DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/96/2021

Date of Institution : 16.04.2021

Date of Decision : 20.09.2023

1. Vani Goyal wd/o Sorabh Goyal 38 years.

2. Lakshit Goyal 6 years minor s/o Sorabh Goyal U/G of mother Vani Goyal wd/o Sorabh Goyal R/o H. No. B-XI/1225, St. No. 1, KC Road, Barnala.  

                     …Complainants

Versus

1. SBI General Insurance Co. Ltd. Regd. & Corporate Office 301 “Nataraj” Junction of Western Express Highway & Andheri Kurla Road, Andheri East (Mumbai) through Authorized Officer.

2. SBI General Co. Limited, Chhoti Baradari, 2nd Floor, SCB-7, Patiala through Manager.

3. Paramount Health Services and Insurance TPA (P) Ltd., Plot No. A-442, Road No. 28, M.I.D.C Ind. Area, Wagle Estate Ramnager, Vithal Rukmani Mandir, Thane (400069).

4. SBI Main Pakka College Road, Barnala.

               …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. Gaurav Bansal Adv counsel for complainants.

Sh. AK Jindal Adv counsel for opposite parties No. 1, 2 & 4.

Opposite party No. 3 exparte.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2. Smt. Urmila Kumari : Member

 

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

    The complainant Vani Goyal and another filed the present complaint under Section 35 of the Consumer Protection Act 2019 against SBI General Insurance Company Limited, Mumbai and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that Sorabh Goyal was holder of Saving Account No. 10659844099 with opposite party No. 4 who got mediclaim insurance policies of Rs. 4,00,000/- i.e. policy No. 4510623-03 of Rs. 1,00,000/- and policy No. 12703463 of Rs. 3,00,000/- from opposite parties for Sorabh Goyal and Vani Goyal and for Sorabh Goyal, Vani Goyal and Lakshit Goyal. Premium for said policies was paid and transferred from the said account of Sorabh Goyal by opposite party No. 4 to the opposite parties. Now Sorabh Goyal expired and complainants are entitled to receive pending treatment expenses from the opposite parties. 

3. It is further alleged that opposite parties on receipt of premiums of Rs. 2,200/3,000/- and Rs. 10,502/- issued two mediclaim insurance policies i.e. policy No. 4510623-03 of Rs. 1,00,000/- for Sorabh Goyal and Vani Goyal and issued member ID card Nos. SBIG6646203 and SBIG6646262 in the name of Sorabh Goyal and Vani Goyal and also issued policy No. 12703463 of Rs. 3,00,000/- for Sorabh Goyal, Vani Goyal and Lakshit Goyal and issued member ID card Nos. SBIG0000000019063297, SBIG0000000019063636 and SBIG0000000019063750 which were valid and applicable on all policies issued in continuation so complainants and Sorabh Goyal were eligible for cashless treatment up to Rs. 4,00,000/- under said policies. 

4. It is further alleged that during validity period of policies No. 4510623-03 and 12703463 Sorabh Goyal was admitted in Aastha Hospital Barnala twice on 3.11.2019 and 29.11.2019 and remained under treatment from 3.11.2019 to 7.11.2019 and was discharged on 7.11.2019 and from 29.11.2019 to 2.12.2019 and discharged on 2.12.2019. Complainant on 3.11.2019 and 29.11.2019 on admission showed said cards to Aastha Hospital and requested to provide cashless treatment but they refused to provide cashless treatment and said that hospital is not recognized and asked to get treatment on cash. Sorabh Goyal got treatment on cash from Aastha Hospital and paid all treatment expenses including hospital, pharmacy and nursing bills etc in cash to the said hospital. Sorabh Goyal could not sent treatment expenses bills of Aastha Hospital for payment of Rs. 36,666/- and same were sent with claim form to the opposite party No. 2 only on 19.3.2021 vide registered letter. But opposite parties had not paid claim. Sorabh Goyal during treatment in DMCH expired on 14.8.2020 and survived by Vani Goyal widow and minor son Lakshit Goyal, so complainants are entitled to receive treatment expenses of Rs. 36,666/-. But opposite parties had not paid the said expenses which amounts to deficiency in service. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay Rs. 36,666/- alongwith interest at the rate of 12% per annum from the date of treatment till payment. 

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment and Rs. 30,000/- as litigation expenses.

