Haryana

Charkhi Dadri

CC/79/2022

Vinod Kumar - Complainant(s)

Versus

M/s SBI General Insurance Co. Ltd. - Opp.Party(s)

Complainant In Person

08 Jan 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, CHARKHI DADRI

 

CONSUMER COMPLAINT NO.79 of 2022

DATE OF INSTITUTION: - 29.03.2022

DATE OF ORDER: -           08.01.2024    

 

Vinod Kumar aged 37 years S/o Shri Balbir Singh R/o H. No.186, Village KakroHatti, PO Kakroli Sardara, Distt. Charkhi Dadri-127306 (Haryana)

    ……………Complainant.

VERSUS

M/s SBI General Insurance Co. Ltd. Natraj-301, Andheri Kurla Road, Andheri (East) Mumbai-400069

………….. Opposite Party.

 

          COMPLAINT UNDER CONSUMER PROTECTION ACT

 

BEFORE :-  Hon’ble  Sh. Manjit Singh Naryal, President

Hon’ble Sh. Dharam Pal Rauhilla, Member

 

Present: - Shri MC Sharma, Advocate for complainant.

      Shri Rahul Sheoran, Advocate, for the OP.

 

ORDER:-

 

1.                The case of the complainant in brief, is that he insured under CORONA Rakshak Policy for a sum of Rs. 2,50,000/- vide policy No. POCRP00100000809 for the period from 24.04.2021 to 05.11.2021 effective from 09.05.2021.  In June, 2021 on development of symptoms of Corona Virus, the complainant got himself tested from Government Hospital.  The sample of the complainant was collected on 12.06.2021 and tested on 13.06.2021 in Lab of Civil Hospital Bhiwani under patient ID RT-PCR/BWN/132021. According to RTPCR Test Report (COVID-19) the complainant was declared positive on 14.06.2021. After that he was admitted in Shree Ganesha Hospital, Dadri Gate, Kaunt Road, Bhiwani for CORONA treatment and discharged on 18.06.2021. Treatment was cashless being amount Rs. 87,938/- under Health Insurance Scheme through Aditya Birla Health insurance Company Limited.  The complainant has lodged his claim with SBI General Co. Ltd. vide Claim No. CL-00108109 on 28.06.2021 enclosing all the necessary documents in compliance of terms and conditions of the policy. The claim was to be settled within 45 days of the receipt of necessary documents. But OP had repudiated the claim after the passage of more than two months on 30.10.2021 stating that claim was submitted on the basis of illegal investigation and submission of fake documents and alleged that to get undue claim by misrepresentation of facts and misleading the company is arbitrary and illegal in order to repudiate the claim. The complainant visited to the office of the OP, time and again for obtaining the claim but to no avail. Hence, the present complaint has been preferred for deficiency in service on the part of OP resulting into monetary loss as well as mental and physical harassment with a prayer for issuance of directions to OP pay sum insured alongwith compensation and litigation expenses etc. apart from other relief that the Hon’ble Commission deems it fit and proper to award during the pendency of the complaint.

2.                 On appearance, OP had filed written statement and took preliminary objections and denied the allegations of the complainant. It is submitted that the OP had acceded the request   of the complainant and has issued Corona Rakshak Policy No. PCRP00100000809 on 24.04.2021 for sum assured Rs.2,50,000/-. It is alleged that complainant submitted claim form mentioning therein that he was admitted in Shree Ganesha Hospital, Bhiwani on 14.06.2021 and was discharged on 18.06.2021 due to Covid-19. Alongwith claim form complainant has submitted the bills and treatment of the hospital. After receiving the claim papers, the OP deputed Reckon Health Care Services for the investigation of the matter. The OP has sent letter dated 26.08.2021 to submit the certified copy of HRCT report. After receiving the documents and investigation report the authority of OP has gone through the papers available on the file and after due application of mind, repudiated the claim vide letter dated 30.10.2021 on the following grounds:-

This is with reference to claim lodged by you on 28.06.2021. we acknowledge the receipt of documents.

We have carefully perused claim documents and noted that you have claimed for benefit under the policy towards alleged hospitalization due to Covid 19 positive. Our investigations have established that you have misled the company by misrepresenting the facts and have submitted fake documents to gain undue insurance benefit from company. Hence, your claim is repudiated.

The foregoing repudiation by us on liability is issued based on the facts as at present. We reserve the right to extend or modify this repudiation in the event of new/additional facts or circumstances brought to our knowledge.

The claim of the complainant was repudiated by the competent authority as per terms and conditions of the policy.  Hence, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of OP and complaint of the complainant is liable to be dismissed with costs.

3.                In order to make out his case, the complainant has placed on record affidavit Ex.CW1/A and documents Ex.C1 to Ex.C5 and closed the evidence on 21.02.2023.

4.                The counsel for OP has placed on record affidavit Ex.RW1/A and documents Ex.R1 to Ex.R5 and closed the evidence on 06.10.2023.

5.                 We have gone through the record of the case carefully and have heard the learned counsels for the parties.

6.                The complainant has submitted written arguments in which he has stated that the said agency Reckon Healthcare Service is not registered with Insurance Regulatory and Development Authority of India and its allegation that bills submitted by the complainant were fake, should not be accepted. OP has taken reference of the report of Investigating Agency but no report was submitted to the Commission in this regard. The complainant has fulfilled all the eligibility criteria for payment of insurance claim based on genuine bills/documents of the Hospital.

7.                The OP has failed to adduce any reliable evidence in support of their ground for repudiation of the claim of the complainant except version of OP that based on report of investigating agency the claim was repudiated. The scope of cover under the policy viz. CORONA RAKSHAK POLICY is as under:-

“Lump sum benefit equal to 100% of the sum insured shall be payable on positive diagnosis of COVID requiring hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of COVID shall be from a government authorized diagnostic centre.”

 The complainant has submitted RTPCR Test Report dated 12.06.2021 issued by Civil Surgeon Office, Civil Hospital Bhiwani and the same has not been challenged by the OP. We have also observed that expenses for Rs. 87,938/- have been reimbursed by another insurance company viz. Aditya Birla Health Insurance Co. Ltd. with which the complainant has obtained mediclaim policy for the said treatment. However, OP has repudiated the claim for CORONA RAKSHAK POLICY. We hold that the OP has no justification to repudiate the claim as the complainant has met basic criteria of the policy as mentioned above. Hence, OP is deficient in service. Resultantly, we allow the complaint of the complainant and passed following award.

1. OP is directed to pay the sum insured of Rs. 2,50,000/- (Rupees Two Lakh Fifty Thousand only) alongwith interest @ 6% p.a. from the date of filing the present complaint till its realization.
2. OP is also directed to pay Rs.5000/-(Rupees Five thousand only) as compensation on account of mental pain and agony and Rs.5000/-(Rupees Five Thousand only) as litigation expenses to the complainant.

8.                The above order be complied within 45 days from the date of this order failing which further interest @9% will be paid by the OP for the delayed period.

9.                Certified copies of the order be sent to the parties free of costs.  File be consigned to the record room, after due compliance.