DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/30/2023
Date of Institution: 20.03.2023
Date of Decision: 02.09.2024
Amarjit Singh Dathor aged about 53 years son of Sh. Tarlok Singh resident of House No. B-/632, Raj Mahajan Street, Ward No. 12, Barnala, Tehsil and District Barnala, Punjab.
…Complainant
Versus
1. SBI General Insurance Company Limited, Corporate and Registered Office: 9th Floor, A & B Wing, Fulcrum Building, Sahar Road, Andheri East, Mumbai- 400099 through its Director/Chairman/Authorized Signatory.
2. SBI General Insurance Company Limited, State Bank of India, Branch Barnala, through its Branch Manager/Authorized Signatory.
3. SBI General Insurance, 1st Floor, SCF 135, Guru Knshi Marg, Opp. Three Cinemas Bathinda-151001 through its Authorized Signatory.
4. SBI General Insurance, SCO-138, 3rd Floor, Feroze Gandhi Market, Ludhiana-141001 through its Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Munish Kumar Garg Adv counsel for complainant.
Sh. Ankur Jindal Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against SBI General Insurance Company Limited, Corporate and Registered Office: 9th Floor, A & B Wing, Fulcrum Building, Sahar Road, Andheri East, Mumbai- 400099 through its Director/Chairman/Authorized Signatory & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant in the month of March 2022 visited the bank where the representative of opposite party Bank allured the complainant of Medical insurance policy of opposite parties by telling their best services. It is alleged that believing upon the assurance the complainant agreed to purchase the medical insurance policy and as such a Policy No. POOPDH00100111094 was issued to the complainant on 17.03.2022 upto 16.03.2023 under policy name-Arogya Plus Policy for total sum insurance of Rs. 5 lac and the complainant had paid an amount of Rs. 25,500/- against the said policy. It is further alleged that on 03.04.2022 the complainant fell ill and as such he visited Bhim Nursing Home, Barnala for his checkup where he was checked by the doctor and was admitted on 03.04.2022 to the hospital from where he was discharged on 06.04.2022 and total expenditure on the treatment was Rs. 83,098/- for which the complainant retained bills. It is further alleged that intimation of the claim was given to the opposite parties and they asked the complainant to send the requisite documents along with all the requisite bills and discharge summary of hospital and the complainant duly sent the same to the opposite parties. But instead of disbursement of the insurance claim of the complainant the opposite parties send a Deficiency List of documents to the complainant but it is strange that the complainant had already submitted all the requisite documents to the opposite parties in original but instead of disbursing the same the opposite parties keeping sending reminders to the complainant for submission of documents mentioned in the deficiency list. It is further alleged that the complainant got served a legal notice upon the opposite parties and asked them to pay the insurance claim of amounting to Rs. 83,098/- along with interest @12% from the date of filing of claim till realization and further to pay an amount of Rs.1,00,000/- towards mental tension and harassment of the complainant, but the opposite parties No. 3 and 4 did not receive the said legal notice on the pretext that the office of them shifted. As such, the act and conduct of the opposite parties comes within the definition of deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay Rs. 83,098/- to the complainant as expenditure.
- To pay Rs. 100,000/- towards mental tension and harassment.
- Further, to pay Rs. 10,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the opposite parties cancelled the cashless claim request of complainant due to non receipt of required documents. It is submitted that the instant complaint is a gross abuse of the process of law and the complainant has approached this Commission with unclean hands and has suppressed material facts and as such, this complaint is liable to be dismissed on this very ground. It is submitted that the captioned complaint is frivolous, vague and vexatious in nature and there has been no 'Unfair Trade Practice" or "deficiency of service" on the part of opposite parties.
4. On merits, it is admitted that Arogya Plus Policy bearing No. POOPDH00100111094 was issued for the period 17.03.2022 to 16.03.2023 and this policy has sum insured of Rs. 3,00,000/- subject to certain terms, conditions, exclusions and the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. It is further alleged that it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED" It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form and the same was served to the complainant along with the Policy Schedule. It is further alleged that upon receipt of claim request for hospitalization from Bhim Nursing Home, Barnala for the treatment of Achiles Tendon resulting from accident and had complaint of pain in ankle, instability to walk for which treatment of ruptured tendo achillis repair under SA, they have issued requirement letter seeking enlisted documents i.e. reminder/letters dated 29.06.2022, 10.07.2022, 19.07.2022, 27.07.2022, 07.08.2022, 18.08.2022, 01.09.2022, 09.09.2022, 20.09.2022, 02.10.2022, 13.10.2022 and 25.10.2022 to the complainant for not submitted following documents:
i. Details from treating doctor if same was carried by patient then provide date of pre pathology tests of patient before surgery.
ii. Copy of pre operative pathology test along with doctor prescription for same.
iii. X-ray report and film done at Sheetal Orthopaedics.
iv. Required original invoice or sticker of implants used during the surgery.
v. Original payment receipt of final hospital bill with bill number and receipt number. As submitted only Rs. 21,218/-. Please provide us the balance receipt of Rs. 33,822/-.
It is further alleged that but the complainant failed to submit the above said documents, as such the claim was rightly treated as no claim. All other allegations are denied and prayed for the dismissal of complaint.
