The titled senior-citizen complainant being upset/ aggrieved at the alleged arbitrary rejection/repudiation of his hospitalization-claim for Rs.67,300/- pertaining to his indoor treatment for Bronchitis Emergency (cum General Weakness) at Dr.Ved Gupta Hospital, Amritsar, has filed the present complaint against the titled opposite party insurers seeking settlement of the impugned claim at double the amount @ Rs.1,34,600/- with interest @ 18% PA besides Rs.10,000/- as the litigation cost. The complainant had purchased the Med-claim Health Insurance Policy # P/211214/01/2019/001490 on 31.03.2019 valid up to 30.03.2020 covering his comprehensive medical-treatments up to Rs.5.0 Lac and also of his spouse Mrs.Veen Abrol. The policy premium(s) have been paid regularly since thereafter as have been duly accepted by the OP insurers.
2. The complainant suffered repetitive cough cum breathlessness and was hospitalized at Dr.Ved Gupta Hospital, Amritsar w.e.f. 14.09.2019 to 18.09.2019. The complainant had duly intimated the OP insurers on phone that the Hospital had refused the cashless-treatment in spite of its being on their list of Network Hospitals and was in turn advised to pay the Bills and to claim reimbursements, upon discharge. Thus, the complainant did pay Rs.67,300/- upon discharge and filed the related claim along with the requisite documents for reimbursement that however was declined by the OP insurers vide their letter dated 06.11.2019 citing it as the one 'preexisting-disease' despite an appropriate certification (11.10.2019) by Doctor Sukesh Bhatia (at Bhatia Heart Care Center, Amritsar) that the complainant had visited him on 31.08.2019 for the first time and there were no signs/symptoms of the said disease. Further, the complainant has clarified that 'preexisting- disease' is the one that existed prior to the inception of the related insurance policy but all his requests fell on deaf ears and thus prompted the present complaint.
3. In his complaint, the complainant has prayed for directives to the titled OP insurers to settle and pay the hospitalization-claim at double the claim-amount @ Rs.1,34,600/- with interest @ 18% pa besides Rs.10,000/- as cost cum compensation, all in the interest of justice; and, in support, has filed his Affidavit along with other documents, in evidence, as: Own Affidavit (Ex.CW/1) along with; copies of Medical Bills (Ex.C1 to Ex.C14); copy of related Policies (Ex.C15 & Ex.C16); copy of Dr.Sukesh Bhatia Letter 11.10.2019 (Ex.C17); and, copy of OP Insurers' Repudiation (Ex.C18).
4. The titled opposite party insurers (the OP1 & OP2), in response to the commission’s summons appeared through their common counsel and filed their joint written statement putting forth therein preliminary as well as 'on merits' objections as:
5. That the complainant had no 'cause of action cum locus-standee' to file the present complaint as he had violated the policy terms through concealment of the preexisting disease whereas an 'insurance' being a contract in utmost good faith it had been his duty to disclose the material facts at the time of purchase of the related policy.
6. The OP insurers plead that there had been no deficiency in service on their part as the hospital's case records (filed along with the claim-documents) dated 15.09.2019 reveal that the patient/complainant has been suffering 'breathlessness' for the last (6) six months whereas 'insurance' was purchased on 31.03.2019 and thus the 'disease' under treatment has been 'existing' at the time of purchase but was suppressed from the OP insurers who thus have rightly repudiated the hospitalization-claim in terms of the policy. Further, the PFT (Pulmonary Function Test) Report (10.09.2019) shows severe restriction and C. T. Scan (Computerized Tomography Scan) Report (10.09.2019) shows bronchial thickening in all the lobes involving segment-AL & sub-segment-AL Bronchi-tees indicating thereof a long-term continuing disease. On merits, the OP insurers do admit issuance of the health-policy and the lives covered but repeat 'repudiation' of the hospitalization-claim on the grounds of preexisting disease and lastly seek dismissal of the complaint, with costs, in the interest of justice. The OP insurers, in support of prosecution of its defense have filed the Affidavit by its authorized signatory (Ex.OP1,2/1/A) Sh.Rajiv Jain along with other documents, in evidence, as: copy of the related policy with its Terms & Conditions (Ex.OP1,2/1); copy of the related proposal form (Ex.OP1,2/2); copy of the claim form (Ex.OP1,2/3); copy of the Discharge Summary (Ex.OP1,2/4); copy of the Test Report (Ex.OP1,2/5); copy of the PFT Report (Ex.OP1,2/6); copy of the advanced diagnostics (Ex.OP1,2/7); copy of the final Bill (Ex.OP1,/8); copy of Repudiation letters (Ex.OP1,2/9 & Ex.OP1,2/10); copy of the India Post Tack Consignment - Registered Parcel (Ex.OP1,2/11); and, copy of the Billing Assessment (Ex.OP1,2/12).
