Punjab

Fatehgarh Sahib

CC/48/2019

Satwant Kaur - Complainant(s)

Versus

SBI General Insurance - Opp.Party(s)

Sh. Tejinder Singh Kang

07 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.                                                                         

CC No. 48 of 2019

                                                                             Date of Institution: 02.08.2019

                                                                             Date of Decision:    07.10.2022

 

Satwant Kaur aged about 56, years daughter of Amrik Singh, resident of Ward No.4, Khamanon, Khamanon, District Fatehgarh Sahib, Tehsil                                                                                                                                                  …………....Complainant(s)

                                                 Versus

1. SBI General Insurance Company Ltd. 2^nd Floor, SCB 7, Chotti Baradari, Patiala, District Patiala through its Branch Manager,

 

2. SBI General Insurance Company Ltd, Head Office: Miles High Corporate Hub, 2^nd Floor, Patto, Panaji, Goa-403001 through its Authorized Persons.

 

3. Paramount Health Service (TPA) Pvt. Ltd. Plot No. A-442, Road No. 28, MIDC, Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukhmani Mandir, Thane, West, Maharashtra.

 

4. State Bank of India Grain Market, Khamanon, Tehsil Khamanon, District Fatehgarh Sahib

…………....Opposite Party(s)

 

Complaint under Section 11 to 14 of the Consumer Protection Act

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

 

Present: Sh.T.S. Kang, Counsel for Complainant

              Sh. Amit Gupta, Counsel for OP Nos.1 & 2.

              Sh. B.L.Gupta, Counsel for OP No.4.

              OP No.3 Ex parte.

 

 

 

