Haryana

Karnal

CC/569/2019

Sunil Kumar - Complainant(s)

Versus

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

Pawan Kumar Goyal

24 Jan 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 569 of 2019

                                                        Date of instt.02.09.2019

                                                        Date of Decision:24.01.2023

 

Sunil Kumar son of Shri Ram Sawroop, resident of village Kabulpur Khera, Tehsil Assandh, District Karnal.

                                               …….Complainant.

                                              Versus

 

1.     SBI General Insurance Company Ltd. office at SCO-388-389, First floor, Karan Commercial Complex, old Mugal Canal Road, Karnal through its Branch Manager.

 

2.     Paramont Health Services and Insurance TPA Pvt. Ltd. plot no.A-442, Road no.28, MIDC Industrial Area, Wagale East, Ram Nagar, Vitthal, Rukhumani Mandir, Thane, Mumbai.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Shri Vineet Kaushik……Member

      Dr. Rekha Chaudhary…….Member

                   

Argued by: Shri Vishal Goel, counsel for complainant

                   Shri Naveen Khetarpal, counsel for the OP no.1.

                   OP no.2 exparte.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has obtained a health insurance policy from the OP no.1, the policy was obtained in the month of July, 2018 and same was bearing policy no.0000000006644974-01 and an amount of Rs.1102/- was paid for the policy as premium. The complainant was insured for sum of Rs.1,00,000/-. Complainant has availed the policy in the year 2017 and the period of policy was 2017-2018 and the same renewed 17.07.2018 to 16.07.2019. At time of obtaining the policy, complainant disclosed each and every fact to the OP no.1 and nothing was kept concealed. The policy is cashless policy and in case of any health problem no amount is required to be paid on account of hospitalization etc. On 18.3.2019, complainant all of sudden felt pain in abdomen, vomiting were started and problem of nasea, obstipation were developed and was got admitted in Satyam Hospital, Assandh where the concerned doctor disclosed the complainant that he is suffering from acute pancreatitis with shock disease. The complainant was got admitted in the hospital on 18.03.2019 for treatment and remained admitted in hospital till 23.03.2019. The policy in question was cashless policy, so the complainant is entitled to cashless treatment but the OP no.2 refused to give cashless treatment and advised the complainant to appear for reimbursement. Complainant spent Rs.48,738/- on his treatment. After discharge from the hospital, complainant submitted his claim with the OP no.1 on 26.03.2019 alongwith all the required documents but nothing was done by the OP no.1. It is further averred that complainant received a letter dated 10.04.2019 from OP no.2 in which they demanded certain documents i.e. “Item and cost wise details breakup of the investigation as mentioned final bill and original payment receipt of final hospital bill with bill number and receipt number”. Complainant sent the said documents to the OP no.2, vide courier dated 13.04.2019 but nothing was done by the OP no.2. Complainant approached the OPs so many times and requested to settle the claim but OPs did not pay any heed to the request of complainant and lastly repudiated the claim of complainant, vide letter dated 10.06.2019, mentioning therein that they are unable to consider the claim of complainant. In the said letter additional requirement are yet to be received from the end of complainant and further alleged that requirement letter were sent on 02.05.2019, 13.05.2019 and 24.05.2019. Complainant received only letter dated 23.04.2019 and no abovesaid requirement letters have been received from the OP no.2. OPs have not entertained the claim of the complainant and repudiated the same on baseless grounds. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; limitation; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the present complaint is pre-mature as till date complainant has not provided requisitioned documents to the OP to take the action on the claim as per terms and conditions of the policy. It is further pleaded that after getting the intimation regarding claim of the complainant, OP requested the complainant to provide requisitioned documents to process the claim of the complainant but complainant did not provide the same, so OP no.2 issued letter dated 10.04.2019 on behalf of answering OP to provide six requisitioned documents i.e. (i) Degree Details (ii) Details from Attending doctor (iii) Hospital registration number (iv) previous consultations (v) Investigation reports (vi) Main Hospital bill payment. But complainant has not provided the same, then OP no.2 on behalf of OP again sent letters dated 23.04.2019, 02.05.2019, 13.05.2019 and 24.05.2019 but complainant did not provide the documents, perforce the claim of the complainant was closed vide closure letter dated 10.06.2019.  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.             OP no.2 did not appear despite service and opted to be proceeded against exparte, vide order dated 29.07.2022 of the Commission.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy Ex.C1, copy of health card Ex.C2, copy of courier receipt Ex.C3, copy of insurance policy Ex.C4, copy of medical bills Ex.C5, Ex.C6 and Ex.C16, copy of Aadhar card Ex.C7, copy of tax invoice Ex.C8 and Ex.C9, copy of x-ray report Ex.C10, copy of investigation report Ex.C11, copy of ultrasound report Ex.C12 to Ex.C15, copy of letter dated 10.04.2019 Ex.C17, copy of courier receipt Ex.C18, copy of receipt Ex.C19, copy of registration certificate Ex.C20, copy of certificate of medical council Ex.C21, copy of hospital record Ex.C22, copy of letter by Satyam Hospital Ex.C23, copy of letter dated 23.03.2019 Ex.C24 and closed the evidence on 12.09.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Jitendera Dhabhai, Manager Legal Ex.RW1/A, copy of deficiency letter dated 10.04.2019 Ex.R1, copy of partial deficiency letters dated 23.04.2019, 02.05.2019, 13.05.2019 Ex.R2 to Ex.R4, copy of final reminder-cum closure letter dated 24.05.2019 Ex.R5, copy of closure letter dated 10.06.2019 Ex.R6, copy of insurance policy Ex.R7 and closed the evidence on 28.09.2022 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant has purchased a health insurance policy from the OP no.1 in the year 2017 and the same renewed from 17.07.2018 to 16.07.2019. On 18.3.2019, complainant all of sudden felt pain in abdomen and was got admitted in Satyam Hospital, Assandh where the concerned doctor disclosed the complainant that he is suffering from acute pancreatitis with shock disease. The complainant was got admitted in the hospital on from 18.03.2019 to 23.03.2019. The policy in question was cashless policy, so the complainant was entitled to cashless treatment but the OP no.2 refused to give cashless treatment. Complainant spent Rs.48,738/- on his treatment. After discharge from the hospital, complainant submitted his claim with the OP no.1 alongwith all the required documents but nothing was done by the OP no.1. Complainant approached the OPs so many times and requested to settle the claim but OPs failed to do so and  repudiated the claim of complainant, vide letter dated 10.06.2019 on the false and frivolous ground and lastly prayed for allowing the complaint. Learned counsel for the complainant relied upon the judgment of Hon’ble Supreme Court case titled as Gurmel Singh Versus Branch Manager, National Insurance Co. Ltd. in civil appeal no.4071 of 2022, date of decision 20.05.2022.

