The titled complainant Sh. Naresh Kr. Kohli, aggrieved at the repudiation of his hospitalization-claim for his medical treatment of Hernia-Repairs at the Max Health Care Hospital, N. Delhi; has filed the present complaint. The Complainant had held one Health Policy from M/s TATA AIG General Ins. Co. Ltd., since the year 2014-15 and afterwards had ported to the OP1 insurer M/s NIC Ltd., w e from 23.03.2018 to 23.03.2019 and further refreshed/renewed up to 22.03.2020 for an S.A. (Sum Assured) of Rs.5.0 Lac. The OP1 through its representatives had assured coverage to all medical-treatments but the policy's Terms and Conditions were never supplied to him. Somehow, in the month of April' 2019, the complainant had to stay hospitalized w e from 09.04.2019 to 12.04.2019 for his Hernia Repairs at the Max Hospital and paid Rs.212,697/- as treatment bills from his own sources. 

2.       Upon discharge from the Hospital, the complainant filed his hospitalization claim bill for Rs.212,697/- along with original Hospital Bills to the OP1 Insurer who in turn denied/repudiated the same under the policy's exclusion clause # 4.3 that bars Hernia Repairs for a period of two years from the date of inception of the related policy. The complainant did  repeatedly plead with the OP1 insurer that his policy had been continuing since the year 2014 and he had simply ported to NIC in the year 2018 and that shall not alter/ pre-pone the policy's date of inception but the OP1 refused to relent/ review its repudiation hence the present complaint seeking directives to the OP1 insurer to amicably settle his claim(s) for Rs.212,697/- along with interest @ 9% PA from the date of filing of complaint till paid and also to pay him an additional Rs.50,000/- as compensation for suffering harassment and mental agony besides Rs.20,000/- for deficiency in service and Rs.10,000/- as cost of present litigation etc., in the interest of justice. The complainant has placed forth the listed documents in support of success of his complaint. These are:

          i)       Ex.Cw1/A – Affidavit by complainant deposing the contents of his complaint and also the sanctity of his evidence/                            documents;

          ii)      Ex.C1 – Policy Schedule by TATA AIG exhibiting inception since 2014;

          iii)     Ex.C2 – Ported Policy with NIC Ltd.;

          iv)     Ex.C3 – Renewed Policy covering the period of hospitalization; 

3.       The titled opposite party1 (the OP1), in response to the commission’s summons/ notice did appear through its counsel whereas the OP2 TPA (Third Party Administrator) did prefer to stay absent and were ordered to suffer ex-parte proceedings on 12.02.2021. The OP1 filed its written reply stating therein preliminary as well as other objections (on merits) as: Firstly, the OP plead absence of cause of action and deficiency in service on its part as the Hernia Repairs Expenses are not admissible for first two years of the policy. The Claim was examined by the OP2 TPA and subsequently rejected and the same was duly advised to the complainant on 11.05.2019.

4.       The OP1 has further pleaded that in the eventuality of an adverse orders against them, the liability may kindly be fixed in terms of the policy, only. And, on merits, the OP1 pleads that it has no link with previous insurers TATA AIG Gen. Ins. Co. Ltd., and have further addressed the contents of the complaint as matter of records or as subject matters of denial. The complainant had never requisitioned the terms and conditions of the policy from the OP1 insurers and thus the hospitalization claim for Hernia Dressing was rightly denied in terms of the exclusion clause 4.3 of the policy and the present complaint being bereft of any merit deserves dismissal. Lastly, the OP1 insurers, endeavoring to get the complaint dismissed have put forth before us the herein listed documents:

          i)       Ex.OP1/1/A – Affidavit Dy. Manager Kewal Raj deposing contents of reply;

          ii)      Ex.OP1/1 – Proceedings before the Insurance Ombudsman;

          iii)     Ex.OP1/2 – Policy expiring on 22.03.2019;

          iv)     Ex.OP1/3 – Repudiation Confirmation dated 05.11.2019;

          v)      Ex.OP1/4 – The OP2 TPA's Denial (12.04.2019) of the Claim;

          vi)     Ex.OP1/5 – Previous Policy valid up to 22.03.2020                                                                                                                                                                                                                                                                                                                                               

          vii)    Ex.OP1/6 – National Medi-Claim Policy (Terms and Conditions);

          viii)   Ex.OP1/7 – Discharge Summary Max Health Care  Hospital;

          ix)     Ex.OP1/8 – Claim Form filed with the OP1 insurer.

5.       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 evidence/ 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, by the OP1 insurers.

6.       We understand that the present policy with the OP1 insurers had prompted through 'porting' of previous policy with the TATA AIG having its inception rooted in the year 2014 and it is an accepted proposition in insurance para-lance that date of inception does not alter through porting from one insurer to another one otherwise no insured, in one's rigth wisdom, would ever dare to port. We further observe that the OP1, in its reply, have pleaded that the complainant had never requisitioned the terms and conditions of the policy whereas it's always the duty of the insurer to provide the same (Ts & Cs of the policy) to the insured along with policy schedule. Here, the OP1 insurers have not even attempted to supply the Ts & Cs of the policy  and have issued one fresh policy in a most unfair manner and thus are liable to an adverse orders under the applicable statute. Thus, we shall disapprove here the applicability of clause 4.3 barring Hernia Dressing etc in the present situation when the policy has been issued by keeping the insured/ proposer in the dark

7.       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 partly allow the present complaint and ORDER the OP insurers to pay Rs.212,697/- as payment of the impugned ‘insurance claim(s)’ along with other accrued benefits, if any, pertaining to the related policy with interest @ 6% PA we from the date of filing of the claim besides Rs.10,000/- 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.

8.       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.

9.       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 08, 2022.                                           Member.

YP.