Haryana

Yamunanagar

CC/1288/2012

Mangat Ram Sharma S/o Inderjeet Sharma - Complainant(s)

Versus

SBI Life Insurance Company Ltd. - Opp.Party(s)

N.K.Kochar

13 Jun 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                                                          Complaint  No.1288  of 2012.

                                                                                          Date of institution: 13.12.2012

                                                                                          Date of decision: 13.06.2017

Mangat Ram Sharma aged about 46 years son of Sh. Inderjeet Sharma resident of H. No. 373, Near Rana Clinic, Ward No. 23, Tilak Nagar, Jagadhri Workshop, Tehsil Jagadhri, District Yamuna Nagar.                                                                                                                                                                                                                          

                                                                                                                            …Complainant.

 

                                                Versus

1. SBI Life Insurance Company Ltd. Behind Jindal Hospital, SCO No.____. Sector 17, HUDA, Jagadhri, Distt. Yamuna Nagar through its Branch Manager.
2. SBI Life Insurance Company Ltd., SCO No. 109-110, 1^st Floor, Sector 17-B, Chandigarh- 160017 through its Regional Manager.                                                                                                                                            

                                                                                                                            …Respondents.  

BEFORE:       SH. ASHOK KUMAR GARG, PRESIDENT,

                        SH. S.C.SHARMA, MEMBER

                        SMT. VEENA RANI SHEOKAND, MEMBER.

                       

 

Present: Sh. Naresh Kumar Kochar, Advocate, counsel for complainant.   

              Sh. Brijesh Chauhan,  Advocate, counsel for respondents.

 

ORDER( ASHOK KUMAR GARG PRESIDENT)

 

1.                     Complainant Mangat Ram has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date.

2.                     Brief facts of the present complaint, as alleged by the complainant, are that complainant purchased a  health insurance policy bearing No. 46003029909 which was commenced from 16.11.2011 from the respondents (hereinafter respondents will be referred as OPs) for a sum insured of Rs. 3,00,000/-. Unfortunately, on 17.06.2012 complainant felt expectoration and breathlessness and palpitation, on this, the complainant examined himself from the doctors of Gulati Hospital, Sarojini Colony, Yamuna Nagar but due to serious condition of the complainant he remained in ICU from 17.06.2012 to 21.06.2012 in the Gulati Hospital, Yamuna Nagar and discharged from the hospital on 23.06.2012. The complainant spent near about Rs. 40,000/- on his treatment including hospital charges and other special care and diet charges etc. and after discharge from the hospital, the complainant lodged his claim with the OPs Insurance Company but the OPs Insurance Company wrongly and illegally repudiated the claim of the complainant vide their repudiation letter No. EMSL/REJ/5794 dated 23.07.2012 which constitute the deficiency in service and unfair trade practice on its part and lastly prayed for directing the OPs to pay the claim amount and also to pay compensation as well as litigation expenses.

3.                     Upon notice, OPs Insurance Company appeared and filed its written statement by taking some preliminary objections such as complainant is demanding to settle the claim arising of an ailment is not covered irrespective of its declaration in the proposal form, as mentioned under clause 6.3.2.5 of the policy document. Moreover, the hospital wherein he was admitted did not fulfill the criteria of a legitimate (hospital) as defined in the policy document; an insurance policy is the evidence of contract between the insurer and policy holder and the policy holder are required to abide by the terms and conditions of the policy; clause 2 definitions; (19) hospital is an institution in India established for indoor care, offering allopathic treatment only for sickness and injuries and which is registered as a hospital or nursing home with the appropriate authorities and is under the supervision of a registered and qualified physician and provides all the following facilities. At least 10 patients beds, fully equipped operation theatre of its own where surgical operations are carried out, and fully qualified nursing staff under its employment 24 hours per day, and fully qualified physicians in supervision 24 hours per day, and maintains a daily medical record for each of its patients. For the purpose of this policy, the term hospital shall not include any institution which is primary a rest home or convalescent facility, a place for custodial care, a facility for the aged or alcoholic or drug addicts or for the treatment of psychiatric or mental disorders, even if the institution has been registered as a hospital or nursing home with the appropriate authorities. In the instant case, the complainant was not eligible for any kind of relief as demanded in the complaint since he was diagnosed for (Acid Peptic Disease) which is excluded as per terms and conditions exclusion clause 6.3.1 of the policy in question. As per discharge sheet of Gulati Hospital, Yamuna Nagar, the complainant was a known case of diabetes mellitus (O/C DM) which was not disclosed at the time of availing the insurance cover. Thus, there was a suppression of material facts in the proposal form and on merit it has been admitted to the extent that complainant was insured under policy bearing No. 46003029909 with the date of commencement of risk as 16.11.2011 for a sum insured of Rs. 3,00,000/-. Further, it has also been admitted to the extent that complainant was reported to have been admitted in Gulati Hospital, Yamuna Nagar from 17.06.2012 to 23.06.2012 for the treatment of acute Bronchitis, Acide Peptic Disease and pre-existing diabetes mellitus. It has been further mentioned that the claim of the complainant has been rightly repudiated by the OPs Insurance Company vide its letter dated 23.07.2012 (Annexure C-2) on the ground that “ we are in receipt of the claim form and associated documents of Mr. Mangat Ram Sharma. On scrutiny of the same, we observed that he was admitted in Gulati Hospital. As per section (1) definition 19 in the head of hospital –cum-treating doctor criteria- hospital is not registered, this does not fulfill hospital criteria, hence cannot be settled as per clause 6.3.2.5 is not payable. Lastly, prayed for dismissal of complaint.

