The titled complainant Sh. Maan Singh, being aggrieved at the arbitrary rejection of the enhanced payment to the concerned hospital for his wife's full/complete medical-treatment after having paid the first-installment of Rs.30,000/- through pre-authorization sanction on 30.07.2019 for cashless treatment of his insured wife Smt. Neelam at the Nav Chetan Multispeciality Hospital, Pathankot; has filed the present complaint against the titled opposite parties (hereinafter for short, be called the opposite parties insurers) seeking refund of Rs.63,349/- plus Rs.12,154/- (being cost of medicines) as duly paid by him as the balance hospital-payment with interest besides cost and compensation etc.

2.       The Complainant had held an insurance (Family Health Optima Insurance Plan) policy (Ex.C2) with the titled opposite parties insurers valid w.e.f. 17.10.2018 to 16.10.2019. Further, the complainant's wife Smt. Neelam stayed hospitalized in Nav Chetan Hospital for treatment of HYN/T2DM/ ARDS (Acute Renal Failure) w.e.f. 22.07.2019 to 29.07.2019 (Ex.C3).

3.       The OP insurers had initially approved pre-authorization cash-less hospitalization but somehow had rejected the request for subsequent enhancement and paid Rs.30,000/- only to the hospital upon discharge of the patient vide their letter dated 30.07.2019 vide (Ex.C20 to Ex.C23) vide which the reason of rejection of enhancement request was advised as discharge of the insured patient on 29.07.2019, itself. However, the hospitalization bills did amount to Rs.93,349/- so the complainant had to pay balance of Rs.63,349/- from his own pocket besides having (Ex.C4 to Ex.C19) paid Rs.12,154/- as cost of medicines.

4.       The complainant had addressed the said rejection of the hospital's request for enhanced pre-authorization as deficiency on the part of the opposite parties insurers and had sought its redress/relief by way of filing of the present complaint seeking refund of the balance sums of amounts of Rs.63,349/- + Rs.12,154/- (paid by him) with interest @ 12% PA from the date of admission till its realization besides Rs.50,000/- as compensation and Rs.20,000/- as cost of litigation all to meet the ends of justice. Lastly, the complainant in order to pay/award sanctify cum support to his above numbered exhibit (Ex.C2 to Ex.C23) has lodged his Self-declaration (Ex.CW1/A) along with his duly sworn-in affidavit (Ex.C1) besides his having filed Rejoinder/ Replication to the OP insurers' written reply.

5.       The titled opposite parties insurers (the OP1 & the OP2), in response to the commission’s notice/summons did appear through its counsel who filed the written statement stating/raising  therein preliminary as well as other objections (on merits) as: Firstly, the opposite parties plead absence of cause of action n locus-standee to the complainant to have filed the present complaint and further insurance-contract being based on utmost good faith relieves the insurer upon breach of the same by the insured; and the parties are also bound by the terms of policy that cannot be altered post-execution. Further, upon receipt of the hospital's request for enhancement (27.07.2019) of pre-authorization amount certain queries were raised by the opposite parties experts that were responded to on 30.07.2019 only whereas the patient/insured stood discharged on 29.07.2019 hence the said request was rightly rejected; and the insured had been always at liberty to file the balance as post-discharge hospitalization-claim.

6.       The opposite parties insurers, on merits, have merely repeated their objections while denying all other allegations as being incorrect or not being in knowledge etc and finally the opposite parties have addressed the complaint as immature since the post-discharge hospitalization-claim was not filed by the insured/complainant and they have also expressed their willingness to consider the claim on merits even at this belated stage if the insured preferred the same. The opposite parties have further pleaded that in the eventuality of an adverse orders against them, the liability may kindly be fixed in terms of the policy, only. Lastly, the OP1 insurers, in their endeavor to get the complaint dismissed have put forth the herein listed documents:

          1.       Ex.OP1,2/A–Affidavit Sumit Kumar Sharma authorized signatory;

          2.       Ex.OP1,2/1 – Copy of Policy Terms etc.; Ex.OP1,2/2– Copy Power of Attorney;

          3.       Ex.OP1,2/3 –Copy of Pre-Authorization Request;

          4.       Ex.OP1,2/4 Copy Cashless Authorization Letter; Ex.OP1,2/5 – Query Letter;

          5.       Ex.OP1,2/6 –Copy Cashless Authorization Letter;

          6.       Ex.OP1,2/7–Query on Enhancement of Pre-authorization;

          7.       Ex.OP1,2/8 & 9 –Rejection Letters;

          8.       Ex.OP1,2/10 –Copy Bill Assessment Sheets;

          9.       Ex.OP1,2/11 & 12 –Copies of Common Proposal Form & Portability Form.

7.       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 for of the impugned rejection of enhancement-request for cashless pre-authorization on the lame excuse/pretext of discharge of the insured patient on 29.07.2019 sans having afforded the requisite consideration to the hospital-reply admitted to have been duly received at their end.

8.       Thus, we do hereby disapprove the impugned rejection as well as the repudiation in the present situation when the ported policy terms and conditions duly provide for resolve of the request for enhanced pre-authorization requests and that too after having received the hospital's reply to their queries. In our considered opinion it not only reflects deficiency in service but also displays an employ of the unfair trade practices by the opposite parties insurers and that for sure lines them up for adverse statutory award under the herein applicable statute.   

9.       In the light of the all above, we set aside the opposite parties insurers' impugned rejection of the complainants’ hospital's request for enhanced pre-authorization as being unfair, arbitrary (and in contravention to laws of equity and natural justice) and amounting to ‘unfair trade practice cum deficiency in service’. Thus, we partly allow this complaint and ORDER the opposite parties insurers to pay the complainant balance hospitalization bills, in full, amounting to Rs.63,349/- plus cost of medicines Rs.12,154/- both with interest @ 6% PA from the date of discharge 29.07.2019 till actually paid 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 amounts shall attract additional interest upon these @ 3% PA form the date of filing of the complaint till actually paid.

10.     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.

11.         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)

SEPT. 02, 2022.                                           Member.

YP.