DATE OF FILING: 09.01.2014

DATE OF DISPOSAL: 20.12.2017

Dr. N.Tuna Sahu, Presiding Member: 

            The complainant has filed this consumer dispute  under Section 12 of the Consumer Protection Act, 1986, alleging deficiency in service against the Opposite Parties (in short the O.Ps.) and for redressal of his   grievance before this Forum.

            2. The brief facts that are relevantly required for disposal of this consumer dispute is that being persuaded by the Mr. K.Krishna Murty Patra (IA Code 12084658), the Agent of the O.Ps, the complainant obtained an insurance policy namely SBI Life – Hospital Cash from the O.Ps on payment of Rs.10,781/- towards premium for an assured cash benefit of Rs.5,00,000/-. On 31.08.2012 the complainant submitted the proposal form duly filled in by the Manager of O.P.No.2 and paid the premiums through cheque No.692809 dated 31.08.2012 for Rs.10,781/- and the O.Ps assured cash benefits for 2(two) persons of his family. Accordingly, the O.Ps issued the insurance policy bearing No.46005149504 in their office letter dated 04.09.2012. While the matter stood thus the complainant suffered from Kidney disease and was admitted in Kalinga Hospital, Bhubaneswar as an indoor patient from 14.03.2013 to 25.03.2013 for kidney transplantation. The kidney was donated by Smt. Sunita Kumari Panda, wife of the complainant who is also covered under the S.B.I. Life – Hospital Cash Benefit policy. It is also stated in the complaint that Smt. Sunita Kumari Panda was admitted in the Kalinga Hospital, Bhubaneswar on 14.03.2013 and discharged from the Hospital on 20.03.2013 and incurred expenditure of Rs.40,000/- towards hospitalization charges. The complainant after returning from Kalinga Hospital, Bhubaneswar submitted his hospital claim for Rs.1,10,000/- only @ Rs.10,000/- for ten days from 19.03.2013 to 25.03.2013 and daily hospital cash benefit @Rs.5,000/- for one day. The complainant submitted Claim Form along with documents before the O.P.No.2 on 03.05.2013 and requested for settlement of the same. On receipt of the claim application, the TPA sought for documents in letter dated 13.05.2013 which was received by the complainant on 27.05.2013 and the complainant complied on 20.06.2013. Again the O.P.No.1 required further documents in his office letter dated 02.07.2013 which was received by the complainant on dated 23.07.2013 and the complainant complied the same through  Email on 01.08.2013. Even after furnishing all required papers/documents, the O.Ps instead settling the claim of the complainant repudiated the same in its  letter dated 16.12.2013 stating that the claim is closed as “No claim”. It is also alleged that the claim of hospitalization charges of his wife Smt. Sunita Kumari Panda, who is also covered under the policy in question for Rs.40,000/- was also repudiated by the O.Ps in the letter dated 11.06.2013. When the O.Ps did not give any heed to settle the claim of the complainant, he filed this consumer complaint in this Forum alleging deficiency in service on the part of the O.Ps and prayed to direct the O.Ps to pay Rs.1,10,000/- towards hospitalization charges of the complainant and a sum of Rs.40,000/- towards claim of his wife Smt. Sunita Kumari Panda and to award Rs.30,000/- as compensation for harassment and mental agony and to pay Rs.5,000/- as cost of litigation in the best interest of justice.