4.                     In support of his case, counsel for the complainant tendered into evidence short affidavit of complainant as Annexure CW/A and documents such as Photo copy of letter dated 22.10.2012 as Annexure C-1, Photo copy of repudiation letter dated 23.07.2012 as Annexure C-2, Photo copy of letter  dated 17.10.2012 as Annexure C-3, Photo copy of prescription slip as Annexure C-4, Photo copy of claim form as Annexure C-5 to C-8, Photo copy of hospitalization details as Annexure C-9, Photo copy of claim process letter as Annexure C-10 and C-11, Photo copy of conditions for hospitals for hospital cash policy as Annexure C-12, Photo copy of discharge card of Gulati, Hospital as Annexure C-13, Photo copy of hospital bill of Gulati Hospital as Annexure C-14 and closed the evidence on behalf of complainant.

5                      On the other hand, counsel for the OPs Insurance Company tendered into evidence affidavit of V.Srinivas authorized representative of SBI Life Insurance as Annexure RW/A and documents such as Photo copy of proposal form as Annexure R-1, Photo copy of Letter dated 17.11.2011 alongwith terms and conditions as Annexure R-2, Photo copy of discharge card as Annexure R-3, Photo copy of repudiation letter dated 23.07.2012 as Annexure R-4 and closed the evidence on behalf of OPs Insurance Company.

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very minutely and carefully. Counsel for the complainant reiterated the averments made in the complaint and prayed for its acceptance whereas the counsel for the OP Insurance Company reiterated the averments made in the reply and prayed for its dismissal.

7.                     It is not disputed that the complainant purchased a medi-claim policy bearing No.46003029909 dated 16.11.2011 from the OPs Insurance Company for a sum of Rs. 3,00,000/-. It is also not disputed that complainant lodged the claim for reimbursement of medical expenses with the OPs Insurance Company which was repudiated by the OPs Insurance Company vide its repudiation letter dated 23.07.2012 Annexure C-2.

8.                     The only plea of the OPs Insurance Company is that the patient was admitted in Gulati Hospital and that hospital was not registered and also does not fulfill hospital criteria and further as per clause 6.3.2.5, the claim of the complainant is not payable but this plea of the OPs Insurance Company is not tenable as the OPs Insurance Company has totally failed to place on file any cogent evidence to prove that Gulati Hospital, Yamuna Nagar was not fulfill the criteria as mentioned in section 1 definition 19 in the policy in question. Neither any affidavit of any authority or any official of the Ops Insurance Company who visited that hospital has been placed on file nor any other independent evidence has been placed on file to prove that Gulati Hospital, Yamuna Nagar did not having required facilities of 10 in patient beds, fully equipped operation theatre of its own where surgical operations are carried out, and not fully qualified nursing staff under its employment 24 hours per day, and lastly not fully qualified physicians in supervision 24 hours per day, and also not maintains a daily medical record of each patients as mentioned in the repudiation letter Annexure C-2. it is not the case of the OPs Insurance Company that the complainant was having any pre existing disease at the time of taking insurance policy in question and suppressed the material facts from the Ops Insurance Company. Although, the OPs Insurance Company has placed on file proposal form as Annexure R-1 and insurance policy with its terms and conditions Annexure R-2 but the Ops Insurance Company has totally failed to prove that which question of the proposal form was answered as “NO” and which question of answered as “YES” and the same was wrong by the complainant at the time of taking of the insurance policy. In the absence of any previous treatment record, it cannot be presumed that the complainant was having any pre-existing disease.

9.                     In the circumstances noted above, we are of the considered view that the OPs Insurance Company has wrongly and illegally repudiated the claim of the complainant on false and flimsy ground. As such, the complainant is entitled for relief. Further, the complainant has not disclosed in his complaint that in actual how much money he has spent on his treatment. He has placed on file only hospital bill of Gulati Hospital amounting to Rs. 11.950/- Annexure C-14. Except this one,  nothing has been placed on file to prove that he has spent Rs. 40,000/-, as alleged in the complaint. Even, we have also perused the claim form Annexure C-5 in that also the complainant has not disclosed any amount. As such, the complainant is entitled for only Rs. 11950/-.

10.                   Resultantly, we partly allow the complaint of complainant and direct the Ops Insurance Company to pay a sum of Rs. 11,950/- on account of medical expenses to the complainant alongwith interest at the rate of 6% per annum from the date of filing of the present complaint till its realization and further to pay Rs.1500/- as litigation expenses. Order be complied within a period of 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned as per rules. File be consigned to the record room after due compliance.

Announced in open court. 13.06.2017.

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

                                                                                    DCDRF, YAMUNANAGAR

 

                (VEENA RANI SHEOKAND)                 (S.C.SHARMA)

                  MEMBER.                                               MEMBER