DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 30th day of April 2018
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 23/04/2016
: Sri.V.P.Anantha Narayanan, Member
(C.C.No.55/2016)
Rasiya,
W/o Sidhik.K,
Kandangatil Veetil House,
Pattambi Taluk, Ottapalam. - Complainant
(By Adv.K.Dhananjayan)
V/s
1. M/s SBI General Insurance Co.Ltd,
DD Trade Tower,
Room No.3, C, Kaloor, Kadvanthara Road,
Cochin, PIN.
2. M/s SBI General Insurance Co.Ltd,
Rep.by its Manager/Principal Officer/
Authorised Signatory, DD Trade Tower,
Room No.3, C, Kaloor, Kadavanthara,
Cochin, Pin.
(By Adv.P.Prasad)
3. Branch Manager, - Opposite parties
SBI,Vallapuzha Branch,
Ottapalam Taluk,
Palakkad District Code No.7397.
(By Adv.Shiju Kuriakose)
O R D E R
By Sri. V.P.Anantha Narayanan, Member
The case of the complainant is briefly stated as follows.
Complainant’s husband Sidhik has taken a SBI Mediclaim Policy, which is issued by 1st & 2nd opposite parties bearing No-0000000002429411. As per this policy terms and conditions, the complainant and her husband are also covered for medical expenses incurred during the existence of the policy. The policy coverage is for Rs.2 lakhs. The tenure of the policy is from 10.01.2015 to 09.01.2016 and the package of the policy is known as “SBI Optima Family Plus”. After paying Rs.4,300/- premium amount, the 3rd opposite party issued a policy to the complainant. The complainant was affected by stress urinary incontinence rectocele and later on, she underwent a surgery in the Perinthalmanna nursing home where surgery was conducted on 01.10.2015 by expert doctors and she was discharged on 04.10.2015. For the surgery and the allied treatment, the complainant incurred Rs.45,000/-. According to the complainant, she is covered by medical insurance and the opposite parties are legally liable to reimburse the amount to her or directly to the hospital. After her admission to the above mentioned hospital, complainant’s husband intimated about her treatment to the opposite parties especially to the 3rd opposite party. The 3rd opposite party intimated the complainant to send all the original medical records to the 1st and 2nd opposite parties to enable them to process the claim which the complainant did and on 12.10.2015 the medical records were sent to the 1st & 2nd opposite parties by Professional Couriers and the opposite parties have received the same on 27.10.2015. According to the complainant, the opposite parties have neither rejected the claim nor allowed the claim. Hence, in order to avoid a litigation, the complainant sent a lawyer notice to the opposite parties on 28.11.2015 asking them to pay Rs.45,000/- plus cost of lawyer notice; according to the complainant, although the opposite parties received the lawyer notice on 04.12.2015, no positive response came from their side. Complainant, further, pleads that, as per the terms and conditions of the policy, the product type of the policy is “Family Floater” and complainant and her husband are entitled to get the policy benefits. Hence, complainant is a consumer under the Consumer Protection Act 1986 and she can file this complaint before this Forum in her own capacity. According to the complainant, the act of non reimbursement of the amount and non indemnification, though the complainant has valid coverage of the policy, during the time of surgery, amounts to deficiency in service and unfair trade practice on the part of the opposite parties. The complainant is legally entitled to get from the opposite parties Rs.45,000/- plus auxiliary expenses of Rs.10,000/- plus Rs.10,000/- towards mental agony plus cost of litigation incurred. Hence, complainant filed a complaint before this Forum to get a compensation of Rs.65,000/- from the 1st, 2nd & 3rd opposite parties who are jointly and severally liable to compensate the complainant. Hence, complainant’s prayer to the Hon’ble Forum to admit the complaint and direct the opposite parties to pay Rs.65,000/- with interest to the complainant till realization plus any other interim reliefs.
