DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/66

Date of Institution : 30.01.2018/29.11.2021

Date of Decision : 04.08.2022

Kuldip Singh son of S. Gulzar Singh aged about 34 years resident of 122, 40Khooh, Near Jaura Phatak, Rasoolpur Rohi, Amritsar. …Complainant

Versus

1. SBI General Insurance Company Limited, Natraj 101, 201 and 301, Junction of Western Expression, Highway, Andheri-Kurla Road, Andheri (East), Mumbai-400069 through its Manager/Chief Manager/ Authorized Signatory/Person over all Incharge. 

2. Paramount Health Services (TPA) Private Limited, Plot No. A-442, Road No. 28, MIDC Industrial Area, Ram Nagar, Wagle Estate, Thane (W)-400604 through its Manager/Chief Manager/Authorized Signatory/ Person over all Incharge.

3. BVG India Limited, 106, 1st Floor, Mercantile House, 15, Kasturba Gandhi Marg, New Delhi-110001 through its Director/Managing Director/Partner/Prop./Authorized Signatory/Person over all Incharge.

4. BVG India Limited, having its local office at Golden Temple Plaza Golden Temple Entrance, Near Jauraghar, Amritsar through its Branch Manager/Manager, Director/Managing Director/Partner/Prop./Authorized Signatory/Person over all Incharge.

5. Dhruv Nursing and Maternity Home, Near Gopal Mandir, 270-D, Kashmir Avenue, Amritsar through its Partner/Proprietor/Authorized Signatory/Person over all Incharge.

…Opposite Parties

Complaint U/S 11 and 12 of The Consumer Protection Act 1986 as amended upto date.

Present: Ms. Shikha Sanhotra Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite party No. 1.

Opposite parties No. 2, 3, 4 and 5 exparte.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 11 and 12 of the Consumer Protection Act 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 the opposite party No. 3 is an employer of the complainant and is having employee ID S3109 and opposite party No. 3 obtained Group Health Insurance Policy for his employees from the opposite party No. 1 vide Group Health Policy No. 173763-0000-00/ Membership ID 31702442 issued by opposite party No. 1 and an amount of Rs. 1,200/- was deducted from the salary of the complainant towards premium of the said policy. The said scheme was ensure cashless all Indoor Medical Treatment, Pre and Post Hospitalization, specified as defined, Day Care Procedures (requiring less than 24 hours hospitalization) and OPD medical expenses relating to chronic diseases upto a sum of Rs. 1,00,000/- per year on floater basis. Medicines for chronic diseases will also be made available on cashless basis from designated stores and hospitals in every district and block. 

3. It is further alleged that this policy cover the risk of the complainant and his family members consisting of Mrs. Preeti wife of complainant and son of complainant Joydeep Singh. During the validity period of the said policy the wife of the complainant got admitted in the hospital of opposite party No. 5 on 9.5.2017 and delivered a female child and she was being operated by the concerned doctors in the said hospital. The complainant presented the card issued by the opposite parties in the said hospital but they refused the complainant to to provide cashless facility and insisted him to deposit cash amount and under compelling circumstances complainant got medical treatment from the said hospital and made payment of bill in cash and wife of complainant discharged on 18.5.2017. The complainant spent a total sum of Rs. 52,330/- on the medical treatment. Thereafter, all the requisite bills alongwith relevant documents have been sent to the opposite parties No. 1 and 2 for reimbursement but opposite parties failed to process the claim of the complainant within the stipulated period and raising false and frivolous grounds for not processing the genuine claim of the complainant, which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay the amount of Rs. 52,330/- alongwith interest at the rate of 12% per annum.   

2) To pay Rs. 20,000/- on account of compensation for mental agony and harassment. 

3) To pay litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite party No. 1 filed written statement taking preliminary objections that the wife of complainant joined the policy on 4.7.2017 whereas she was admitted in the hospital on 9.5.2017 so the expenses arising out of ailment is not payable since hospitalization is out of the policy period. The claim for hospitalization falls beyond purview of policy coverage, therefore, is not payable and due intimation of the same was given to the complainant vide letter dated 8.9.2017, so the present complaint is not maintainable. The complainant has concealed material facts from this Commission and not come to this Commission with clean hands. The complainant has no cause of action and locus standi to file the present complaint.

5. On merits, it is submitted that wife and son of the complainant joining the policy on 4.7.2017 and as per record wife of complainant admitted in hospital on 9.5.2017 so the expenses arising out of ailment is not payable since hospitalization is out of policy period. It is further submitted that after receiving the documents the claim of the complainant was scrutinized and it has been observed that wife of the complainant joined the policy on 4.7.2017 and admitted in hospital on 9.5.2017 so the expenses of treatment not payable since hospitalization is out of policy period. The claim of the complainant was rightly repudiated as per terms and conditions of the policy. Lastly, the opposite party No. 1  prayed for the dismissal of the present complaint qua the answering opposite party. 

6. The opposite parties No. 2 to 5 preferred to remain exparte. 

7. The complainant tendered in evidence his own affidavit Ex.CW-1/A alongwith documents Ex.C-1 to Ex.C-17 and closed the evidence. 

