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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 not discussed this aspect in the order, especially since the documents had not been denied by the respondent. It was also contended that the respondent had not filed the affidavit of the treating doctor at Apollo Hospital in support of his arguments that the hospitalization was not related to either RA or COPD. It was submitted that the State Commission failed to appreciate that as per condition no. 4 failure to provide requisite documents amounted to violation of policy conditions and therefore repudiation was justified. According to the appellant the respondent was responsible for not cooperating with them in the reimbursement of his claim. It was also submitted that the impugned order had directed payment of medical reimbursement and imposed excessive and unwarranted compensation (Rs 15,00,000/-), punitive costs (Rs 5,00,000/-) and high rate of interest (12%). It was argued that the State Commission incorrectly relied upon the judgment in Gurmel Singh Vs. Branch Manager, National Insurance Co, Ltd., Civil Appeal No. 4071/2022), the ratio of which did not apply to the case and that the Policy was a contract which had to be strictly interpreted as held by the Hon'ble Supreme Court in Export Credit Guarantee Corp. of India Vs. Garg Sons International, (2013) 3 (1) SCALE 410. It was therefore prayed that the appeal be allowed, and the impugned order set aside.

5.      Per contra, it is the case of the respondents that the contentions of the appellant were unfounded since the pre-authorization for cashless treatment was rejected on superfluous and arbitrary grounds that it was not possible to establish duration of Chronic Obstructive Pulmonary Disease (COPD) and Rheumatoid Arthritis (RA) which was not related to the respondent's condition for which he was admitted to the hospital. It was submitted that the appellant's case that the respondent was suffering from COPD and RA was incorrect as he had no such medical history and was therefore unrelated to the processing of the claim for hospitalization and subsequently reimbursement. Respondent had been admitted to the hospital on account of high fever, chills and rigors in an emergency situation and was admitted to the ICU being a senior citizen aged 67 years and, in view of his vulnerable state with no support except his wife, the respondent had requested for cashless facility. It was the respondent's case that despite the Policy providing for cashless facility, the same was denied to him by asking for unrelated documents which was a deficiency in service and unfair trade practice on part of the appellant. It was submitted that the Policy was advertised as a 'Red Carpet' health insurance policy which came with a high premium but when a legitimate claim was preferred the same was denied on flimsy grounds. It was therefore submitted that the appellant failed to meet its commitment as an insurer under the policy by requisitioning documents that were completely unrelated to his health condition/hospitalization. It was submitted that the asking for records relating to therapy sessions at Saaol Hospital two years prior were unrelated to the cause of his hospitalization and were asked for intentionally in order to turn down the request for pre-authorization and, later, re-imbursement. It was submitted that the Policy was based on uberrima fidei or utmost good faith and that diabetes and hypertension having been declared as pre-existing illnesses, the Policy attracted significantly higher annual premium which had been accepted by the appellant. It was contended that the onus of proving that the respondent suffered from COPD and RA lay on the appellant which had not been discharged through any documentary evidence. It was argued that the appellant acted with malicious intent since it sought unrelated and extraneous documents knowing full well that they either did not exist or were beyond the control of the respondent to produce to deny his legitimate claim. It was further argued that the appellant failed to discharge even its admitted liability. According to the respondent, the State Commission's reliance on Gurmel Singh (supra) was valid as the ratio in that case squarely applied to the instant case as it had been held that an insurance company cannot become too technical and act arbitrarily by refusing to settle claims on grounds of non-submission of documents beyond the control of the insured.

7.      From the foregoing it is manifest that the Policy was designed for senior citizens. The Policy therefore had features that were designed to factor in the special requirements of diseases and illnesses that afflict the aged. It was further marketed as a 'Red Carpet' Policy that connoted that it would provide special and expedited services as the policy holder belonged to a special class of (senior) citizens through a heightened sensitivity to their requirements. It also conveyed that the service under the policy would be as provided to privileged customers as connoted through the moniker 'Red Carpet'. The facts of the case on hand, however, indicate that the appellant as the insurer delayed and thereafter denied pre-hospitalization authorization by insisting on production of documents pertaining to a treatment availed two years prior. It has not been established by the appellant how the documents sought were material to the hospitalization of the respondent. If the respondent had been admitted for RA and COPD in Apollo Hospital, the requisitioning of the documents would have been germane to the processing of the case by the appellants. In the absence of any documents being brought on record to support this, the contention of the respondent that these were unnecessarily being sought to deny him the facility of cashless treatment in the hospital thereby gets credence. In this context, the reliance placed by the State Commission on Gurmel Singh (supra) notwithstanding the judgment in Garg Sons International (supra) cannot be found fault with. The appeal is therefore liable to be disallowed.