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 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.
8. We find that the present dispute has arisen on account of the impugned 'repudiation' of the related hospitalization-claim on account of the sole reason of the alleged 'non-disclosure' of preexisting disease/ material information relating to the period prior to inception of the related policy, by the complainant.
9. We observe that the OP insurers allege that the complainant was carrying/suffering the preexisting disease of Bronchitis at the time of purchase of the related insurance but he did not disclose the same in the proposal-form and have further produced the following documents, in evidence as:
10. The OP insurers have pleaded/alleged vide the written statement (paragraph 4 of the preliminary objections & paragraph 4 of the objections raised on merits) & Repudiation Letters (Ex.OP1,2/9 & 10 - paragraph 3 & 4) that from the indoor-reports of the treating-hospital (Ex.OP1,2/3 to Ex.OP1,2/7) as filed/receipted with the hospitalization-claim, it gets known/revealed that the patient/complainant has been suffering from Bronchitis since last (6) six months and that was not disclosed in the related proposal-form.
11. We have thoroughly examined all the indoor reports of the treating-hospital, as listed here-under, but did not find any certification not even any mention of '6' months as incumbency/duration of the Bronchitis with the patient/complainant. No doubt, in the Discharge Summary (Ex.OP1,2/4) under the head Chief Complaints/ Reason of Admission, it is mentioned (as is usually intimated by the patient's accompanying attendant) that the 'Cough, Breathlessness and General Weakness' all for past 4 months' that however hold/ carry no authenticity either in medical-terms nor in legal-terms. Further, the complainant has appropriately produced the treating doctor's certification (Ex.C17) that no symptoms of Bronchitis were observed/ diagnosed upon him on his first visit on 31.08.2019 and he was never hospitalized before 14.09.2019, Ex.OP1,2/3 – The Claim filed by the complainant with the OP insurers; Ex.OP1,2/4 – The Discharge Summary @ Dr.Ved Gupta Hospital; Ex.OP1,2/5 – The Clinical Test Report; Ex.OP1,2/6 - The PFT Report; Ex.OP1,2/7 – The Advanced Diagnostics;
12. We observe further that the OP insurers' noting, as marked out in paras 3 & 4, in the Repudiation (Ex.OP1,2/9 & 10) are admittedly the layman's observations and not the expert opinion and carries neither the legal weight nor the evidentiary value to attract any affordable consideration, during the present proceedings.
13. Thus, we find that the OP insurers have failed to produce any cogent evidence of its alleged main objections of 'non-disclosure' of the preexisting disease and in its absence these are no more than mere bald statements sans 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 and not in an arbitrary manner but need to explain the logic as to how the same have been reached.
14. Lastly, we wish the herein complainant to understand that all 'compensations' and for that matter all legal propositions are governed by Majesty of Justice (To All, Alike) and Costs, Penalty/fines etc do strictly follow the Law of Moderation unless supported by the legislative law and there's no statutory provision to double the amount of a judicious claim getting unjustly declined that however attracts a somewhat matching compensation but it be known that undue enrichment through litigation shall always be discouraged.
15. In the light of the all above, we set aside the OP insurers' impugned repudiation of the hospitalization-claim, in question, being arbitrary (and in contravention to the laws of equity, good conscious and natural justice) and also 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 Bills drawn for medical attendance/expenses @ Rs.65,020/- (as per the Bill Assessment Sheet – Ex.OP1,2/12) in terms of the related policy with interest @ 6% PA w e from the date of admission 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 realization.
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: (B.S.Matharu)
DEC. 21, 2022. Member.
YP.