8. To rebut the case of the complainant the opposite party No. 1  tendered in evidence affidavit of Jitendra Dhabhai Ex.OP-1/1, copy of special power of attorney Ex.OP-1/2, copy of repudiation letter Ex.OP-1/3, copy of endorsement of Group Health Insurance Ex.OP-1/4, copy of policy alongwith terms and conditions Ex.OP-1/5 and closed the evidence.   

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

10. The complainant alleged in that the complaint that he is employee of opposite party No. 3 and opposite party No. 3 obtained Group Health Insurance Policy for his employees from the opposite party No. 1 vide Group Health Policy No. 173763-0000-00/ Membership ID 31702442 issued by opposite party No. 1 and an amount of Rs. 1,200/- was deducted from the salary of the complainant towards premium of the said policy. The complainant further alleged in the complaint that this policy cover the risk of the complainant and his family members consisting of Mrs. Preeti wife of complainant and son of complainant Joydeep Singh. The complainant further alleged that the wife of the complainant got admitted in the hospital of opposite party No. 5 on 9.5.2017 and delivered a female child and she was being operated by the concerned doctors in the said hospital. The complainant presented the card issued by the opposite parties in the said hospital but the hospital refused to provide cashless facility. The complainant paid an amount of Rs. 52,330/- on the medical treatment and wife of complainant discharged on 18.5.2017. The complainant applied for reimbursement but opposite party No. 1 failed to process the claim of the complainant within the stipulated period and raising false and frivolous grounds for not processing the genuine claim of the complainant.  

11. On the other hand the opposite party No. 1 appeared and  filed written version and alleged that the wife of complainant joined the policy on 4.7.2017 whereas she was admitted in the hospital on 9.5.2017 so the expenses arising out of ailment is not payable since hospitalization is out of the policy period. The opposite party No. 1 further alleged that  the claim for hospitalization falls beyond purview of policy coverage, therefore, is not payable and due intimation of the same was given to the complainant vide letter dated 8.9.2017. 

12. The complainant has produced the document Ex.C-3 dated 14.1.2017 issued by BVG India Private Limited an employer of the complainant in which it is mentioned that Group Mediclaim policy of Rs. 1,00,000/- includes employee, spouse and first two children will be applicable after three months of the joining. The complainant has also produced a letter dated 23.5.2017 Ex.C-4 which was issued by the Paramount Health Services Private Limited vide which the complainant was intimated that his health insurance policy was issued by SBI General Insurance Company. The complainant has also produced the health card Ex.C-5 of SBI General Insurance Company in which it is mentioned that the insurance start date was 22.4.2017. The opposite party No. 1 has taken an objection that the wife of the complainant joined the policy on 4.7.2017 but as per Ex.C-5 the policy was started on 22.4.2017. The complainant produced  Ex.C-3 in which it is mentioned that the employee, spouse and his two children are covered under the Group Mediclaim policy of Rs. 1,00,000/-. 

13. Learned counsel for the complainant argued that the policy of the complainant and his family members was started on 22.4.2017 and the genuine claim of the complainant was wrongly repudiated by the opposite party No. 1. 

14. On the other hand learned counsel for the opposite party No. 1 argued that the wife of the complainant joined the policy on 4.7.2017 and also produced the document Ex.OP-1/4 in which on the Sr. No. 144 it is mentioned that the wife and son of the complainant joined the policy on 4.7.2017. But opposite party No. 1 failed to produce any evidence to establish that why the family members of the complainant was not covered from the date of the commencement of the policy whereas it is admitted case of the opposite parties that policy was issued to the complainant on 22.4.2017. It is clear from document Ex.C-3 that the Group Mediclaim Policy covered the employees and their family members including wife and two children. The document Ex.OP-1/4 produced by the opposite party No. 1 is an excel sheet and it is nowhere mentioned in the said document that same was issued to anyone or not. The complainant has produced the medical bills of Dhruv Nursing and Maternity Home dated 18.5.2017 Ex.C-15 of Rs. 52,330/- and also produced the receipt of the said hospital Ex.C-14 of the same amount. It is established that the complainant has spent Rs. 52,330/- on the treatment of his wife namely Preeti. As per the policy employees and family members are covered under the Group Health insurance policy and in this regard the premium amount of Rs. 1,200/- was also deducted from the account of the complainant. On the other hand the opposite party No. 1 failed to produce any evidence to establish that why the wife and children of the complainant were not covered from the date of commencement of the insurance policy.

15. From the above discussion, it established that the claim repudiated by the opposite party No. 1 vide letter dated 8.9.2017 Ex.OP-1/3 was unreasonable and unjustified and there is clear cut deficiency in service on the part of opposite party No. 1. Therefore, complaint is partly allowed against the opposite party No. 1 and opposite party No. 1 is directed to pay the amount of Rs. 52,330/- to the complainant alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite party No. 1 is also directed to pay Rs. 10,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as costs and litigation expenses. 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 will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        4th Day of August 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member