The titled complainant, aggrieved at the repudiation of his Daughter's (Ms. Tamana Sondhi) hospitalization-claim pertaining to her treatment for a medical emergency (Chest Pain, Breathlessness & Palpitation) at the M/s J. K. Super Specialty Hospital & Emergency Medical Cent-re at Gurdaspur, has filed the present complaint. The OP insurers had sold him a Family Health Policy # 11222270 (Ex.C1) bearing Insurance Certificate # 11819816 covering medical-treatment to all his four family-members and having renewed w.e. from 16.11.2019. The complainant's daughter Ms Tamana as was also duly covered under the related policy somehow got indisposed on 03.06.2020; and admitted at the OP5 Hospital. She got discharged on 06.06.2020 and was charged a sum of Rs.27,066/- towards medical-attendance and Rs.16,966/- towards medicines-consumed during her hospital-stay.

­2.       The related Reimbursement Claim was duly filed with the OP insurers who raised some queries that were duly replied by the Hospital on 10.08.2020 (EX.C2) and the claim was duly followed-up by the complainant. However, the OP insurers unceremoniously repudiated/rejected the hospitalization-claim (Ex.C5) simply alleging mismatch of the statements with no details of whatsoever. The OP insurers were served upon with Registered Legal Notice (Ex.C6/Ex.C7) that however could not move them to review/reconsider their hasty/ arbitrary resolve to the impugned claim and thus prompted the present complaint.

3.       The titled opposite parties insurers (the OP1 to 4), in response to the commission’s summons/notice appeared through their common counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as:

          By the OP1 to OP4 the Insurers:

          The complainant has no cause of action/ locus-standee to file the present complaint and there has been no deficiency in service on their part. The OP upon receipt of the claim had conducted an inquiry/investigation through the Co.'s Surveyor/Investigator and found that the OP5 Hospital does not fit into the criterion of hospitals as per the terms of the policy hence the claim was rightly

rejected/ repudiated. Lastly, the complaint has been prayed to be dismissed being meritless, in the interest of justice, equity and fair play.

4.       The OP insurers have put forth in evidence in prosecution of their defense through the hereunder listed documents:

          i)   Ex.OP1to4/1/A – Affidavit of Sahil Chauhan Authorized Signatory with the OP insurers;

          ii)  Ex.OP1to4/1 – Certificate of Insurance;

          iii) Ex.OP1to4/2 – Copies of OP letters to the complainant;

          iv) Ex.OP1to 4/3 – Copy of Terms and Conditions of the applicable policy;

          v) Ex.OP1to4/4 to 10 – Copies of OP letters to the  complainant;

          vi) Ex.OP1to4/11 & 12 – Legal Notice and its Reply;

          vii)Ex.OP1to4/13 & 14 – Copy of Medicines-Bill and Clinical Reports.

5.       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. We find that the present dispute has arisen on account of the impugned ‘repudiation’ of the hospitalization-claim pertaining to the Policy in question, for sole reason of the Hospital not matching the OP standard criterion as depicted vide the policy's prescribed terms and conditions. Upon query by the OP, the Hospital authority has very explained its competence to handle emergent health situations and the formal as well as mandatory registrations with various authorities. Of late, the Hospital has been under expansion/renovation to be at par with the best med-standards. Moreover, in Gurdaspur like towns there may not be the best standard modern hospitals and for trivial emergency treatments etc., patients cannot every time rush to bigger cities. We also find that the OP insurers have not placed forth any cogent evidence of delivery/ dispatch of all these terms to the complainant side at the time of renewal of the insurance. It shall not be just to reject such a small amounted but otherwise a genuine medi-claim at the face of the S.I. (Sum Insured) @ Rs.5 Lac.

6.       We further observe that the OP insurer's other trivial objections are ambiguous and no more that petty queries in non-fidelity/ignorance and have been well responded by the complainant in his rejoinder arguments to their pleadings. The OP have also omitted/ignored to produce some cogent evidence in support of their allegations that otherwise are no more than bald statements. Thus, the OP insurers have failed to produce on record some cogent evidence, to its prime assertions preceding the rejection/repudiation. The OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial review and thus need be determined with due application of mind and not in an arbitrary manner and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached.

7.       In the light of the all above, we set aside the OP insurers' impugned repudiation/rejection of the complainants’ hospitalization-claim being arbitrary (and in contravention to laws of natural justice) and amounting to ‘unfair trade practice/deficiency in service’. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ to the tune and order of both the Bills drawn separately for medical attendance @ Rs.27,066/- and medicines @ Rs.16,966/- 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, otherwise the entire awarded amount shall attract additional interest @ 3 % PA form the date of the orders till actually paid.       

8.         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.

9.        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)

JULY 08, 2022.                                          Member.

YP.