DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA :  AGARTALA

 

 

CASE   NO:   CC- 47 of 2021

 

 

Mr. Samrat Kar Bhowmik,

Son of Shri Manish Kar Bhowmik,

Dhaleswar, Road No.4,

P.O.-Dhaleswar, P.S.- East Agartala,

Pin-799007, Dist.- West Tripura …....…....................Complainant.

 

 

 

-VERSUS-

 

 

 

SBI General Insurance Company Limited,

Sriram Plaza, Ground Floor, Ker Choumuhani,

T.G. Road, Agartala, P.S.-West Agartala,

Dist.-West Tripura, Pin-799002

Represented by Branch Manager...........…...............Opposite party.

 

 

 

    __________PRESENT__________

 

 SRI RUHIDAS  PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

      WEST TRIPURA, AGARTALA. 

 

DR (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR  GUPTA

MEMBER,

  DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA. 

 

 

C O U N S E L

 

For the Complainant : Shri Sampad Choudhury,

  Advocate. 

For the O.P. : Shri Prabal Kumar Ghosh,

  Advocate. 

 

 

JUDGMENT  DELIVERED  ON: 25/05/2022.

J U D G M E N T

The complainant Shri Samrat Kar Bhowmik,  set the law in motion by presenting the petition U/S. 35 of the Consumer Protection Act, 2019 complaining deficiency of service committed by the O.P.  

  The complainants' case, in brief, is that on 29/03/2018 the Complainant subscribed a health insurance policy from O.P.,SBI General Insurance Company Ltd. vide Policy No.0000000008814728 of which Policy name was “Arogya Premier Policy” the sum assured the Policy was Rs.15,00,000/- and premium of Rs.23,142/- was paid for the said policy. But subsequently the Complainant continued with the said policy and lastly on 09/04/2021 the Complainant again renewed the policy and the policy was renumbered by the O.P. vide Policy No.0000000017634429-01. The sum assured under the Policy was Rs.15,00,000/- only and the cumulative bonus acquired under the policy was Rs.3,00,000/- only. The aforesaid Policy commenced from 09/04/2021 to 08/04/2022(Midnight). The Policy have the benefit of cashless treatment. On 12/04/2021 the Complainant suddenly he became unconscious and fallen ill. Then, the Complainant was shifted to ILS Hospital, Agartala and admitted therein for treatment. Thereafter, the Complainant was finally discharged from the ILS Hospital, Agartala on 18/04/2021 at the time of admission of the Complainant in the ILS Hospital, Agartala the Complainant's family members duly informed the concerned authority of SBI, General Insurance Company Ltd. about his sudden illness and admission in the ILS Hospital and requested to initiate claim for Cashless Benefit. After completion of treatment when the Complainant on 18/04/2021 was discharged from ILS Hospital, the ILS Hospital authority raised total bill amounting to Rs.4,19,992/-  only but O.P., SBI General Insurance Company Ltd. settled insurance claim amounting to Rs.4,00,514/- only and most arbitrarily denying to pay the rest bill amounting to Rs.19,478/- only and as such Complainant was compelled to pay the rest bill amount. But O.P. suddenly denied to facilitate the Complainant with full cashless benefit, the ILS Hospital Authority gave Rs.6,200/- discount from the whole bill amount, as the Complainant was in shortage of cash in hand and the Complainant from his own paid Rs.13,278/- only to the ILS Hospital for his treatment. 

Being aggrieved and dissatisfied with the services of the O.P. the complainant filed this complaint praying for balance amount of bill which the Complainant paid at ILS Hospital & compensation of Rs.1,93,278/- on mental agony, frustration and depression, deficiency in service & cost of litigation. 

Hence this case. 

