BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
KADAPA Y.S.R DISTRICT
PRESENT SMT. K. SIREESHA, B.L., PRESIDENT FAC
SRI M.V.R. SHARMA, MEMBER.
Friday, 11th July 2014
CONSUMER COMPLAINT No. 20 / 2014
Chinnapareddy Rama Murthy Reddy,
S/o Narayana Reddy, age 47 years,
H.No. 1-6-12, Nagarigutta, Opp. Nalanda School,
Pulivendula (T & M), Kadapa District. ….. Complainant.
Vs.
1. The Manager, SBI Life Insurance Co. Ltd.,
D.No. 6/460, 1st floor, R.S. Road, Opp. Sub-Collector’s office,
Rajampet, Kadapa Dist.
2. The Regional Director, SBI Life Insurance Co. Ltd,
Ground floor, D.No. 5-9-588, Parishrama Bhavan,
Basheerbagh, Hyderabad – 500 024.
3. The General Manager, SBI Life Insurance Co. Ltd,
Central Processing Centre, 2nd floor, Kapas Bhavan,
Plot No. 13 A, Sector No. 10 CBD, Bellapur,
Navi Mumbai – 400 614. ….. Opposite parties.
This complaint is coming before us for final hearing on 23-06-2014 and perusing complaint and other material papers on record and on hearing the arguments of Sri G. Siva Kumar, Advocate for complainant and Sri T. Jayaram, Advocate for O.P.1 to 3 and the matter is having stood over for consideration this day, the Forum made the following:-
O R D E R
(Per Sri M.V.R. Sharma, Member),
1. This Complaint is filed under section 12 of the Consumer Protection Act 1986 requesting this forum to direct the Opposite parties:-
(a) To pay the amount of Rs. 31,760/- towards hospital charges and medicines incurred by the complainant.
(b) To pay Rs. 15,000/- towards mental agony.
(c) To pay Rs. 10,000/- towards cost of the complaint.
2. The case of the complaint is that, the complainant and his family members with care of their health and believing the words of O.P.1, the complainant received SBI Life Hospital Policy bearing No. 46003327002, with proposal No. 46-742830, dt. 14-11-2011 from O.P1 and paid premium regularly.
3. On 23-3-2013 night the complainant suffered with fever and admitted as inpatient with I.P.No. 5010 in Raja Raghavendra Nursing Home on 24-3-2013 and there the doctors examined the complainant and identified that he was suffering with Malaria and Jaundice. The complainant has taken treatment in hospital and after ten days he was discharged on 2-4-2013 from Raja Raghavendra Nursing Home. The complainant paid an amount of Rs. 19,800/- towards hospitalization and Rs. 11,960/- towards medicines. The prescriptions and other medical receipts were kept with the complainant.
4. After discharging the complainant sent claim form and other original receipts to the SBI Life Insurance for claiming the policy amount. The SBI Life Insurance has not paid any amount to the complainant and also the opposite parties were asking some papers. The opposite parties are dragging the matter without settling the amount and complainant sent legal notice and opposite parties also sent a reply notice to the complainant on 6-8-2013.
5. The panel doctor of the insurance company was examined and issued policy to the complainant. The complainant has not overlooked the terms and conditions of the policy. The opposite parties gave evasive response to evade the payment of Rs. 31,760/- to the complainant. Hence, this complaint.
6. Opposite parties filed joint counter and denied all the allegations made in the complaint and accepted that the complainant is the holder of the policy bearing No. 46003327002 with date of commencement as 25-11-2011. The terms and conditions of the policy with daily cash benefit of Rs. 2,000/-, ICU benefit of Rs. 4,000/- and family fare benefit of Rs. 10,000/-. The claim for hospitalization of the complainant at Raja Raghavendra Nursing Home from 24-3-2013 to 2-4-2013 was received. The number of days of hospitalization is nine days, as per the definition of the day mentioned under clause (2) definition of sub-clause 12 of the policy document the company has registered the said claim of the complainant. But it was not consider the claim because he did not submitted the requirements and further the prayer of the complainant to pay the expenses incurred in the hospital, is against the terms and conditions of the policy. Thus the prayer of the complainant to pay the expenses incurred in hospital is not maintainable. It is specifically denied that Rs. 19,800/- or Rs. 31,760/- is payable. It is also stated that even, if the claim is admitted in receipt of the requirement to the satisfaction of the O.P’s an amount of Rs. 18,000/- will be paid towards the claim which is as per the terms and conditions of the policy. The complaint issued legal notice was received and the same was duly replied vide letter dt. 06-8-2013 in which the list of pending requirements were clearly mentioned.
