| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 204 of 5-8-2019 Decided on : 09-06-2023 Gursewak Singh aged about 32 years, S/o Sh. Jeet Singh S/o Sh. Chhotu Singh, R/o St.No.10/3, Darbara Singh MC Wali Gali, Paras Ram Nagar, Bathinda. ........Complainant Versus SBI General Insurance Company Limited, Branch Office SCF 135, First Floor, Guru Kashi Marg, Opposite Three Cinemas, Bathinda through its Branch Manager. SBI General Insurance Company Limited, 3rd & 4th Floor, Lotus IT Park, Road No.16, Plot No. B-18-19, Sagle Industrial Estate, Thane (W) through its Regional Manager/authorized signatory. (deleted vide order dated 13-8-2019) SBI General Insurance Company Limited, Regd & Corporate office, Natraj 101, 201 & 301, Junction of Andheri-Kurla Road and Western Express Highway, Andheri East, Mumbai, through its M.D./ Authorized Signatory.
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present : For the complainant : Sh. S.S Sohal, Advocate. For opposite parties : Sh. Vinod Garg, for Opposite parties No.1 & 3. Opposite party No.2 deleted. ORDER Lalit Mohan Dogra, President The complainant Gursewak Singh (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against SBI General Insurance Company Limited & others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that the complainant purchased mediclaim insurance policy No.0000000009572174 for the period 19.07.2018 to 18.07.2019 of opposite parties. The opposite parties had assured that the insurance policy covers all type of medical expenses on the treatment in case of any disease or accident. The opposite parties did not issue any terms and conditions of the policy. Rather only policy number was supplied/intimated. It is alleged that during the period of said policy, the complainant suddenly suffered with High Grade Fever and vomiting etc. He was got admitted in Dr. Ravinder Hospital on 01.10.2018 at 10 A.M. and was discharged on 02.10.2018 in the evening. The above said doctor intimated the opposite parties by submitting claim form on behalf of complainant on 02.10.2018. The complainant thereafter followed up treatment as OPD. It is also alleged that the complainant submitted claim for reimbursement of medical expenditure of Rs.10,789/- and submitted all original documents relating to treatment and medical bills to the opposite parties at their office at Bathinda which were received by Mr. Khushwinder Singh officials of opposite parties but the opposite parties demanded more and more documents although the original documents were already submitted by the complainant to the opposite parties. It is further alleged that thereafter the complainant approached the opposite parties at Bathinda with the request to pay the claim and the opposite parties obtained the signatures of the complainant on some blank printed forms with the assurance the claim will be paid shortly but no payment was made rather the opposite parties kept on lingering on the matter on one pretext or the other and kept on asking for submission of more and more documents again and again although the complainant had submitted all the documents required for processing of the claim. The complainant alleged that the complainant repeatedly requested the opposite parties for the reimbursement of claim amount as the complainant has already submitted the documents to the opposite parties required for the settlement of the claimt but the opposite parties wrongly and illegally repudiated the claim of the complainant vide letter dated 20-12-2018, on totally false grounds that the opposite parties shall be under no obligation to make any payment under the policy unless the opposite parties have been provided with the documents and information. The said repudiation letter dated 20.12.2018 is totally illegal null and void and having no binding effect on the rights of the complainant as the complainant is entitled to reimbursement of his claim. Due to non-reimbursement and nonpayment of claim, the complainant has suffered mental agony and pains for which he claims compensation to the tune of Rs. 20,000/-. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay a sum of Rs.10,789/- on account of reimbursement of medical expenses as per claim lodged with the opposite parties alongwith interest @ 18% p.a. and Rs.20,000/- as compensation for sufferings besides Rs.10,000/- as litigation expenses. On the statement of learned counsel for complainant, name of opposite party No. 2 was deleted from the array of the opposite parties vide order dated 13-8-2019. Upon notice, opposite parties No.1 & 3 appeared through counsel and contested the complaint by filing joint written reply raising legal objections that intricate and contentious questions of fact and law are involved in the present complaint, which require extrinsic oral and voluminous documentary evidence as such the same cannot be decided by way of summary jurisdiction enacted before