5. Upon notice of this complaint, opposite parties No. 1 and 2  filed written reply taking legal objections that intricate question of law and facts are involved in the present complaint which require documents and evidence so appropriate remedy if any lies only in civil court. The  complainants have concealed material facts from this Commission. The deceased Sorabh Goyal husband of complainant No. 1 availed two SBI General Group Health Insurance Policy bearing No. 4510623-03 for the period 25.5.2019 to 24.5.2020 and 12703463 for the period 16.3.2019 to 15.3.2020. The terms and conditions of the policy were explained to the insured at the time of proposing policy who accepted the same. The complainants reported claim for reimbursement of expenses in Aastha Hospital for treatment of type 2 diabetes mellitus with acute alcoholic pancreatitis with depression for which medical management was done. As per the TPA claim No. 4542864 it was observed that patient was having history of diabetes mellitus and alcoholic pancreatitis since 10 years which is pre existing in nature and current ailment is complication of the same. The first policy inception date is 25 May 2016. As per the terms of the policy expenses arising out of the above ailment is not payable as pre existing illness is not covered under the policy as per policy exclusion Clause 1 which states as benefits will not be available for any condition ailment or injury or related condition for which the insured has been diagnosed receiving medical treatment prior to inception. As per clause 17 any complications arising out of or ailments requiring treatment due to use or abuse of any substance drug or alcohol and treatment for de-addiction is excluded from the scope of policy coverage so the same was repudiated vide letter dated 30.4.2021. Further, complainant has no locus standi or cause of action to file the present complaint. 

6. On merits it is submitted that the benefits of the policy are strictly subject to policy terms and conditions. Further, the submissions submitted on merits already submitted in the legal objections so there is no need to reiterate the same. The claim has already been repudiated as per terms and conditions of the policy. There is no deficiency in service on the part of the opposite parties. Lastly, the opposite parties No. 1 and 2 prayed for the dismissal of the present complaint with costs. 

7. The opposite party No. 4 also filed written reply taking legal objections that the opposite party No. 4 is not in the business of insurance and only doing the business of banking and insurance policy is issued by opposite parties No. 1 and 2. Therefore no cause of action arose against the opposite party No. 4 and opposite party No. 4 is not liable to pay any amount to the complainants. Further, it is settled principle of law under Section 230 of Indian Contract Act that an Agent can neither sue nor be sued. The complainants have not come in the Commission with clean hands. The complainants got no locus standi or cause of action to file the present complaint against the answering opposite party as the complainants paid alleged amounts to the SBI General Insurance Company Limited. The complaint is abuse of process of law and bad for non joinder of necessary parties. 

8. On merits, it is admitted that Sorabh Goyal was having saving account with the answering opposite party No. 4. The complainants never approached to the answering opposite party for any such type of insurance policy nor advised by the employees of the opposite party No. 4 to the complainants. The complainants purchased the insurance policy from the opposite parties No. 1 and 2. The answering opposite party have no concern with the alleged insurance policies. There is no deficiency in service on the part of opposite party No. 4 and lastly they prayed for the dismissal of the present complaint with costs.

9. Notice was sent to the opposite party No. 3, but they failed to appear and was proceeded against exparte vide order dated 11.10.2021. 

10. Rejoinder to the written reply of opposite parties No. 1 & 2 has been filed.

11. In support of their complaint, the complainants tendered into evidence copy of statement of account Ex.C-1, copy of policy dated 28.5.2019 Ex.C-2, copy of policy dated 31.3.2019 Ex.C-3, copies of Member ID card Ex.C-4 to Ex.C-8, copy of claim form Ex.C-9, copies of bills and reports Ex.C-10 to Ex.C-33, copy of death certificate Ex.C-34, copy of request letter Ex.C-35, copy of legal notice Ex.C-36, postal receipts Ex.C-37 and Ex.C-38, copy of Kursi Nama Ex.C-39, copy of special power of attorney Ex.C-40, affidavit of Vani Goyal Ex.C-41 and closed the evidence. 

12. To rebut the case of the complainant the opposite parties No. 1 and 2 tendered in evidence copy of policy dated 28.5.2019 Ex.OP-1.2./1, copy of policy dated 16.3.2019 Ex.OP-1.2/2, copy of letter dated 30.4.2021 Ex.OP-1.2/3, copy of letter dated 30.3.2021 Ex.OP-1.2/4, copy of letter dated 7.4.2021 Ex.OP-1.2/5, copy of letter dated 18.4.2021 Ex.OP-1.2/6, copy of claim form Ex.OP-1.2/7, affidavit of Jitendra Dhabhai Ex.OP-1.2/8, copy of letter dated 6.9.2020 Ex.OP-1.2/9 and closed the evidence. The opposite party No. 4 tendered in evidence affidavit of Vimal Kumar Ex.OP-4/1 and closed the evidence. 

13. We have heard learned counsel for the parties and have gone through the record on file. Written arguments also filed by the parties. 

