BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.229 of 2017
Date of Instt. 14.07.2017
Date of Decision: 02.04.2019
Charanjit Kaur Maan aged about 52 years W/o Sh. Gurmej Singh Maan, resident of 5-A, A. S. S. M. College Flats, VPO Mukandpur, Distt. S. B. S. Nagar, Punjab-144514.
..........Complainant
Versus
1 SBI General Insurance Company Ltd. State Bank of India, 1st Floor, State Bank of India, Above SBI Main Branch, Near Hotel Skylark, Jalandhar-144001.
2. State Bank of India, Near Petrol Pump, Jalandhar Road, Nakodar Distt. Jalandhar.
3. Paramount Health Services TPA Pvt. Ltd. A-342, Road No.28, MIDC Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukhumani, Thane-400604 through its Managing Director.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. V. K. Singla, Adv Counsel for the Complainant.
Sh. Vikas Bhardwaj, Adv Counsel for the OP No.1.
OPs No.2 and 3 exparte.
Order
Karnail Singh (President)
1. The complainant has filed the instant complaint with the prayer that the complainant is having bank account with OP No.2, which is one of the branches of the State Bank of India and OP No.1 is the subsidiary company of the State Bank of India and the OP No.1 is engaged in the business of General Insurance and is having liaison with the OP No.3, which is also engaged in the Insurance business. The officials of the OPs allured the complainant by representing that the OP No.3 having liaison with the OP No.1, provides very good services in health insurance and the complainant should get medical/health insurance policy for any contingency with regard to health and in case of need for getting treatment or hospitalization, the complainant can get cashless treatment or the complainant will be reimbursed the medical treatment expenses etc. within few days and the complainant will not face any difficulty or harassment in getting the claim. Thus, allured by the assurance given by the complainant purchased the 'SBI General's Group Health Insurance Policy' from the OPs for sum of Rs.3,00,000/- valid for one year from 31.07.2015 to 30.07.2016 against the consideration of premium paid by the complainant to the tune of Rs.5400/- for the same and the OPs issued Insurance Policy No.0000000003292561 and thereby undertaking the liability to compensate/reimburse the complainant up to the sum of Rs.3,00,000/- in case the complainant had to undergo any medical treatment during the validity period and as such, the complainant is a consumer of the OP.
2. That in September 2015, the complainant suffered health problem and as per advice of the doctor, the complainant had to get emergency medical treatment from Dayanand Medical College & Hospital, Ludhiana for which the complainant was admitted to hospital on 30.09.2015 and was discharged on 06.10.2015. The OPs had not sent the original policy document to the complainant till said period, as such the complainant could not get the benefit of cashless treatment. However, the complainant submitted her claim to the OP No.2, vide letter dated 12.10.2015 by registered post enclosing therewith the hospital bill, discharge summary and other required documents, but the OPs did not take any steps for the same for about three months. However, on 12.01.2016 the complainant received a phone call from the office of the OPs that they have received the claim, but they have need the concerned documents, but it was not disclosed as to which documents they were talking about. Thus, the complainant sent a letter dated 13.01.2016 enquiring as to which documents were required by them so that the complainant could provide the same.
3. That thereafter, the OPs again kept mum for about 1½ months and then the OP No.3 sent a letter dated 29.02.2016 thereby demanding some documents etc. and the complainant complied with the same by sending all the possible documents and information etc. on 16.03.2016 to the OP No.1 through OP No.2, but the OP by adopting delaying tactics again raised the demand of some documents vide letter dated 31.03.2016 issued by the OP No.3. However, the complainant duly replied the said letter to the OPs, vide letter dated 13.06.2016 sent through registered post. But the OP No.3 sent a letter dated 22.06.2016 thereby again demanding some documents, though the complainant had already provided the concerned documents which the complainant could submit. However, the complainant again provided copy of the same and requested the OPs to reimburse the claimed amount at the earliest, but the OPs did not pay any heed to the same and the OPs instead again sent a letter dated 19.08.2016 thereby again raising the demand of some documents again despite the fact that the complainant had clarified all the matter and had submitted all the documents with her, but the OPs have adopted delaying tactics and are trying to avoid their liability towards the complainant in one way or the other. The complainant has incurred the expenses to the tune of Rs.1,10,215/- as medical expenses on her treatment besides the other incidental expenses to the tune of Rs.30,000/-, but the OPs have not paid even a single penny to the complainant against her claim till date and they have remained grossly deficient in providing required services to the complainant and have adopted unfair trade practice and thus, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay medical treatment expenses to the tune of Rs.1,10,215/- along with incidental expenses of Rs.30,000/- to the complainant along with interest @ 18% per annum and further OPs be directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.2,00,000/- and be also directed to pay litigation expenses of Rs.3300/-.
