The titled complainant, aggrieved at the alleged arbitrary repudiation by the titled OP insurers of his Son's (Master Harsimran Singh – 3 years) hospitalization-claim pertaining to his medical-treatment cum surgeries for medical emergency (Reconstructive Surgery - Para-Ureter Diverticulitis) first at Kidney Hospital & Stone Clinic, Pathankot and finally at Miglani Hospital, Amritsar, has filed the present complaint. The OP insurers had sold him the Medi Claim Policy # 13351332 (Ex.C2) Sum Assured of Rs.5 Lac on 27.11.2018 (through their local agent) @ a premium of Rs.11,768/- that he got renewed (Ex.C3) on 27.11.2019 @ a repetitive premium of Rs.11,768/- valid up to 26.11.2020 covering comprehensive medical treatment to the complainant, his wife Rimpika and their 2017 born minor son Harsimran under the policy. Somehow, Harsimran got sick and was hospitalized (Ex.C4) w.e.f. 06.12,2019 to 09.12.2019 at Pathankot; but he had to be shifted to Miglani Hospital at Amritsar where he underwent surgery and stayed hospitalized up to 18.12.2019 (Ex.C5).

2. By the time, the complainant had spent Rs.1,78,172/- towards medical-attendance of his son and so he filed an interim claim with the OP insurers who vide the deficiency letters dated 01.02.2020 & 14.02.2020 had sought certain documents that were duly provided to them. In the meantime, the complainant on 07.02.2020 got his son Harsimran admitted to the Amritsar Hospital for removal of the DJ Stunt on 08.02.2020 and paid the Hospital Bill for Rs.43,660/- (Ex.C6) that he could not claim from the OP insurers. Thus he had paid an aggregate hospital-stay bills amount to Rs.2,21,832/- that he has been legally entitled to claim from the OP insurers, in terms of the related insurance policy.

3. However, the OP insurers vide their letter dated 01.03.2020 repudiated the claim on the alleged pretext of exclusion clause barring reimbursement cover for the Genito Urinary Surgery during the waiting period of two years unless necessitated by malignancy (cancer). The complainant affirms having not known/apprised of these exclusion clauses and even the policy document was delivered to him after one month of the policyinception. Lastly, the OP insurers were contacted and apprised of all the above facts with request to review their unfair repudiation resolved in haste that however could not move them to reconsider their arbitrary resolve to the impugned claim and thus prompted the present complaint as duly supported by the complainant's affidavit (Ex.C1) along with the preceding exhibits (Ex.C2 to Ex.C7) and further strengthened by his rejoinder and written arguments.

4. The titled opposite parties insurers (the OP1, the OP2 and the OP3), 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. The OP insurers admit the issuance of the policy, in question, and also the three lives covered vide the same; And, their Co.'s name presently stands duly changed (Annexure 'A') Certificate by the Registrar of Companies (ROC), New Delhi to 'Care Health Insurance Ltd.'. Further, the complainant has no cause of action as well as locus-standee to file the present complaint. Moreover, he has concealed the material facts whereas an 'insurance' being a contract of good faith it has been the insured's duty to have disclosed the relevant facts.

6. The complainant has himself failed to provide all the requisitioned documents and as such there has been no deficiency in service on the OP part. The OP upon receipt of the claim had conducted an inquiry/investigation and upon scrutiny of the same rejected the same in terms of the policy on account of: First, the prescribed Two years waiting period for Genito Urinary Surgeries and, Second, the absence of malignancy (cancer) for which the insurance cover has been available/provided in the policy hence the claim was rightly rejected/repudiated. Lastly, the complaint has been prayed to be dismissed being meritless, in the interest of justice, equity and fair play.

7. The OP insurers have put forth in evidence in prosecution of their defense through the hereunder listed documents:

i) Ex.OP1,2/1/A–Affidavit of Tejinder Singh Authorized Signatory with the OP insurers;

ii) Ex.OP1,2,3/1–Welcome Letter cum Certificate of Insurance etc. (dated 26.11.2018);

iii) Ex.OP1,2,3/2–Policy Renewal Letter dated 23.11.2019;

iv) Ex.OP1,2,3/3 – Copy of Terms and Conditions of the applicable policy;

v) Ex.OP1,2,3/4–Copies of the impugned Claim by the complainant;

vi) Ex.OP1,2,3/5 & Ex.OP1,2,3/6 – Copies of Deficiency Letters 01.02.2020 & 11.02.2020;

vii) Ex.OP1,2,3/7 – Copy of Non-Registration of the Claim 01.03.2020;

viii) Ex.OP1,2,3/8 – Copy of the Hospital Discharge cum Follow-up Card;

ix) Ex.OP1,2,3/9 - Copy of the Histopathology Reports;

x) Copy of the NCDRC Orders in RP No.1009 of 2015 against the orders of the Punjab State Commission in First Appeal No.1626/2012 & an apex court orders alongwith rejoinder.

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 ‘repudiation’ of the hospitalization-claim pertaining to the Policy in question, for of the sole reason of the ailments and its medical-attendance having fallen under the 'exclusion-clause' of the prescribed terms and conditions of the related insurance policy. We observe that the OP insurers have neither contested the onemonth late-delivery of policy letter/document nor the nondelivery/non-apprising of the policy terms & conditions as claimed by the complainant. No doubt, the OP insurers have produced (Ex.OP3) on records of the present proceedings the unacknowledged though enumerated terms and conditions of the policy but they have failed to produce any cogent evidence of its delivery or even dispatch to the complainant who had purchased and even got the related policy renewed sans any notice and knowledge of its exclusion clauses. We further find that the OP insurers have not placed forth any cogent or otherwise an evidence of delivery/dispatch of these terms to the complainant side at the time of renewal of the insurance policy. We also observe that the OP insurers have not put forth any document in evidence and/or in support of the policy's terms and conditions having undergone the legal scrutiny of some statutory body say IRDA (Insurance Regulatory & Development Authority) or others alike especially of the exclusion term disallowing insurance cover upon Genito Urinary Surgeries sans malignancy (cancer) whether it is common as an accepted general-rule by all the insurers. Of-late, vide the accepted provision in law by virtue of the apex court verdict an ambiguously included term shall not be applied to the detriment of the consumer.

10. We further observe that the OP insurer's other trivial objections are ambiguous and no more that petty queries in nonfidelity/ignorance and have been well responded by the complainant in his rejoinder arguments/pleadings. The OP insurers have also omitted/ ignored to produce some cogent evidence in support of their allegations that otherwise are no more than bald statements. 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.

11. In the light of the all above, we set aside the OP insurers' impugned repudiation/rejection 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 @ Rs.2,21,832/- (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.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.

12. 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.

13. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                                    ANNOUNCED:                                                                          (Naveen Puri) President.

                                  SEP. 23,2022.                                                                                 (B.S.Matharu)  Member.

                                     YP