Haryana

Karnal

CC/82/2018

Sandeep Tyagi - Complainant(s)

Versus

SBI General Insurance Company Limited - Opp.Party(s)

14 Mar 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 82 of 2018

                                                          Date of instt. 03.04.2018

                                                          Date of Decision 14.03.2019

Sandeep Tyagi aged about 36 years son of Shri S.P. Tyagi resident of house no.38, New Friends Colony, Panipat, Mobile-94661-00051.

                                                                       …….Complainant.

                                                  Versus

SBI General Insurance Company Limited, having its office: 1^st floor, B.D. International, SCO no.388-389, Karan Commercial Complex, near Guru Hari Kishan School, Sector-13, Karnal through its Managing Director/Authorized person.

                                                                                                                                                                         …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Complainant in person.

                   Shri Mohit Goyal Advocate for OP.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that the complainant had purchased a health policy on payment of premium of Rs.2500/-, vide policy no.0000000002684741-02 on 22.03.2015 for one year from the OP at Panipat and same was renewed by the complainant every year. This policy was cashless of penal hospital and reimbursement of medical claim of non-penal hospital with respect to the complainant. The claim amount of aforesaid policy is Rs.3,00,000/-. On 27.05.2016 the complainant suddenly suffered pain in his stomach and get checked himself in OP’s penal hospital Dr. Prem Hospital, Panipat and as per the advised of the doctor, complainant got admitted there where necessary tests/investigation were conducted upon the complainant and remained there under treatment as indoor patient and discharge on 28.05.2016 from the hospital. On 27.05.2016, the complainant and doctor of Prem Hospital, Panipat informed regarding the fact to the OP through email with the request to get sanction for cashless treatment but despite several e-mails, the OP did not provide sanction of cashless treatment to the complainant till 28.05.2016 for which the complainant is legally entitled. Thus, complainant paid bill of Rs.10,550/- to the hospital. After that the OP’s authorized person visited at the house of the complainant and collected all the relevant information/documents from the complainant and assured the complainant that his medical bills will be reimbursed within few days. Thereafter, complainant again fell ill and admitted in Bala Ji Multi Specially Hospital, Panipat and remained there as indoor patient from 10.02.207 to 11.02.2017. At that time as per assurance of the OP the complainant paid bill of Rs.6499/- to the hospital. After that as per instruction of the OP complainant sent required documents to the OPs and that time OP assured that his medical bills will be reimbursed within few days but OP did not reimbursed the medical bills despite repeated requests made by the complainant. Thereafter, complainant contacted the OP through telephonically and personally with the request to reimburse the medical bill but OPs prolonging the matter on one pretext or the other and did not pay the amount. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint

2.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. The true facts are that TPA of OP has written letters on 12.08.2017 and than on 23.08.2017 and finally on 02.09.2017 to ask some additional documents in order to process the claim of complainant. But complainant did not reply. As per condition precedent:-Claim Procedure: Section D (Pint iii)”  Insured has to file the claim with all necessary documentation within 15 days of discharge from Hospital, provide insurer with written details of quantum of any claim alongwith all original bills, receipts and other documents upon which a claim is based and shall give insurer such additional information and assistance as insurer may require in dealing with the claim. In case of delay submission of claim and in absence of justified reason for delayed submission of claim, the insurer would have right of not considering the claim for reimbursement. Therefore, the competent authority of the OP has repudiated the claim of the complainant, vide letter dated 26.09.2017. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence documents Ex.C1 to Ex.C22 and closed the evidence on 4.10.2018.

4.             On the other hand, OP tendered into evidence affidavit of Jitendra Dhabhai Ex.RW1/A and documents Ex.R1 to Ex.R30 and closed the evidence on 7.2.2017.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties

6.             The case of the complainant is that the complainant had purchased a Health policy on 22.03.2015 for a sum assured amount of Rs.3 lakhs from OP. On 27.05.2016 complainant suffered pain in his stomach and admitted in Prem Hospital, Panipat and spent Rs.10,550/- for his treatment. The complainant again fell ill and admitted in Balaji Multi Specialty Hospital, Panipat and paid a bill amount of Rs.6499/- to the hospital. Thereafter, complainant submitted all the medical bills for reimbursement with the OP. But OP did not release the medical bill of the complainant.

7.             On the other hand, the OP has written letter on 12.08.2017 and then on 23.08.2017 and finally on 02.07.2017 to ask some additional documents in order to process the claim of the complainant. But the complainant did not reply. As per condition precedent:- Claim Procedure: Section D (Pint iii)”  Insured has to file the claim with all necessary documentation within 15 days of discharge from Hospital, provide insurer with written details of quantum of any claim alongwith all original bills, receipts and other documents upon which a claim is based and shall give insurer such additional information and assistance as insurer may require in dealing with the claim. In case of delay submission of the claim and in absence of justified reason for delayed submission of claim, the insurer would have right of not considering the claim for reimbursement.” OP has rightly repudiated the claim of the complainant.

8.             Admittedly, the complainant had taken treatment during the subsistence of the policy. The medical claim was repudiated by the OP on the ground that did not supply additional documents in order to process the claim of the complainant. In this regard, OP written letters (Ex.R1) dated 24.03.2017, (Ex.R2), dated 01.04.2017, (Ex.R3), dated 09.05.2017, (Ex.R4), dated 17.05.2017, (Ex.R5), dated 29.05.2017, (Ex.R6), dated 01.06.2017, (Ex.R7), dated 14.06.2017, (Ex.R8), dated 22.06.2017, (Ex.R9), dated 03.07.2017, (Ex.R10), dated 14.07.2017, (Ex.R11), dated 04.08.2017, (Ex.R12), dated 12.08.2017, (Ex.R13), dated 23.08.2017, (Ex.R14), dated 04.09.2017, (Ex.R15), dated 18.04.2018, (Ex.R16), dated 27.04.2018, (Ex.R17), dated 03.05.2018, (Ex.R18), dated 12.05.2018, (Ex.R19), dated 23.05.2018, (Ex.R20), dated 30.05.2018, (Ex.R21), dated 07.06.2018, (Ex.R22), dated 18.06.2018, (Ex.R23), dated 29.06.2018, (Ex.R24), dated 7.7.2018, (Ex.R25), dated 17.07.2018, (Ex.R26), dated 25.07.2018, (Ex.R27), dated 03.08.2018, (Ex.R28), dated 11.08.2018, (Ex.R29), dated 22.08.2018 and (Ex.R30), dated 03.09.2018. Despite sent above mentioned letters, complainant failed to supply the required documents to the OP. Thus, we are of the considered view that at the stage OP is not deficient in service.

9.             In view of the above discussion, we dispose off the present complaint with the direction, the complainant supply the additional documents as required by the OP within 30 days from the date of order. Thereafter, the OP to decide the claim of the complainant within 30 days after receiving the documents. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:14.03.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member