The titled complainants being first aggrieved at the alleged arbitrary repudiation of their pre-authorization request on 03.11.2018 for cashless treatment/hospitalization of his wife Suruchika (the complainant 2) at the EMC Super Specialty Hospital, Amritsar and again at the final repudiation on 10.01.2019 of her hospitalization-claims for medical treatment at that very Hospital; has filed the present complaint.

2.       The Complainants had been holding one Health Policy (for all family-members) with the OP insurers since the year 2014 and were renewing the same from time to time and the present one being valid up to 16.08.2019. However, on 03.11.2018 Smt. Suruchika had somehow accidentally swallowed down the poisonous substance (Seonk Insecticide) taking it as one of her prescribed medicine as its pack was lying along with other medicines  at home and thus she had to be admitted to the EMC Hospital at Amritsar, on the same day.

3.       The EMC Hospital filed the requisite pre-authorization request for cashless treatment on the very date of admission (03.11.2018) but the same was unceremoniously refused by the OP1 insurers. However, the medical-treatment continued and the patient complainant 2 was discharged on 10.11.2018 with all the treatment expenses amounting to Rs.1,21,966/- paid by the complainants, themselves; who have also deposed of the narrated facts vide exhibits Ex.CW1/A and Ex.CW2/A.

4.       In due course of time, the complainants submitted the hospitalization-claim with the OP insurers who somehow again repudiated the same vide its communique of 10.01.2019 (Ex.C2) addressing the intake of poison as intentional and for self-harm and that falls under the exclusion clauses of the terms of the related policy. The complainants did file their protest with the OP1 on the strength of the hospital discharge summary (Ex.C1) that does   mention the intake of poisonous substance as accidental but the insurers stayed adamant and refused to listen to the logical explanations etc. The complainants do further state to have filed all the related hospital/ medicines bills (Ex.C3 to Ex.C30) along with the claim amounting to Rs.1,21,966/- with the insurers.

5.      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.1,21,966/- along with interest @ 12% PA from the date of claim till realization and also to pay an additional Rs.30,000/- as compensation for having infringed sufferings upon them by way of harassment and mental agony besides Rs.20,000/- for deficiency in service and Rs.10,000/- as cost of the present litigation, in the interest of justice.  

6.       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 intake of poisonous substance cannot be accidental as it could have been clearly differentiated from the medicines. 

7.       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.1,08,344/- only. And, on merits, the OP insurers have addressed the contents of the complaint as matter of records or as subject matters of denial. The complainant had never requisitioned the terms and conditions of the policy from the OP insurers and thus the hospitalization claim for the undergone medical treatment was rightly denied in terms of the exclusion clause 4.7 of the policy and the present complaint being bereft of any merit deserves dismissal.

8.       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 – Denial of per-authorization;

          3.       Ex.OP1,2/2 – Query on per-authorization;

          4.       Ex.OP1,2/3 – Copy of Claim Form;

          5.       Ex.OP1,2/4 Hospital Record;

          6.       Ex.OP1,2/5 – Copy Claim Repudiation;

          7.       Ex.OP1,2/6 to 9: Copies of Policies;

          8.       Ex.OP1,2/10 – Policy Terms and conditions;

          9.       Ex.OP1,2/11 – Pr-authorization request;

          10.     Ex.OP1,2/12 Proposal Form;

          11.     Ex.OP1,2/13: Hospital Bill;

          12.     Ex.OP1,2/14: Pr-authorization Rejection;

          13.     Ex.OP1,2/15: Hospital In-patient Register.

9.       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 final ‘repudiation’ of the hospitalization-claim as filed by the titled complainants pertaining to the Policy in question, by the OP insurers.

10.     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/ hospitalization-claim had been their own belief/opinion that 'poisonous substance' cannot be swallowed accidentally taken for some medicine as the same has been quite differentiable from medicines. 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 presumption cum probability etc.

11.     In the light of the all above, we set aside the OP insurers' impugned rejection as well as repudiation of the complainants’ hospitalization-claim 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 ORDER the OP insurers to pay 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.10,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the copy of these orders.           

12.      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.

13.      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)

JULY 28, 2022.                                            Member.

YP.