DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 443 of 24.10.2016
Decided on: 7.9.2017
Gurmeet Singh aged about 61 years son of Late S.Amir Singh, resident of H.No.412/1, Nattan Street , Sheran Wala Gate, Patiala.
…………...Complainant
Versus
1. State Bank of Patiala, Head Office, Patiala Near Sheranwala Gate, Patiala through M.D.
2. United India Insurance Co.Ltd., Branch Office Leela Bhawan, Patiala, through B.M.
3. Heritage Health TPA Pvt. Ltd.,NICCO House, 5th Floor, 2 Hare Street, Kolkata, India.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.Gurmeet Singh, complainant with his counsel
Sh.A.D.S.Bhullar,Advocate.
Sh.Hemant Nanda, Advocate,
counsel for Opposite Party No.1
Sh.D.P.S.Anand, Advocate,
counsel for Opposite Party No.2.
Opposite Party No.3 ex-parte.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Sh.Gurmeet Singh, complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.).In brief, the case of the complainant is as under:
2. That the complainant was the employee of OP no.1 i.e. State Bank of Patiala and retired on 6.6.2007. Thereafter, OP no.1 offered a scheme of health insurance to be maintained by OP no.2 i.e. United India Insurance Co, for its retired employees according to their category/job profile. The complainant accepted the offer and executed the required documents with OP no.1 and also provided the premium amount out of his bank account No.65018747449, maintained with OP no.1 which was deducted on 26.11.2015. OP no.2 generated the health insurance card bearing policy No.DNOHHSB-0700312853 and P.F. No.G00256. It is stated that in the said policy his wife was also covered for availing the health insurance benefits. It is further stated that the complainant got himself treated for health issues relating to his heart, sugar and blood pressure and the bills with regard to the medicines and doctor fee were submitted with OP no.1, the detail of which has been given as under:
- Rs.11,616/- dated 8.1.2016
- Rs.2175/- dated 5.2.2016
- Rs.2184/- dated 3.3.2016
- Rs.2050/- dated 4.4.2016
- Rs.4771/- dated 28.6.2016
- Rs.33044/- dated 28.6.2016( Note: Out of this Rs.25000/- sanctioned balance Rs.8044/- indoor hospitalization bill not paid )
- Rs.2386/- dated 5.7.2016
- Rs.4772/- dated 6.6.2016
- Rs.2386/- dated 15.10.2016
He submitted the aforesaid bills with OP no.1 for encashment but OP failed encashed the same. He sent letter dated 7.9.2016 to OPs No.1&3 but they failed to pay any amount with regard to the aforesaid bills, for which he has been facing mental agony and physical harassment. The OPs are also deficient in providing the service. Hence this complaint with a prayer for direction to the OPs to clear the medical bills amounting to Rs.58,000/- alongwith damages of Rs.50,000/- and also to pay Rs.50,000/- as compensation for causing mental agony and physical harassment.
3. On being put to notice, OPs No.1&2 appeared and filed their separate written versions while OP no.3 failed to come present despite service and was accordingly proceeded against exparte.
4. In the written version filed by Op no.1 it has taken preliminary objections that the complaint is not maintainable; that the complainant has not come to the Forum with clean hands and the complaint is liable to be dismissed. On merits, it is stated that the insurance policy was taken by the complainant on his own will. It is admitted that the premium with regard to the policy was deducted from account No.65018747440 maintained with it. It is stated that the bills submitted by the complainant were related to domiciliary/OPD treatment, which were not payable as per condition no.2 of the insurance policy. It is also stated that the rejection of claim was on the part of OP no.2 and if OP no.2 clears the claim of the complainant then it has no objection with regard to the claim. There is no deficiency in service on its part. After denouncing all other allegations going against it, it was prayed to dismiss the complaint.