this Commission. The complainant has concealed material facts from this Commission. It has been pleaded that the claim of complainant is for the treatment of AFI with LPC. The opposite parties have received documents relating to the claim of the complainant but the complainant has not sent the required documents and additional requirements to the opposite parties. The opposite parties sent various letters dated 03.11.18, 12.11.2018, 23.11.2018, 4.12.18 and 20.12.2018 through TPA to the complainant to submit those documents/ requirements viz. delay reasons, details from attending Doctor, NEFT details and investigation reports. The opposite parties are under no obligation to make any payment under this policy unless as opposite parties have been provided with the documents and information unless the insured person has complied with his obligation under this policy, hence the claim of the complainant stands rejected vide letter dated 20.12.2018, due to non compliance and non submission of required documents. The opposite parties reserve the right to decide the claim of the complainant as per policy terms and conditions as and when the required documents are received from the complainant. Further legal objections are that the complainant has no locus standi or cause of action to file the present complaint. The complainant does not fall within the definition of 'consumer' and that the insured has violated the terms and conditions of the policy. On merits, opposite parties No.1 & 3 have reiterated their stand as pleaded in legal objections and detailed above. In support of his complaint, the complainant has tendered into evidence his affidavit dated 1.8.2019 (Ex. C-1) and documents (Ex.C-2 to Ex.C-28). In order to rebut the evidence of complainant, the opposite parties No.1 & 3 have tendered into evidence affidavit of Jagdish Kumar Dated 16.9.2019 (Ex. OP-1/1) and documents (Ex.OP-1/2 to Ex.OP-1/9). The learned counsel for the complainant has argued that complainant had purchased medical claim Insurance policy and during the period of policy, complainant remained admitted in Dr. Ravinder Hospital and had spent Rs. 10,789/- on his treatment but the claim submitted with the opposite parties was illegally and unlawfully repudiated by the opposite parties which amounts to deficiency in service on their part. On the other hand, learned counsel for the opposite parties No. 1 & 3 argued that complainant was time and again requested to complete the documents i.e. reason of delay, details of attending doctor, NEFT details and investigation reports but the complainant failed to submit the said documents. As such, claim was rejected vide letter dated 20-12-2018 and there is no deficiency in service on the part of the opposite parties and has prayed for dismissal of complaint. We have heard learned counsel for the parties and gone through the file carefully. It is admitted fact that complainant had obtained medical claim insurance policy and during continuation of policy, he remained admitted in Dr Ravinder Hospital. The only objection for rejection of claim is non-submission of documents. We have gone through letter Ex. OP-1/6 as per which, the opposite parties have demanded : (i) Reason of delay (ii) Details from attending doctor – exact time for date of admission and date of discharge in am and pm format (iii) NEFT details (iv) Investigation reports – Item-wise cost-wise detailed breakup of the investigations in submitted bills. We have gone through the record and evidence on record and this Commission is of the view that in Discharge Card, date of admission and discharge is duly mentioned, which is Ex. C-4 on record. In Certificate Ex. C-5, time of admission is clearly mentioned as 10 A.M and complainant has already attached/submitted the bills in respect of payment made to the above said hospital. However, learned counsel for the opposite parties No. 1 & 3 has not been able to explain as to how much delay in intimation was there and what pre-judice has been caused to the opposite parties. Accordingly, from the above discussion and evidence on record, deficiency in service on the part of the opposite parties No. 1 & 3 in repudiating the claim of the complainant vide letter Ex. OP-1/7 is clearly proved. Resultantly, this complaint is partly allowed. The opposite parties No. 1 & 3 are directed to pay medical reimbursement claim of Rs. 10,789/- to complainant alongwith interest @9% p.a. from the date of filing of complaint till realization. However, the complainant is also directed to submit fresh NEFT details with the opposite parties, within a week from the date of receipt of copy of this order and opposite parties No. 1 & 3 are directed to comply with the order, within 45 days thereafter. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 09-06-2023 (Lalit Mohan Dogra) President (Shivdev Singh) Member
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