DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/253/2021

Date of Institution : 02.11.2021

Date of Decision : 20.01.2023

Harinder Kumar Goyal s/o Raghuvir Chand resident of 116, 16 Acre Near Bus Stand, Barnala, District Barnala, Punjab. 

                            …Complainant

Versus

1. SBI General Insurance Company Limited, Registered and Corporation Office: Natraj, 301, Junction of Western Express Highway & Andheri Kurla-Road, Andheri (East), Mumbai-400069 through its Chairman/Director/Authorized Signatory. 

2. SBI General Insurance Company Limited, SCO 335-336, 1st and 2nd Floor, Sector 35-B, Chandigarh-160022 through its Branch Manager/Director/Authorized Signatory. 

3. The Branch Manager/Authorized Signatory, Paramount Health Services & Insurance TPA Private Limited Plot No. A-442, Road No. 28 MIDC Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukhumani Mandir, Thane-400604.

…Opposite Parties

Complaint Under Section 35 of the Consumer Protection Act, 2019.

Present: Sh. Varinder Kumar Goyal Adv counsel for complainant.

Sh. A.K. Jindal Adv counsel for opposite parties No. 1 & 2.

Opposite party No. 3 exparte.  

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 and others (in short the opposite parties). 

2. The facts leading to the present complaint are that the complainant had purchased an insurance policy, from the opposite party No. 1 & 2 and the opposite party No. 3 is the TPA of opposite parties No. 1 & 2 bearing policy No. 11320549-02 vide Customer ID : 16403040 for the period 8.1.2021 to 7.1.2022 and had duly paid the insurance premium against the said policy against receipt dated 23.12.2020 for sum assured of Rs. 3 lac and the date of inception of said policy was 1.8.2019. It is further alleged that in the month of June, 2021 the complainant faced problem in his vision and visited the doctor and got checked up and Cataract Surgery in left eye of the complainant was advised by the doctor on 12.6.2021. The complainant on 14.6.2021 got his problem treated and got surgery from Prem Eye & Maternity Hospital, Barnala. It is further alleged that the complainant supplied the requisite documents to the opposite parties for the release of his claim against the said treatment through Deepak Chugh agent of the opposite parties. Thereafter, the opposite parties issued a letter dated 19.8.2021 to the complainant requiring some of the documents for the release of claim amount. The complainant sent all the requisite documents to the opposite parties but the opposite parties again issued a letter dated 1.9.2021 for the deficiency of documents. It is further alleged that the complainant already submitted the requisite documents but the opposite parties demanded documents from the complainant. The complainant many times requested the opposite parties to disburse the claim amount of the complainant incurred by the complainant on his treatment but the opposite parties lingered on the matter on one pretext or the other, which is clearly deficiency in service and unfair trade practice on part of opposite parties. The complainant also served a legal notice dated 13.9.2021 to the opposite parties, but of no use. Hence, the present complaint is filed for seeking the following reliefs.-

i)The opposite party may be directed to pay the insurance claim by releasing the amount of insurance claim alongwith interest.

ii)To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment to the complainant. 

iii)Further, to pay Rs. 20,000/- as litigation expenses.  

3. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version by taking legal objections interalia on the grounds of no locus standi or cause of action, concealment of material facts, maintainability, etc. It is alleged that the complainant has concealed the facts that the opposite party No. 3 wrote the letters for demanding the documents i.e. details from attending doctor duly signed and stamped certificate from the treating doctor stating (1) Exact duration of symptoms and signs diminished off vision due to cataract, main hospital bill, original final hospital bill with break up of (details/amt), as submitted as on letter head, implants and required original invoice of implants (IOL) used during the surgery but the complainant failed to submit the same so the claim of the complainant was closed vide letter dated 18.10.2021. The complainant has no locus standi or cause of action to file the present complaint and complaint is not maintainable. 

4. On merits, the purchase of policy, validity, payment of premium, sum assured and date of inception of the policy not denied by the opposite parties No. 1 and 2. The amount payable under any claim is to be calculated as per terms and conditions of the policy. It is further submitted that the complainant lodged the claim with the opposite parties but failed to submit the documents despite letters dated 19.8.2021, 27.8.2021, 1.9.2021, 9.9.2021, 20.9.2021 and 1.10.2021. It is denied that complainant had submitted all the requisite documents with the opposite parties. There is no deficiency in service or unfair trade practice on the part of the opposite parties. Rest of the submissions in the present complaint are denied by the opposite parties No. 1 and 2 and lastly prayed for the dismissal of the present complaint. 

