STATE CONSUMER DISPUTES REDRESSAL COMMISSION WEST BENGAL CONSUMER COMPLAINT NO. SC/19/CC/525/2019 Rajesh Marwah PRESENT ADDRESS - S/o J C Marwah, 3A, Ripon Street, Kolkata - 700 016. ,WEST BENGAL.

.......Complainant(s)

Versus Manipal Cigna Health Ins. Co. Ltd. & Others PRESENT ADDRESS - Local office at Krishna Building, 3rd Floor, Unit 317 & 318, 224A, A.J.C.

Bose Road, Kolkata - 700 017. ,WEST BENGAL.

Medi Assist Insurance TPA Pvt. Ltd.

PRESENT ADDRESS - Regd. office at Tower -D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghata Road, Bangalore - 560 029. ,WEST BENGAL.

ICICI Lombard General Insurance Co. Ltd.

PRESENT ADDRESS - ICICI Lombard House, 414, Veer Savarkar Marg, near Siddhivinayak Temple, Prabhadevi, Mumbai - 400 025. ,WEST BENGAL.

.......Opposite Party(s)

BEFORE:

HON'BLE MR. AJEYA MATILAL , JUDICIAL MEMBER HON'BLE MR. NITYASUNDAR TRIVEDI , MEMBER FOR THE COMPLAINANT:

Rajesh Marwah, Mr. G. P. Shaw (Advocate)

FOR THE OPPOSITE PARTY:

Manipal Cigna Health Ins. Co. Ltd. & Others, Mr. Debasish Nath (Advocate)

Medi Assist Insurance TPA Pvt. Ltd.Mr. Debojit Dutta. (Advocate)

DATED: 16/09/2025

ORDER

HON’BLE MR. NITYASUNDAR TRIVEDI, MEMBER Today is fixed for pronouncement of the Judgment of this complaint case. The summary of the complaint is like that one Mr. Rajesh Marwah was Policy Holder of an ICICI Lombard General Insurance Company. Due to his convenience subsequently he went for portability of this Insurance Policy and got it listed under the Manipal Cigma Health Insurance Company Limited previously (Cigma TTK General Insurance Company Limited) fulfilling necessary formalities which had a risk coverage of Rs.3,00,000/-. This Policy ran upto 2017.

th On 10 July, 2016 the Complainant went for Health Insurance Policy of Manipal Cigma Health Insurance Company Limited thinking it will be better suited to him.

Subsequently, the son of the Complainant had to be admitted on 19.07.2017 but that claim was refused on the ground “......as the patient had history of internal derangement of knee which was already disclosed with pre-portability institution....”

Initially Manipal Cigma tried to push the renewed policy as a new role over one, so as to absolve themselves of all pre-existing diseases cover came to them on portability. On repeated persuasion of the Complainant they reluctantly incorporated the previous Insurance details and issued a fresh Policy instead, by an endorsement. The Complainant branded this attitude of the OP No. 1 as an ulterior motive.

The OP No. 1 while issued a new certificate noted the description of his sons pre-existing diseases in the new policy issued by them. But the subject matter of this Complaint is not denial of benefit of Insurance Policy for the son of the Complainant. It is of the Complainant’s claim for Insurance benefit.

In June, 2018 the Complainant felt breathing related problem and he had to be taken to C.K. Birla Hospital on 19.06.2018 and there he was diagnosed to have Atrial Septal defect (ASD). Later on, the Complainant th had to be hospitalised at NH Hospital, Bangalore on 12 July, 2018 for Cardiac Cauterization to locate the ASD and for ASD closure procedure thereafter. The OP No. 1 allegedly declined cashless facility to this Complainant with the note as per their available document the Complainant was suffering from ASD since 2016 that is since before commencement of the Policy and since pre-existing diseases are not covered under the Policy for 36 months as per Clause V.1 his claim was repudiated under Clause VIII.1.

In their repudiation letter the OP No. 1 stated the Complainant was covered since 22.03.2011. The grievance of the Complainant is since the OP No. 1 themselves admit 22.03.2011 to be the basis of the Policy he is otherwise entitled to have the Insurance benefit since 36 months is already over for which Clause No. VIII.1 and Clause No.V.1 are not applicable to him.

Perused the BNA submitted by the Complainant. It is seen in the BNA the Complainant has emphasised not only on the citation of th