Punjab

Fatehgarh Sahib

CC/92/2021

Jasvir Kaur - Complainant(s)

Versus

SBI General Insurance Co etc - Opp.Party(s)

Sh N S Toor

18 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                            COMMISSION

                      FATEHGARH SAHIB.

                                                             

Consumer  Complaint No.	:	CC/92 of 2021
Date of Institution	:	24.09.2021
Date of Decision	:	18.04.2023

 

 

Jasvir Kaur  aged about 51 years , wife of Sh. Updesh Singh, resident of Village Khanian, Tehsil Amloh, District Fatehgarh Sahib.       

 

                                                                                                        …………....Complainant

 

                                                Versus

 

1. SBI General Insurance Company Limited, Branch Office at 2^nd  Floor, SCB-7, Chotti Baradari, Patiala, Tehsil and District Patiala-147001,  through its Manager.
2.  SBI General Insurance Company Limited. Registered and Corporate Office at “ Natraj” 301, Junction of Western Express Highway & Andheri Kulra Road,  Andheri (East), Mumbai-400069 through its authorized signatory/person.
3. Paramount Health Service & Insurance TPA Pvt. Ltd. Plot No.A-442, Road No.28, Wagle Industrial Estate, Thane (West)-400604, India through its Authorized signatory / person.    

 

 

..………....... Opposite Parties

 

 

 

Complaint under Section 35 of Consumer Protection Act 2019

 

Quorum

 

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

Present: Sh.N.S.Toor, counsel for complainant.

              Sh.Amit Gupta, Counsel for OPs no.1 and 2.

              Complaint not admitted against OP no.3.

 

 

   

The  complaint has been filed against the OPs (opposite parties)  under Section 34 of Consumer Protection Act-2019 alleging deficiency in service with the prayer for giving direction to the OPs to pay  medical claim of Rs.42,684/- , to pay Rs.1,00,000/-  as compensation on account of mental agony and Rs.22,000 as litigation expenses.

1. The husband of the complainant namely Updesh Singh purchased a Arogya Plus insurance Policy   from OP1  bearing no.0000000021247473, Customer ID 0000000038398717 w.e.f. 2/2/2021 to 1/2/2022. The complainant suffered from upper respiratory tract infection  and got admitted in satyam Multispecialty Hospital , Khanna on 1/5/2021  and discharged on  8/5/2021. She spent Rs.42,684/- upon her treatment.  The complainant applied for reimbursement of mediclaim  and   sent the relevant documents to the OPs through courier on  20.7.2021. The claim  was repudiated on the ground that  hospitalization is not continuous.  Hence this complaint.
2. Notice of the complaint was given to the OPs through registered Post OPs no.1 and 2 appeared through their Counsel  and filed  written version. Complaint was not admitted against OP no.3 vide order dated 30.9.2021.
3.        The complaint has been contested by the OPs  no.1 and 2and they  filed written version jointly  by raising preliminary and legal objections. The complainant has submitted bills of Rs.42,680/- for reimbursement spent on her  treatment . Her claim was repudiated on ground that  she used to go to her home daily in evening.  Her stay in  hospital was not continuous. Hence, prayer for dismissal of complaint  with cost has been made.
4. The complainant in support of her complaint tendered in evidence her  affidavit Ex.CW1/1,  and  Photo copies of documents i.e ExC1 insurance Policy no.0000000021247473, Ex.C2 Aadhaar Card, Ex.C3 Pan Card, Ex.C4 Arogya Plus Policy card. Ex.C 5 to Ex.C10 admission file along with medical record, Ex.C11 receipt of courier ,  Ex.C12  repudiation letter. In rebuttal the OPs no.1 and 2 tendered Ex.OPA affidavit  Jitendra Dhabhai, Legal Manager SBI  General Insurance Co. New Delhi,  Ex.OPB   Affidavit of Rohit Sharma, Manager, Paramount Health Service Thane ,  Ex.OP1 Policy insurance Policy no.0000000021247473 with terms  and conditions , Ex.OP2  claim Form,  Ex.OP3 claim Form verified by Hospital,  Ex.OP4 medical bills, Ex.OP5  detailed split charges of hospital,  Ex.OP6 certificate issued by Hospital,  Ex.OP7 to Ex.OP11 Letters , Ex.OP12 repudiation letter. and closed their evidence.
5.   Heard. Entire record perused.
6. Admittedly , complainant had  Arogya Plus Policy bearing no.0000000021247473 w.e.f. 2.02.2021 to 1.2.2022 vide Ex.C1. The complainant  spent Rs.42,684/-  on her  treatment vide Ex.C5 OPs repudiated her claim on ground that her  stay in hospital  was not continuous vide Ex.OP12.
7. From the perusal of the record  on file, we find that complainant got admitted in hospital  on 1.5.2021 and discharged on  8.5.2021 vide Ex.C6. The OP can not go beyond the record of hospital. The Insurance  companies can not reject the claim by saying  that the  patient was not hospitalized.  Rejection of claim purely on  technical grounds will result in Policy holder’ loosing confidence in  Insurance Companies & giving  rise to excessive litigation. It would not be fair & reasonable to reject  genuine claims. The insured had submitted all the documents as sought by the Insurance Company but Insurance Company failed to settle the claim .  Therefore, OPs no.1 and 2 are held liable for  deficiency in service.
8.  As  a corollary of our above discussion, the present complaint is partly allowed.  OPs no.1 and 2 are held  jointly & severally liable for deficiency in service. The OPs no.1 and 2 are directed as under:-

[a] To pay claim of Rs.42,684/- to the complainantalong with interest@ 6% P.A from the date of filing of complaint within 30 days, failing which interest @ 9% P.A. shall be payable.

          [b] To pay Rs.10,000/-  compensation for harassment  and  litigation charges to the complainant

    Compliance of the order be made by the OPs no.1 and 2 within30 days from the date of receipt of certified copy of this order. Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record room.   

Pronounced 18 April 2023.

                                                           

                                                                      (S.K. Aggarwal)

                                                                      President

                                                                      

    

                                                                             (Shivani Bhargava)

                                                                              Member

 

                                                                             ( Manjit Singh Bhinder )

                                                                                            Member