5. The complainant filed rejoinder to the written version of opposite parties vide which the complainant denied the averments as mentioned in the version.
6. The complainant tendered into evidence affidavit of complainant Ex.C-1, copy of insurance policy Ex.C-2, copy of legal notice Ex.C-3, envelope Ex.C-4 and Ex.C-5, copy of bills Ex.C-6 to Ex.C-14, copy of crossed blank cheque Ex.C-15, copy of OPD slip Ex.C-16 to Ex.C-19, copy of opinion of doctor Ex.C-20 and Ex.C-21, copy of OPD slip Ex.C-22, copy of claim form Ex.C-23, copy of insurance card Ex.C-24, reply of insurance company Ex.C-25, affidavit of Dr. Anshul of Bhim Nursing Home, Barnala Ex.C-26 and closed the evidence.
7. The opposite parties tendered into evidence copy of policy as Ex.OPs-1 (5 pages), copies of letters dated 29.06.2022, 10.07.2022, 19.07.2022, 27.07.2022, 18.08.2022, 01.09.2022, 09.09.2022, 20.09.2022, 02.10.2022, 13.10.2022, 25.10.2022, 10.11.2022 are Ex.OPs-2 to OPs-14 respectively, copy of complete policy Ex.O.Ps-15 (5 pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that Arogya Plus Policy bearing No. POOPDH00100111094 was issued for the period 17.03.2022 to 16.03.2023 and this policy has sum insured of Rs. 3,00,000/- vide which the complainant was insured under the policy (as per Ex.C-2 & Ex.O.Ps-15). It is further not disputed between the parties that the complainant on 03.04.2022 fell ill and as such he visited Bhim Nursing Home, Barnala for his checkup where he was checked by the doctor and was admitted on 03.04.2022 to the hospital from where he was discharged on 06.04.2022 (as per Ex.C-6).
10. Ld. Counsel for the complainant argued that the total expenditure on the treatment was Rs. 83,098/- (as per Ex.C-6 to Ex.C-14) for which the complainant retained bills. It is further argued that intimation of the claim was given to the opposite parties and they asked the complainant to send the requisite documents along with all the requisite bills and discharge summary of hospital and the complainant duly sent the same to the opposite parties but instead of disbursement of the insurance claim of the complainant the opposite parties send a Deficiency List of documents to the complainant. It is further argued that it is strange that the complainant had already submitted all the requisite documents to the opposite parties in original but instead of disbursing the same the opposite parties keeping sending reminders to the complainant for submission of documents mentioned in the deficiency list. It is further argued that the complainant got served a legal notice dated 19.1.2023 Ex.C-3 upon the opposite parties and asked them to pay the insurance claim of amounting to Rs. 83,098/- along with interest @12% from the date of filing of claim till realization and further to pay an amount of Rs.100,000/- towards mental tension and harassment of the complainant, but the opposite parties No. 3 and 4 did not receive the said legal notice on the pretext that the office of them shifted.
11. On the other hand, Ld. Counsel for the opposite parties argued that the terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. It is further argued that it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED" It is further argued that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy and the complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form and the same was served to the complainant along with the Policy Schedule. It is further argued that upon receipt of claim request for hospitalization from Bhim Nursing Home, Barnala for the treatment of Achiles Tendon resulting from accident and had complaint of pain in ankle, instability to walk for which treatment of ruptured tendo achillis repair under SA, they have issued requirement letter seeking enlisted documents i.e. reminder/letters dated 29.06.2022, 10.07.2022, 19.07.2022, 27.07.2022, 07.08.2022, 18.08.2022, 01.09.2022, 09.09.2022, 20.09.2022, 02.10.2022, 13.10.2022 and 25.10.2022 to the complainant for submitting the required documents as mentioned in the letters but the complainant failed to submit the above said documents, as such the claim was rightly treated as no claim vide letter dated 10.11.2022 Ex.C-14.
12. We have carefully gone through the facts and entire evidence produced by the parties. We have gone through copy of closure letter dated 10.11.2022 Ex.O.Ps-14 placed on record by the opposite parties vide which it is mentioned that “We regret to inform you that the above mentioned documents have not been received by us till the date of this letter. Due to non-submission of above said documents, we are constrained to treat your claim as No Claim”. On the other hand, Ld. Counsel for the complainant has specifically argued that the complainant has already submitted all the original bills and medical record to the opposite parties. Moreover, from the perusal of the file it shows that all the documents (alongwith medical record) are already on the Court file and we are of the view that if the opposite parties required the same to settle the claim of the complainant, then they could have procure the same from the Court file. The complainant specifically denied about the reminders/letters in rejoinder. The opposite parties have failed to produce any postal receipt or any other evidence to prove that they have sent the above said letters (Ex.O.Ps-2 to Ex.O.Ps-14). So, we are of the view that at this stage the opposite parties (insurance company) cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. Ld. Counsel for the complainant relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
13. From the above discussion, it is proved that the claim of the complainant was closed/rejected by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
14. The complainant to prove his case has placed on record copies of bill and receipts Ex.C-6 to Ex.C-14 which shows that the complainant has paid the net amount of Rs. 83,098/- to the hospital on his treatment.
15. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 83,098/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
2nd Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
