The titled complainant, aggrieved at non-reply/non-payment/non-consideration of his hospitalization-claim pertaining to his treatment at DMC (Dayanand Medical College) Hospital, Ludhiana; has filed the present complaint against the OP insurers who had sold him Parivar Mediclaim Policy # 401500/48/17/8500000121 (Ex.C1) w e from 22.09.2017 to 21.09.2018. Somehow, the complainant got indisposed on 24.09.2017; & was admitted to DMC Hospital. He got discharged on 03.10.2017 (Ex.C2) having paid the Bill @ Rs.2,46,310/- towards medical-attendance and medicines-consumed during his 10 day hospital-stay.
2. The requisite Reimbursement Claim along with all the related papers were duly filed with the OP2 insurer who however preferred to stay silent/keep sleeping over the matter and did neither acknowledge/sanction nor reject/repudiate etc. The OP insurers were also served upon with Legal Notice (Ex.C3, C4 & C5) that however could not get any fruitful results and thus prompted the present Complaint + Affidavit (Ex.Cw1/A) duly filed seeking reimbursement of Hospital Bill @ Rs.246,310/- along with interest @ 18% PA besides compensation @ Rs.50,000/- and Rs.20,000/- as litigation-cost all in the interest of justice.
3. The titled opposite parties insurers (the OP1 & the OP2) appeared in compliance to the commission’s summons/notice through their common counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as:
By the OP1 & the OP2 the Insurers:
The complainant has no cause of action/ locus-standee to file the present complaint and the insurance is a contract between the two parties and both are bound by its terms. That the complainant is bad for non-joinder of the necessary parties. The policy clearly shows that policy is Parivar Medi Claim Policy and its TPA (Third Party Administrator) has been M/s Park Mediclaim TPA Pvt. Ltd., so the claim was to be filed before the TPA to get its authorization. The complaint cannot be decided in the absence of the TPA and as such the present complaint be dismissed on this very count. Further, there has been no deficiency in service on their part. The DMC Hospital upon admitting the complainant for medical-attendance on 25.09.2017 has requisitioned pre-authorization from the TPA who raised certain queries to which the Hospital never replied. The OP insurers further alleged a pre-planned fraud and wastage of the forum's time. The complaint was alleged to be premature as no claim was raised before the TPA after getting discharged from Hospital. If all the papers are supplied to the insurers even then liability remains limited by the terms of the related policy. Further, it exhibits a pre-existing ailment as the policy was purchased on 22.09.2017 and the hospital-stay started w e from 25.09.2017 and policy was purchased through concealment of facts. Lastly, the legal notice was duly replied to and the complainant has not come to the court with clean hands thus the complaint has been liable to dismissal. On merits, the OP Insurers have simply re-pleaded their objections as raised preliminarily i.e., concealment of true facts; non-filing of the claim to the TPA; no papers submitted to the TPA; non joining of the TPA as party to the complaint; legal-notice suitably replied to by the OP insurers; And, all other contents of the complaint have been straightaway denied by the OP insurers and lastly its dismissal with costs has been prayed along with filing of the Affidavit/deposition and the supporting papers Ex.OP1 to Ex.OP6.
4. The OP insurers have put forth in evidence in prosecution of their defense through the hereunder listed documents:
i) Ex.OPw1 – Affidavit of Sh. Kulbhushan the Branch Manager at the OP2 insurers;
ii) Ex.OP1 – TPA Query to the Hospital;
iii) Ex.OP2 – TPA to the OP insurers;
iv) Ex.OP3 – Reply of Legal Notice by the OP to the complainant;
v) Ex.OP4 – Policy Schedule with agent Name as Ramesh Kumar;
vi) Ex.OP5 – Proposal Form;
vii) Ex.OP6 – DMC Hospital Papers pertaining to diagnosis & treatment.
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 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 ‘non-reply’ of the insurance hospitalization-claim pertaining to the Policy in question, by the opposite party insurers, as filed by the present complainant.
6. We observe that the OP insurers' prime ground for 'non-reply' (amounting to rejection) of complainant's hospitalization-claim has been the alleged non-disclosure of the pre-existing/continuing heart-ailment otherwise their filing of the Ex.OP6 i.e., hospital papers prove the receipt of claim by them and they could have very well passed on the same to the TPA qua their internal arrangement. Further, the complainant's hospitalization just after two days of purchase of the policy supports/ strengthens their presumption of non-disclosure etc. However, the proposal-form and the policy schedule (Ex.C4 & Ex.C5) reveals that the continuing ailment, if any, had been in the active notice and knowledge of the OP insurer's representatives/agents and the one Ramesh Kumar, the agent as mentioned herein, by name.
7. Here, we are inclined to refer to section 45(3) of the Insurance Act, 1938 (as amended up to date) that bars repudiation of Policy on account of any of all such mis-statement(s) and/or suppression of fact(s) that are within the knowledge of the insurers or its representatives.
8. In the light of the above, the OP2 insurers are stopped from rejecting of the claim arising out of policy sold out knowingly in non-conformity to its cardinal-terms just to earn revenue by way of premium. It certainly amounts to an employ of unfair trade practices amounting to deficiency in service at their end.
9. Somehow, we do not concur with the logic of the implied/attempted repudiation and are inclined to examine the validity & legality of the impugned repudiation (of the related insurance-claim) in the back-drop of the preceding and also the succeeding acts & events in the light of the facts on records and current law on insurance vis-à-vis consumer proposition’s subject matter, in issue. We observe that such like health med-claim policies are issued on the strength of the insured undergoing an exhaustive medical examination at the hands of medical staff of the OP nomination and thus his health status (including pre-existing diseases, if any) gets fully known to the OP and its agents/ representatives and presently the OP are stopped from repudiating the insurance-claim on the strength of flimsy aspersions based on the randomly procured documents from the treating Hospitals. And, to top it up all the OP have ignored to get the claim resolved/investigated upon receipt of the same. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be taken with due application of mind and not arbitrarily 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.
10. Finally, in the matter pertaining to the present complaint and in the light of the all above, we partly allow the same and thus ORDER the OP Insurers to settle and pay the impugned claim, within 45 days of receipt of the copy of these orders, besides this OP shall also pay Rs.5000/-to the complainant as compensation and litigation charges.
11. 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.
12. 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)
JULY 06, 2022. Member.
YP.
