The titled complainant, aggrieved at the repudiation of his hospitalization-claim for his medical treatment of DM & CKD (Diabetes Mellitus & Chronic Kidney Disease) including dialysis at Shrimann Super Specialist Hospital at Jalandhar has filed the present complaint. The OP insurers had sold him a Health Policy 2825-2018-1450-3404-000 medical-treatment (Proposer HSN Code 997133) having commenced from 19.05.2017. The complainant had fallen sick to CKD in March' 2018 requiring 'Peritoneal Dialysis' as was covered under the said policy as duly confirmed by the OP on mail. The complainant got himself admitted in the Hospital on 19.06.2021 and the related Reimbursement Claim for Rs.64,901/- was filed on 10.07.2021 that was repudiated by the OP on 09.10.2021 citing it as preexisting disease not disclosed at the time of purchase of the policy in the related proposal.

2.         The complainant has further stated that at the time of purchase of the said policy in the year 2017 he had disclosed all these diseases in the proposal form (submitted with the OP at that point of time) and nothing of whatsoever was ever suppressed. Moreover, he had known of the present ailment requisitioning treatment, first time in March' 2018, only; and he has been regularly paying the premiums since May' 2017. The OP insurers were duly approached by the complainant and apprised of all the facts favoring an amicable settlement of his claim but the OP did not relent and thus prompted the present complaint. The complainant addressing the impugned repudiation as arbitrary and unfair and further in support of his allegations has filed herewith, the listed documents as:

          i)       Ex.C1 to Ex.15 - Hospital Treatment Prescriptions; w e from 16.03.2018;

          ii)      Ex.C16 - Hospital Admission on 19.06.2021 and Claimed Amount Bill Rs.64,109/-

          iii)     Ex.C17 & C18 – Dispatch Receipt + Canceled Check;

          iv)     Ex.C19 + C20 to C26 – Legal Notice + Postal Receipts;

          v)      Ex.C27 – Repudiation dated 09.10.2021;

          vi)     Ex.C28 – Reply (11.10.2021) to Legal Notice;

          vii)    Ex.C29 to Ex.C31 – Bills being part of the Med-claim. 

          Viii)   Rejoinder to the OP Reply filed on 31.03.2022.

3.       The titled opposite parties, in response to the commission’s summons appeared through their common counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as:

By the OP1 & OP2 the Insurers:

4.       The 2019' C P Act has no provision U/s 12 to file consumer complaint and so the present complaint is wrongly filed needs be dismissed. No cause of action arises as the filed documents are not proved and the charge has been that of 'cheating' that does not fall under the commission's jurisdiction.

5.       The OP insurers have admitted repudiation of claim vide letter 24.09.2021, but on the valid grounds of non-disclosure of existing diseases of Diabetes, Diabetic Nephropathy and Chronic Kidney Disease since the year 2015 i.e., before policy inception date. Further, the terms of presently applicable policy have since changed from the one purchased initially in the year 2017 and the same still stand unchallenged/ undisputed. The complainant was hospitalized on 19.06.2021 but has been shown receiving treatment there on 16.03.2018, 03.05.2018 and 31.07.2018. The Treating Hospital Doctor vide his certificate of 08.07.2021 has confirmed that patient had visited him first on 16.03.2015. Lastly, the insured had not disclosed in the related proposal at the time of purchase of the policy in the year 2017 regarding his continuing aliments since the year 2015 and thus the claim has been rightly repudiated and similarly the present complaint be also dismissed. The OP insurers have also quoted/ cited five nos. of senior court judgments on the subject in issue before closing in its preliminary objections.

6.       On merits, the OP has first addressed the policy as a matter of record and that too subject to its terms and conditions that have not been in dispute. The contents of paragraphs 2, 3, 5 and 9 to 12 have been denied and further non-disclosure and non-submission (paragraph 6 & 7) of the requisitioned papers on the part of the complainant has been alleged. In reply to paragraph '8' the OP have again alleged misrepresentation and also affirmed having canceled the policy, itself, in terms of the declaration given by the complainant at the time of purchase of the same. Lastly, the complaint has been prayed to be dismissed in the interest of justice, equity and fair play.

