The titled complainants being legal heirs of Late Sh. Jawahar Lal Marwaha, the DLI (Deceased Life Insured) and aggrieved at the alleged repudiation of his death claim by the OP insurers (the titled opposite party insurers) have filed the present complaint praying for issuance of directives to the OP to pay Rs.6,23,511/- full amount of the impugned death-claim, besides Rs.20,000/- each for cost and compensation, in the interest of justice.
2. The DLI during his life-time had purchased one Medical (Health) Insurance Policy for the period 2012-13 to 2017-18 from M/s National Insurance Co. Ltd., and had later ported to the OP insurers (the titled opposite parties) w.e. from 22.03.2018 to 21.03.2019 under the Policy # P/211214/01/2019/001252 that was again renewed w.e. from 22.03.2019 to 21.03.2020. However, on 10.05.2019 the DLI fell ill to be diagnosed for Malignant Tumor and stayed U/treatment at various Hospitals to finally breathe his last on 19.06.2019.
3. In due course of time, the complainants submitted the death-claim for Rs.6,23,511/- with the OP insurers who somehow repudiated the same vide its letter dated 08.10.2019 on account of non-disclosure of the pre-existing coronary artery disease at the time of the purchase of the health policy. The complainants did file their protest with the OP1 on the strength of the hospital discharge summary and other documentary evidence but the OP insurers stayed adamant and refused to listen to all their logical explanations etc.
4. The complainants put forth their pleadings before the OP insurers but that all failed to make them review and relent over their repudiation hence prompted the present complaint seeking directives to the OP insurers to amicably settle their claim for an amount of Rs.6,23,511/- along with interest from the date of claim till realization and also to pay an additional Rs.20,000/- as compensation for having infringed sufferings upon them by way of harassment and mental agony besides Rs.20,000/- as cost of the present litigation, in the interest of justice. The complainant(s), in support of their claim have filed their Affidavit as evidence Ex.CW1/A/Ex.C1; Copies of the policies Ex.C2 to Ex.C9; Copies of all Medical Treatment Record Ex.C10 to Ex.C20; Death Summary Ex.C21 and Death Certificate Ex.22; Denial Pre-authorization Ex.C23; Repudiation Letter Ex.C24; Medical Bills Ex.C25 to Ex.C89.
5. The titled OP Insurers (the OP1 & the OP2), in response to the commission’s notice/summons did appear through their counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as: Firstly, the OP plead absence of cause of action and deficiency in service on its part as the DLI had been suffering from IHD (Ischemic Heart Disease) since 08.12.2018 and thus the claim was rightly repudiated. The OP insurers have further pleaded that in the eventuality of an adverse orders against them, the liability may kindly be fixed in terms of the policy i.e. Rs.4,24,246/- only. And, on merits, the OP insurers have addressed the contents of the complaint as matter of records or as subject matters of denial. And, thus the impugned death-claim for the undergone medical treatment was rightly denied in terms of the exclusion clause 4.3 of the policy and the present complaint being bereft of merit deserves dismissal, in the interest of justice.
Lastly, the OP1 insurers, endeavoring to get the complaint dismissed have put forth before us the herein listed documents:
1. Ex.OP1,2/1/A–Affidavit Chief Manager Rajiv Jain deposing contents of reply;
2. Ex.OP1,2/1 – Request for cashless hospitalization;
3. Ex.OP1,2/2 – Field Visit Report;
4. Ex.OP1,2/3 & Ex.OP1,2/4 Queries on per- authorization;
5. Ex.OP1,2/5 – Pre-authorization letter;
6. Ex.OP1,2/6 - Copy Claim Form;
7. Ex.OP1,2/7 – Discharge Summary;
8. Ex.OP1,2/8 – Prescription 08.12.2018;
9. Ex.OP1,2/9 - Death Summary;
10. Ex.OP1,2/10 – Discharge Medanta;
11. Ex.OP1,2/11 – Discharge Cancer Institute;
12. Ex.OP1,2/12 – Final Bill;
13. Ex.OP1,2/13 – Repudiation Letter;
14. Ex.OP1,2/14 – Portability Form;
15. Ex.OP1,2/15 - Copies of Policies;
16. Ex.OP1,2/16 – Policy Terms and conditions;
17. Ex.OP1,2/17 - Proposal Form;
18. Ex.OP1,2/18 - Billing Assessment Sheet.
6. 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 first for of the impugned rejection of cashless pre-authorization and again upon the final ‘repudiation’ of the impugned death-claim as filed by the titled complainants pertaining to the Policy in question, by the OP insurers.
7. We understand that the lone logic/basis as put-forth/addressed by the OP insurers in support of the impugned rejection/repudiation of the pre-authorization/death-claim had been the non-disclosure of the pre-existing Coronary Artery Disease qua the prescription dated 08.12.2008 for treatment of IHD (Ex.OP8) - 8th Dec.' 2018; which is 2nd year of porting U/portability provision but the 8th year from the original purchase of the related policy. So, for all purposes it shall be the 8th year of even the ported policy. We observe that the OP insurers' said pleading does not attract acceptance in law as the same has been totally bereft of any sort of legal support. Somehow, we do not concur with the same, too. Thus, we do hereby disapprove the impugned rejection as well as repudiation in the present situation when the very logic has been based upon conjectures and assumptions etc.
8. In the light of the all above, we partly allow this complaint and set aside the OP insurers' impugned rejection as well as repudiation of the complainants’ death-claim being unfair, arbitrary (and in contravention to laws of equity and natural justice) and amounting to ‘unfair trade practice cum deficiency in service’.
9. Thus, we ORDER the OP insurers to pay the full amount of the impugned claim for the complainant's hospitalization cum medical expenses for the full amount of the impugned-claim in terms of the policy along with other accrued benefits, if any, pertaining to 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.
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)
AUG. 03, 2022. Member.
YP.
