The titled complainant, aggrieved at the repudiation of his hospitalization-claim for his medical treatment of C.A.D. (Coronary Artery Disease) through Angioplasty/ Stunt Insertion etc at the Fortis, Amritsar; has filed the present complaint. The OP insurers had sold him a Healthcare Policy H0116353-I-0 covering all the diseases and medical-treatment expenses etc w e from 29.06.2019 to 28.06.2020. The complainant had suddenly fallen sick and taken to Fortis Hospital, Amritsar where he was diagnosed for CAD and stayed there hospitalized for treatment with effect from 23.10.2019 to 01.11.2019. The OP insurer were duly intimated but they issued Auth. Denial Letter to the Hospital on 23.10.2019 for cash less treatment citing First Year of Policy and Non-disclosure of pre-existing disease as its reason and thus the complainant had to himself foot the medical bills of Rs.215,250/-.
2.The complainant upon recovery and discharge from the hospital had been regularly following up the matter with the OP who continued procrastinating the same on one pretext or the other. The complainant got served legal notice upon the OP insurer on 10.08.2020 from his legal councilor for his claim-sanction but even that did not make the OP respond and thus prompted the present complaint praying for his claim payment of Rs.215,250/- with interest @ 24% from the due date till realization along with Rs.50,000/- as compensation. Lastly, the complainant addressing the impugned repudiation as arbitrary and unfair and to further support his allegations has filed herewith, the listed documents as:
i) Ex.Cw1/A – Affidavit by the complainant deposing the contents of his compliant and also the sanctity of his evidentiary documents;
ii) Ex.C1 – Copy of the Health Care Policy H0116353-1-0;
iii) Ex.C2 to Ex.C6 – Fortis Hospital Bills for Rs.215,250/-
iv) Ex.C7 – Repudiation Letter i.e., Auth. Denial Letter.
v) Ex.C8 & Ex.C9 – Copy of Legal Notice and its Postal Receipt.
vi) Rejoinder to the OP Reply filed on 07.04.2021.
- 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:
Firstly, the OP state to deny and dispute each and every allegation, averments and submissions made in the complaint except that are specifically admitted. Next, the complaint is not admissible and need be dismissed with costs. That the patient had concealed the material fact at the time of inception of the policy as he has been a known case Diabetes Mellitus and Hypertension (DM & HTN) and that was not disclosed in the proposal form and that being a breach of principal of utmost good faith makes the complaint liable to dismissal.
Again, on merits (para-wise reply), the OP states that the complainant had on 29.06.2019 filled in the proposal form for purchase of the Family Health Protector Policy H0116353 with an SI (Sum Assured) of Rs.2.50 Lac that covered him besides his wife and child and covering all the ailments but in terms of the said policy, only. Further, paragraphs 2 and 3 are denied. However, the Fortis's cashless request of 23.10.2019 was refused as the patient was a KNO (known case of) DM/HTN. These ailments were somehow not disclosed in the related proposal form. Further, the OP have also cited two senior court judgments to support their prosecution of defense. Lastly, denying all other allegations the OP insurers while addressing the present complaint as false, frivolous and vexatious have prayed for its dismissal but with exemplary costs. The OP have also produced the listed documents to strengthen its prosecution of defense.
i) Ex.OP1,2/1A – Affidavit of OP DGM Mridul Ranjan deposing contents of the reply;
ii) Ex.OP1,2/1 – Proposal Form dated 29.06.2019;
iii) Ex.OP1,2/2 – Policy Schedule with SI Rs.2.50 Lac and other details etc.;
iv) Ex.OP1,2/3 – Request by Fortis for Cash Free Treatment;
v) Ex.OP1,2/4 – Fortis Diagnosis dated 23.10.2019;
vi) Ex.OP1,2/5 – Auth Denial Letter dated 23.10.2019;
4. 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.
5. We understand that the present policy has been in force w e from 29.06.2019 for one year and having its date of inception also as: 29.06.2019. We observe (rather have determined) that there is only one basic points of contention/ disagreement between the insured and the insurer and thus resolving this shall autobiographically resolve the complaint.
Continuing Ailments: DM/ HTN & its Non-disclosure in the proposal Form (29.06.2019):
The complainant has repeatedly and firmly pleaded that his present ailment 'CAD' dates back to 23.10.2019 only when he suddenly fell sick and was admitted to the Fortis Hospital at Amritsar; And, prior to that he was not knowing of any of his aliments including the DM and HTN etc. On the other hand, the OP insurers allege rather assert that the complainant has been suffering from DM/HTN and also had CAD as continuing ailment with him. Thus, the ONP (onus of proof) had shifted upon the OP insurers since it's have been they who allege non-disclosure and pre-existing continuing ailments. However, the OP have failed to prove through some cogent independent evidence by way of records of past hospitalization or past diagnosis/ prescription/
treatment etc to prove presence of continuing ailment(s) and non-disclosure etc., otherwise the complainant's deposition will be legally acceptable and cannot be ignored. Moreover, it is quite natural, common and usual that persons suffering from one or more than one ailments will not know of these or will not be conscious of the same unless the ailments aggravate and the doctor diagnoses them. Also, the OP insurers' professional duty warranted of them to have get the proposer/insured medically examined to their full satisfaction prior to selling of the insurance product. Thus, we find and hold that the complainant was known to have contacted CAD after the mutually-admitted dated of inception of the policy I.e., 29.06.2019 and he was not aware of his having DM and HTN etc., prior to that date. Thus, the complainant was not known to be/aware of suffering/ from CAD or DM/HTN on the inception of the policy and claim cannot be rejected on account of pre-existing disease/non-disclosure etc.
6. We observe that the OP insurer's other trivial objections are ambiguous and no more that 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 the terms of the applicable policy but did not produce any evidence of communicating of the same to the complainant. We have observed many such petty anomalies mentioning of which shall not serve purpose at this stage. So we move ahead with furtherance.
7. 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.
8. In the light of the all above, we set aside the OP insurers' impugned repudiation of the complainants’ hospitalization-claim being unfair, 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 pay Rs.215,250/- as payment of the impugned ‘insurance claim’ 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 (till actually paid ) besides Rs.10,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the copy of these orders.
9. 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.
10. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
JUNE 01, 2022. Member.
YP.
