The titled complainant has availed of the credit facility of Rs.2.0 Lac in April' 2019 from the OP2 Financier who had him have the one Cashless Group Insurance Policy # 0025 8800201800 for an S.I. (Sum Insured) of Rs.5.0 Lac valid w.e.f. 30.04.2019 to 29.04.2020 from the OP1 insurers who issued him the insurance certificate # 7214821 on 18.07.2019.
2. However, on 16.08.2019 (during continuation of the Group Policy) the complainant had to be hospitalized at the OP3 Hospital (Jalandhar) for his medical-treatment but there the OP1 insurers refused the related pre-authorisation request for cashless hospitalization on the pretext of non-establishment of the liability. Somehow, the complainant managed to continue his treatment at the OP3 Hospital and also paid Rs.99,000/- upon discharge on 19.08.2019 and also filed the related insurance-claim # 463384 with the OP1 insurers on 01.10.2019 along with all the requisite documents/ papers etc.
3. The complainant has further pleaded having been in contact with the OP1 insurers regularly for more than a year for settlement of his hospitalization-claim and finally having fed up with the OP1 's unending procrastination he has filed the present complaint seeking directives to the OP1 insurers to settle the impugned claim, in full, as per the terms of the herein applicable group-policy besides Rs.30,000/- as compensation and Rs.10,000/- as the cost of litigation, in the interest of justice.
4. The complainant in order to accomplish the successful prosecution of his complaint has also filed her duly Sworn-in Affidavit (Ex.C1) along with i) Copy of Insurance Certificate (Ex.C2); ii) Copy of pre-authorization denial (Ex.C3); iii) Copy of the Consent Letter (Ex.C4); iv) Copy Proposal Form (Ex.C5); v) Copies of Medical Bills (Ex.C6 to Ex.25); vi) Copy of the Courier Receipt (Ex.C26); and, vii) Rejoinder(s).
5. The titled opposite party No.1 insurers (the OP1 insurers), in response to the commission’s summons appeared through their counsel and filed the written reply introducing therein themselves as duly incorporated NOIDA Based company under the Company's Act, 1956 and engaged in health-insurance business further denying in ex-tensor n extremity the present complaint addressing it as false, baseless and misconceived and pleading therein the preliminary as well as other (on merits) objections as:
6. That the OP1 insurers plead that the complainant has not filed the requisitioned information/documents/hospital-discharge necessary to settle the insurance-claim with them upon discharge from Hospital whose request for cashless treatment stood rejected and the patient had paid the hospital's bills from his own sources. The OP1 insurers, upon scrutiny of the claim papers (as filed by the complainant), had requisitioned some other additional information necessary to resolve the claim but those papers/information were not provided to them and thus the claim was rejected. Further, the complaint is not maintainable as there's no deficiency in service on the OP1 Part and the compliant needs be dismissed with heavy costs, in the interest of justice.
7. On merits, the OP1 insurers have denied all other contents/allegations as put forth in the complaint addressing these as incorrect/matters of records etc and has finally prayed for dismissal of the present complaint with costs in the interest of justice. However, the OP1 insurers have neither filed its mandatory affidavit nor any documentary evidence to support the contents of its reply and/or pleadings/allegations etc.
8. Similarly, the titled opposite party No.2 financiers (the OP2 financier), appeared in response to the commission’s summons through their counsel who filed the written reply stating therein preliminary as well as other (on merits) objections as: The present complaint has been wrongly addressed to them and such is not maintainable in its present form as no cause of action did ever accrue in the complainant's favor against the financiers and even no relief stood claimed against them. The complainant has sought amendment to the head-note of his complaint which was allowed and he has subsequently amended the head-note of his complaint. Somehow, the OP2 financiers have denied all the contents of the complaint and have vehemently contested the complaint even on behalf of the OP1 insurers who have participated in the proceedings, as well. The mandatory affidavit Ex.OP2/A along with the other documentary evidence (Ex.OP2/1 to Ex.OP2/7) have also been filed by the OP2 financiers that are of no significance assistance to the present resolve.
9. Somehow, the titled opposite party No.3 Hospital preferred to stay absent and thus they were ordered on 29.01.2021 to be proceeded against ex-parte.
10. 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 of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments/oral as well as written, as put forth by the learned counsels for their respective litigants.
11. We find that the present dispute has arisen on account of the impugned repudiation of the cashless request for hospitalization-treatment of the complainant by the OP1 insurers and further non-resolve/non-settlement of his hospitalization-claim since its filing. We have minutely examined all the documents produced in evidence by the complainant and find that he has responded/replied and supplied the requisitioned papers through courier and all other information to the OP1 insurers who have not even filed the mandatory affidavit (and other documents in evidence) in support of its written-reply and other pleadings/allegations which in absence of the same are mere bald statements, only.
12. We observe the OP1 insurers' present role fully marred by an employ of unfair-practices and unscrupulous exploitation of the innocent consumer and that amounts to an open play of deficiency in service at its full volume. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality. And, of course we do not concur with the logic of the herein impugned 'non-resolve' of the hospitalization-claim and also of the 'repudiation' of the cashless hospitalization request and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned non-resolve of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same so as to cause an unjust loss to the complainant.
13. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the impugned 'repudiation' and 'non resolve' of the request for cashless hospitalization and hospitalization-claim by the OP1 insurers as a sure ‘deficiency in service' cum 'unfair-practices' at full display and thus ORDER them to pay the impugned hospitalization-claim of Rs.99,000/-, in full, to the herein complainant, in terms of the related policy with interest @ 6% PA from the date of hospitalization till actually paid, in full, besides to pay him Rs.10,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid.
14. 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.
15. 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)
NOV. 9, 2022. Member.
YP.
