Tripura

Gomati

CC/16/2022

Sri Sujit Saha - Complainant(s)

Versus

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

Md. Asif Iqbal

24 Jul 2024

ORDER

BEFORE THE

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

GOMATI DISTRICT :UDAIPUR

C A S E   NO. C. C. 16/2022

 

Sri Sujit Saha

S/O. Lt. Hiren Chandra Saha

Near Teen Mandir, Badarmokam,

P.O & P.S- R.K. Pur

Udaipur, Gomati District, Tripura

                       

                                          …....…......COMPLAINANT.  

 

           V E R S U S

 

1. SBI General Insurance Company Ltd.

Ground Floor, Sriram Palza,

Ker Chowmuhani, T.G. Road,

P.S- West Agartala, District- West Tripura

Pin-799002

 

2. The Branch Manager

State Bank of India,  

Ramesh Chowmuhani Branch,

P.S- R.K. Pur, Udaipur, Gomati Tripura

 

                                                               …....……OPPOSITE PARTIES

                                                    

P R E S E N T

 

                                                  

SHRI S.L.DUTTA

PRESIDENT

CONSUMER DISPUTES REDRESSAL COMMISSION

      GOMATI DISTRICT: UDAIPUR

A N D

SHRI S. Nandi, MEMBER

SMT. B. SOM, MEMBER

   DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

      GOMATI DISTRICT: UDAIPUR

 

C O U N S E L S

 

For the Complainant: -       Md. Asif Iqbal, Advocate

ORIGINAL DATE OF INSTITUTION: 22-09-2022

DATE OF EX-PARTE ARUGMENT: - 04-07-2024

 

JUDGMENT DELIVERED ON: 24- 07-2024

 

 

J U D G M E N T

 

                        This complaint has been filed by the complainant Sri Sujit Saha Under Section 35 of the Consumer Protection Act, 2019 (Act in short hereinafter) against the opposite parties alleging deficiency in service regarding reimbursement of treatment expenses.

2)                    The facts as pleaded in complaint petition  are  that the complainant is a valuable customer of State Bank of India, Udaipur Branch and have a joint Savings Account No. 30385941559 with his wife and that on 30-01-2022, he purchased, by paying Rs. 10,502/- ,  a Health Insurance Policy “Arogya Plus” by the introduction of  O.P No. 02 i.e. Branch Manager, S.B.I, Ramesh Chowmuhani Branch bearing policy No. 0000000026644810 covering period from 30-01-2022 to 29-01-2023 issued by the O.P No. 01 and that   during the existence of the said Insurance Cover on 06-05-2022 the complainant suddenly became ill and admitted at R.N. Tagore hospital, Kolkata  and took treatment up to on 12-05-2022 as an indoor patient and for treatment purpose Rs. 49,667/- (Rupees Forty Nine thousand Six hundred sixty seven) only was spent.

1. Thereafter on 13-05-2022 the complainant attended the O.P.D of Fortis Hospital, Kolkata and several examination was done by the Doctor of Fortis Hospital and took treatment up to 17-05-2022 and spent an amount of Rs. 1, 10,068/- (Rupees One Lac Ten thousand Sixty Eight) only for the purpose of treatment totaling Rs. 1, 59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five) and that thereafter the complainant filed an application along with all documents issued by Rabindranath Tagore International Institute of Cardiac Sciences & Fortis Hospital claiming reimbursement of medical expenses amounting to Rs. 1,59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five) only to SBI General Insurance Company Ltd and after submission of the claim, the complainant contacted with the opposite parties many times but the claim was not honored and that on 14-06-2022 the complainant again filed claim application to the opposite parties and on 23-06-2022 the opposite party No. 01 sent a letter to the complainant stating that they were not able to consider the claim of the complainant by mentioning false allegation and on 24-06-2022 the O.P No. 01 sent another letter to the complainant by stating the same thing and again on 25-07-2022 the O.P No. 01 again sent another letter by stating that the policy of the complainant was cancelled due to non disclosure of pre-existing diseases. Thereafter the complainant requested many times to settle the rightful claim without further delay but the O.Ps did not reimburse the treatment expenses of the complainant and thus the complainant claimed Rs. 2,39,735/- as compensation.  

4)                    Notice was sent and issued to the Opposite parties. Opposite parties though appeared twice but thereafter did not appeared and so the case was ordered to be proceeded ex-parte against them.  

5)                    In absence of any pleading from the respondent, no issues were framed. However for proper adjudication of this dispute, the following points arise for determination.

