ORDER

BEFORE:

HON’BLE MR. SUBHASH CHANDRA, PRESIDING MEMBER

HON’BLE DR. SADHNA SHANKER, MEMBER

For the Appellant                Mr Ashwary Kathed, Proxy Counsel for

                                       Mr Navneet Kumar, Advocate

For the Respondent             Mr Neil Hildreth, Advocate and

                                       Mr Kshitiz Arya, Advocate

ORDER

PER SUBHASH CHANDRA

1.      This appeal under Section 19 of the Consumer Protection Act, 1986 (in short, the “Act”) is directed against the order dated 08.07.2022 of the Odisha State Consumer Disputes Redressal Commission, Cuttack in Complaint no. 19 of 2018 allowing the complaint in part and directing the opposite party (appellant herein) to pay the complainant (respondent herein) Rs 3,20,000/- as hospitalization charges, Rs 15,00,000/- towards compensation, Rs 5,00,000/- as punitive damages and Rs 25,000/- towards costs within 45 days of the order.

2.     We have heard the learned counsel for the parties and perused the records. The delay of 33 days in the filing of the appeal was considered in light of the application seeking condonation of the delay. For the reasons stated therein, the delay was condoned in the interest of justice.

3.     The relevant facts of the case, in brief, are that the appellant, who is a health insurance company, had approved a “Senior Citizens Red Carpet Health Insurance Policy” in respect of the respondent with effect from 05.04.2016 for a sum assured of Rs 10,00,000/- against receipt of premium of Rs 25,875/-. Under the scheme, the respondent was declared as suffering from diabetes and hypertension as pre-existing diseases and was eligible for treatment, including hospitalization, subject to terms and conditions. The respondent was admitted to the Intensive Care Unit (ICU) of the Apollo Hospital, Bhubaneshwar on 10.01.2018 for fever with diagnosis of diabetes melitus, lobar pneumonia and DCM. Respondent applied to the appellant for pre-authorization for cashless facility of treatment under the Policy on 11.01.2018. The respondent asked for details of past hospital discharge from SAAOL Heart Centre of 21.05.2016 with duration of treatment of COPD and Rheumatoid Arthritis (RA) and statement from the treating consultant along with past treatment details and first prescription and investigation reports including x-ray, PFT, blood reports and temperature chart. On 12.01.2018 appellant asked for a letter from the treating doctor clarifying when COPD and RA were diagnosed was asked for. On 16.01.2018 the appellant conveyed to the respondent that “As per hospital documents patient has COPD with seropositive rheumatoid arthritis. Duration and past treatment details of the above not provided. It is not possible to establish duration of COPD and rheumatoid arthritis in cashless. We regret that cashless is denied. Please go for reimbursement.”  Thereafter, the reimbursement claim preferred under the Policy was also repudiated. Respondent filed a complaint before the State Commission which was disposed of, on contest, by order dated 08.07.2022 which is impugned before us.   

4.      On behalf of the appellant it was argued that under the terms of the Policy, cashless treatment was available to policy holders under the “co-payment” clause which required payment of 50% of the bill for existing diseases and 30% of each and every claim for all other claims. It was contended that the appellant had acted as per the policy and sought details of previous treatment and hospitalization which was not provided and therefore the cashless facility and subsequently the reimbursement was not approved. It was contended that the requisite documents were not provided by the respondent during pre-authorization request and subsequently when reminder letters were sent on 01.03.2018 and 16.03.2018. It was averred that the State Commission had erred in not appreciating the treatment record of the respondent which revealed that he was a known case of rheumatoid arthritis and COPD and had