5. In the written version filed by OP no.2, it has also taken the preliminary objections that the complaint is not maintainable as complicated questions of law and facts are involved in the same for which civil court is competent to try the present complaint; that this Forum has no territorial jurisdiction to try the present complaint as the policy was issued by the Mumbai office of the company. On merits, it is stated that Indian Bank’s Association A/c State Bank of Patiala Head Office, The Mall, Patiala had purchased Tailor made Group Medi claim Policy (Retirees) from OP no.2 for the period from 6.11.2015 to 31.10.2016, covering the expenses of insured person who shall contract any disease or suffer from any illness or sustained any bodily injury through accident , subject to terms, conditions, exclusion of the insurance policy. The complainant was covered under the policy being insured and retiree of the State Bank of Patiala. The wife of the complainant was also covered under this policy. It is stated that the complainant had lodged as many as 9 claims , out of which 8 claims were for domiciliary treatment . Accordingly to Policy Additional Condition No.2, no expenses related to domiciliary / OPD treatment are payable . However, one claim for cataract left eye treatment, wherein cashless approval had been granted for Rs.25000/-. The insured lodged pre and post hospitalization claim for a sum of Rs.8014/- .Same was processed and it was found that admissible amount was Rs.6029/-against submitted documents to Rs.7664/-. The 9 claims submitted by the complainant in a policy period of one year have been settled and intimated to the complainant. There is no deficiency in service on its part. After denouncing all other allegations going against it, it was prayed to dismiss the complaint.
6. On being called to do so, the complainant has tendered in evidence his affidavit,Ex.CA alongwith documents Exs.C1 to C8 and closed the evidence.
The ld. counsel for OP no.1 has tendered in evidence Ex.OPB, sworn affidavit of Manager, SBOP and closed the evidence.
The ld. counsel for Op no.2 has tendered in evidence Ex.OPA, sworn affidavit of Smt. Kanta Devi alongwith documents Exs.OP1 to OP2 and closed the evidence.
7. We have heard the ld. counsel for the parties alongwith the complainant and have also gone through the record of the case, carefully.
8. Admittedly, complainant, who being the retired employee of the bank i.e. State Bank of Patiala, was duly insured with the OP no.2 i.e. United India Insurance Co. under the Medical Insurance Scheme, launched by OP no.2.The grievance of the complainant is that the Ops did not reimburse the amount of Rs.58000/- which he had incurred for taking medical treatment. The plea of OP no.1 is that since the insurance policy was issued by the OP no.2 and it refused to pay the claim amount to the complainant, therefore, it has no role to play and cannot be said to be deficient in providing services. Therefore, the complaint filed against it, may kindly be dismissed. The OP no.2 has pleaded that the complainant lodged in total 9 claims with it, out of which 8 claims were for domiciliary treatment. As per condition No.2, of the policy, No expenses related to domiciliary/OPD treatment were payable. However, one claim for treatment of cataract in left eye had already been paid .As such, there is no deficiency of service on its part and the complaint filed against it is liable to be dismissed.
9. We have perused the copy insurance policy,Ex.OP1. In condition No.2 of the same, it is categorically mentioned that,No expenses related to domiciliary / OPD treatment is payable”. But this fact cannot be denied that in the 10th BIPARTITE SETTLEMENT DATED 25 MAY,2015,under the head Domiciliary Treatment , Ex.C8, it is mentioned that , “domiciliary treatment shall also be covered under the scheme i.e. treatment taken for specified disease which may or may not require hospitalization ……..”. Even in the copy of circular No.GB/IND/4/15-16 dated 19 October,2015, of State Bank of Patiala, which is annexed alongwith Ex.C8, it has been categorically mentioned that expenses for hospitalization and domiciliary treatment are covered, meaning thereby that 10th BIPARTITE SETTLEMENT and circular have been issued by OP no.1 in contravention of terms and conditions of the insurance policy in question. Taking these facts and circumstances into consideration, we are of the view that as per the insurance policy in question, the complainant is not entitled for the reimbursement of the expenses of domiciliary/OPD treatment. However, this fact cannot be ignored that the complainant by relying upon the aforesaid circular issued by OP no.1 and the BIPARTITE SETTLEMENT, which are in contravention of the terms and conditions of the insurance policy, has filed the present complaint before this Forum, with the hope to get the reimbursement of the amount incurred by him on his domiciliary treatment, which caused him a lot of mental agony and physical harassment . Therefore, OP no.1 is liable to compensate the complainant adequately. It may be stated that neither any specific allegations have been raised against OP no.3 nor the same have been proved, therefore, no deficiency of service can be attributed to it.
10. In view of the aforesaid discussion, we dismiss the complaint against Ops no.2 &3 . However, we dispose of the complaint against OP no.1 with a direction to pay a sum of Rs.10,000/- to the complainant as compensation for causing mental agony and physical harassment and Rs.10,000/- as litigation expenses. The OP no.1 is further directed to comply this order within a period of 30 days from the receipt of the certified copy of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:7.9.2017
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