7. Opposite parties are also stated that the address of the O.P.2 & O.P. 3 is at Hyderabad and Navi Mumbai respectively. But the complaint is filed before the Hon’ble forum at Kadapa. Hence, the complaint is not maintainable for territorial jurisdiction of this forum. Hence, on this ground alone the complaint is liable to dismiss against O.P.2 & 3. Hence, dismissed the complaint with costs.
8. To prove the case the complainant filed an affidavit along with documents and got marked Ex. A1 to A4 and on behalf of the opposite parties filed affidavit, counter, written arguments and documents marked as Ex. B1 to B5.
9. On the basis of the above pleadings the following points are settled for determination.
- Whether the complainant is eligible for compensation as prayed by him?
- Whether there is negligence or deficiency of service on the part of opposite parties?
- To what relief?
10. Point Nos. 1 & 2. The contention of the complainant is that, the complainant and his family members with care of their health and believing the words of O.P.1, the complainant received SBI Life Hospital Policy bearing No. 46003327002, with proposal No. 46-742830, dt. 14-11-2011 from O.P1 and paid premium regularly. On 23-3-2013 night the complainant suffered with fever and admitted as inpatient with I.P. No. 5010 in Raja Raghavendra Nursing Home on 24-3-2013 and there the doctors examined the complainant and identified that he was suffering with Malaria and Jaundice. The complainant has taken treatment in hospital and after ten days he was discharged on 2-4-2013 from Raja Raghavendra Nursing Home. The complainant paid an amount of Rs. 19,800/- towards hospitalization and Rs. 11,960/- towards medicines. The prescriptions and other medical receipts were kept with the complainant.
11. Further contention of the complainant that, after discharging the complainant sent claim form and other original receipts to the SBI Life Insurance for claiming the policy amount. The SBI Life Insurance has not paid any amount to the complainant and also the opposite parties were required some papers. The opposite parties are dragging the matter without settling the amount and complainant sent legal notice and opposite parties also sent a reply notice to the complainant on 6-8-2013. The panel doctor of the insurance company was examined and issued policy to the complainant. The complainant has not overlooked the terms and conditions of the policy. The opposite parties gave evasive response to evade the payment of Rs. 31,760/- to the complainant. Hence, this complaint.
12. The contention of the Opposite parties that they accepted that the complainant was the holder of the policy bearing No. 46003327002 with date of commencement as 25-11-2011. The terms and conditions of the policy with daily hospital cash benefit of Rs. 2,000/-, ICU benefit of Rs. 4,000/- and family care benefit of Rs. 10,000/-. The claim for hospitalization of the complainant at Raja Raghavendra Nursing Home from 24-3-2013 to 2-4-2013 was received. The number of days of hospitalization is nine days, as per the definition of the day mentioned under clause (2) definition of sub-clause 12 of the policy document the company has registered the said claim of the complainant. But it was not consider the claim because he did not submitted the requirements and further the prayer of the complainant to pay the expenses incurred in the hospital, is against the terms and conditions of the policy. Thus the prayer of the complainant to pay the expenses incurred in hospital is not maintainable. It is specifically denied that Rs. 19,800/- or Rs. 31,760/- is payable. It is also stated that even, if the claim is admitted in receipt of the requirement to the satisfaction of the O.P’s an amount of Rs. 18,000/- will be paid towards the claim which is as per the terms and conditions of the policy. The complaint issued legal notice was received and the same was duly replied vide letter dt. 06-8-2013 in which the list of pending requirements were clearly mentioned.
13. Further contention of the Opposite parties that the address of the O.P.2 & O.P. 3 is at Hyderabad and Navi Mumbai respectively. But the complaint is filed before the Hon’ble forum at Kadapa. Hence, the complaint is not maintainable for territorial jurisdiction of this forum. Hence, on this ground alone the complaint is liable to dismiss against O.P.2 & 3. Hence, dismissed the complaint with costs.