The complaint was admitted and notices were issued to the opposite parties to enter appearance and file their versions. In the version jointly filed by 1st & 2nd opposite parties, they deny all the allegations, averments and claims in the complaint except those specifically admitted and contend that complaint is false, frivolous, vexatious and unsustainable. As per the policy conditions, the insurance company is not liable to make payment under the policy as per exclusion clause No.3. According to 1st and 2nd opposite parties, the complainant was admitted in hospital with cellulitis diabetics and hypertension. Diabetes predisposes to cellulitis. As per exclusion clause No.3 of the policy, there is one year waiting period for the treatment of diabetes and its complications. The policy starts from 10.01.2015 and she was admitted to the hospital on 18.08.2015 that is within one year from the inception of the policy. As per the request for cashless hospitalization for medical insurance, the complainant stated that she had diabetes for the last two years and was admitted with cellulitis diabetes and hypertension. Hence, the complainant is not entitled to get reimbursement as per the policy exclusion clause No.3 and the company is not liable to make any payment under this policy in respect of any expenses incurred by the insured person. Further, surgery for urinary incontinence rectocele is not covered under the exclusion clause no.3 of the policy under the head “surgery of genitourinary tract”, as there is one year waiting period for that surgery. Therefore, 1st and 2nd opposite parties contend that there is no deficiency in service or unfair trade practice on their part and these opposite parties have not caused any mental agony to the complainant. Hence, they pray to the Hon’ble Forum that complaint should be dismissed with cost. In his version, the 3rd opposite party contends that, the complaint is not maintainable and devoid of good faith and liable to be dismissed. This opposite party denies the aversions of the complainant except those admitted by him. This opposite party agrees that 3rd opposite party is acting as an agent of 1st and 2nd opposite parties, complainant’s husband has taken a medical insurance policy but denies any role in respect of the insurance policy mentioned in the complaint; it does not come within the authority of the 3rd opposite party, in respect of this policy, by examining the documents the final decision cannot be taken by the 3rd opposite party for which no authority is given to him. 3rd opposite party also contends that after taking this policy, when the complainant and her husband contacted him this opposite party correctly and truly told and convinced them. Hence, no deficiency of service has arisen from this opposite party. Also, this opposite party has no authority to examine the policy related documents and take a final decision. Therefore, this opposite party contends that this opposite party is not a necessary party in this case.
3rd opposite party was called absent, and hence, set ex-parte, but 3rd opposite party filed IA 306/16 to set aside ex-parte order and the same is allowed on cost. 1st, 2nd & 3rd opposite parties filed their chief affidavits. The complainant filed chief and additional affidavits. From the side of the complainant Exts.A1 to A7 were marked. Complainant also filed questionnaire for answers by 2nd opposite party to which the latter filed answers. From the side of the opposite parties, Ext.B1 was filed and marked. Complainant and opposite parties were also heard.
The following issues are considered in this case.
- Whether there is any deficiency in service and/or unfair trade practice on the part of the opposite parties?
- If so, the relief and cost available to the complainant?
Issues No.1 & 2
This complaint is filed to get compensation on account of deficiency in service occurred on the part of the opposite parties. Complainant’s husband has taken a SBI mediclaim policy, from the 1st opposite party. The original insurance policy issued by the 1st & 2nd opposite parties is marked as Ext.A1 which shows policy no., premium details, exclusions applicable etc. The coverage of the policy was for Rs.2,00,000/-; the tenure of the policy was from 10.01.2015 to 09.01.2016 and the package of the policy is known as “SBI Optima Family Plus”. Being affected by “stress urinary incontinence rectocele”, complainant underwent a surgery in Perinthalmanna Nursing Home on 01.10.2015 and was discharged on 04.10.2015. For the surgery and allied treatment complainant incurred Rs.45,000/-. The discharge card dated.08.10.2015 issued by the above hospital is marked as Ext.A5 which shows, diagnosis, treatment, name of the doctor, name of the patient etc. The admission slip issued by the above hospital is marked as Ext.A6 which shows name of the patient, name of the doctor, date of admission, IP No., OP No. etc. Soon after the admission, complainant’s husband intimated the opposite parties about the treatment. The pharmacy of the above hospital issued a cash bill dated.01.10.2015 to the complainant patient which is marked as Ext.A7 which shows bill no., doctor’s name, other particulars and total net amount. According to the complainant, since she has protection of medical insurance, the opposite parties are legally liable to reimburse the amount to her or pay directly to the hospital. As per the direction given by the 3rd opposite party, complainant sent all the original medical records to the 1st & 2nd opposite parties on 12.10.15 through professional couriers and they have received the same on 27.10.15. Original receipt dated.12.10.2015 issued by professional couriers is marked as Ext.A2 which shows name of the consigner, name of the consignee (SBI General Insurance Company, Ltd, Kochi), receipt by consignee of the original medical records in good condition on 27.10.15 CN No. etc. According to the complainant, the opposite parties did not either reject the claim or allow the claim of the complainant. On 28.11.2015 complainant sent a lawyer notice to the opposite parties asking them to pay Rs.45,000/- plus cost of lawyer notice, but