The titled complainant being aggrieved at the alleged arbitrary repudiation of his hospitalization-claim pertaining to his angioplasty cum medical-treatment for the medical emergency (PTCA Stent-LIMA-LAD) at Fortis Escort Hospital, Amritsar, has filed the present complaint against the titled OP insurers. The complainant had, on 18.07.2018 purchased the CARE Comprehensive Health Insurance Policy # 12714311 (Ex.C1) with Rs.5.0 Lac as Sum Assured valid up to 17.07.2019 covering the comprehensive medical treatment of the complainant, his wife Rajani Bala and their daughter Ananya Sharma. The policy premium @ Rs.10,003/- was paid through SBI (ATM Debit-Card) as debited (Ex.C2) to his bank A/c.

2.       The complainant suffered chest-pain on 23.08.2018; was first examined at the Noor Hospital, Qadian; but was finally hospitalized at Fortis Hospital, Amritsar from 28.08.2018 to 30.08.2018 to undergo PTCA (Stent-LIMA-LAD) Procedure costing him Rs.1,78,467/-.

3.       As the OP insurers had on 28.08.2018 refused the Fortis Hospital's pre-authorization (Ex.C3) request for cashless treatment etc., the complainant had filed hospitalization-claim # 80200122 as he himself had paid all the Hospital Bills @ Rs.1,78,467/- (Ex.C4 to Ex.C13) that however was rejected by the OP insurers through their pre-intimation canceling the related policy vide (Ex.C14) Pre-Notice of 19.11.2018 that was duly replied (Ex.C15) on 28.11.2018. But, the OP insurers instead of considering the contents of the reply (Ex.C15) dispatched the Cancellation (Ex.C16) dated 01.01.2019, of the related policy and thus prompted the present complaint as duly supported by the complainant's affidavit along with the above exhibits (Ex.C1 to Ex.C16) and further strengthened by his rejoinder. Lastly, the complainant has prayed for directives to the OP insurers to pay the hospitalization impugned claim Rs.1,78,467/-, in full, with interest @ 18% pa from the date of admission till realization, in full, besides Rs.1,00,000/- as compensation and Rs.20,000/- as cost of the present litigation, all in the interest of justice.   

4.       The titled opposite parties insurers (the OP1 and the OP2), in response to the commission’s summons/notice appeared through their common counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as:

5.       That the complainant has no cause of action and no locus-standee to file the present complaint as he has concealed the material facts whereas an 'insurance' being a contract of good faith it becomes the insured's duty to disclose the relevant facts. Further, the OP admit issuance of the policy (Ex.OP1,2/1) and also the 3 lives covered vide the same; And, their Co.'s name presently stands changed with the Registrar of Companies (ROC), New Delhi to 'Care Health Insurance Ltd.' and there has been no deficiency in service on their part. On 25.08.2018, request for cashless treatment (Ex.OP1,2/3) at Fortis, ASR for Rs.13,900/- was received and in response the requisite deficiency letter (Ex.OP1,2/4) seeking duration and past history of the present ailment was requisitioned along with conduct of an investigation; and upon receipt of these results the denial-letter (Ex.OP1,2/5) was issued for of non-disclosure of pre-existing ailments in the proposal (Ex.OP1,2/2).         

6.       The OP insurers have further said that the complainant as per the OPD prescription dated 02.01.2018 (Ex.OP1,2/6) of the Noor Hospital had been a case of Dyslipidemia and symptomatic towards CAD prior to the policy-inception and he was prescribed Rosuvastatin tablets used for the prevention of the above ailments. As the complainant did not intentionally declare the above in the related proposal that amounted to non-disclosure under the clause 7.1 (Ex.OP1,2/7) warranting rejection of all benefits under the policy and forfeiture of premium, ab-initio. Also, clause 19(4) of the IRDAI Regulations' 2017 (Ex.OP1,2/8) cast an absolutely duty to disclose all the material facts to the insurer in order to assess the risk as its capacity. Thus, the related policy was rightly canceled (Ex.OP1,2/10) as duly advised to the complainant on 01.01.2019 by issuing pre-notice (Ex.OP1,2/9). Lastly, the OP insurers have also produced treatment records (Ex.OP1,2/11) at Fortis, ASR and have also cited five nos of senior court judgments exhibited here as Ex.OP12 to Ex.OP17.          

7.       On merits, the OP insurers have denied almost all the contents and allegations as made out in the complaint and have focused their reply on the sole issue of non-disclosure of preexisting ailments in the proposal form. Lastly, the OP insurers have filed the affidavit Ex.1,2/1/A along with the above exhibits and have sought/ prayed dismissal of the present complaint being meritless.

8.       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/not produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants.

9.       We find that the present dispute has arisen on account of the impugned 'cancellation' of the related policy resulting into the subsequent ‘repudiation’ of 'insurance -claim' of the complainant's hospitalization on account of the sole reason of the alleged 'non-disclosure' of pre-existing ailments/material information relating to the period prior to inception of the related policy, by the complainant.

10.     We observe that the OP insurers have alleged that the complainant had been under the treatment for the these ailments at the Out-patient Department of Noor Hospital w.e.f. 02.01.2018 as diagnosed for CAD etc., vide the OPD record (Ex.OP2) as produced in evidence which is rubber stamped with three nos. of dates and no name on its page '2' and with no signatures of an attending physician. The genuineness cum authenticity of this document cannot be determined in the absence of an affidavit of the investigator or any of the hospital authority etc. Further, Ex.OP11 (In Patient History & Physical Record) of the patient reveals history of chest pain 3-4 days old with no history of other ailments/surgery.              

11.     Thus, we find that the OP insurers have failed to produce any cogent evidence of its alleged main objections of 'non-disclosure' and in its absence these are no more than mere bald statements with no legal values, in evidence. We further observe that the OP insurer's other trivial objections are ambiguous, in nature, and no more that petty queries in non-fidelity/ignorance and have been well responded by the complainant in his rejoinder arguments/pleadings. The OP insurers must realize that their resolves to the claims are open to judicial review and need be determined with application of mind not in an arbitrary manner but need to explain the logic as to how the same has been reached.

12.     Lastly, we confirm having respectfully read/studied the OP produced senior court judgments but observe that these do resolve but different legal-propositions and shall be of no assistance to the OP insurers during the present proceedings. 

13.     In the light of the all above, we set aside the OP insurers' impugned cancellation of the policy, in question, and also the repudiation of the complainants’ hospitalization-claim being arbitrary (and in contravention to laws of natural justice) and amounting to ‘unfair trade practice/deficiency in service’. Thus, we partly allow this complaint and ORDER the OP insurers to pay the impugned ‘hospitalization-claim’, in full, to the tune and order of all the Bills drawn for medical attendance/expenses @ Rs.1,78,467/- (collectible from the records of the present proceedings, if need be) in terms of the related policy with interest @ 6% PA w e from the date of filing of the claim besides Rs.15,000/- 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.                                                                 

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:                                (B.S.Matharu)

SEP. 21, 2022.                                            Member.

YP.