Order by

Manjit Singh Bhinder, Member

1.                    This complaint has been filed by the complainant(hereinafter referred to as CC) for directing the opposite parties(hereinafter referred to as OPs) to pay the amount of her treatment i.e. Rs.3,81,326/- along with interest @ 24% per annum and CC is also seeking compensation of Rs.1,00,000/- for mental and physical harassment and also claiming litigation expenses and any other relief.
2.                          The CC has alleged that she is an account holder of State Bank of India, Branch Khamanon and consumer of OPs. She alleged that on the assurance of the employees of OP No.4, CC purchased the policy on 03.06.2017 and policy premium of Rs.9900/- was sent through SBI Branch Khamanon/OP No.4 in to the account of SBI General Insurance/OP No.1. CC stated that the payment was to be deducted automatically from the account of CC through OP No.4. CC alleged that the above said policy was continued from 03.06.2017 till today. CC renewed the said policy from 07.06.2018 to 07.06.2019 and after that CC again renewed the said policy through SBI Bank Branch Khamanon and the payment was deducted from the account of CC. The CC alleged that the said policy is cashless policy and the OPs assured that she can hand over only the cover note/receipt of payment in the Hospital for cashless treatment and OP No.2 will pay whole amount of treatment to the extent of Rs.5,00,000/- directly in the account of Hospital. CC further stated that on 10.6.2019, Rs.12,500/- was deducted from bank account of the CC through direct Credit Transaction ID 75747501 dated 10.06.2019, so the said policy No. 0000000006821542-02 renewed automatically through Direct Credit Transaction.
3.                        CC alleged that she went to the office of OP No.4 for renewal of policy on 21.05.2019 and 07.06.2019 but the system had given the message "SBIGEN003: RENEWAL REGISTRATION CAN BE PROCESSED ONLY AFTER 07-06-2019 (07/06/2019+365 Days). After that on 08.06.2019 and 09.06.2019 were bank holidays. After that on 10.06.2019, SBI Khamanon automatically remitted the instalment in the account of SBI General Insurance. CC alleged that the OP No.1 wrongly continued the insurance from 10.06.2019 instead of 07.06.2019. The account of CC has sufficient amount to deduct the instalments from their account but instalments were not deducted by the bank in view of above mentioned facts.  
4.                 CC further alleged that she was admitted in the Fortis Hospital, Mohali on 07.06.2019 and discharged on 14.06.2019 and after necessary documentation to employees of Fortis Hospital contacted with the OPs. Previously the OPs have given the consent to start the treatment on 07.6.2019 but after sometime, they refused to reimburse any payment to the hospital. So the CC has no option to deposit the amount of Rs.3,81,326/- i.e. the bill which was issued by Fortis for her Knee Joints replacement.
5.                      CC alleged that 8^th & 9^th  June 2019 were holidays of SBI Bank, so the payment remitted by OP No.4 in the account of OP No.1 on 10.06.2019, because on 21.05.2019 and 07.06.2019 amount was not transferred by the OP No.4 to OP No.1 due to the above mentioned message in their computer and OP No.4 also issued the certificate to the CC on 12.6.2019 regarding this fact.
6.                  CC alleged that the OP No.3 is a service provider of OP No.1. The whole documentary formalities and payment of premium were completed by the employees of OP No.4. After the treatment the CC went to OPs and requested many times to reimburse the payment of Rs.3,81,326/- but the OPs refused to reimburse the payment. So, CC filed the present complaint and prayed that her complaint may be allowed and the OPs may be directed to pay her claim i.e. Rs.3,81,326/- along with interest. CC also claimed Rs.1,00,000/- as compensation for mental and physical harassment and also claimed litigation expenses.
7.                    Notice of the complaint was given to the OPs and Sh. Amit Gupta, Adv appeared on behalf of the OP Nos.1 & 2 and Sh. B.L Gupta, Adv appeared on behalf of the OP No.4 and filed reply/version. However, OP No.3 did not turn up despite service of notice, hence proceeded against ex parte.
8.                  In reply, OP No.1 & 2 stated that the CC being the account holder of OP No.4 has purchased Group Insurance Policy covering herself w.e.f. 07.06.2018 to 06.06.2019 and again the said policy was renewed from 10.06.2019 to 09.06.2020. OPs No.1 & 2 alleged that during the continuation of the policy w.e.f. 07.06.2018 to 06.06.2019, the CC has submitted cashless request for knee replacement which was approved by the answering/OP on 22.05.2019 for a sum of Rs. 1,70,000/- for the treatment of CC at Fortis Heart Institute, Mohali. But no treatment was taken by the CC during the continutation of the policy w.e.f. 07.06.2018 to 06.06.2019. and the current policy was renewed on 10.06.2019 to 09.06.2020 after taking the treatment. The CC is claiming the hospitalization expenses for the period w.e.f. 07.06.2019 to 09.06.2019 as no insurance policy covering that period was ever issued by the answering OP and no premium for this period has been taken by the insurance company as such the present complaint in which the CC is claiming the reimbursement for abovesaid period is liable to be dismissed. The CC filed rejoinder to the written reply filed by the OP Nos.1 and 2, reiterating the facts contained in the complaint and denying the written reply filed by OP. OP No.4 also stated that the CC has no cause of action to file the present complaint, so the present complaint is liable to be dismissed. OP No.4 admitted that the CC visited the OP No.4 on 21.05.2019 and 07.06.2019 for getting the renewal of health policy by making the payment of premium deposited with the SBI General Insurance Company from her saving bank account No.55068683547 maintained with OP No.4. But the system did allow to do so and gave the message "SBIGEN003: RENEWAL REGISTRATION CAN BE PROCESSED ONLY AFTER 07-06-2019”. The CC was then asked by the Bank official to come on 10.06.2019 for getting the remittance of premium amount of Rs.12,500/- from her account to the account OP NO.1, as 08.06.2019 & 09.06.2019 were bank holidays. The CC was told that she can also transfer online the premium amount to OP No.1 for obtaining health policy. On 10.06.2019 the representative of the CC approached the Bank official of OP No.4 for getting the remittance of premium amount of Rs.12,500/- from account of CC to OP No.1. Accordingly the said policy was renewed at the option and request of the CC herself.  The allegations to the effect that on 10.06.2019, OP No.4 automatically remitted the instalment in account of OP No.1 wrongly started the insurance on 10.06.2019 in place of 07.06.2019 are all wrong and  hence denied. So the complaint is liable to be dismissed with heavy costs. The CC also filed rejoinder to the written reply filed by the OP Nos.1 and 2, reiterating the facts contained in the complaint and denying the written reply filed by OP No.4.
9.                          In evidence, the CC furnished her affidavit reiterating the contents of the complaint as Ex.CW-1/A and also proved copies of receipts of payment as Ex.C-1 to Ex.C-3, photocopy of SBI General Insurance Card as Ex.C-4, copies of Statements of account as Ex.C-5 to Ex.C-8, copy of policy as Ex.C-9, copy of insurance certificate as Ex.C-10, copy of premium receipt issued by SBI General as Ex.C-11, copy of message of SBI Bank as Ex.C-12, copy of certificate of SBI Bank as Ex.C-13, copy of discharge summary as Ex.C-14, copy of detailed bill/receipt of payment of Fortis Hospital as Ex.C-15, copy of policy dated 13.06.2019 as Ex.C-16, copy of receipt dated 13.06.2019 as Ex.C-17. On the other hand, OP No.1 & 2 have furnished reply-cum-affidavit as Ex.OP.1/W, copy of policy dated 09.08.2018 as Ex.OP.1/2, copy of policy dated 13.06.2019 as Ex.OP.1/3, and OP No.4 have furnished reply-cum-affidavit as Ex.OP.4/W-A & Ex.OP.4/W-B, copies of receipt as Ex.OP.4/A to Ex.OP.4/C, photocopy of SBI General Insurance Card as Ex.OP.4-D
10.                   We have heard the counsels for the parties and have gone through the file carefully and also gone through the written arguments submitted by the CC.
11.                  In their reply, OP Nos.1 & 2 has stated that the CC did not take treatment during validity of the policy w.e.f. 07.06.2018 06.06.2019 and that the policy was renewed after taking treatment on 10.06.2019.                           OP No.4(SBI Branch, Khamano) in its reply, has stated that the CC visited OP No.4 on 21.05.2019 and   on 07.06.2019 for getting the renewal of health policy by making the payment of premium deposited with the SBI General Insurance Company Ltd. from her saving bank account maintained with OP No.4. Further OP  NO.4 has stated that the system did not allow to do so and gave a message "SBIGEN003: RENEWAL REGISTRATION CAN BE PROCESSED ONLY AFTER 07-06-2019”. The CC was then asked by the bank official to come on 10.06.2019 for getting the remittance of premium amount of Rs.12,500/-, as 08.06.2019 and 09.06.2019 were bank holidays (a certificate was also given by the bank which is Ex.C-13). On 10.06.2019, the representative of the CC approached the bank official of OP No.4 for remittance of the premium from her bank account with OP No.4 to the account of account of SBI General Insurance Company Ltd. and accordingly the said health policy was renewed.

