IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 27th day of January, 2014.
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member)
C.C.No.112/13 (Filed on 20.08.2013)
Between:
Sukumaran Nair. R,
Gayathri Bhavan,
Elakolloor.P.O.,
Konni, Pathanamthitta.
(By Adv. Akhilesh. S) ….. Complainant
And:
1. Managing Director,
SBI Life Insurance Co. Ltd.,
Registered Office,
‘Natraj’, M.V. Road & Western-
Express Highway Junction,
Andheri (East),
Mumbai – 400 069.
2. Medical Manager,
E-Meditek (TPA) Services Ltd.,
Regional Office,
208/209 Turf Estate,
Off Dr.E.Mases Marg,
Beside Mhalekshmi Station,
Mahalekshmi,
Mumbai – 400 011.
3. Operation Manager,
SBI Life Insurance Co. Ltd.,
T.C.9/1094(1),
3rd Floor,
Satheesh Building,
Sasthamangalam,
Thiruvananthapuram.
4. Branch Manager,
SBI Life Insurance Co. Ltd.,
1st Floor, Thekkemuriyil Arcade,
Opp. South Indian Bank,
Near Hotel Mannil Regency,
College Road, Pathanamthitta. …. Opposite parties.
(By Adv. Sunitha. K.K counsels for 1,3 & 4)
O R D E R
Sri. Jacob Stephen (President):
The complainant has filed this complaint against the opposite parties for getting a relief from the Forum.
2. The brief facts of this complaint is as follows: The complainant is a health insurance policy holder of the opposite parties under SBI Life Hospital Cash Plan. The said policy started on 05.10.2011 and is valid for 3 years. The assured amount is Rs.2 lakhs and the policy covers the complainant as well as his wife Rajamma. As per the terms and conditions of the policy in question, policy holders are entitled to get Rs.2,000/- per day if the policy holder is admitted in an ordinary ward and Rs.3,000/- per day if admitted in ICU of an hospital for any treatments, provided the hospital admission should be for more than 24 hours.
3. While so, the complainant met with a road traffic accident on 07.09.2012 and sustained injuries and he was admitted at Pathanamthitta General Hospital on the same day at 11.50 a.m as an inpatient. In the said accident he had fracture on his left hand elbow and left shoulder and also sustained other minor injuries. Consequent to the accident and injuries he was admitted in the ICU for the 1st 3 days and in the ward for the remaining 18 days and he was discharged on 28.09.2012. Thereafter the complainant submitted his claim along with all hospital records before the 1st opposite party through 4th opposite party on 10.10.2012. After receiving the complainant’s claim 2nd opposite party directed the complainant to submit the attested copies of the indoor case papers and the nursing chart. Accordingly to the complainant sent the said documents to the 2nd opposite party. After receiving the said document the 2nd opposite party sent a letter dated 07.04.2013 informing that the nursing chart submitted is incomplete. On the basis of the said letter, the complainant obtained a certificate from the orthopedic consultant Dr. Lagy Joshua who treated the complainant showing that the complainant was an inpatient from 07.09.2012 to 28.09.2012 and the said certificate was sent to 2nd opposite party. Such a certificate was obtained as the nursing chart is not found in the hospital. After receiving the said certificate, opposite parties called the complainant to his mobile phone and told that his claim will be settled within 7 working days. But they have not settled the complainant’s claim as per their assurance. So the complainant contacted opposite parties in person and through telephone several time for settling his claim. But they have not settled the complainant’s claim so far. The above said act of the opposite party is a clear deficiency in service which caused mental agony and financial loss to the complainant and the opposite parties are liable to the complainant for the same. Hence this complaint for the realization of a total amount of Rs.1,63,050/- under various heads from the opposite parties.
4. Opposite parties 1, 3 and 4 entered appearance and filed a common version. Opposite party 2 is exparte.
5. The main contentions raised in the version of the contesting opposite parties is as follows: According to the opposite parties, the complainant has not submitted the required documents for processing the complainant’s claim in spite of the communications and reminders to the complainant. In order to process the claim of the complainant, indoor case papers with nursing chart of hospitalization is required. But the same is not properly submitted by the complainant and it was intimated to the complainant. On the basis of the said intimation the complainant submitted certain documents which are not complete. So the opposite parties are not a possession to settle the claim. As per the terms and conditions of the claim, opposite parties are at liberty to disallow the claim, if the formalities are not properly complied by the claims. In such a situation, opposite parties cannot be blamed. Thus they contended that they have not committed any deficiency in service to the complainant and hence the complainant is not entitled to get any of the reliefs claimed for by the complainant. Apart from the above contentions opposite parties also raised certain objections regarding the maintainability of the complaint on the ground of misjoiner of parties, territorial jurisdiction, cause of action etc. With the above contentions, opposite parties prays for the dismissal of the complaint.
6. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
7. The evidence of this complaint consists of oral deposition of PW1 and Exts.A1 to A8. After closure of evidence, both sides were heard.
8. The Point:- The complainant’s case is that he is a policy holder of the opposite parties and the policy benefit is the hospitalization expenses incurred by the policy holders. According to the complainant, he is entitled to get Rs.48,000/- from the opposite parties for his hospitalization from 07.09.2012 to 28.09.2012, consequent to the injuries sustained to the complainant due to the road traffic accident. But opposite parties failed to allow the complainant’s claim, though the complainant had complied all formalities properly for getting his claim. The above said acts of the opposite parties is a clear deficiency in service and hence opposite parties are liable to the complainant for the same.
9. In order to prove the case of the complainant, the complainant filed a proof affidavit in lieu of his chief examination along with 8 documents. On the basis of the proof affidavit, complainant was examined as PW1 and the documents produced are marked as Exts.A1 to A8. Ext.A1 is the policy documents in the name of the complainant issued by the opposite parties in respect of the policy in question. Ext.A2 is the copy of FIR No.770/12 of Konni Police Station registered in connection with the complainant’s accident. Ext.A3 is the copy of treatment records issued from General Hospital, Pathanamthitta in the name of the complainant in connection with the complainant’s treatment from 07.09.2012 to 28.09.2012. Ext.A4 is the copy of a certificate issued by Dr. Lagy Joshua Tharakan, Junior Consultant, Orthopedic, General Hospital, Pathanamthitta showing that the complainant was under his treatment as an inpatient in the ICU and the ward from 07.09.2012 to 28.12.2012. Ext.A5 is the reminder letter dated 22.03.2013 issued by the TPA of the opposite parties in the name of the complainant. Ext.A6 is another reminder letter dated 07.04.2013 issued by the TPA of the opposite parties in the name of the complainant. Ext.A7 is a copy of letter dated 08.02.2013 issued by the complainant in the name of the medical officer of TPA of the opposite parties. Ext.A8 is a certificate dated 02.01.2014 issued by Dr.G.C.S. Unnithan of People’s Clinic Hospital, Pathanamthitta in the name of the complainant.
10. The contentions raised by the opposite parties in their version regarding the question of maintainability of this complaint on the grounds of mis-joinder of parties, territorial jurisdiction, cause of action etc. are not considered in the absence of any evidence from the side of opposite parties to substantiate their said contentions. Apart from the above contentions, opposite parties main contention is that the complainant has not submitted the relevant records necessary for processing the complainant’s claim in spite of their reminders and therefore they could not process the complainant’s claim and hence they argued that they have not committed any deficiency in service and prays for dismissing the complaint.
11. Though opposite parties raised certain contentions against the allegation of the complainant, they have not adduced any oral or documentary evidence in their favour. But they have cross-examined PW1.
12. On the basis of the contentions and arguments of the parties, we have perused the available materials on record and found that the opposite party has no dispute with regard to the validity of the policy in question, the accident of the complainant and his treatments and his hospitalization. The only dispute raised by the opposite party is that the complainant has not submitted the relevant documents which are required for processing the claim along with his claim application and even after the reminders sent by the opposite parties to the complainant for producing the said documents. According to the complainant, he had submitted the relevant documents along with his application and as per the reminders of the opposite parties. Even after the submission of the required documents opposite parties informed the complainant that the documents produced are in complete and also directed to produce the complete set of the documents. For complying the said direction, the complainant approached the hospital authorities for obtaining the same, but it was not received as the said documents are not found there. So he obtained certificate from the doctor who treated him showing that he was under his treatment at Govt. General Hospital, Pathanamthitta from 07.09.2012 to 28.09.2012 and showing that the entries in the nursing chart may be inadvertently left by the nursing section. The said certificate was sent to the opposite party through a registered letter dated 28.05.2013.