7.         The OP insurers have put forth its evidence in defense through the hereunder listed documents:

          i)       Ex.OP1,2/1 – Affidavit of Ms Shaweta Pokhriyal Manger Legal with OP1&2;

          ii)      Ex.OP1,2/2 – Authority Letter/ POA by the OP insurers to Manager Legal;

          iii)     Ex.OP1,2/3 – Copy of the applicable Policy;

          iv)     Ex.OP1,2/4 – Copy of Terms and Conditions of the applicable policy;

          v)      Ex.OP1,2/5 – Copy of the Claim, in dispute/ question;

          vi)     Ex.OP1,2/6 – Copy of Medical Record;

          vii)    Ex.OP1,2/7 – Copy of Repudiation Letter 24.09.2021; 

          viii)   Ex.OP1,2/8 – Copy of Intimation of Cancellation of the Policy;

          ix)     Ex.OP1,2/9 - Copy of Proposal Form;

          x)      Ex.OP1,2/10 to 13 – Copies of Deficiency Letters; 

We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ of the hospitalization-claim pertaining to the Policy in question, and its subsequent cancellation by the OP insurers.

8.       We understand that the present policy has been in force w e from 13.06.2021 for one year but has been in continuation of the First Policy having its date of inception as: 19.05.2017. We observe (rather have determined) that there are two basic points of contention/ disagreement between the insured and the insurer and thus resolving these shall autobiographically resolve the complaint.

9.       I)   Pre-existing Ailments: DM & CKD:

          The complainant has repeatedly and firmly pleaded that his present ailments 'DM & CKD (5)–On dialysis' date back to March' 2018 only and were first known on 16.03.2018 when he visited/consulted Doctor Vijay Marwaha at Shrimann Super Specialty Hospital at Jalandhar.

          On the other hand, the OP insurers insist that the complainant's ailments have been continuing since March' 2015 i.e., 16.03.2015 to be exact and that is much earlier to the date of inception 19.05.2017, of the policy.

          We further observe that there's a complete harmony as to the date of inception of the policy between the two sides. Interestingly, both the sides have produced the same document Ex.C1 and Ex.OP1,2/6 in evidence i.e., the treating Doctor's Certificate dated 08.07.2021 (in running hand) confirming that the complainant had first consulted him in OPD on 16.03.2018 when he diagnosed him as suffering from DM & CKD. The OP have inadvertently misread 16.03.2018 as 16.03.2015 in their hurry for a favorable support. We overrule/direct that it is written as 16.03.2018; shall be read as 16.03.2018. Thus, the complainant was known to have contacted DM & CKD after the mutually-admitted dated of inception of the policy I.e., 19.05.2017. Thus, the complainant was not known to be suffering from DM & CKD on the inception of the policy and claim cannot be rejected on account of pre-existing disease.

          II.      Non-disclosure of Ailments in the Proposal Form:

          We find that the OP insurers have not produced any other document except Ex.OP1,2/6 to prove preexisting disease and nondisclosure of material information material to disclose. However, we find that the complainant has duly disclosed Diabetes, Thyroid (disorder) etc., in Proposal Form Ex.OP1,2/9 as produced by the OP and that absolves him of both the allegations.

10.     We observe that the OP insurer's other trivial objections are ambiguous and no more than petty queries in non-fidelity/ignorance and have been well responded by the complainant in his rejoinder to their written reply. The OP have also omitted/ ignored to produce some cogent evidence in support of their allegations that otherwise are no more than bald statements. The OP did mention of altered terms with every renewal of the continuing policy but did not produce any evidence of communicating of the same to complainant. We have observed many such petty anomalies mentioning of which shall not be serving any purpose at this stage. So we move ahead towards furtherance.

11.     Thus, the OP insurers have failed to produce on record some cogent evidence, to its prime assertions of pre-existing ailments and non-disclosure etc. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be determined with due application of mind and not in an arbitrary manner and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law.

12.     In the light of the all above, we set aside the OP insurers' impugned repudiation of the complainants’ hospitalization-claim as well as cancellation of the applicable policy both being arbitrary (and in contravention to laws of natural justice) and amounting to ‘unfair trade practice cum deficiency in service’. Thus, we ORDER the OP insurers to continue pay the impugned ‘insurance claim’ to the tune of full sum assured of Rs.5.0 Lac along with other accrued benefits, if any, pertaining to the related policy with interest @ 6% PA w e from the date of filing of the claim besides Rs.20,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the copy of these orders, otherwise the entire awarded amount shall attract additional interest @ 3 % PA form the date of the orders till actually paid.  

13.     The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

14.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

   (Naveen Puri)

                                                                   President.   

ANNOUNCED:                                   (B.S.Matharu)

JUNE 02, 2022.                                           Member.

YP.