9.             Per contra, learned counsel for the OP no.1 while reiterating the contents of written version, has vehemently argued that the present complaint is pre-mature. On receipt of intimation regarding claim of the complainant, OP requested the complainant to provide requisitioned documents to process the claim of the complainant but complainant did not provide the same so the claim of the complainant was closed vide closure letter dated 10.06.2019 and lastly prayed for dismissal of the complaint.

10.            We have duly considered the rival contentions of the parties. 

11.           Admittedly, the complainant purchased a health insurance policy from the OP no.1. It is also admitted that complainant had taken treatment during the subsistence of the insurance policy.

12.           The claim of the complainant has been closed by the OPs, vide letter Ex.R6 dated 10.06.2019, on the ground for non-submission of required documents. Documents sought by the OPs, reproduced as under:-

(i)     Degree Details

(ii)    Details from attending doctor

(iii)   Hospital registration number

(iv)   Previous consultations

(v)    Investigation reports

 (vi)  Main Hospital bill payment.

 

13.           Complainant has placed on file, registration certificate Ex.C20, certificate of Medical Council Ex.C21, hospital record Ex.C22, letter written by Satyam Hospital Ex.C23 when the complainant has placed on record the said documents then as to why he would not have supplied the same to the OPs when his personal interest is involved.  The other documents sought by OPs unnecessary and irrelevant just to harass the complainant and delay the claim of the complainant. Further, in Gurmel Singh’s case (supra) Hon’ble Supreme Court held that “while settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control”.

14.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                “It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

15.           Keeping in view the ratio of the law laid down in the aforesaid judgments, the facts and circumstances of the present complaint, we are of the considered view that the act of the OPs while closing the claim of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine.

16.          The complainant has spent Rs.48,738/-on his treatment  and in this regard he has placed on record, medical bill Ex.C5. The said bills have not denied by the OPs. Hence the complainant is entitled for the said amount alongwith interest, compensation and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.48,738/- (Rs. forty eight thousand seven hundred thirty eight only)   to the complainant alongwith interest @ 9% per annum from the date of closing of claim till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and  Rs.5500/- towards the litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:24.01.2023     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)                         

      Member                             Member