                            We have further observed that the CC had earlier obtained the insurance policy on 03.06.2017 and renewed the same on 07.06.2018 by paying the premium from her SBI account with OP No.4. It is clear that the CC on all earlier occasions had made the payment of insurance premium by way of debit from her SBI Bank account with OP No.4. When the CC had visited OP No.4 on 21.05.2019, OP No.4 could have taken note of her visit and debited the premium for renewal of her policy, as and when due. The CC had again visited OP No.4 on 07.06.2019 for renewal of her policy but due to system constraints of the OPs the premium could not be remitted. It is also observed that the CC was having sufficient funds in her bank account with OP No.4.

                   Now we observed that, in spite of bona fide intention of CC for getting the policy renewal beyond 07.06.2019, for which she had duly visited OP No.4 on 21.05.2019 and 07.06.2019, the policy could not be renewed due to system constraints of the OPs for which the CC cannot be held responsible.

                    The CC had performed the act obligatory for getting the policy renewal by visiting OP No.4 well in time. OP No.4 and OP Nos.1 and 2 all related with SBI. Had the CC any doubt or apprehensions about timely renewal of the policy she could have easily scheduled her treatment on 10.06.2019 or any later date as the treatment of CC was not of urgent nature. The obvious and clear reason for delay of two days in renewal of the policy was the system constraints of OP No.4 for which the CC cannot be held responsible. Therefore, we feel that it will be harsh and not in interest of justice to hold CC responsible for the delay of two days in renewal of the policy

11.           In view of our aforesaid discussions, the present complaint is  allowed to the extent that the OPs are directed to make the payment to the CC for her treatment as per terms and conditions of the policy The compliance of this order be made by the OPs within a period of 45 days on receipt of certified copy of this order. This complaint could not be decided within a specific period as provided by the statute due to rush of work and large pendency. Copy of this order be sent to the CC and the OPs as per rules. File be consigned to record room.

 Pronounced:-

         07.10.2022                                                 

       

                                                                      (Pushvinder Singh)

                                                                                     President

 

 

 

    (Manjit Singh Bhinder)

                                                                                                     Member

 

 

               

                                                                            (Shivani Bhargava)

   Member