The titled complainant has filed the present complaint against  the titled opposite party insurers (hereinafter for short, the OP insurers) being aggrieved at the arbitrary repudiation of her hospital's pre-authorization request for cashless-treatment and further non-payment of her hospitalization expenses of Rs.3,50,000/- incurred towards her indoor-surgery at Medanta Hospital, Gurgaon to treat her anterior wedge compression fracture of 12-vertebral body suffered on account of an accidental fall at her house.

2.       The complainant on 28.06.2016 had purchased Med-classic Insurance Health Policy # P/211214/01/2019/000237 with Rs.5.0 Lac Sum Insured and had been renewing the same every year, the last renewal validating it up to 27.06.2019. However, the complainant had fallen down at home in December' 2018 and had suffered the recurring-pain back-injury.

3.       The complainant had consulted the local/near-by orthopedic-surgeons but finding little relief had finally approached Medanta Hospital, Gurgaon and was diagnosed hair-thin spinal vertebrate fracture warranting orthopedic-surgery. The treating hospital applied for the cashless-authorization with the OP insurers who rejected the same on the pretext of presence of Rheumatoid Arthritis prior to inception of the related policy although it had no relation with cause and/or effect of the said surgery. The complainant stayed admitted in the Hospital w.e.f. 31.01.2019 to 03.02.2019 and pleads to have spent Rs.3.50 Lac on her treatment (still continuing since then) to which she claims to be entitled for refund and has thus filed the present complaint seeking directives to the OP insurers to pay her the Policy's Sum Insured of Rs.5.0 Lac along with Rs.50,000/- as compensation and Rs.20,000/- as cost of litigation besides any other relief to which she be deemed fit by the honorable commission, in the interest of justice.             

4.       Lastly, the complainant, in order to facilitate successful prosecution to her complaint has filed her Affidavit (Ex.CW-1) along with herein listed documents, in evidence, as: Ex.C1– Copy of the related policy; Ex.C2– Copy of the Radiology Report; Ex.C3– Copy of the Discharge Summary; Ex.C4 – Copy of the OP letter dated 01.02.2019; Ex.C5 – Copy of the OP letter dated 02.02.2019; Ex.C6 – Copy of the OP letter dated 04.02.2019; Ex.C7– Copy of the Opinion by the Board of Hospital Doctors; Ex.C8 to Ex.C22– Copy of the Hospital Bills for Rs.2,75,073.34p; Ex.C23– Copy of the Second Radiology Report; Ex.C24 – Copy of the Doctor Consultation dated 10.12.2018.  

5.       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 other 'on merits' objections as:

6.       That the complainant had no 'cause of action cum locus-standee' to file the present complaint as she had violated the policy terms through concealment of the preexisting disease whereas an 'insurance' being a contract in utmost good faith it had been her duty to disclose the material facts at the time of purchase of the related policy. The OP insurers plead that there's no deficiency in service on their part as complainant's husband Ashok Kr has been the proposer of the related policy and all its terms and conditions were explained to them and served upon them along with its schedule. As per the treating doctor's report of 27.08.2018 the complainant has been suffering from Sero-positive A R for the last eight years and further from the patient record/progress sheet the treating doctor opines that complainant suffered from Sero-positive A R for the last twelve years and thus the said disease has been preexisting and thus not covered as was not even disclosed at the time of purchase of the policy and as such there's no liability of the OP insurers. On merits, the OP insurers do admit issuance of the health-policy and the insured life 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/A) Sh.Rajiv Jain along with other documents, in evidence, as: copy of the related proposal form (Ex.OP1,2/1);  copy of the related policies (Ex.OP1,2/2 to Ex.OP1,2/44); copy of the related request for cashless-authorization (Ex.OP1,2/5); copy of the treating doctor's certificate (Ex.OP1,2/6); copy of the Rejection Letter dated 02.02.2019 (Ex.OP1,2/7 & Ex.OP1,2/8); copy of the Second Request for cashless-authorization (Ex.OP1,2/9); copy of the Hospital Document 28.08.2018 (Ex.OP1,2/10); copy of the OP Query on Pre-authorization (Ex.OP1,2/11);  copy of the Hospital Document 29.08.2018 (Ex.OP1,2/12); copy of the Treatment documents (Ex.OP1,2/13); copy of the Rejection of Pre-authorization (Ex.OP1,2/14  & Ex.OP1,2/15); copy of the letter of 04.02.2019 (Ex.OP1,2/16) & of 14.03.2019 (Ex.OP1,2/17); copy of the endorsement of policy cancellation (Ex.OP1,2/18); copy of Policy Terms & Conditions (Ex.OP1,2/19); copy of the IRDA Regulations (Ex.OP1,2/20).

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 cashless authorization 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. However, it has not been the case of the OP insurers that the pre-existing disease has been known to the complainant, as they have neither produced nor even attempted to produce some cogent/independent evidence, in support. We observe that the OP insurers have relied upon the treating doctor opinion report to support their allegation that the complainant was carrying/suffering the preexisting disease of Sere-positive Rheumatoid Arthritis at the time of purchase of the related insurance but she had not disclosed the same in the proposal-form and have further produced the general (hearsay) information reports sans the necessary certification etc. 

9.        The OP insurers have pleaded/alleged vide the written statement (paragraph 4 & 5 of the preliminary objections and paragraph 4 of the objections raised on merits) and Repudiation Letters that from the treating doctor's and other indoor-hospital reports as filed/receipted with the cashless treatment request, it gets known/revealed that patient/complainant has been suffering from R A since last 8-12 years and that was not disclosed in the related proposal-form.

10.     We have thoroughly examined all the indoor reports of the treating-doctor/hospital, as listed here-in-above, but did not find any certification not even any confirmation of 8-12 years as incumbency/ duration of the R A with the patient/ complainant. No doubt, in the Summary Reports etc under the head Complaints/Reason of Admission, it is mentioned (as is usually intimated by the patient's accompanying attendant) that the said disease has been for past 8-12 years 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 that the present surgery has nothing to do with the prior diseases as it has been the result of the fall-injury only. We observe further that the OP insurers' noting, as marked out in paras 3 & 4, in the Rejection has been admittedly the layman's observations and not an expert opinion and thus carries no legal weight nor any value in evidence to attract any affordable consideration, during the present proceedings.

11.     Thus, we find that the OP insurers have failed to produce any cogent independent evidence in support 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 vide her arguments/pleadings.

12.     In the light of the all above, we set aside the OP insurers' impugned rejection 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/produced for medical attendance/expenses etc. in terms of the related policy with interest @ 7% PA w.e.f. the date of admission till realization besides to pay a sum of Rs.15,000/- in lump sum as compensation/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.    

13.      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.

14.      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)

DEC. 23, 2022.                                           Member.

YP.