4. Notice of the complaint was given to the OPs, but OP No.3 despite service did not come present and ultimately, OP No.3 was proceeded against exparte. OP No.1 duly served and appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is not maintainable before this Forum because no cause of action arose to the complainant within the territorial jurisdiction of this Forum and therefore, the complaint deserves to be dismissed and further averred that the present complaint is frivolous and the same is liable to be dismissed with cost. It is further averred that the complainant is trying to mislead this Forum by suppressing the true facts, just to extort illegal money under the beneficial legislation meant for innocent consumers. The complainant has himself failed to adhere to the Act and Policy conditions and has now approached this Forum and is guilty of suppression of material facts. So, the complaint of the complainant is liable to be dismissed on this score and further alleged that the complaint of the complainant is time barred. On merits, it is admitted that the complainant obtained insurance policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
5. Similarly, OP No.2 filed its separate reply and contested the same by taking preliminary objections that this Forum has no territorial jurisdiction to try the present complaint and further alleged that the instant complaint is not maintainable because there is no deficiency in service on the part of the OP No.2 as the answering OP has no concern with this policy except transferring of amount of the insurance at the instance of complainant in the account of OP No.1, hence the complaint is liable to be rejected against OP. On merits, the contents of the complaint are controverted and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed being devoid of merits.
6. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-32 and closed the evidence.
7. Similarly, counsel for the OP No.1 tendered into evidence affidavit Ex.OP1/A along with some documents Ex.OP-1 to Ex.OP-20 and closed the evidence.
8. Thereafter, the case was fixed for evidence of the OP No.2, but nobody has appeared on behalf of the OP No.2 and ultimately, OP No.2 was proceeded against exparte.
9. We have heard the argument from learned counsel for the respective parties and also gone through the case file very minutely.
10. The factum in regard to taking of insurance policy from OP No.1 by the complainant after making a payment of premium of Rs.5400/-, is not in dispute. It is also not disputed by the OPs that the insurance claim of the complainant has been received, but the same is still pending for want of some documents and now we have to consider which documents are required for the purpose of settlement of the insurance claim of the complainant. In order to facilitate his version, the complainant has brought on the file his affidavit Ex.CA and supplementary affidavit Ex.CB, whereby reasserted the entire facts as detailed in the complaint. Further, the complainant has also brought on the file Insurance Certificate Ex.C-1 and medical documents i.e. Discharge Summary Ex.C-2, Medical Bills Ex.C-3, Ex.C-5 to Ex.C-22 and thereafter, the complainant sent a letter to the OP for reimbursement of hospital charges bill, the said letter is Ex.C-23 dated 12.10.2015, then again complainant sent an other letter for reimbursement of the insurance medical claim, vide letter Ex.C-25 dated 13.01.2016. In response to aforesaid letters, the OP sent a letter to the complainant Ex.C-26 dated 29.02.2016, whereby asked to submit some documents Sr. No.1 to 12 and in response to that letter, the complainant wrote a letter by giving detail of each documents whether it is available or not, despite that information, the OP just to delaying the matter of the complainant, again sent a letter dated 31.03.2016 Ex.C-28, whereby again asked to submit some documents and its reply has been again given by the complainant, vide letter Ex.C-29 dated 13.06.2016, wherein categorically mentioned whatsoever original advance payment receipts were supplied by the hospital has already been submitted along with the final bill, but the OP did not make satisfy itself and again sent a letter Ex.C-30 dated 22.06.2016, whereby again demanded some documents and its reply has been also given by the complainant, copy of the same is ExC-31 dated 19.08.2016.
11. Further, the OP has also brought on the file some letters, whereby the OP No.1 alleged that the documents demanded from the complainant never supplied, these letters are Ex.OP-3 to Ex.OP-20. No doubt, the OP has brought on the file so may letters, whereby demanded some documents from the complainant, out of these letters, some letters have been admitted by the complainant and its reply has been duly given, but it is the duty of the OP to prove and establish on the file how and in what manner, the other letters were sent to the complainant for submitting of desire document whether it is through registered post, if so, then the postal receipts must be placed on the file. In the absence of such type of evidence, it become doubtful that the said letter had ever seen the light of day or not rather it remained in lock of the Almirah of the OP.
12. Furthermore, we find that when the complainant has made the position clear by sending a reply that whatsoever documents are available, has been already submitted and if any further information in regard to what treatment given to the complainant, original test reports etc., then the OP can directly contact to the hospital and got the said documents there-from, because the original required documents always remained in the hospital and are not available with the complainant, then where-from he can produce the same. So, from all angles, itself shows that the OPs are lingering the matter on one pretext or the other simply on the pretext for not producing some documents by the complainant, which is apparently wrong, illegal, with malafide intention and as such, we are of the opinion that the complainant is entitled for the relief claimed.
13. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 and 3 are directed to pay medical treatment expenses as well as incidental expenses of Rs.1,10,215/- Plus Rs.30,000/- be paid to the complainant with interest @ 12% per annum from the date of filing complaint i.e. 14.07.2017, till realization. Further, OPs No.1 and 3 are directed to pay compensation to the complainant for harassment, to the tune of Rs.25,000/- and further OPs No.1 and 3 are directed to pay litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
14. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
02.04.2019 Member President
