The titled complainant has been the holder of the S.B. A/c # 01285011000518 with the OP2 Bank and who being Agent/Broker of the OP1 insurers/the OP3 TPA got him buy the Health Insurance: OBC Oriental Royal Med Policy # 233300/48/2013/3116 valid from 21.01.2013 up to 20.01.2014 for Sum Insured of Rs.3.0 Lac @ a premium of Rs.4,620/- and got it renewed as Policy # 233300/48/2014/4484 for another one year w.e.f. 21.01.2014 up to 20.01.2015. Again the policy was renewed as # 233300/48/2015/4527 w.e.f. 24.01.2015 up to 23.01.2016 @ premium of Rs.4,620/- paid through the OP2 Bank. Next, the OP2 Bank in order to get the policy renewed did draw the premium draft # 237497 for Rs.4709/- with covering letter dated 05.01.2016 but the policy was renewed w.e.f. 27.04.2016 with a clear gap of 3 months and 7 days as the draft was delayed/not dispatched in time on account of negligence on the part of OP2 Bank employee(s).
2. Thereafter, the related policy was being renewed every year w e from 27th April to 26th April of the next year with the gap (of 3months+7 days) continuing, as such; the last renewal being the policy # 233300/48/2019/297 valid w.e.f. 27.04.2018 to 26.04.2019. However, on 15.07.2018 (during continuation of the last renewed policy) the complainant had to be hospitalized at DMCH (Dayanand Medical College & Hospital), Ludhiana for the medical- treatment and upon getting discharged on 23.07.2018 he had to pay hospital bills of Rs.89,844.16 p from his own pocket as the OP1 insurers had refused cashless treatment to the Hospital although the OP3 TPA (Third Party Administrator) had first allowed request for cash-less treatment but had later withdrawn the same without assigning any reason.
3. Upon discharge from the Hospital, the complainant submitted/filed all the papers to the OP3 TPA for reimbursement etc of the insurance hospitalization-claim by the OP1 insurers but they had requisitioned for the continuation certificate of the related policy and the same was not issued in spite of his repeated requests to all the titled OP in spite of the Legal Notice dated 14.08.2018 thus prompted the present complaint seeking directives to the OP to pay her hospitalization-bills of Rs.89,844.16p in full, in terms of the related policy besides to pay her Rs.25,000/- as compensation and Rs.15,000/- as cost of litigation, in the interest of justice; along with any other relief as deemed fit to the commission.
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) Copies of Renewed Insurance Policies (Ex.C2 to Ex.C7); ii) Copy DMC Hospital Discharge Summary (Ex.C8); iii) Copy of the OP1 + the OP2 ID Cards (Ex.C9); iv) Copy DMC Hospital Bills Rs.89,844.16p (Ex.C10); v) Copy of OP3 Letter 18.07.2018 to OP1 seeking information (Ex.C11); vi) Copy of the OP3 Letter 19.07.2018 to OP1 seeking information (Ex.C12); vii) Copy of Legal Notice + Postal Receipt (Ex.13 & Ex.C14); viii) Copy of the OP3 TPA Letter 23.07.2018 seeking information from Treating Hospital (Ex.C15); ix) Copy - the OP2 Bank Mail 24.07.2108 to the OP1 advising of its draft 237497 Rs.4,709/- Covering letter 05.01.2016 (Ex.C16) and, x) Website Shot - the OP3 TPA Site Cashless Sanction Rs.27,000/-; (Ex.C17) + Rejoinder(s).
