BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.229 of 2017
New CC No.158 of 2022
(Remanded Back) 19.08.2021
Date of Inst. 14.07.2017
New Date of Inst.16.05.2022
Date of Decision: 16.06.2022
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: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (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
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been remanded back by the Hon’ble State Commission, vide order dated 19.08.2021, whereby the order of this Forum dated 02.04.2019 had been set-aside and further, a direction was given to this Commission to reconsider the matter and decide the complaint afresh on merits after taking into consideration the documents produced by the parties and after giving adequate opportunities to both the parties of being heard.
2. Brief facts of the complaint are 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.
3. 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.
4. 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/-.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. The OP No.1 filed appeal before the Hon’ble State Commission. The Hon’ble State Commission, vide order dated 19.08.2021 set-aside the order dated 02.04.2019 passed by the District Commission and directed the District Commission to reconsider the matter and decide the complaint afresh on merits after taking into consideration the documents produced by the parties and after giving adequate opportunities to both the parties of being heard.
11. In compliance of the Order dated 19.08.2021 of the Hon’ble State Commission, the notice was sent to the parties. Sh. Vikas Bhardwaj, Adv. appeared on behalf of the OP No.1 and filed written arguments on behalf of OP No.1. The Ld.Counsel for the complainant orally argued the complaint and we have gone through the case file as well as written arguments submitted by the counsel for the OP No.1 very minutely.
12. It is not disputed that the complainant took insurance policy from OP No.1 after making a payment of premium of Rs.5400/-. It is also not disputed that the complainant fell ill and she was admitted to DMC Hospital on 30.09.2015 and was discharged on 06.10.2015. The claim was filed and the same was received by the OPs also. The contention of the OPs is that the complainant has failed to submit the documents required for the settlement of the claim. It is his contention that the complainant was asked to supply the documents vide number of letters which have been proved on record from Ex.OP-3 to Ex.OP-20 including the last reminder dated 19.09.2016 as per the submission of the OPs. It is the contention of the OPs that the complainant provided the documents as demanded by the OPs in deficiency letters in piecemeal and the documents being received by the OPs were subtracted in subsequent letters and only six documents material to the decision of the claim were pending, which was never supplied by the complainant. Before the Hon’ble State Commission, the OP No.1 had submitted that the documents submitted by the complainant alongwith discharge summary were not considered by the Ld. District Commission and the District Commission was directed to reconsider all the documents.
13. The complainant has filed on record Ex.C-1, the certificate of insurance and Ex.C-2 is discharge summary. He has also filed on record the documents Ex.C-3 to Ex.C-22, which are the bills and receipts of the medicines purchased by the OP from DMC Hospital. Ex.C-23 is the letter dated 12.10.2015, which was written by the complainant to the manager SBI that she has not got the original policy documents so far. Therefore, she could not get the benefit of cashless treatment and with the letter she has attached the hospital bill and the discharge summary as per the letter dated 12.10.2015. Again on 13.01.2016, she has written a letter vide Ex.C-25 to the manager SBI alleging that her claim has been received and she specifically inquired as to what documents are required by the policy head quarter, so that the same be furnished. Ex.OP-3 is dated 19.02.2016, vide which the documents have been demanded by the OPs from the complainant. Similarly, on 29.02.2016 vide Ex.OP-4 and Ex.C-26 the documents were demanded by the OPs from the complainant. Ex.C-27 is reply to the letter in which reply to all the columns i.e. 12 columns have been given by the complainant on 16.03.2016. The required documents which were in her possession have been attached with the letter as per the letter Ex.C-27. Ex.OP-5 is the same letter, which is Ex.OP-4. In Ex.OP-6, the same documents have been demanded. On 19.03.2016, vide Ex.OP-7 again similar documents have been demanded by the OPs as were demanded in Ex.OP-4 to Ex.OP-6. In letters from Ex.OP-7 to Ex.OP-20, the similar documents have been demanded, but in all these documents, there is no reference of the letter written by the complainant which is Ex.C-27. In Ex.C-27, para wise reply has been given by the complainant in which it has specifically been mentioned that since it was an emergency case, therefore there was no letter and the claim was made within time. Certificate of the doctor was attached as per Ex.C-27 and whatever the documents were with the complainant, those were supplied to the OPs as per letter Ex.C-27 and which were not given to the complainant were not in possession of the complainant. It was specifically mentioned in letter Ex.C-27, but perhaps the OPs did not consider this reply and again demanded the same documents from the complainant. Vide Ex.C-29, the complainant in detail had given the reply to all the OPs mentioning therein that the documents have already been submitted to them, but the OPs did not pay any heed and issued letters in a routine matter and kept on sending letters to the complainant raising the demand of the documents despite the fact that in Ex.C-29 the complainant had clarified and explained all the matter, but the OPs adopted delaying tactics and avoided their liability. As per the record of DMC Hospital, which includes the discharge summary consisting of 10 pages in which the detail of the patient has been mentioned showing the procedure performed on the patient i.e. the complainant medication, which was administrated and the treatment which was given by the DMC to the complainant. The receipts and bills show that she has spent Rs.1,10,215/- + Rs.30,000/- for her treatment. As per submission of the OPs, the complainant has not supplied the documents as per letter dated 19.08.2016, which is Ex.OP-16. As per Ex.OP-16, they have demanded the investigation reports, xerox copies of the indoor case papers with history sheet OT note, nursing chart, pre consultation notes, treating consultant stating duration of ailment, item wise and cost wise detailed breakup of OT expenses of Rs.10,250/-, Pharmacy charges of Rs.3906/- and the original advance payment receipts of the bill of Rs.45,761/-. The reply to the documents mentioned in serial no.1 to 6 has already been given by the complainant vide Ex.C-27 and as per the reply given in Ex.C-27 some of the documents available with the complainant were submitted by her and remaining were either not provided to her or were not in her possession. Even if for the sake of arguments, it is assumed that the original reports were not supplied by the complainant, then the OP can ask the hospital authorities to supply those documents as the insurance company always remained in touch with the hospital authorities. Even otherwise, the original file of the patient remains with the hospital and the OPs can get the same if they required. Everything has been mentioned in the discharge summary.
14. From the above detailed discussion, it is concluded that the OPs have intentionally not settled the claim of the complainant and as such, the complainant is entitled for the relief as claimed and accordingly, the complaint of the complainant is partly allowed. OPs are directed to pay medical treatment expenses as well as incidental expenses of Rs.1,10,215 plus Rs.30,000/- to the complainant with interest @ 9% per annum from the date of filing complaint i.e. 14.07.2017 till realization. Further, OPs are directed to pay Rs.10,000/- as compensation for harassment. Further, OPs are directed to pay Rs.7000/-as cost of litigation, if not paid earlier to the complainant as per order dated 02.04.2019. The entire compliance be made within 45 days from the date of receipt of the copy of order. The complaint could not be decided within stipulated time frame due to rush of work.
15. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
16.06.2022 Member Member President