On the other hand O.P. SBI General Insurance Company Limited has contested the claim by way of filing written objection and in their written objection it is stated that the petition is not maintainable in its present form and there is no cause of action for filing the complaint and complaint is bad for non-joinder of necessary party. It is further stated that on 18/04/2021 the Complainant applied for cashless benefit under Arogya Premier Policy of Rs.4,19,992/- wherein the O.P. settled the claim for Rs.4,00,514/-. O.P. further stated that based on the terms and conditions of the said policy under clause Exclusions(39) which specifies that the Insurer will not pay expenses, incurred in respect of claims arising out of or howsoever related to any kind of surcharges, admission fees/ registration charges etc. levied by the hospital. O.P. also stated that as per the clause 8 b (iii) of the said policy states that “If the procedure is followed as per clause 8 (a), Insured will not be required to directly pay for the medical expenses in the network hospital that Insurer is liable to indemnify under cover IV. O.P. above and the original bills and evidence of treatment in respect of the same shall be left with the network hospital. Pre-authorization does not guarantee that all cost and expenses will be covered, administrator reserves the right to review each claim for medical expenses and accordingly coverage will be determined according to the terms and conditions of this Policy. Insured will, in any event, be required to settle all other expenses directly. O.P. also stated that the terms and conditions of the above mentioned policy regarding the payment of Rs.4,00,514/- towards the said claim. So there is no question of harassment and negligence or any deficiency of service on the part of the O.P. 

        The O.P. has thus prayed for dismissal of the Complaint for the interests of justice.     

 3. EVIDENCE ADDUCED BY THE PARTIES:

In support of the Complaint, the Complainant Shri Samrat Kar Bhowmik was Examined himself as PW-1 and produced 4 documents comprising 44 sheets by Firisti dated 30/06/2021 and also produced 5 documents comprising 50 sheets by Firisti dated 19/11/2021. 

On behalf of the O.P. one witness namely Sri Subhadeep Banerjee, S/O. S. K. Banerjee of Room No.1508, 15th Floor, P.S.-Srijan Corporate Park, GP Block, Sector V, Bidhannagar, Kolkata, was Examined. 

 

 POINTS TO BE DETERMINED:- 

4.  Based on the contentions raised by both the parties the following issues were framed for determination:  

   i). Whether  there was  any deficiency of service committed by the O.P. towards the Complainant?

    (ii). Whether the Complainant is entitled to get any  compensation/relief ?

5. ARGUMENTS OF BOTH SIDES:

We have heard arguments from both sides. At the time of argument, Learned Counsel of the Complainant submitted that on 29/03/2018 the Complainant subscribed a health insurance policy from O.P.,SBI General Insurance Company Ltd. vide Policy No.0000000008814728 of which Policy name was“Arogya Premier Policy” the sum assured was Rs.15,00,000/- and premium of Rs.23,142/- paid for the said policy. But subsequently the Complainant continued with the said policy and lastly on 09/04/2021 the Complainant again renewed the policy and the policy was renumbered by the O.P. vide Policy No.0000000017634429-01. The sum assured under the Policy was Rs.15,00,000/- only and the cumulative bonus acquired under the policy was Rs.3,00,000/- only. The aforesaid Policy commenced from 09/04/2021 to 08/04/2022(Midnight). The Policy is live till date and is having the benefit of cashless treatment. On 12/04/2021 the Complainant suddenly became unconscious and fallen ill. Then, the Complainant was shifted to ILS Hospital, Agartala and admitted therein for treatment. Thereafter, the Complainant was finally discharged from the ILS Hospital, Agartala on 18/04/2021 at the time of admission of the Complainant in the ILS Hospital, Agartala the Complainant's family members duly informed the concerned authority of SBI, General Insurance Company Ltd. about his sudden illness and admission in the ILS Hospital and requested to initiate claim for Cashless Benefit. After completion of treatment when the Complainant on 18/04/2021 was discharged from ILS Hospital, the ILS Hospital authority raised total bill amounting to Rs.4,19,992/-  only but O.P., SBI General Insurance Company Ltd. settled insurance claim amounting to Rs.4,00,514/- only and most arbitrarily denying to pay the rest bill amounting to Rs.19,478/- only and as such Complainant was compelled to pay the rest bill amount. 

On the other hand Learned Counsel of the O.P. submitted that there is no fault on the part of the O.P. as well as there is no deficiency of service and complaint is liable to be dismissed. Learned Counsel of the O.P. submitted that there is no cause of action for filing the complaint and complaint is bad for non-joinder of necessary party. It is further stated that on 18/04/2021 the Complainant applied for cashless benefit under Arogya Premier Policy of Rs.4,19,992/- wherein the O.P. settled the claim for Rs.4,00,514/-. O.P. further stated that based on the terms and conditions of the said policy under clause Exclusions(39) which specifies that the Insurer will not pay expenses, incurred in respect of claims arising out of or howsoever related to any kind of surcharges, admission fees/ registration charges etc. levied by the hospital. O.P. also stated that as per the clause 8 b (iii) of the said policy states that “If the procedure is followed as per clause 8 (a), Insured will not be required to directly pay for the medical expenses in the network hospital that Insurer is liable to indemnify under cover IV. O.P. also stated that the terms and conditions of the above mentioned policy settled the payment of Rs.4,00,514/- towards the said claim. 