 

POINTS FOR DETERMINATION

 

1. Whether the complainant is a consumer of the respondents?
2. Whether there was any deficiency in service on the part of O.P No. 1 in serving the Health Insurance Policy No. 0000000026644810?
3. Whether the complainant is entitled to any compensation and if so, what shall be the quantum and who shall be liable to pay the same?

 

6)                    To prove the case the complainant adduced his evidence by filling his examination- in-chief on affidavit as P.W-1.  In support of his evidence, P.W-1 produced the following documents. 

                        1. Policy book issued by SBI General Insurance which was  marked as Exbt. P-1.

                        2. Photocopy of my discharge summary issued by Rabindranath Tagore International Institute of Cardiac Sciences in 02(two) sheets.

                        3. Photocopy of Echo report issued by Rabindranath Tagore International Institute of Cardiac Sciences in 01(one) sheet.

                        4. Photocopy of O.P.D consultation issued from Fortis hospital in 02 (two) sheets.

                        5. Photocopy of discharged summary issued by Fortis hospital in 02(two) sheets.

                        6. Photocopy of department of Radiology issued by International hospital Limited in 02(two) sheets.

                        7. Photocopy the declaration of the Fortis hospital dated 17-05-2022.

                        8.  Original receipt issued from Rabindranath Tagore International Institute of Cardiac Sciences and Fortis hospital in total 05(five) sheets which were marked as Exbt. P-2 (i-v).

                        9. Photocopies of the bills issued from Rabindranath Tagore International Institute of Cardiac Sciences and Fortis hospital.

7)                    During cross-examination, the P.W-2 has exhibited the following documents:-  

1. Copy of receiving E-mail received from S.B.I General Insurance given by one Mithun Saha in 02(two) sheets which were marked as Exbt.P-3 (i-ii).

 

DISCUSSION, DECISION WITH REASONS

 

8)                    In the complaint and evidence the complainant stated that he had a joint savings account with his wife at S.B.I Udaipur branch and on 31-01-2022 he purchased a health insurance policy namely “Arogya Plus policy” under the introduction of branch Manager, S.B.I Ramesh Chowmuhani branch i.e O.P No- 02  vide  Policy No 0000000026644810 for 01 (one) year for all diseases and treatments by paying Rs. 10,502/- (Rupees ten thousand five hundred two) for himself and his wife covering the period from 31-01-2022 to 29-01-2023 with  health card bearing  ID No. 4038233109 and that premium was paid under the agreement and as per the terms and conditions of the policy, the O.Ps will bear all the treatment expenses of the complainant and his wife. Such assertion of the complainant gets proved by Exbt. P-1 i.e. the policy book where from it appears that on 30-01-2022 Arogya plus Policy was issued to Sujit Saha under policy No. 0000000026644810   for coverage of the complainant and his wife from 30-01-2022 to 29-01-2023 on receipt of premium of Rs. 10,502(Rupees  Ten thousand Five hundred Two).

9)                    In the customer information sheet  as  available in the policy document the details of coverage i.e. hospitalization expenses, O.P.D treatment  and tele-consultation , pre and post hospitalization  expenses, day care expenses, ambulance  expenses, alternative  treatment   etc.  are mentioned . However in the policy there are also exclusion clauses i.e. pre-existing diseases, specific disease / procedure waiting period, reflective error, cosmetic or plastic surgery, breach of law sterility and infertility, change of gender, obesity / weight control unproven treatment etc. In the policy document it is also mentioned that there will be initial waiting period of i)30(thirty) days for all illnesses, ii)90(ninety ) days for specified disease and procedures iii)12(twelve) months specific surgeries  treatments diseases, iv) 48(forty eight) months for pre-existing diseases.

                        Thus, it is held that the complainant is a consumer of the O.P No. 1.   

10)                  As per the evidence of the complainant during the subsistence of the insurance coverage, he suddenly became ill on 6-05-2022 when his son Dr. Sourav Saha i.e. P.W -2 treated him and on 11-05-2022 P.W-2 took him to Kolkata where the complainant attended O.P.D of  R.N Tagore hospital and as per advice of Doctor he was admitted there and treated up to 12-05-2022 on which day he was discharged and that during such treatment he had to spend Rs.  49,667/- (Rupees Forty Nine thousand six hundred sixty seven).   He further stated that on 17-05-2022 and 18-05-2022 he filed claim application through Fortis hospital and R.N. Tagore hospital with all original documents such as discharge summary, prescription, test reports , cash memos, bills, vouchers which were supplied to him, claiming Rs. 1,59,735/- (Rupees One Lac Fifty Nine thousand seven hundred thirty five)  bearing S.B.I claim No. 200322037835-01 , TPA claim No 108081363 and that the complainant also made contact with the O.Ps on several occasions  but they did not pay the expenses incurred for his treatment and that again on 14-06-2022 he filed claim but  on 23-06-2022 O.P-1 sent a letter to him stating that they were unable to consider the claim .