5. The opposite party No. 3 preferred to remain exparte.  

6. In order to prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of deficiency letter Ex.C-3, copy of legal notice Ex.C-4, copies of postal receipts Ex.C-5 to Ex.C-7, copy of claim form Ex.C-8, copies of emails with replies ExC-9 and closed the evidence on behalf of the complainant.

7. The opposite parties No. 1 and 2 tendered into evidence copies of letters Ex.OP-1.2/1 to Ex.OP-1.2/7, copy of policy Ex.OP-1.2/8, copy of claim form Ex.OP-1.2/9, affidavit of Jitendra Dhabhai Ex.OP-1.2/10 and closed the evidence. 

8. We have heard the learned counsel for the parties and have gone through the record on the file.

9. The complainant alleged in the complaint that he had purchased the insurance policy from the opposite parties No. 1 and 2 and opposite party No. 3 is the TPA of opposite parties No. 1 and 2 for the period from 8.1.2021 to 7.1.2022 for Rs. 3 lacs. The complainant further alleged in the complaint that in the month of June 2021 the complainant faced problem in his vision and he visited the doctor and cataract surgery in the left eye of the complainant was advised by the doctor. On 14.6.2021 complainant got his problem treated and got surgery from Prem Eye and Maternity Hospital, Barnala. The complainant alleged that he supplied all the requisite documents to the opposite parties for the release of the claim for the said treatment. The opposite parties issued a letter dated 19.8.2021 to the complainant and asked some documents for the release of the claim amount and complainant sent all the documents to the opposite parties but despite that the opposite parties again issued a letter dated 1.9.2021 for deficiency of documents. The complainant alleged in the complaint that he has already submitted all the documents but the opposite parties lingered on the matter on one pretext or the other, which is clearly the deficiency in service and unfair trade practice on the part of the opposite parties. The complainant also served a legal notice dated 13.9.2021 to the opposite parties but of no use. 

10. On the other hand the opposite parties filed the written version and alleged that the complainant has not supplied the relevant documents despite letters dated 19.8.2021, 27.8.2021, 1.9.2021, 9.9.2021, 20.9.2021 and 1.10.2021. 

11. The policy and the treatment in the present case is admitted by the opposite parties. The only dispute is that whether the complainant has supplied the required documents to the opposite parties for settlement of the claim or not. The complainant has produced Ex.C-8 containing 13 pages vide which the complainant had applied for the reimbursement alongwith the relevant documents and hospital bills at Page No. 8 of Ex.C-8, the complainant has also produced the certificate issued by Prem Eye and Maternity Hospital, Barnala vide which hospital certify that the complainant Harinder Kumar has been operated for cataract surgery of left eye on 14.6.2021 and it is further certified that the patient Harinder Kumar has been charged Rs. 48,000/- inclusive of lens charges, medicine charges, surgeon charges, OT charges, room charges, nursing charges etc. The complainant also produced the receipt of Rs. 48,000/- issued by Prem Eye and Maternity Hospital, Barnala. 

12. Learned counsel for the opposite parties argued that the opposite parties sent various reminders to the complainant for submitting the relevant documents but the complainant failed to supply the same, therefore, vide letter dated 18.10.2021 the opposite parties closed the claim of the complainant. 

13. Learned counsel for the complainant argued that the complainant has supplied all the documents mentioned in the letter dated 18.10.2021.

14. On the perusal of the file it is established that the complainant has deposited all the documents as the opposite parties were demanding the Detail of attending doctor, main hospital bill and implant bill. As per Ex.C-8 it is clear that the complainant supplied all the documents as demanded by the opposite parties but despite that the opposite parties closed the claim of the complainant on unreasonable and unjustified grounds which is deficiency in service and unfair trade practice on their part. 

15. In view of the above discussion, present complaint is partly allowed and the opposite parties are directed to pay the amount of Rs. 48,000/- to the complainant alongwith interest at the rate of 7% per annum from the date of filing the present complaint till actual realization. The opposite parties are also directed to pay Rs. 10,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as litigation expenses. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. All the opposite parties jointly and severally liable to comply with the above mentioned order. Copy of the order be supplied to the parties free of costs. File be consigned to its records after its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

        20th Day of January 2023 

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member