14. As seen above averments Ex. A1 and B1 reveals that the complainant and his family insured with SBI Life Hospital policy bearing No. 46003327002, dt. 14-11-2011 from O.P.1 and he paid premium regularly. On 23-3-2013 night the complainant suffered with fever and he admitted as in patient with I.P. No. 5010 in Raja Raghavendra Nursing Home, Puliendula, Kadapa Dist. On 24-3-2013 and there the doctors examined and identified that the complainant suffering with Malaria and jaundice as per Ex. A4. The complainant taken treatment for a period of 10 days from 24-3-2013 to 2-4-2013 and incurred an amount of Rs. 19,800/- towards hospitalization. The complainant also incurred an amount of Rs. 11,960/- as per Ex. A3, towards medicines charges totaling (Rs. 19,800/- + Rs. 11,960/- Rs. 31,760/-).
15. After discharging from hospital the complainant sent claim form along with original bills as Ex. A3 and A4 to the opposite parties for claiming the policy amount. As seen Ex. B2 & B3 the opposite parties sent letters to the complainant for requirement of more information. Hence, the SBI Life not paid any amount to the complainant, after that the complainant sent legal notice to the opposite parties and the O.P’s duly replied on 6-8-2013. The O.P’s gave evasive replies to evade the payment.
16. The contention of the O.P’s as the policy conditions were with daily hospital cash benefit of Rs. 2,000/-, ICU benefit of Rs. 4,000/-, family hospital cash benefit Rs. 10,000/- the claim for the hospitalization of the complainant at Raja Raghavendra Nursing home from 24-3-2013 to 2-4-2013, the number of days of hospitalization is nine days. Under the clause No. 2 definition sub-clause 12 of the policy company registered his claim. The claim is admitted on receipt of the requirement to the satisfaction of the O.P’s an amount of Rs. 18,000/- will paid towards claim, which as per the terms and conditions of the policy.
17. As seen Ex. B1 clause 2 definitions the sub-clause 12 of the policy not seen daily hospital cash benefit of Rs. 2000/- as per O.P’s contention and also the O.P’s are admitted in counter their liability. Hence, this contention of the O.P’s is not tenable.
18. Further contention of the O.P’s that the address of this O.P.2 and 3 is at Hyderabad and Navi Mumbai respectively. But the complaint is filed before the Hon’ble Forum, Kadapa. Hence, the complaint is not maintainable for want of territorial jurisdiction of this forum.
19. As per Section 11 of Consumer Protection Act 1986 the Opposite parties 2 & 3 branch office i.e. O.P.1 office is situated in territorial jurisdiction of District Consumer Disputes Redressal Forum, Kadapa. Hence, the O.P’s contention is not tenable.
20. As discussed above the complainant proved deficiency in service on the part of the opposite parties. Hence, the complainant is eligible for hospitalization and medicines charges. The points are answered accordingly.
21. Point No. 3 In the result, the complaint is allowed, directing the opposite parties 1 to 3 jointly and severally liable to pay Rs. 31,760/- towards medical charges for hospitalization, to pay Rs. 5000/- towards mental agony, to pay Rs. 5,000/- towards cost of the complaint, within 45 days of date of receipt of orders.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 11th July, 2014
MEMBER PRESIDENT FAC
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant NIL For Respondents : NIL
Exhibits marked for Complainant: -
Ex. A1 P/c of SBI Life Insurance cash policy bearing No. 46003327002,
dt. 26-11-2011.
Ex. A2 P/c of admission certificate issued by the Hospital.
Ex. A3 P/c of the medical prescriptions and cash bills 5 in number, dt. 24-3-2013,
25-3-2013, 27-3-2012, 29-3-2012 and 01-4-2013.
Ex.A4 P/c of discharge summary along with certificate cum cash receipt issued by
the hospital.
Exhibits marked for Opposite parties : -
Ex. B1 P/c of the policy document.
Ex. B2 P/c of letter dt. 4-5-2013.
Ex. B3 P/c of letter dt. 16-5-2013.
Ex. B4 Copy of letter, dt. 18-4-2014.
Ex. B5 Copy of the reply to the legal notice dt. 6-8-2013.
MEMBER PRESIDENT FAC
Copy to :-
- Sri G. Siva Kumar, Advocate for complainant.
- Sri T. Jayaram, Advocate for O.P.1 to 3.
B.V.P. - - -