            3. Upon notice, the O.Ps appeared through learned counsel Shri A. Uma Maheswar Rao, Advocate and filed written version on 19.03.2014 and written argument on 16.02.2016. It is stated in the written version/argument that the complainant is holder of policy bearing No.46005149504 with date of commencement as 03.09.2012 with daily hospital cash benefit of Rs.5,000/-, ICU benefit of Rs.10,000/- and family care benefit of Rs.10,000/-. The policy provides for the fixed daily hospitalization cash benefit as stated above to the policy holder with a ceiling up to a sum of Rs.5,00,000/-. The complainant Sri Satyabadi Panda was the insured one under the policy and the complainant’s wife, Smt. Sunita Kumari Panda was the insured two under the policy. The O.Ps have received the claim intimation from the complainant regarding hospitalization in the Kalinga Hospital, Bhubaneswar for the period 14.03.2013 to 25.03.2013 for kidney transplantation. The complainant has claimed ICU benefit for 10 days i.e. Rs.1,00,000/- and daily hospital cash benefit for 1 day i.e. Rs.5,000/-. Hence, the total claim of the complainant was Rs.1,05,000/-. The Company has registered the said claim with claim ID No.100051302927 and the claim was pending for following requirements which were asked for vide letter dated 13.05.2013.  i) kindly provide all investigation reports in support of final diagnosis, ii) kindly confirm when ailment was first diagnosed certified by treating doctor  CKD, iii) Kindly provide attested copy of Indoor case papers with nursing chart of hospitalization and iv)  Kindly provides completely filed hospital cum treating doctor’s certificate. It is also stated that as the complainant has not submitted all the requirements called for, the O.Ps have sent a letter dated 16.12.2013 to the complainant stating that the complainant’s claim is treated as “No claim” owing to non receipt of documents. However, the O.Ps vide letter dated 16.12.2013 have also requested the complainant to provide the said documents but the complainant failed to submit the same.  Since the complainant did not comply with necessary requirements, the O.Ps are not able to examine the admissibility or otherwise of the claim. However, it is stated that O.Ps 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. The O.Ps reserve their rights to decline the claim benefit within the terms and conditions of the policy. It is also admitted that O.Ps have also received the claim intimation from the complainant’s wife regarding hospitalization in the Kalinga Hospital Bhubaneswar for the period 14.03.2013 to 20.03.2013as a donor for kidney transplantation. The complainant’s wife has claimed ICU benefit for 4 days i.e. Rs.40,000/- (Rs.10000X 4 days ) and daily hospital cash benefit for 3 days, i.e. Rs.15,000/- (Rs.5000 X 3 days). Hence the total claim of the wife of the complainant was Rs.55,000/-. The company has registered the said claim with Claim ID No. 1000051302928. The wife of the complainant, Smt Sunita Kumari Panda was admitted in Kalinga Hospital as a donor for kidney transplantation and the same is permanently excluded from the insurance cover as per the terms and conditions of the policy vide policy clause 6.2.11 of the policy conditions. Hence the claim of the complainant’s wife Smt. Sunita Kumari Panda was rejected by the O.Ps. The reliefs prayed for in the complaint are unjust, illegal and unfair on the part of the complainant and the present complaint is frivolous and vexatious and is an abuse of the process of law. The complainant is not entitled to any relief of whatsoever nature hence the Forum be pleased to dismiss the complaint with costs to the O.Ps.

            4. On the date of hearing of the consumer dispute, we have heard the learned counsel for the complainant as well as for the O.Ps. We have also gone through the submissions and verified the materials placed on the case record. During the course of hearing of the matter, the learned counsel for the complaint contended that the complainant being a resident of Ganjam district deposited the annual premium amount of Rs.10,781/- in the office of the O.P. No.2 located at Aska Road, Berhampur who transacts insurance business in Ganjam district hence the issue of maintainability of the case does not arise on the ground of territorial jurisdiction. The O.Ps issued a policy bearing No.46005149504 dated 04.09.2012 under product name SBI Life – Hospital Cash, a health insurance plan covering the life of present complainant Satyabadi Panda and his wife Sunita Panda. He further submitted that the complainant was hospitalized for kidney transplantation in Kalinga Hospital, Bhubaneswar for the period 14.03.2013 to 23.03.2013 and a sum of Rs.1,10,000/- was spent towards the hospitalization and treatment and as per the policy conditions, the complainant is entitled for reimbursement of the expenditures of hospitalization from the O.Ps. It is also submitted that the wife of the complainant Sunita Panda is also covered under the policy and in the same hospital she was also admitted as a kidney donor from 14.03.2013 to 20.03.2013 and an amount of Rs.40,000/- was spent in her hospitalization which is liable to be reimbursed by the O.Ps as per the policy conditions. However, on submission of the claim amount of Rs.1,50,000/- by the complainant after treatment for reimbursement, the O.Ps repudiated the claim on the ground of ‘the claim was closed due to non-submission of documents’ by the complainant. The complainant requested the O.Ps for settlement of his claim amount but the O.Ps did not give any heed to his grievances hence he has filed this consumer complaint and claimed the relief as prayed in the complaint.

