Punjab

Ludhiana

CC/15/469

Sham Lal - Complainant(s)

Versus

SBI Gen.Ins.Co.Ltd. - Opp.Party(s)

M.S.Sethi Adv.

06 Jun 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 469 of 07.08.2015

Date of Decision            :   06.06.2016 

 

Sham Lal aged 40 years s/o Jai Bhagwan r/o 146, Jain Bhawan Road, Mullanpur, Ludhiana.

….. Complainant

                                                         Versus

 

1.SBI General Insurance Company Limited, Registered & Corporate Office ‘Natraj’ 101, 201 & 301, Junction of Western Express Highway & Andheri- Kurla Road, Andheri(East) Mumbai-400069 through authorized signatory.

2.SBI General Insurance Company Limited, Mullanpur Dakha Branch 50738, Ludhiana through authorized signatory.

3.Paramount Health Services(TPA) Pvt. Ltd., Plot No.442, Road No.28, M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukhumani Mandir, Thane (W)-400604 through authorized signatory.

…Opposite parties 

 

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT                                     

MRS.          BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

 

For complainant                      :          Sh.M.S.Sethi, Advocate

For OP1 and OP2           :          Sh.Vyom Bansal, Advocate.

For OP3                         :         Ex-parte.

 

PER G.K.DHIR, PRESIDENT

 

1.                Complainant hired the services of Ops for purchasing Group Health Insurance Policy for the period from 26.11.2014 to 25.11.2015 through State Bank of India by paying the premium of Rs.3700/- for the assured sum of Rs.3 lac. Necessary medical tests were carried and proposal form was got signed from the complainant. Thereafter, Ops issued the certificate of insurance against Policy No.0000000002319882 dated 26.11.2014. The said policy was disclosed as cashless and issued by PHS ID with No.16600347. During the policy period, the complainant was admitted in DMC Hospital on 26.02.2015 and was discharged from that hospital on 2.3.2015. Ops vide SMS message dated 28.2.2015 sent to the complainant confirmed about receiving of cashless claim bearing No.2716218. Claim form, discharge certificate, medical tests and reports along with hospital bills and other documents were sent, despite the fact that treatment of the complainant still going on. Op3 vide its deficiency letter dated 12.5.2015 pointed out certain objections and complainant after receiving the said letter, approached OPs for clarifying that there is no delay in submission of documents because those were submitted as and when received from the hospital. Regarding other objections, complainant disclosed that in case OPs not satisfied with the documents issued by the concerned hospital or laboratory, then they can verify the record and claim documents from the concerned hospital/laboratory because he is unable to get more documents from concerned. Thereafter, OPs vide SMS message sent to the complainant on 3.7.2015, repudiated the claim of the complainant on ground that claim closed on account of non retrieval of document within the prescribed period as specified by the insurance company. Rejection of claim after long period alleged to be an act of deficiency in service on the part of OPs. It is claimed that instructions followed just for denying the claim on flimsy, false and illegal grounds. It was the primary duty of OPs to visit the concerned authority for verifying the documents because the policy was cashless and OPs bound to collect the documents from the concerned hospital itself. However, instead of performing these duties, claim repudiated by adopting unfair trade practice. The hospital where from treatment got by the complainant namely DMC Hospital is considered as the best. Complainant after submitting the claim form along with discharge bill of amount of Rs.20,000/- of DMC Hospital, Ludhiana, again submitted revised form for Rs.1,20,000/- because he has been getting regular treatment by purchase of medicines from Brij Agencies during period from 9.3.2015 to 25.5.2015. Prayer made for granting Rs.25,000/- as compensation for mental harassment, agony and sufferings. Litigation expenses of Rs.7500/- more claimed. Even prayer made for directing OPs to settle and pay the medi claim of amount of Rs.1,20,000/- with interest @18% p.a.

