The titled complainant Smt. Sureshta Devi has been the holder of the Senior Citizens Red Carpet Health Insurance Policy: MED-PRD-070 No. P/211212/01/2021/003231 having purchased from the titled OP insurers for Sum Assured @ Rs.10 Lac Premium @ Rs.26,550/- valid w.e.f. 22.01.2021 to 21.01.2022 in her name with her son Rohit as nominee. The Assured Life's Health Status along with her other requisitioned particulars were duly made available/disclosed to the titled opposite parties who had cross-checked the same prior to acceptance of the related proposal.

2.        Unfortunately, the complainant was diagnosed suffering from some Hip-Joint situation and was admitted at Amandeep Hospital, Amritsar on 23.12.2021 for medical-treatment/surgery but somehow the OP insurers refused cashless hospitalization to her and thus she had to pay the related medical-bills/expenses of Rs.1,28,300/- from her own sources. 

3.        Having spent substantial amounts on her Hip-surgery cum medical-treatment the complainant had been urgently in need of funds so she filed the insurance hospitalization-claim with request to the OP insurers for an expeditious settlement. But, the OP insurers instead repudiated the claim on 27.12 2021 on the pretext that she had been suffering from NONHODGKIN'S LYMPHOMA (NHL)-cancerous growth in human lymphatic system–and that condition was suppressed/not-disclosed at the time of purchase of the policy. The complainant admits that she did suffer from cancerous conditions prior to year 2010 only and subsequently she was fully cured through advanced treatment and on 27.09.2010 she got the Fully Cured Report from 'Rajeev Gandhi Cancer Institute & Research Institute' and even the Amandeep Hospital's Certificate confirms that she was admitted/treated on account of Hip-situation, only. And, as such she was not carrying any pre-existing disease on her at the time of purchase of the related policy from the OP insurers.                   

4.       Finally, the complainant having tired of the presistent harassment at the hands of the OP insurers has filed the present complaint seeking directives to the OP insurers to pay her hospitalization-claim of Rs.1,28,300/-, in full, in terms of the related policy besides to pay her Rs.1,00,000/- as compensation and Rs.20,000/- as cost of litigation, in the interest of justice; along with any other relief as deemed fit to the commission.

5.       The complainant in order to accomplish the successful prosecution of her complaint has also filed her duly Sworn-in Affidavit (Ex.CW1/A) along with i) Copy of the Insurance Policy (Ex.C1); ii) Copy of Amandeep Hospital Discharge Summary (Ex.C2); iii) Copies of the Hospital Bills (Ex.C3); iv) Copy of Repudiation Letter (Ex.C4) and v) Copy of Report (Ex.C5) of 27.09.2010 from Rajiv Gandhi Cancer Institute & Research Center.

6.       The titled opposite party insurers (the OP insurers), in response to the commission’s summons appeared through their learned counsel who filed their written reply stating therein preliminary as well as other (on merits) objections as:           

7.       The complainant has no cause of action to file the present complaint as the parties to the contract of insurance are bound by the terms of the related policy and it has been her duty to have disclosed all material facts at the time of purchase of the policy but she had not disclosed her having got the chemotherapy/other treatment for NHL cancerous growth in the year 2008 that was revealed during the present investigations. As per the Discharge Certificate the complainant was having in left lower limb for the last 10 years  but the same was not-disclosed by her at the time of purchase of the policy and thus the claim was rightly repudiated as the policy itself turned void ab-initio and was canceled. The OP insurers have mentioned of the past treatments undergone by the insured and have also quoted Senior Court Judgments to support and strengthen their resolve determining repudiation to the impugned insurance-claim. The insured/Life Assured had replied, in negative, thus suppressing the pre-existing diseases in reply to the questionnaire accompanying the proposal form, as has also been re-produced in the written reply. Lastly, the complaint has been sought to be dismissed with costs. Again, on merits, the OP insurers have categorically denied all the contents n allegations as put forth by the complainant in the present complaint except that specifically admitted during the course of the herein trial/proceedings.  The written reply is supported by self-attested Affidavit (Ex.OPW1/A) of Sh. Sumit Kumar Sharma Sr. Manager along with other documents as: Ex.OP1–Proposal Form;  & Ex.OP2–Policy Schedule; Ex.OP3–Customer Information Sheet; Ex.OP4–Repudiation dated 30.12.2021; Ex.OP5–Master Circular 22/07/2020; Ex.OP6–Request for Cashless Treat,ment;  Ex.OP7–OPD Abrol Medical Center; Ex.OP8–Emergency Initial Assessment Form Amandeep Hospital; Ex.OP9–Discharge Summary–Land Mark Hospital 06.09.2017; Ex.OP10–Query Letter 24.12.2021; Ex.OP11–Rejection Cashless Request 27.12.2021.

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 of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments/oral as well as written, as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘repudiation' of insurance hospitalization- -claim pertaining to the insured complainant, by the OP insurers who allege non-disclosure of the pre-existing/continuing ailments etc by the Complainant, at the time of insurance.

9.       We have minutely examined all the documents produced in evidence by the complainant and also by the OP insurers as produced and as collected by them during the course of their investigations and find that the insured's health status as well as all clinical and medical-examination reports were in the notice, knowledge and possession of the OP insurers at the time of insurance/policy-selling/pocketing of the fat premium etc and thus they are presently stopped to cause repudiation to the insurance-claim, in question, merely on the strength of photocopies of the alleged past medical-treatments sans any affidavit/deposition/statement of the treating doctors/hospital authorities etc. Further, there's no evidence of delivery (not even that of dispatch) of the OP insurers documents viz: Policy Document, Terms and Conditions and others etc; and, in the absence of cogent evidence the contents/allegations of suppression/non-disclosure of past ailments are not proved and cannot be relied upon since on the other hand complainant has satisfactorily proved the contents/allegations and non-resolve cum delay etc vide the documentary evidence. We observe the OP insurers' present role fully marred by an employ of unfair-practices and unscrupulous exploitation of the innocent consumer and that amounts to an open play of deficiency in service at its full volume. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality. And, of course we do not concur with the logic of the herein impugned 'repudiation' of the hospitalization-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned repudiation of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same to cause an unjust loss to the complainant.       

10.     Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'repudiation' by the OP insurers as ‘deficiency in service' and 'unfair-practices' at play and thus ORDER the OP insurers to pay the insurance-claim of Rs.1,28,300/-, in full, to the herein complainant, in terms of the related policy with interest @ 6% PA from the date of complaint till actually paid, in full, besides to pay her Rs.15,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid.          

11.      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.

12.      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)

OCT. 26, 2022.                                            Member.

YP.