IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM
Dated this the 30th Day of January 2019
Present: - Sri. E.M.Muhammed Ibrahim, B.A, LL.M. President
Smt.S.Sandhya Rani, BSc,LL.B, Member
CC No.191/14
Ravi Kumar.R : Complainant
Kallingazhikathu
Kavanadu P.O
Sakthikulangara Village, Kollam.
[By Adv.I.Sowfiuar]
V/s
- Head-Claims : Opposite parties
S.B.I Life Insurance Co.Ltd.
Central Processing Centre
Kapas Bhavan Sector 10,C.B.D
Belapur, Navi Mumbai-400614.
[By Adv.V.Sugathan]
- The Authorized Officer
E-meditek(TPA)Service Ltd.
No.45,Nathupur Road DLF Phase III
Guargaon-Haryana-122002.
- The Branch Manager
M/s S.B.I Life
S.B.I Main Branch Office Premises
Near Railway Station, Kollam.
[By Adv.V.Sugathan]
ORDER
Smt.S.Sandhya Rani, member
This is a case based on a consumer complaint filed under Section 12 of the Consumer Protection Act 1986.
The averments in the complaint in short are as follows:-
The complainant on 24.01.12 availed insurance service from the opposite parties vide policy No.46004142501 by name SBI LIFE –Hospital Cash. The complainant renewed the policy and it was live as on the date of claim. As per the policy condition the complainant and his family members get
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coverage of Rs.200000/- per year. The complainant was admitted at Upasana Hospital, Kollam as inpatient vide IP No.324593 and diagnosed as D.M.Scrold abson Belainuth and T2DM and admitted there as inpatient on 24.02.2014 and operation was done on 26.02.14 and the following investigation were done. E.C.G, WBC,RBC,Hb,PLT,ESR,BT,CT,Bld Virus,creation on image Idle, HIV and HBS Ag, PT Prother control, BIL, total etc. and finally discharged on 03.03.14. At the time of discharge, the hospital authorities issued a bill for Rs.19318/- and the complainant has remitted the bill on the belief that, the amount will be refunded by the opposite parties. The complainant has duly submitted the bill with claim form with opposite parties on 27.03.14 and after five months the complainant has received the claim closure letter dated 04.08.14 by stating that your claim was closed as ‘No-Claim’ owing to non-receipt of documents. The reasons stated in the repudiation letter are untenable and against law of insurance and natural justice. The repudiation of claim by the opposite parties caused much mental agony, in convenience and financial loss to the complainant. As an insurance company and a service provider the act of opposite parties are not trustworthy and it amounts to a mode of cheating and breach of contact and also amounts to deficiency in service and unfair trade practice. As per the insurance law the insured is having right to claim within the period of insurance for its benefits from the insurer(opposite parties), and the insurer are liable to pay the claim amount to insured within reasonable time.
The 3rd opposite party is the branch of the 1st opposite party insurance company having branches at Kollam and doing insurance business at Kollam. The complainant further prays to direct the opposite parties to pay the claim amount of Rs.19318/- with interest @ 12% per annum from 27.03.14 onwards. Rs.14000/- as daily cash benefit, Rs.2000/- as Incentive Care Unit benefit and Rs.10000/- as compensation. Hence the complaint.
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The opposite party No.1&3 filed joint written version raising the following contentions.
The complaint is not maintainable for want of territorial jurisdiction. The complaint is against the terms and conditions of the policy. The complainant is demanding hospital expenses which are not available as per the terms and conditions of the policy. There is no deficiency or negligence in the service of opposite party No.1&3. The complainant by suppressing material documents preferred the complainant with distorted facts. The insurance company deserve their right to decline the claim benefit if the claim is found to be inexpensable as per the terms and condition of the policy or if any other valid grounds exists. There is no valid cause of action to the complainant and the cause of action alleged is premature and hence the claim of the complainant has to be dismissed in-limine. However the opposite party No.1&3 would admit that they have received the claim intimation from the complainant regarding hospitalisation in Upasana Hospital, Kollam for the period from 24.02.14 to 03.03.14 for D.M.Scrotal abscess and T2DM. The complainant was admitted in the hospital for 7 days and the daily hospital cash benefit for 7 days was Rs.14000/-(2000X7 days). The company has registered the said claim with ID No.100041403782 and the claim has been pending for want of the following requirements which are intimated to the complainant vide letter dated 10.04.14. Those requirements are :-
- Kindly provide Justification of prolonged duration of stay, line of treatment-certified by treating doctor.
- Kindly confirm when ailment was first diagnosed certified by treating doctor for type 2 Diabetes and obesity.
- Kindly provide attested copy of indoor case papers with nursing chart of hospitalisation with admission history sheet, operation notes, progress notes.