2.                In the joint written statement filed by OP1 and OP2, it is pleaded interalia as if complaint is not maintainable; complainant has no cause of action and this Forum has no territorial jurisdiction; complaint is frivolous; complainant has suppressed the material facts with dishonest intention of extorting illegal money under the beneficial legislation meant for innocent consumers; complicated question of law and facts requiring elaborate evidence involved and as such, those cannot be decided in consumer proceedings by this Forum. Besides it is claimed that complaint has been filed after the expiry of limitation period of 2 years. Admittedly, the complainant got the insurance policy in question for the period from 26.11.2014 to 25.11.2015 for a maximum sum of Rs.3 lac after understanding the terms and conditions of the policy. Benefits under the policy are governed by the terms and conditions of the policy. Documents as per claim closure letter dated 10.06.2015 are still outstanding and pending from the complainant. All the letters were duly received by the complainant, but despite that he choose not to supply the documents to the insurance company. After receipt of the claim from the complainant, the same was duly registered and thereafter, it was processed through OP3. Admittedly, the deficiency letter dated 12.5.2015 was sent to the complainant for calling upon him to supply the documents detailed in that letter, but after not hearing anything from the complainant, reminders through letters dated 19.5.2015, 30.5.2015 and 10.6.2015 were sent to the complainant, but no response was received from him and that is why, claim was closed on account of non retrieval of the documents within the prescribed period. That closure of the claim defended as legal and valid, being in accordance with the terms and conditions of the insurance policy. Each and every other averment of the complaint denied.

3.                OP3 was proceeded against ex-parte in this case vide order dated 29.09.2015.

4.                Counsel for the complainant tendered in evidence affidavit Ex.CA1 of complainant along with documents Ex.C1 to Ex.C52 and thereafter, closed the evidence.

5.                On the other hand, counsel for the OP1 and OP2 tendered in evidence affidavit Ex.RA of Sh.Manish Laxman Kerkar, Authorized Signatory of SBI General Insurance Co.Ltd., along with documents Ex.R1 to Ex.R6 and thereafter, closed the evidence.

6.                          Written arguments not submitted by any of the parties. Oral arguments alone addressed by the counsel for the parties and those were heard. Records gone through minutely. 

7.                Contents of certificate of insurance Ex.C3 along with Welcome letter Ex.R1 and affidavit Ex.CA1 of complainant and Ex.RA of Ops establishes that actually cashless policy for group health insurance of Rs.3 lac was purchased by the complainant from Op1 and OP2. Undisputedly, the claim was lodged by the complainant through claim form Ex.R2 because of his admission in DMC Hospital, Ludhiana, during period from 26.2.2015 to 2.3.2015. That claim was entertained and processed and that is why deficiency letters Ex.R3 to Ex.R5 and final reminder-cum-closure letter Ex.R6 and also placed on record as Ex.C4 were sent by the OPs to the complainant. Complainant through letter Ex.C52 informed Op3 as if he has never received letter dated 10.06.2015 placed on record as Ex.R6. Even if through Ex.C52, complainant has denied about receiving letter Ex.R6, but despite that he has not denied about receipt of the other letters placed on record as Ex.R3 to Ex.R5.

8.                Through letter Ex.R3 to Ex.R5 of dates 12.5.2015, 19.5.2015 and 30.5.2015, complainant was called upon to submit 9 documents mentioned in these letters. The demanded records through these letters mentioned as under:-

1)A letter from treating consultant stating duration of complaints(diabetes, hepatitis C, and chronic liver disease) and personal habit of patient required.

2)Duly attested and paginated Xerox copies of the indoor case papers with history sheet and nursing chart(full set) of hospital.

3)All original previous consultation letters/papers required.

4)A letter from insured stating reason for delay in submission of claim documents.
5)As per the instruction from the insurance company, you are requested to submit the following NEFT details in order to make the Electronic Transfer of the claim amount to the insured person’s account. Hence, we request you to provide following details to TPA: Name of account holder, Bank of Name, Full Bank account No.(without/,- or any special character), IFSC Code, Account Type, Bank Address, Mobile Number, Cancelled Copy of cheque with name mentioned & printed on it, E-Mail ID.

6)Item wise and cost wise detailed breakup of pathology charges mentioned in final hospital bill of Rs.330/- with reports.

7)Item wise and cost wise detailed breakup of biochemistry charges mentioned in final hospital bill of Rs.1910/- with reports.

8)Item wise and cost wise detailed breakup of microbiology charges mentioned in final hospital bill of Rs.500/- with reports.

9)Original ECS report of Rs.220/- required mentioned in final bill.

