Orissa

Sambalpur

CC/2/2020

Mrs. Santilata Pradhan - Complainant(s)

Versus

1-The B.M. SBI general Insurance Company Ltd. - Opp.Party(s)

Sri. P.K.Bohidar & Sri K.C. Majhi

30 Jan 2023

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint Case No.- 2/2020

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

 

Mrs. Santilata Pradhan,

W/O-Late Durga Madhab Pradhan,

R/O-Pattnaikpara, PO-Jharuapara, Ps-Town,

Dist-Sambalpur, Odisha.                                          ...………..Complainant

                                                Versus

1. The Branch Manager, SBI General Insurance Company Ltd.

Swagat (Bijaya Bhawan), Second Floor (G2),

Ainthapali, PO-Budharaja,

Dist-Sambalpur-768004, Odisha.

2. The Manager, SBI General Insurance Company Ltd.

‘Natraj’ 301, Junction of Western Express Highway & Andheri

Kurla-Road, Andheri(East),

Mumbai, Maharashtra.                                  …………...Opp.Parties

 

Counsels:-

1. For the Complainant           :-       Sri. S.Dash & Associates
2. For the O.Ps                        :-       Sri. B.K.Purohit

 

Date of Filing:02.01.2020,Date of Hearing :15.11.2022Date of Judgement : 30.01.2023

Presented by Dr. Ramakanta Satapathy, President

1. The Complainant has come before the Commission alleging deficiency in service of the O.Ps. The case of the complaint is that the Complainant is having a “Group Health Insurance Policy” bearing policy No. 0000000002574226 and health card I.D. No. SBIG 3652791 for a sum of Rs. 1.00 lakh w.e.f. 16.02.2015 and the Complainant is regularly paying the premium to the O.Ps.

On 14.05.2018 the Complainant fell ill with high fever and chills with body ache, taken to Sanjivani Hospital, a network hospital of the O.Ps for treatment. After test it was diagnosed with ‘Urinary Tract Infection and advised for hospitalisation. The Complainant put forth her claim before O.P. No.1 through the hospital but the O.P. No.1 declined and rejected the request of the Complainant with a plea that ‘Urinary Tract Infection’ was due to her pre-existing diseases and not entitled for the claim. The Complainant paid the entire expenditure of treatment to the hospital and on 16.05.2018 discharged. The Complainant thereafter visited the office of O.P. No.1 but was ignored. A legal notice was also served but no any action was taken. Being aggrieved this complaint was filed.

2. The O.Ps after appearance filed their version and submitted that the Complainant is having renewal Policy No. 2574226-03 (Arogya Plus Policy) for the period 01.03.2018 to 28.02.2019. The Complainant was hospitalised on 24.05.2018 on account of HTN, CVA(R+) Hemiphegia, GTC seizure and discharge on 16.05.2018, from Sanjivani Hospital. The Complainant was hospitalised due to pre-existing disease which is excluded from the policy terms and condition. It is only allowed only after 48 consecutive months from the inception of the first –group Health Policy. The O.Ps have filed the pre-existing nature of illness treatment details. The Complainant has not filed any cogent documentary evidence. The O.Ps are not deficient in their service and the complaint is liable to be dismissed.
3. Perused the documents filed by the Complainant and O.Ps. It is the admitted case of both the parties that from 01.03.2018 to 28.02.2019 policy No. 2574226 was in force. The O.P. received a sum of Rs. 7900/- vide receipt No. 7234386 dated 25.02.2018.

The O.P. in Para-3 of its version submitted that, “the cause of loss which prompted the hospitalisation is actually a pre-existing disease of the Complainant which is excluded from the policy Terms and conditions.” The claim was evaluated when a fair chance was given to the O.P. Sanjivani Hospital wrote a letter to Medicare TPA Pvt. Ltd. On 16.05.2018 for settlement @Rs. 10,378/- Dr. K.D. Purohit opined on date of discharge i.e. 16.05.2018 that case of the Complainant is year old HTN, CVA (R+), Hemiplegia, GTC Seizure etc. CVA in January 2015 and cause of Seizure is Cerebral Stroke for which CT scan of the brain done. The O.P. not filed a single documents of the medical opinion given by the insurance doctor engaged. It was the duty of the O.P. to get a thorough check up test and basing on the said report enter into the contract of insurance.

In the present case continuance of the original health policy signified that the insurance companies in a whimsical way to promote their business not collecting proper information of the insured. No doubt insurance contract is basing on good faith and it is the duty of the insured to disclose the history but at the same time it is the duty of insurance Company to enter into contract after proper physical verification and report. This part lacks in this case. When a patient is admitted into a hospital, denial of the claim is shocking but also harassment to the patient/insured.

The duty casted up on the O.P. has not been complied by the O.P. property, it amounts to deficiency in service. Accordingly, it is ordered:

 

6698606.  

The complaint is allowed on contest against the O.P. The O.P. is directed to pay an amount of Rs. 10,378/- to the Complainant to-wards medical expenses, Rs. 50,000/- to-wards deficiency in service and Rs.10,000/- to-wards litigation expenses within one month of this order. In case of non-compliance entire amount will carry 10% interest P.A. from 16.05.2018 till date of realisation.

Order pronounced in open court on this 30^th day January 2023.

Supply free copies to the parties.