramjit Singh, Adv. Proxy for Sh.Inderjit Singh, Counsel for the OPs.

       

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.         The complainant has filed the present complaint pleading therein that she took the Health Insurance under the Prot Health Protect Plan from the OP bearing Policy No.PROHLN981855385, valid from 27.08.2020 to 26.08.2021, which was renewed from 07.09.2021 to 06.09.2022 by paying the premium of Rs.28,468.89.  In the month of December, 2020 there was sudden pain in the left arm as there was swelling on it. Subsequently, she was diagnosed to be suffering from malignant neoplasm of nipple and areola, left female breast lump at PGIMER, Chandigarh as per report dated 14.01.2021 (Annexure C-3).  She took treatment for the same from different hospitals i.e. Vijayanand, Polo, Ivy Hospital, Mohali and PGIMER, Chandigarh and is still getting the treatment. She submitted the claim of Rs.1,26,956/- for reimbursement with documents, which was rejected by the OP vide letter/e-mail dated 14.01.2021 (Annexure C-5) on the ground that the mammography report of the complainant shows that the said disease had a history of past 10 months i.e. prior to the policy and as such the case of the complainant is not covered under the policy.  It has been stated that the policy was issued to her after completion of all formalities required for the medical health policy and there is no untrue or incorrect statements, misrepresentation etc. on her part.  It has been stated the claim has been illegally repudiated by the OPs. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to release Rs.2,60,203/- towards medical reimbursement and to pay the compensation for mental agony and physical harassment as well as litigation expenses.
2.         After service of notice upon the OPs, they filed the written statement and admitted the factual matrix of the case.  The OPs have stated that at time of proposal the complainant had disclosed that she was not suffering from any pre-existing disease/illness and upon the receipt of the claim, the said disclosure statement was found to be false and incorrect as  the complainant was having some existing medical conditions such 1) diabetes Miletus Type-2 since  years and on regular medication of “Meformin 500”(3) Breast Lumps since 10 months w.e.f. 14.01.2021 (Mammographcy report date) which is prior to the policy inspection.  However, the complainant has concealed the aforesaid facts at the time of taking the policy and therefore, the claim of the complainant was rightly repudiated as per the terms and conditions of the policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, the OPs prayed for dismissal of the complaint.
3.         The parties filed their respective affidavits and documents in support of their case.
4.         We have heard the Counsel for the contesting parties  and have gone through the documents on record including written submissions.
5.         From the perusal of the rival submissions of the parties and the documentary evidence on record, it is observed that the complainant namely Smt.Nimesh Lata, was duly insured under the policy in question when she was diagnosed to be suffering from malignant neoplasm of nipple and areola, left female breast lump at PGIMER, Chandigarh.  She took treatment for the said disease from different hospitals i.e. Vijayanand, Polo, Ivy Hospital, Mohali and PGIMER, Chandigarh and was still getting the treatment and incurred a sum of Rs.1,26,956/- at the time of filing the complaint. It is observed from the documents that the complainant had submitted the reimbursement of the mediclaim in respect of malignant neoplasm of nipple and areola, left female breast lump and not with respect to Diabetes MellitusType-2. The Diabetes MellitusType-2 has no nexus whatsoever with the disease of breast cancer.  In addition to this, the OPs have not led any evidence that the disease of breast cancer had any connection or nexus with the Diabetes MellitusType-2. In the absence of any evidence of nexus with the Diabetes MellitusType-2, the claim for treatment of the breast cancer cannot be said to have been rightly repudiated on the ground of non-disclosure of the material facts by the policy holder.
6.         Moreover the disease for which the complainant had took the treatment was covered under Manipal Cigna Pro Health Protect V3-Non Floater Policy and the complainant was diagnosed to be suffering from disease of breast cancer only on  14.01.2021 and 22.01.2021 when the mammography test and other tests were conducted at the PGIMER, Chandigarh. The complainant has also placed on record the report dated 15.01.2021 at page 46 of the PGIMER, Chandigarh wherein under the heading of diagnosis, it was clearly stated that there was no evidence of malignancy. Even the doctors of the PGIMER, Chandigarh were not sure that the complainant was suffering from malign cancer or not. As such it cannot be said that the complainant had any prior knowledge about her disease and she had concealed any material fact regarding her health at the time of obtaining the insurance policy. 
7.         The complainant–Smt.Nimesh Lata died on 27.05.2023 during the pendency of the complaint and her son Sh.Dheeraj Chandan being her only LR has been impleaded in her place.   During the pendency of the complaint, the complainant vide application dated 07.03.2023 has placed on record the medical bills Ex.C-8 to C-32 to show that the complainant has also incurred a sum of Rs.3,07,479/- besides the amount of Rs.1,26,956/- and as such it is observed that the complainant- Smt.Nimesh Lata had incurred a sum of Rs.4,34,435/- on her treatment.
8.      It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.
9.         In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

        “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

10.         In view of the above discussion, it can be safely concluded that the OPs -Insurance Company have committed deficiency in service by wrongly and illegally rejecting the genuine claim of the complainant.
11.         Consequently, the present complaint deserves to be partly allowed and the same is accordingly allowed qua the OPs. The OPs are directed to pay Rs.4,34,435/- towards the medical expenses to the complainant  along with interest @ 9% per annum from the date of order till the date of its actual realization to the complainant. 
12.         This order be complied with by the OPs- Insurance Company within 60 days from the date of receipt of its certified copy.
13.         The pending application(s), if any, stands disposed of accordingly.
14.         Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

Announced in open Commission 08.05.2024
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(B.M.SHARMA) MEMBER