     Learned Counsel of the O.P. further submitted that Complainant has failed to prove any deficiency of service against the O.P.     

6. DECISION AND REASONS FOR DECISION:

 

We have minutely gone through the complaint, written statement as well as the documents submitted by the Complainant.  

From the pleadings and documents we found that it is admitted fact that Complainant was Hospitalized for his sudden illness on 12/04/2021 and he was admitted in the ILS Hospital, Agartala and discharged on 18/04/2021 after treatment. It is also admitted fact that ILS Hospital Authority raised total bill amounting to Rs.4,19,922/- but O.P., SBI General Insurance Company Limited settled insurance claim amounting to Rs.4,00,514/- only and they have denied to pay the rest bill amount i.e. Rs.19,478/- only. The grounds shown for rejection of the rest amount was that the terms and conditions of the policy under clause Exclusions (39) which specifies that the Insurer will not pay expenses, incurred in respect of claims arising out of or howsoever related to any kind of surcharges, admission fees / registration charges etc levied by the Hospital Authority. 

From the complaint petition we find that the details of deduction were Medicines /Drugs of Rs.10,897/-, ICU Consultant of Rs.700/-, OT Charges of Rs.1,300/-, Other Misc. Charges of Rs.2,380/-, Room Rent of Rs.2,400/- & ICU Charges of Rs.1,800/- in total of Rs.19,478/-. 

Complainant in his examination-in-chief on affidavit at Para-5 stated that after completion of the treatment when he was discharged from ILS Hospital, Agartala. ILS Hospital Authority raised total bill amounting to Rs.4,19,992/- but most surprisingly O.P. settled the insurance claim amounting to Rs.4,00,514/- and most arbitrarily denied to pay the rest bill amount to Rs.19,478/- and as such Complainant was compelled to pay the rest bill amount. Complainant further stated that the Hospital Authority gave him discount of Rs.6,200/- from whole bill amount and he had some how managed for payment of remaining bill amount and paid Rs.13,278/- only to the ILS Hospital, Agartala on his own. In the said examination-in-chief at Para-7,8,9 & 10 he deposed that subsequently on 08/11/2021 he had filed “90 days post Hospitalization Claim Benefit” amounting to Rs.8,737/- to the O.P., SBI General Insurance Company Limited but O.P. denied to accept the said Post Hospitalization Claim Benefit. 

We have perused the documents submitted by the Claimant by Firisti dated 30/06/2021 & 19/11/2021. 

On overall appreciation of the evidences adduced from both sides we are in the opinion that O.P. i.e. SBI General Insurance Company Limited most illegally settled the insurance claim and denied to pay the rest bill amount for which Complainant had suffered pain mentally and denial of the full insurance benefit to the Complainant amounts to deficiency in service towards the Complainant.

        Hence, it is ordered that O.P. will pay the rest bill amount of Rs.13,278/- as Complainant claimed the amount in the complaint petition and also Rs.15,000/- for causing harassment and mental agony and also litigation costs of Rs.5,000/- i.e. in total of Rs.33,278/-.(Rs.13,278/- + Rs.15,000/- + Rs.5,000/-). The O.P. is directed to make the whole payment within 1 month from the date of this judgment and if the payment is not made within 1 month then it will carry interest @ 7% per annum till the payment is made in full. Accordingly, the complaint is partly allowed. 

      Thus the complaint is disposed of.     

        Supply a certified copy of the judgment to both the parties free of cost. 

   

 Announced.

 

SRI  RUHIDAS  PAL

PRESIDENT,

DISTRICT CONSUMER  DISPUTES 

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA

 

 

 

DR (SMT)  BINDU  PAL

MEMBER, 

DISTRICT CONSUMER DISPUTES 

REDRESSAL COMMISSION, 

WEST TRIPURA,  AGARTALA

 

SRI SAMIR  GUPTA

MEMBER,

 DISTRICT CONSUMER  DISPUTES  

REDRESSAL COMMISSION,

WEST TRIPURA,  AGARTALA.