Owing to non supply of these records by the complainant to OPs, complainant was informed through letter Ex.R6 of 10.6.2015 that in case of non receipt of the documents within 15 days, the claim will be dealt accordingly by paying partial or by denying the same due to non receipt of the documents. So, if contents of Ex.R6 taken into consideration, then the same leads to the inference as if claim of the complainant has not been finally closed. If such final closure has not taken place by denying or partially paying the claim amount, then certainly, submissions advanced by the counsel for OPs has force that complaint is pre-mature. However, complainant can submit only that record, which is available with him and as such, after contacting DMC Hospital authorities, Ops can collect the record from that hospital or can verify about the factual position qua correctness of documents, copies of which are produced on record as Ex.C5 to Ex.C51.

9.                In case titled as Avneet G.Singh vs. ICICI Lombard General Insurance Company Limited and others-2014(2)CLT-374(CHD), it has been held that when a cashless health insurance policy purchased by complainant and he lodged claim by providing the available medical record with him, then claim of insurance cannot be repudiated merely because of non supply of some more record because the insurance company itself can collect medical record from hospital concerned.  In view of this legal proposition, repudiation of claim on the ground of non submission of documents even could not have been ordered. However, Ops in this case have not finally decided the claim yet as disclosed by letter Ex.R6 and as such, directions need  be issued to OPs to reconsider the claim of the complainant within specified period.

10.              Counsel for OPs has placed reliance on a case decided on 17.8.2011 by Hon’ble State Consumer Disputes Redressal Commission, Union Territory, Chandigarh bearing First Appeal No.116 of 2010 titled as Shri Arun Kumar vs. ICICI Lombard General Insurance for contending that in case, the requisite record not produced by the complainant, then it is difficult for the insurance company to process and settle the claim. As the sought documents has not been produced by the complainant and as such, certainly, fault lay with the complainant in not supplying the copies of the documents at earliest, but the law laid down in latest case of Avneet G.Singh(Supra) has to be given precedence over the law laid down by the same State Commission earlier. Rather, as fault lay with the complainant in not submitting the documents and as such, complainant not entitled to any compensation for mental harassment or to litigation expenses.

11.              Now, the complainant has produced on record Microbiology Reports (Ex.C5, Ex.C6 and Ex.C10); Radio diagnosis report(Ex.C7); Upper GI Endoscopy Reports (Ex.C8 and Ex.C9); Biochemistry clinical report (Ex.C11) along with other reports and records of bills of DMC Hospital as well as of bills qua purchase of medicines and as such, Ops after going through that records can now settle the claim. In case, OPs find any difficulty in settlement of claim on the basis of the produced documents as Ex.C5 to Ex.C51, then OPs will issue written notice to the complainant for calling upon him to submit further documents within 30 days. However, in case, those required documents not available with the complainant, then complainant will submit his sworn affidavit qua non possession of those documents. After complying all these formalities, claim must be adjudicated within 60 days and payment of the adjudged amount (if any) be made by the Ops to the complainant within 30 days, failing which, complainant will be entitled to interest @8% p.a. w.e.f. today till recovery. Complaint deserves to be decided accordingly.

12.              Therefore, as a sequel of the above discussion, complaint allowed in terms that complainant will submit the documents or the certified copies thereof available with him within 15 days from the date of receipt of copy of this order with Op1 and OP2 and in case, some more documents required, then OP1 and OP2 will issue notice in writing to complainant within 15 days after receipt of submitted documents as per this direction. After receipt of that requisition( if any) from Ops, complainant will submit further required documents within 30 days and in case, those required documents not available with the complainant, then complainant will submit his sworn affidavit qua non possession of those documents. After completion of these formalities, OP1 and OP2 will adjudicate the claim of the complainant within 60 days therefrom. In case, after such reconsideration, complainant found entitled to any amount, then disbursal of the same will be made by OP1 and OP2 within 30 days from the date of final order to be passed by OP1 and OP2. In case, this compliance not made within 30 days period, then complainant will be entitled to interest on adjudged amount @8% p.a. w.e.f. today till recovery. No order as to costs. Copies of order be supplied to the parties free of costs as per rules.

13.                        File be indexed and consigned to record room.

 

                   (Babita)                                        (G.K. Dhir)

          Member                                          President

Announced in Open Forum

Dated:06.06.2016

Gurpreet Sharma.