            Per contra, the learned counsel for the O.Ps in his submissions contended that there is no dispute or doubt that the present complainant is the holder of policy bearing No.46005149504 which commenced w. e. f. 03.09.2012 with daily hospital cash benefit of Rs.5,000/-, ICU benefit of Rs.10,000/- and family care benefit of Rs.10,000/-. The aforesaid policy provides fixed daily hospitalization cash benefit with a ceiling up to an assured sum of Rs.5,00,000/-. It is further submitted that there is no dispute that the present complainant was admitted in Kalinga Hospital, Bhubaneswar for the period 14.03.2013 to 25.03.2013 for kidney transplantation and accordingly the complainant has claimed ICU benefit for 10 days i.e. Rs.1,00,000/- and daily hospital cash benefit for one day i.e. Rs.5,000/-  hence the total claim amount was Rs.1,05,000/- which has been registered under claim ID No.100051302927 and the claim was pending for consideration due to want of  documents like i) investigation reports in support of final diagnosis, ii) documents regarding confirmation of when ailment was first diagnosed certified by the treating doctor CKD, iii) attested copies of indoor case papers with nursing chart of hospitalization and iv)completely filled hospital-cum-treating doctor’s certificate. Similarly, in case of complainant’s wife, it is submitted that Sunita Kumari Panda has claimed ICU benefit for 4 days @Rs.10,000/- per day i.e. Rs.40,000/- and daily hospital cash benefit for 3 days @Rs.5,000/- per day i.e.  Rs.15,000/- hence the total claim of the complainant’s wife was Rs.55,000/-. The company has registered the claim of the complainant’s wife bearing claim ID No.10005130928. The complainant was time and again requested by the TPA, E-Meditec to submit the aforesaid documents to the O.Ps on 13.05.2013, 29.05.2013, 14.06.2013 respectively and finally the O.Ps on 16.12.2013 sent a letter to the complainant but the complainant did not submit the aforesaid documents as required. Hence, the O.Ps could not examine the admissibility of the claim so there is no deficiency in service on part of the O.Ps. He further submitted that as per the terms and conditions of the policy under exclusion clause 6.2 i.e. under permanent exclusions, a claim arising out of hospitalization where life assured is admitted as a donor for organ transplant is permanently excluded. Since, Smt. Sunita Kumari Panda was admitted in Kalinga Hospital as a donor for kidney transplantation thus the same is permanently excluded from the insurance cover as per the terms and conditions of the policy. As no documents were received by the O.Ps, the O.P has rejected the claim which was intimated to the complainant on 18.05.2013 as per letter submitted as Annedure–E. The learned counsel for the O.Ps also relied on a number of decisions of Hon’ble Supreme Court of India and National Commission, New Delhi in support of his arguments such as in the case of LIC of India Vs.Giriraj Mehta vide R.P.No.3123 of 2008(NC), General Assurance Society Ltd. Vs. Chandumall Jain & Anr reported in (1996) 3 SCR 500, in the case of Reliance Life Insurance Co. Ltd Vs.Madhavacharya(NC) order dated 02.02.2010, in the case of United India Insurance Co. Ltd Vs. Subhash Chandra, R.P. No.469/2006 (NC), in the case of IND Swift Ltd Vs. New India Assurance Co. Ltd decided by Hon’ble National Commission vide F.A.No.157 of 2006 and in the case of Grasim Industries Ltd. Vs. Agarwal Steel, Civil Appeal Nos.5994 of 2004,7477 of 2004 and 1733 of 2005 vide judgment dated 20.10.2009 of Hon’ble Supreme Court of India respectively and copies of which were not supplied by the O.Ps and not available on the case record and stated that as per the decisions cited above, an insurance policy is to be construed strictly as per the terms and conditions of the policy document which is a binding contract between the parties and nothing can be added or subtracted by giving a different meaning to the words mentioned therein. 

            5. In view of the above submissions and considering the fact and circumstances of the case, the issues that are crop up for our consideration as to – i) whether the complainant is entitled to the claim amount or whether O.Ps are justified repudiating the claim of complainant?, ii) whether the claim of the complainant’s wife is admissible or excluded under the permanent exclusion clause of the insurance policy in dispute? And iii) whether the complainant is entitled for any compensation and cost as prayed in the complaint?

6. With regard to the first issue as framed above, we would like to state that in this case as admitted the complainant obtained an insurance policy bearing No.46005149504 issued on 04.09.2012 by O.Ps under the product name SBI Life- Hospital Cash on payment of Rs.10781/- towards annual premium vide Draft No.692809 dated 31.08.2012. When the policy was in force, the complainant suffered from kidney problem and was admitted in Kalinga Hospital, Bhubaneswar for kidney transplantation during the period 14.03.2013 to 25.03.2013 as is evident from the Discharge Summary of Kalinga Hospital placed as an Annexure-3 on the case record filed by the complainant. The complainant submitted the claim along with required document in the office of the O.P.No.1 and it was registered under claim ID No.100051302927 for Rs.1,05,000/-

            The order is pronounced on this day of 23rd December 2017 under the signature and seal of this Forum. The office is directed to supply copy of order to the parties free of cost and a copy of same be sent to the server of