5. The titled opposite party No.1 insurers (the OP1 insurers), in response to the commission’s summons appeared through their counsel who filed the written reply stating therein preliminary as well as other (on merits) objections as:
6. That the OP1 insurers plead that the complainant has not filed any insurance-claim with them after getting discharged from the DMC Hospital whereas his hospital's request for the cashless treatment was rejected and the patent had paid the hospital's bills from his own sources. Further, the complaint is not maintainable as there's no deficiency in service on the OP1 Part and there's gap i.e., in the related policy breaking its continuation link and shall be treated in its 3rd year with only 2 (two) completed insurance years. On merits, the OP1 explains that the 3rd policy in-line had expired on 23.01.2016 whereas the next policy was renewed w e from 27.04.2016 resulting into a gap of more than 3 months thus breaking the policy's continuity. The OP1 has 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. The Reply is duly supported by self-attested Affidavit (Ex.OP1/1) of Sh.Daulat Ram Branch In-charge along with Written Arguments and other documents produced in evidence as: Ex.OP1/2 - Copy of the OP3 letter 23.07.2018 seeking advice from the OP1; Ex.OP1/3–Copy of the DMCH Bills Rs.89,844.16p; Ex.OP1/5 & Ex.OP6–Copies of the related Policy Schedules;
7. Similarly, the titled opposite party2 Bank (the OP2 bank), in response to the commission’s summons appeared through their counsel who filed the written reply stating therein preliminary as well as other (on merits) objections as: The present complaint is not maintainable in its present form as no cause of action did ever accrue in the complainant's favor and he has not come to the court with clean hands having concocted a false story to drag the OP2 Bank into false litigation. On merits, the OP2 Bank has stated having issued the policy-premium draft # 237497 for Rs.4,709/- along with the covering letter 05.01.2016 as such there's no negligence etc on their part so complaint be dismissed with costs.
8. The OP No.2 Bank, in support of its written reply, has filed the lone affidavit of its Chief Manager Sh.Ram Parkash Ex.OP-2/1 and has closed the evidence.
9. Similarly, the titled opposite party No.3 Third Party Administrator (the OP3 TPA), in response to the commission’s summons appeared through its General Manager Sh.Vinay Batra who filed the written reply along with his self-verified affidavit submitting therein as: The related policy was issued by the OP1 insurers and the OP3 TPA is obliged to process the claim in terms of the related policy. The complainant did not provide the requisitioned certificate of 'con-donation of break-in period' from the OP1 insurers with whom 'contract of insurance' and the statutory consumer relations exist/continue and relief, if any, can be provided by them, alone. Lastly, the OP3 TPA has sought deletion of its name from the array of respondents/opposite parties.
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 non-resolve/repudiation of the cashless request for hospitalization of the complainant by the OP3 TPA on behalf of the OP insurers who have alleged non-filing of the hospitalization-claim with them by the Complainant after discharge from the treating Hospital.
12. We have minutely examined all the documents produced in evidence by the complainant and also by the OP insurers as produced and as collected by them during the course of their investigations and find that the insured's health status as well as all DMCH medical-treatment Bills and Reports were in the notice, knowledge and possession of the OP1 insurers through the OP3 TPA but they never attempted an amicable resolve through issuance of the requisite 'condonation of break-in period' to the complainant.
13. 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 'repudiation' of the hospitalization-claim and 'issuance of condonation of break-in period' 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.
14. We find that the OP2 Bank has also failed to provide the date of the 'draft' and has been mentioning the date of the covering letter only with no cogent or other evidence of its timely dispatch to the OP1 insurers like dispatch register etc. Similarly, the OP1 insurers have not produced say its Mail Receipt Register to prove late receipt of the draft resulting into gap/break-up in the policy's continuation etc. Thus, we hold both the OP1 insurers and the OP2 Bank responsible for causing financial-loss cum harassment/mental agony to the ailing complainant and also hold them liable to suffer an adverse award under the provisions of the herein applicable statute.
15. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the 'negligent handling/dispatch of the premium-draft' by the OP2 Bank and the intentional 'non-issuance' of the policy 'continuation-certificate' sans gap through 'condonation of policy break-in period' by the OP1 insurers as ‘deficiency in service' and 'unfair-practices' at play and thus we partly allow this complaint and ORDER them both to pay the insurance hospitalization-claim of Rs.89,844.16p, in full, to the herein complainant, in terms of the related policy with interest @ 6% PA from the date of complaint till actually paid, in full, besides to pay him Rs.15,000/- 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.
16. 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.
17. 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)
OCT. 28, 2022. Member.
YP.