14. It is not disputed between the parties that the deceased Sorabh Goyal got Group Health Insurance Policy for himself, his wife and son from the opposite parties with covering the risk period of 25.5.2019 to 24.5.2020 (Ex.C-2 & Ex.O.P1.2/1). It is also not disputed between the parties that the deceased Sorabh Goyal hospitalized at Aashtha Hospital, Barnala twice on 3.11.2019 and 29.11.2019 and remained under treatment from 3.11.2019 to 7.11.2019 and was discharged on 7.11.2019 and from 29.11.2019 to 2.12.2019 and discharged on 2.12.2019 (Ex.C-10 to Ex.C-33). 

15. Ld. Counsel for complainants argued that Sorabh Goyal got treatment on cash from Aastha Hospital and paid all treatment expenses including hospital, pharmacy and nursing bills etc., in cash to the said hospital. Ld. Counsel for complainants further argued that Sorabh Goyal could not sent treatment expenses bills of Aastha Hospital for payment of Rs. 36,666/- and the same were sent with claim form to the opposite party No. 2 only on 19.3.2021 vide registered letter (Ex.C-35), but the opposite parties had not paid claim. It is also argued that Sorabh Goyal during treatment in DMCH expired on 14.8.2020 (Ex.C-34) and survived by Vani Goyal widow and minor son Lakshit Goyal, so complainants are entitled to received treatment expenses of Rs. 36,666/-, but the opposite parties had not paid the said expenses on the ground of PRE-EXISTING disease. 

16. On the other hand, Ld. Counsel for opposite parties No. 1 & 2 argued that the complainants reported claim for reimbursement of expenses in Aastha Hospital for treatment of type 2 diabetes mellitus with acute alcoholic pancreatitis with depression for which medical management was done. It is further argued that as per the TPA claim No. 4542864 it was observed that patient was having history of diabetes mellitus and alcoholic pancreatitis since 10 years which is pre existing in nature and current ailment is complication of the same. It is argued that the first policy inception date is 25 May 2016 and as per the terms of the policy expenses arising out of the above ailment is not payable as pre existing illness is not covered under the policy as per policy exclusion Clause 1 which states as benefits will not be available for any condition ailment or injury or related condition for which the insured has been diagnosed receiving medical treatment prior to inception. It is further argued that as per clause 17 any complications arising out of or ailments requiring treatment due to use or abuse of any substance drug or alcohol and treatment for de-addiction is excluded from the scope of policy coverage so the same was repudiated vide letter dated 30.4.2021 (Ex.O.P.1.2/3). 

17. From the perusal of the file it is established that the deceased Sorabh Goyal was admitted in Aastha Hospital Barnala twice on 3.11.2019 and 29.11.2019 and remained under treatment from 3.11.2019 to 7.11.2019 and was discharged on 7.11.2019 and from 29.11.2019 to 2.12.2019 and discharged on 2.12.2019. The complainants alleged in the complaint that the deceased Sorabh Goyal spent Rs. 36,666/- which shows from the bills Ex.C-10 to Ex.C-21. On the other hand, the opposite parties have repudiated the claim of the complainant on the ground of Pre-existing disease as the deceased Sorabh Goyal was diagnosed for treatment of type 2 diabetes mellitus with acute alcoholic pancreatitis with depression for which medical management was done and the patient was having history of diabetes mellitus and alcoholic pancreatitis since 10 years which is pre existing in nature and current ailment is complication of the same. Further, the first policy inception date is 25 May 2016 and as per the terms of the policy expenses arising out of the above ailment is not payable as pre existing illness is not covered under the policy as per policy exclusion Clause 1 which states as benefits will not be available for any condition ailment or injury or related condition for which the insured has been diagnosed receiving medical treatment prior to inception. It is further the case of the opposite parties that as per clause 17 any complications arising out of or ailments requiring treatment due to use or abuse of any substance drug or alcohol and treatment for de-addiction is excluded from the scope of policy coverage and this claim for hospitalization falls beyond purview of policy coverage and hence not payable and the same was repudiated vide letter dated 30.4.2021 (Ex.O.P.1.2/3).

18. The learned counsel for complainants referred the judgment Civil Appeal No.7437 of 2011 titled as P.Vankat Naidu Vs LIC of India. The Hon'ble Supreme Court of India held that Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The appeal is allowed. Another case LPA No. 1537 of 2011 titled as Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied. 

19. The Ld. Counsel for complainants further 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. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The insurance company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.

20. So, from the above discussion, it is established that the claim of the complainants was repudiated by the opposite parties No. 1 & 2 on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay Rs. 36,666/- alongwith interest @ 7% per annum to the complainants in equal shares from the date of filing the present complaint till realization. The share of minor Lakshit Goyal be kept in the shape of FDR till he attain the age of majority in the Nationalized Bank. The opposite parties No. 1 & 2 are further directed to pay Rs. 5,500/- on account of consolidated amount of compensation as well as litigation expenses to the complainants.

21. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

22. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       20th Day of September, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member