13. In view of the rival contentions of the parties, the only question to be considered is whether the complainant had submitted the required documents. It is pertinent to note that the opposite party has not adduced any evidence to show that the complainant has not produced the required documents and the reasons for the non-admissibility Ext.A4 certificate issued by the doctor showing that the complainant was under his treatment for 21 days. Further, the 1st page of Ext.A3 case sheet also clearly shows that the complainant was admitted at General Hospital, Pathanamthitta on 07.09.2012 and discharged on 28.09.2012. Further, opposite party had no case that the complainant had not undergone treatment as an inpatient for 21 days and they have not received Ext.A3 and A4 from the complainant. The policy condition that the policy holders are entitled to get Rs.2,000/- per day for the ward and Rs.4,000/- for the ICU if they are hospitalized for more than 24 hours is an admitted fact. Moreover it not a policy for providing the medical bills and Hospital Bills. In this case, the complainant has proved that he had in the ICU for 3 days and in the ward for 18 days. So he is entitled to get Rs.48,000/- (Rs.12,000/- for 3 days in the ICU and Rs.36,000/- for 18 days in the ward) for his hospitalization as per the terms and conditions of the policy. The denial of the said claim by the opposite party is a clear deficiency in service and they are liable to the complainant for the same. Therefore, this complaint is allowable.
14. In the result, this complaint is allowed thereby the opposite parties are directed to pay an amount of Rs.48,000/- (Rupees Forty Eight Thousand only) with 10% interest from the date of filing of this complaint along with compensation of Rs.7,500/- (Rupees Seven Thousand five hundred only) and cost of Rs.1,000/- (Rupees One Thousand only) to the complainant within 15 days from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with interest at the rate of 12% from today till the realization of the whole amount.
Declared in the Open Forum on this the 27th day of January, 2014.
(Sd/-)
Jacob Stephen,
(President)
Smt. K.P. Padmasree (Member) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : R. Sukumaran Nair
Exhibits marked on the side of the complainant:
A1 : Policy document in the name of the complainant issued by the
opposite parties.
A2 : Copy of the FIR No.770/12 dated 09.09.2012 of Konni
Police Station.
A3 : Copy of treatment records issued from General Hospital,
Pathanamthitta in the name of the complainant.
A4 : Copy of a certificate issued by Dr. Lagy Joshua Tharakan, Junior
Consultant, Orthopedic, General Hospital, Pathanamthitta.
A5 : Reminder letter dated 22.03.2013 issued by the TPA of the
opposite parties in the name of the complainant.
A6 : Reminder letter dated 07.04.2013 issued by the TPA of the
opposite parties in the name of the complainant.
A7 : Copy of letter dated 08.02.2013 issued by the complainant in the
name of the medical officer of TPA of the opposite parties.
A8 : Certificate dated 02.01.2014 issued by Dr.G.C.S. Unnithan of
People’s Clinic Hospital, Pathanamthitta in the name of the
complainant.
Witness examined on the side of the opposite parties: Nil.
Exhibits marked on the side of the opposite parties: Nil.
(By Order)
(Sd/-)
Senior Superintendent
Copy to:- (1) Sukumaran Nair. R, Gayathri Bhavan, Elakolloor.P.O.,
Konni, Pathanamthitta.
(2) Managing Director, SBI Life Insurance Co. Ltd.,
Registered Office, ‘Natraj’, M.V. Road & Western-
Express Highway Junction, Andheri (East),
Mumbai – 400 069.
(3) Medical Manager, E-Meditek (TPA) Services Ltd.,
Regional Office, 208/209 Turf Estate, Off Dr.E.Mases Marg,
Beside Mhalekshmi Station, Mahalekshmi,
Mumbai – 400 011.
(4) Operation Manager, SBI Life Insurance Co. Ltd.,
T.C.9/1094(1), 3rd Floor, Satheesh Building,
Sasthamangalam, Thiruvananthapuram.
(5) Branch Manager, SBI Life Insurance Co. Ltd.,
1st Floor, Thekkemuriyil Arcade, Opp. South Indian Bank,
Near Hotel Mannil Regency, College Road,
Pathanamthitta.
(6) The Stock File.
