1. The brief history of the case of the complainant is that while he was working at Koraput had opened an SB Account bearing No.31270923575 with OP.2 bank. At the instance of OP.2 and the agent of SBI General Insurance Co. (GIC), the complainant had proposed for a Group Health Insurance Policy under Family Floated Scheme and the annual premium of insurance was to be auto paid from the SB accounts of the complainant with OP.2. It is submitted that whereas the OP.2 was issued with Master Policy No.171008-0000-00 by SBI GIC, the Insurance Co. issued policy No.0000000002765242-02 in favour of the complainant commencing from 20.03.2015 and the said policy continues till the policy period 20.03.2018 to 10.03.2019 automatically. The complainant submitted that the policy is a non medical test category and only based on disclosure of facts by the insured. It is also submitted that during subsistence of the policy, the complainant lost vision of its left eye suddenly and contacted local Ophthalmologist and as the things did not go well, the complainant was admitted at Sankar Netralaya, Chennai on 13.02.2018. It is also further submitted that the fact of treatment was duly intimated to Ops over phone on 13.02.2018 just before admission in the hospital and after treatment and discharge on 19.02.2018; the complainant furnished the Member ID Card No.SBIG1043179 for use of said hospital to claim reimbursement from OP.1 but the said card was not accepted because it was not for the current session i.e. 20.03.2017 to 19.03.2018 as a result of which the complainant had to pay the hospital bill and advanced a claim of Rs.33, 869/- on 29.03.2019 before OP.1 and furnished all required documents but OP.1 is not showing any interest to settle the claim of the complainant. Thus alleging deficiency in service on the part of the OP.1 he filed this case praying the Forum to direct the OP.1 to pay Rs.33, 869/- towards medical expenses with interest @ 12% p.a. from 19.02.2018 and to pay Rs.35, 000/- towards compensation and cost to the complainant.
2. Both the Ops in spite of 18 consecutive adjournments neither filed counter nor participated in the proceeding in any manner. The complainant has filed certain documents in support of his case. We have perused the documents available on record for orders on merit.
3. In this case, it is an admitted fact that the complainant has got SB accounts with OP.2 vide A/C No.3127-923575 and as per record the complainant has availed Group Health Insurance Policy from SBI GIC, intermediary of which is OP No.2 with Master Policy No.171008-0000-00 issued by said Insurance Co. It is seen that the policy commenced from 20.03.2015 and continued without break till the policy period 20.03.2018 to 19.03.2019. The complainant stated that due to sudden loss of vision of his left eye, he contacted local Ophthalmologist and as per advice of said doctor the complainant was admitted at Sankar Netralaya, Chennai on 13.02.2018 with intimation to Ops over phone who wished early recovery of the complainant from ailments. The complainant stated that after discharge from the hospital on 19.02.2018, he furnished the Member ID Card No.SBIG4013179 to meet the hospitalization charges but the card was not accepted because it was not for the current session i.e. 20.03.2017 to 19.03.2018 for which the card was not effective as declared by the hospital authority and the complainant paid Rs.33, 869/- in cash to the hospital. It is further stated that in spite of assurance, the OP.1 is not settling the claim.
4. In absence of counter and participation of Ops in this proceeding, we have lost opportunity to know anything from them and hence the allegations of the complainant duly supported by the documents remained unchallenged.
5. It is found from the record that the complainant has taken Group Health Insurance Policy from SBI GIC through OP.2 and the OP.1 is the claim adjudicating authority. The insurance policy vide No.0000000002765242 of the complainant was commenced from 20.03.2015 and continued till the period from 20.03.2018 to 19.03.2019. The complainant was admitted at Sankar Netralaya, Chennai on 13.02.2018 i.e. during insurance period 20.03.2017 to 19.03.2018. It is seen from the bank statement of accounts of the complainant available on record that on 20.03.2017 a sum of Rs.11, 200/- has been debited from the SB accounts of the complainant towards premium of health insurance i.e. for the period 20.03.2017 to 19.03.2018. From the above facts it became very much clear that the complainant has received treatment during subsistence of his health insurance policy.
6. The complainant stated that every year, the Ops are to issue separate health card for use of the complainant and his family members but for the period 20.03.2017 to 19.03.2018 the Ops have not issued the Member ID Card in favour of the complainant though the premium has been received by the Ops for the said period. The complainant further stated that before hospitalization he intimated the fact of treatment to the Ops on 13.02.2018 and the Ops assured the complainant for cashless treatment as the complainant has chose a TPA network hospital. As ascertained, the complainant must have intimated the fact of his treatment to the Ops anticipating cost of treatment to be borne by them as because; he has possessed the health insurance policy. As the health card produced by the complainant was found to be not effective, he paid the hospital charges in cash.
7. It is seen that the complainant has advanced a claim of Rs.33, 869/- before OP.1 on 29.03.2018 and submitted required documents through OP.2 but the OP.1 on 16.04.2018 asked clarification about non submission of claim intimation and delay in submission of claim documents.
8. We have carefully gone through the documents and submissions available on record and found that the Ops have received premium for the period 20.03.2017 to 19.03.2018 but have not issued the Member ID Card for the said session for which the complainant suffered at Sankar Netralaya, Chennai after treatment. This inaction of the Ops in our opinion amounts to serious deficiency in service on their part. Further the complainant is a customer of the Ops and the insurance premiums are auto deducted from the accounts of the complainant. It is seen that after receiving premium the Ops have forgotten their duties towards their customer. Further after receipt of claim intimation and required documents from the complainant they have not settle the claim which act of the Ops also leads to unfair trade practice. The Ops cannot debar the complainant to get his legitimate claim as because of the existing contract between the parties. By not issuing the Member Id Card in time, the Ops violated the terms of agreement and for such violation of conditions by the Ops, the complainant suffered.
9. In this case, the complainant has claimed Rs.33, 869/- towards medical expenses which includes different type of examination/test fees as we noticed. Actual medical expenses are Rs.30, 999.60 ps as found from the consolidated bill with details of break up. Hence the complainant is entitled to get Rs.31, 000/- towards medical expenses with interest @ 12% p.a. from OP.1. Further due to such inaction of the OP.1, the complainant must have suffered some mental agony and has come up with this case incurring some expenditure for which he is entitled for some compensation and cost. Considering the sufferings of the complainant, we feel a sum of Rs.5, 000/- towards compensation and Rs.2000/- towards cost in his favour will meet the ends of justice.
9. Hence ordered that the complaint petition is allowed in part and the OP.1 is directed to pay Rs.31, 000/- towards medical expenses with interest @ 12% p.a. from 19.02.2018 and to pay Rs.5000/- towards compensation besides Rs.2000/- towards cost of litigation to the complainant within 30 days from the date of communication of this order.
(to dict.)