11)                 The complainant further stated that on 24-06-2022 he sent another letter to O.P No.1 but on 25-07-2022 O.P No. 1 sent a letter to him by stating that his policy was cancelled due to non-disclosure of pre-existing disease, without paying any cost of treatment.

12)                  In support of his evidence he filed photocopy of discharge summary, Eco report, O.P.D consultation, discharge summary, declaration and bills. Though the aforesaid documents were photocopies but as per order dated- 28-02-2023. it appears that  the complainant filed an application under Order XI Rule-14 C.P.C to direct O.Ps to produce original documents, copy of which were filed by the complainant and accordingly notice was issued to the O.Ps  to produce the original documents but the O.Ps did not comply.

13)                  In his evidence the complainant stated that he claimed compensation from the O.P by annexing all the original documents, copy of which are exhibited as evidence. Thus when the originals are lying with the O.Ps and when the complainant has complied with the provision of Section-65 of the Evidence Act, in absence of production of original documents by the O.Ps, the photocopy of documents submitted by the complainant, are treated to be admissible in evidence. From the copy of the documents submitted by the complainant it appears that he attended R.N Tagore hospital and underwent treatment from 11-05-2022 to 12-05-2022. Further it appears that the claimant was admitted in Fortis hospital on 13-05-2022 and was discharged on 17-05-2022 and for such treatment the complainant had to incur expenditure to the extent of Rs.1,59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five). Further it appears that from the copy of communication of e-mail i.e. exhibit -P-3(i-ii) and exhibit -P-3(ii) it appears that the complainant filed original documents at the time of raising of his claim. Again communication dated 25-07-2022 from O.P No. 1 it appears that O.P No. 1 cancelled the policy on the ground of non-disclosure of pre-existing disease.

14)                  Though the complainant has proved successfully that he purchased health insurance policy and during the coverage of such policy he became ill and took treatment at R.N Tagore hospital and Fortis hospital and for that he had to incur expenditure for Rs.1, 59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five) but the O.Ps did not contest the claim of the complainant nor disputed the evidence adduced by the complainant. When the O.Ps cancelled the policy on the ground of non-disclosure of pre-existing disease then the burden shifts upon the O.Ps to prove that the disease suffered by the complainant where pre-existing. But the O.Ps did not discharge their burden. In absence contrary evidence from the O.Ps it cannot be said that disease suffered by the complainant were pre-existing on his body before issuance of policy. So the cancellation of policy by the O.Ps on the ground of non-disclosure of pre-existing disease is found to be arbitrary and without any reason, which amounts to deficiency in service on the part of O.P No. 1.  

15)                  Thus it is held that there was deficiency in service on the part of the O.Ps in-respect of “Arogya Plus Policy”i.e. Exbt- P-1, as aforesaid, so far it relates to the complainant. It is presumed that because of non-payment of the claimed amount by the O.Ps the complainant had to suffer mental agony and pain with feeling of harassment. Thus the complainant is not only entitled to the amount of Rs.1, 59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five) as incurred for the purpose of his treatment but also entitled to get compensation of Rs. 50,000/- (Rupees fifty thousand) for payment of mental agony and suffering of pain and harassment with litigation cost of Rs. 10,000/-.         

           

O R D E R

 

16)                  In the result, it is ordered that the complainant will get from the O.Ps:

i) Rs.1, 59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five) as the amount incurred for the purpose of his treatment,

ii)  Rs. 50,000/- (Rupees fifty thousand) as compensation for undergoing mental agony, pain and suffering.

iii) Rs. 10,000/- as cost of litigation.

17)                 The O.Ps are jointly and severally liable to pay the same to the complainant within a period of 01 (one) month from today and on failure to pay the same within the stipulated period of 01 (one) month the O.Ps shall have to pay interest @ Rs. 6% per annum only on Rs.1, 59,735/- (Rupees One Lac Fifty Nine thousand Seven hundred Thirty Five).

18)                 The claim thus stands disposed off on contest.  

19)                 Enter the result.  

 

ANNOUNCED