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- Kindly provide valid copy of registration certificate of the hospital with the local authorities.
- Kindly provide completely filled hospital cum treating doctor certificate.
But the complainant has not satisfied the above requirements. Hence the opposite parties No.1&3 again sent letter dated 04.07.14 to the complainant stating that the complainant’s claim is treated as ‘No Claim’ owing to non receipt of documents stated in the 1st letter referred above which are highly necessary to decide the admissibility or otherwise of the claim of the complainant . Still the opposite party No.1&3 company is willing to examine the admissibility or otherwise of the claim of the complainant subject to the submission of the necessary documents as stated above. It is humbly submitted that the opposite parties reserve their rights to decline the claim benefit within the terms and conditions of the policy. The opposite parties will be able to decide the admissibility or otherwise of the claim of the complainant only after the receipt of the above said requirements. All claims shall be subject to requirements as stipulated by the opposite parties. The opposite parties reserved the right to call for any additional information and documents to satisfy itself as to the validity of a claim.
The opposite party No.1&3 would further content that the claim of the complainant is illegal unjust and unfair and the complaint is frivolous, vexation and is an abuse of process of law. The complainant is not entitled to the relief of any nature what so ever and further prays to dismiss the complaint with their costs.
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In view of the above pleadings the points that arise for consideration are:-
- Is not the complaint maintainable?
- Whether there is any deficiency in service or any unfair trade practice on the part of the opposite parties in respect of the medi claim lodged by the complainant?
- Whether the complainant is entitled to get the reliefs sought for?
- Relief and costs.
Point No.1
Section 11(2) & (3) of the Consumer Protection Act deals with territorial jurisdiction of CDRF. As per Section 11 (2) a complaint shall be instituted in a District Forum within the local limits of whose jurisdiction the opposite party or each of the opposite parties, where there are more than one at the time of institution of the complaint, actually and voluntarily resides, or carries on business or has a branch office or personally works for gain Section 11(3) would specifies that a complaint can be instituted where the cause of action wholly or in part arises. Here in this case Section 11 (3) applies as the part of the cause of action arose at Kollam within the jurisdiction of this Forum. The complainant has obtained the policy through the 3rd opposite party Branch of the 1st opposite party. The 3rd opposite party is having its office at Kollam. Further the complainant has undergone treatment at Upasana Hospital, Kollam that he has sent the duly filled up claim form for his native place at Kavanadu, Sakthikulangara Village, Kollam. In the circumstance it is clear that part of the cause of action arose within the Jurisdiction of this Forum. Hence this Forum has ample jurisdiction to entertain this complaint. The point answered accordingly.
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Point No.2 & 3:-
For avoiding repetition of discussion of materials these two points are considered together. The following are the admitted facts in this case.
Complainant is the holder of Ext.P1 Policy No.46004142501 by name SBI-LIFE Hospital cash. As per the terms and conditions of Ext.P1 policy the complainant and his family members will get coverage of Rs.2,00,000/- per year. The contesting opposite party No.1&3 have also not denied having the complainant admitted and treated at Upasana Hospital, Kollam on 24.02.2014 and discharged on 03.03.2014 as shown in Ext.P2 treatment summary. Ext.P4 Hospital Bill amounting to Rs.19,318/- is also not seriously disputed. The opposite parties have also admitted that the complainant has lodged Ext.P2 claim for the above amount by sending the original of Ext.P4 bill. But the opposite parties have rejected the above claim by sending Ext.P5 claim closure letter. According to the complainant the reasons stated in Ext.P5 claim closure letter are false untenable and against law of insurance and natural justice and that he has not received any such communications from the opposite parties.
It is true that the opposite party insurance company is having every right to decline the claim benefit if the claim is not found admissible as per the terms and conditions of the policy or if any other valid ground exists. Now it is to be considered whether the terms and conditions of the Ext.P1 policy document cum policy booklet would justify the denial of claim by the insurance company. The main ground urged by the contesting opposite parties is that they have required the policy holders to produce 5 documents mentioned under paragraph 2 of written version. But the policy holder failed to produce those documents inspite of sending annexure B,C1and C2. But the complainant has clearly denied having received any such communication . It is brought out during cross examination of PW1 that after submitting Ext.P2 claim form he has received only Ext.P5 claim rejection letter and has not received any other
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communication. Hence it is clear that the contention of the contesting opposite parties in paragraph 2 that they have sent letter dated 10.04.2014 and another two reminder letters dated 24.04.2014 and 12.05.2014 are incorrect. It is true that the contesting opposite parties have produced original of the above letter and reminder letters as Annexure B,C1 and C2 along with the written version. But the learned counsel appearing for the opposite parties while cross examining PW1 has not shown those documents to PW1 nor got those documents marked in evidence either through PW1 or by examining any of the officers of the contesting opposite parties. It is pertinent to note that the contesting opposite parties have not cared to materialise Annexure B,C1&C2 documents into evidence probably because of the fear that the forum will find out the falsity of the claim that those documents were duly sent to the complainant as claimed in the written version. The contesting opposite parties have also not produced any oral or documentary evidence such as postal receipt or postal acknowledgment cards evidencing that annexure B,C1&C2 were duly sent in the name and address of the complainant and received by him. In the circumstances there is no merit in contenting that the claim was rejected for non production of documents in spite of repeated requests and reminders issued by the contenting opposite parties.
