The titled complainant, aggrieved at the repudiation of his wife's hospitalization-claim for her medical treatment @ Hormonal Therapy/Adjuvant Therapy through Immune Modulator etc at the S. P. S. Hospital, Ludhiana; has filed the present complaint. The OP1,2 insurers had sold him the Family Medicare Policy that was continuing for the last 15 years and the last renewed No. 2002022817P101459069 had been effective/applicable w e from 29.04.2017 to 28.04.2018. The OP insurers had been since paying the related medical bills/claims but somehow withheld the payment of Five Nos. of bills/claims dating 05.06.2017 to 04.08.2017 summing-up to Rs.2,75,885/- at the opinion/advice of the OP3 Third Party Administrator (TPA) on the strength of the UIC circular HO Health 043:16-17 of 05.05.2016 that barred claims for some of the cancer therapies.

2.       The complainant pleaded with the OP insurers that his continuing and applicable contract of insurance has been with them and so the OP3 TPA opinion was not applicable here and moreover the UIC Bar dated 05.05.2016 to certain therapies cannot be applied to his policy that has been much earlier in point of time. However, the OP insurers did neither respond nor allow the said claim(s) and taking the same as an implied repudiation the present complaint stands prompted praying for directives to the OP insurers to amicably settle all his outstanding claim(s) and also to pay him an additional Rs.10,000/- as cost and compensation for having suffered manifold on account of non-settlement of his otherwise valid claim(s) and the resulting delay culminating into present litigation. The complainant has placed forth the listed documents in support of success of his complaint. These are:

          i)       Ex.C1 – Affidavit by the complainant deposing the contents of his complaint and also the sanctity of his evidentiary                          documents;

          ii)      Ex.C2 – Copy of Letter dated 29.09.2017 to the OP insurers;

          iii)     Ex.C3 – Reminder to the Ex.C2 above;

          iv)     Ex.C4 – Copy Claim Form to the OP insurers; 

          iv)     Ex.C5 – Copy Repudiation Letter by the OP3 TPA;

          vi)     Ex.C6 – Copy of the applicable Policy Schedule;                  

3.       The titled opposite parties (OP1 and OP2), in response to the commission’s summons appeared through their common counsel and filed the written reply stating therein preliminary as well as other objections (on merits) as:

(The OP3 TPA however, preferred to stay absent and thus were ordered to be proceeded against ex-parte vide interim orders dated 09.02.2018).

By the OP1 & OP2 the Insurers:

4.       Firstly, the OP plead absence of cause of action and locus-standi to the complainant to file the present complaint as there has been no deficiency in service on their part. The policy has been a contract between the two parties and both are bound by its terms.

5.       Further, the claim was raised during the period of the policy and the same was forwarded to the OP3 TPA who vide its letters dated 08.08.2017 and 21.08.2017 had opined that the related claim(s) are not payable in the light of UIC Circular Head Quarter Health 043:16-17 dated 05.05.2016 and the same was communicated to the complainant and that there's no deficiency on their part. Lastly, the complaint is not within limitation and the forum lacks the requisite territorial jurisdiction to put the present complaint on trial, here.    

6.       Again, on merits, the OP pleads that policy details are matters of records and the complainant may be directed to place the original policy on records. The treatment taken by the patient was not covered under the policy by virtue of the 05.05.2016 UIC Circular. That repudiation dated 29.08.2017 has been legal and valid as the claim pertaining to the medical treatment taken by the patient was barred by the above referred UIC circular. All other contents and allegations as contained in the present complaint stood denied and lastly, dismissal of the present complaint has been sought. The OP insurers, endeavoring to get the complaint dismissed have put forth before us the herein listed documents:

          i)       Ex.OP1,2/1 – Affidavit Div. Manager Jai Krishan deposing

          contents of reply;

          ii)      Ex.OP1,2/2 – Policy Schedule with S.I. Rs.3.0 Lac and other

          details etc.;

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 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 on account of the impugned ‘repudiation’ of the hospitalization-claim pertaining to the Policy in question, by the OP insurers.

8.       We understand that the present policy has been in force since the past fifteen years (as claimed by the complainant and not contested/challenged by the OP insurer) so, the OP UIC Circular of 2016 cannot have retrospective effect to the detriment of the continuing consumers/ beneficiaries, in the interest of fair-play, equity and natural justice. Even, the judge-made law or for that matter even the statutory law do not approve of it save some requisite exceptions. Thus, we shall disapprove the applicability of the 2016 UIC Circular upon the policies with inception dates earlier in point of time. And, moreover the insurers shall not be allowed to wriggle out of 'renewals' of such like policies till the final exits of the insured. Health insurance business may aim at profit-maximization but not at the cost of the insured to whom the insurers do owe some social liability and responsibility, too.          

9.       In the light of the all above, we set aside the OP insurers' impugned repudiation of the complainants’ hospitalization-claim being unfair, arbitrary (and in contravention to laws of natural justice) and amounting to ‘unfair trade practice cum deficiency in service’. Thus, we partly allow this complaint and ORDER the OP insurers to settle and pay Rs.2,75,885/- as payment of the impugned ‘insurance claim(s)’ 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.

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:                                  (R.S.Sukhija)

JULY 15, 2022.                                          Member.

YP.