there is no positive response from the side of opposite parties. Complainant pleads that she is entitled to get from the opposite parties Rs.45,000/- plus auxiliary expenses of Rs.10,000/- plus compensation for mental agony of Rs.10,000/- plus litigation cost. Copy of the lawyer notice and acknowledgement card to prove the receipt of the lawyer notice by the 2nd opposite party are marked as Ext.A3 series. The 3rd opposite party issued to the complainant his SB account pass book dated.12.08.2008 and on 06.11.2009 to the credit of account no. of complainant’s husband Rs.14,500/- was paid. True copy of this payments to the credit of Sidhik (complainant’s husband) is marked as Ext.A4. As per their version, 1st and 2nd opposite parties jointly contend that they are not liable to make any payment under the policy as per exclusion clause No.3 of the policy. The complainant is admitted with “cellulitis diabetes” and hypertension and diabetes predisposes to cellulitis; as per exclusion clause no.3 of the policy there is one year waiting period for treating diabetes and its complications. Opposite parties further contend that the policy starts form 10.01.2015 and the complainant was admitted in the hospital on 18.08.2015 within one year from the inception of the policy; also, as per the request for cashless hospitalization for medical insurance, the complainant stated that she had diabetes for the last two years and she was admitted with “cellulitis diabetes and hypertension”. Further, the surgery for “stress urinary incontinence rectocele” is also not covered under the policy exclusion no.3 under the head “surgery of genito urinary tract” because there is one year waiting period for such surgery. Hence according to the 1st & 2nd opposite parties, the complainant is not entitled to get reimbursement as per the policy exclusion clause no.3 of the policy. Photocopy of policy exclusion clause no.3 of the policy produced by 1st & 2nd opposite parties is marked as Ext.B1 which indicates policy no., certificate of insurance of group health insurance policy, its terms & conditions, diseases to which exclusions applicable in the 1st year of cover from the commencement of the policy etc. As per the version submitted by the 3rd opposite party, he contends that with respect to insurance policy mentioned in the complaint, the 3rd opposite party has no authority and role and final decision is outside his purview. He also contends that complainant and her husband approached the 3rd opposite party after their taking the mediclaim insurance policy and all information relating to this was clearly given to them by the 3rd opposite party. Hence according to the 3rd opposite party no deficiency in service is committed by him, also scrutiny of the mediclaim insurance policy documents is outside the purview of this opposite party and to get the mediclaim insurance policy benefits necessary documents were also sent to the complainant. Hence this opposite party contends that he is not liable to pay any compensation to the complainant and may be excluded by dismissing the complaint.
From the affidavits and documentary evidences produced before this Forum, we understand that to the complainant surgery for “stress urinary incontinence rectocele” was performed on 01.10.15 in Perinthalmanna Nursing Home and the opposite parties have not yet admitted the claim of the complainant for surgery and allied treatment expenses stating that this surgery and genito urinary tract surgery are one and the same and surgery for urinary incontinence rectocele is not covered under the exclusion clause No.3 of the policy under the head surgery of “genito urinary tract” because there is one year waiting period for that and genito urinary tract surgery is included in the list of exclusion as per exclusions clause No.3 of the policy. But, we view that the opposite parties have not filed a crystal clear and adequate evidence from medical experts to prove that the above mentioned two surgeries are one and the same; we also observe that opposite parties have not filed any documentary evidence to prove that complainant was admitted with “cellulitis diabetes and hypertension” and the complainant had diabetes for the last two years. In the light of all of the above, we view that the opposite parties have been found to have committed deficiency in service and unfair trade practice towards the complainant. The result is that the complaint is allowed.
We order the 1st, 2nd & 3rd opposite parties to be jointly and severally liable to pay to the complainant Rs.45,000/- (Rupees forty five thousand only) towards surgery and allied treatment expenses, Rs.5,000/- (Rupees five thousand only) by way of compensation for mental agony suffered by the complainant and her husband and Rs.3,000/- (Rupees three thousand only) towards cost of proceedings incurred by the complainant.
This order shall be executed within one month from the date of receipt of this order; otherwise complainant is also entitled to interest @ 9% p.a on the total amount due to him from the date of this order to realization.
Pronounced in the open court on this the 30th day of April 2018.
Sd/-
Shiny.P.R
President
Sd/-
Suma.K.P
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext.A1 - Original Insurance Policy issued by SBI General Insurance to the
complainant
Ext.A2 - Original receipt issued by professional couriers to the complainant’s
husband for receiving from him original medical records for sending the
same to SBI General Insurance Company Ltd, Kochi
Ext.A3 - Copy of lawyer notice dated.28.11.2015 along with acknowledgement
card
Ext.A4 - Photocopy of the S.B Account pass book issued by SBI, Vallappuzha
Branch bearing S.B Account No.10610017723
Ext.A5 - Discharge card issued by Perinthalmanna Nursing Home dated.08.10.2015
Ext.A6 - Admission slip of the complainant dated.30.09.2015
Ext.A7 - Photocopy of the cash bill issued by the Perinthalmanna Nursing Home
Exhibits marked on the side of Opposite parties
Ext.B1 - Copy of SBI General Insurance Group Health Insurance Policy
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite parties
Nil
Cost of proceedings
Rs.3,000/-