It is further to be considered whether the production of those 5 documents as demanded by the contesting opposite parties is absolutely essential for the disposal of the claim by the opposite parties. Under the headings claims in Page No.21 of Ext.P1 policy document it is stipulated that the policy holder should intimate the claim in stating at least the policy number and the nature of the illnessclaim. It is further to be pointed that there is no stipulation under clause 10,2(1) to (9) that any such document required by the insurance company in the written version has to be produced by the complainant. It is highly unfair on the part of opposite parties to demand the documents relating to the gensis of the
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hospital gensis of the disease and the authority of the doctor who treated the patient and insist that those documents are to be produced by the complainant as required in the written version. If the insurance company may have any doubt regarding the above aspects they may have to conduct an enquiry by deputing any of their local representatives. It is highly unfair, unethical and unjustifiable in demanding these documents to be produced by the policy holder which is practically not for him to obtain and produce. Even if a condition to the effect that the insurance company is entitled to require any documents from the policy holder to sanction the claim a provided under clause 10.2(5) a person who has obtained the Insurance policy after paying one time premiumwhich is a substantial amount may expect that when he fell it he will get financial assistance and had undergone treatment at the private hospital. The insurance company is expected to receive the claim form along with supporting documents to prove illness, hospitalisation and expenses incurred for the treatment and if they are not satisfied with those documents they can conduct enquiry by deputing their agents and also obtain documents directly from the hospital and local authorities. Insisting the policy holder to produce several documents regarding the establishment of the hospital and authority of the doctor gensis of the disease etc. will be impossible for the complainant to produce. It is highly unfair and unethical to deny the legitimate claims of the policy holder by alleging that he has not produced documents which are not within his reach and are not directly related to his treatment definitely is unfair trade practice on the part of the insurance company.
It is clear from the available materials that complainant who had undergone treatment had lodged a legitimate claim with supporting documents to prove his illness, hospitalisation line of treatment and expenses incurred, along with claim form. But the same has been rejected by the opposite party insurance company without even directing the complainant in writing to rectify
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the defects if any would definitely amounts to deficiency in service also. It is also clear from the available materials that as the legitimate insurance claim lodged by the complainant has been rejected by the opposite parties on the grounds that the complainant has not produced documents which are not within his reach or easily obtainable by him. It is clear that the opposite parties have demanded the complainant to perform the impossibility, simply for the reasons to reject the claim. In the circumstance the argument that the complainant has sustained severe mental agony apart from financial loss is having some force. In the circumstances we have no hesitation to hold that the complainant is entitled to get the reliefs sought for from the opposite party Insurance company. The points answered accordingly.
Point No.4
In the result the complaint stands allowed directing the opposite parties No.1 to 3 to pay Rs.40,318/- (being the amount of Rs.19318/- covered by Ext.P4 discharge bill, Rs.14000/- as daily hospital cash benefit, Rs.2000/- as ICU benefit as claimed and Rs.5000/- as compensation) along with costs Rs.2000/- within 45 days from the date of receipt of a copy of this order, failing which the complainant is allowed to recover Rs.40,318/- with interest at the rate of 9% per annum from the date of complaint till realisation along with cost Rs.2000/- from opposite party 1 to 3 jointly and severally and from their assets.
Dictated to the Confidential Assistant Smt. Deepa.S transcribed and typed by her corrected by me and pronounced in the Open Forum on this the 30th day of January 2019.
E.M.Muhammed Ibrahim:Sd/-
S.Sandhya Rani:Sd/-
Forwarded/by Order
SENIOR SUPERINTENDENT
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INDEX
Witnesses Examined for the Complainant:-
PW1 : Ravikumar.R
Documents marked for the complainant
Ext.P1 : Copy of policy document
Ext.P2 : Copy of claim form
Ext.P3 : Copy of Discharge card
Ext.P4 : Copy of discharge bill
Ext.P5 : Copy of claim closure letter
Witness examined for the opposite party:-Nil
Documents marked for the opposite party:-Nil
E.M.Muhammed Ibrahim:Sd/-
S.Sandhya Rani:Sd/-
Forwarded/by Order
SENIOR SUPERINTENDENT
