Haryana

Bhiwani

CC/99/2018

Usha Rani - Complainant(s)

Versus

SBI - Opp.Party(s)

Neeraj Sharma

30 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                            Consumer Complaint No.  :  99 of 2018

                                                       Date of Institution            : 11.07.2018

                                                                 Date of order                   : 30.07.2024

 

Smt. Usha Rani widow of late Sh. Jai Krishna Dahiya, Ex. Staff Clerk, R/o R.K. Niwas, Ward No.3, Village Tigrana, Tehsil and District Bhiwani.

  

           ……Complainant.

 

Versus

 

1. The Chief Manager, Bank of India, Bhiwani branch.

 

2. United India Insurance Company Ltd., having its branch office at Zoo Road, Red Cross Building, Bhiwani, Tehsil and District Bhiwani through its Manager.

…… Opposite Parties.

 

COMPLAINT U/S 12 OF CONSUMER PROECTION ACT, 1986.

 

BEFORE:       Mrs. Saroj Bala Bohra, Presiding Member.

  Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Neeraj Sharma, Advocate for complainant.

                     Sh. Avinash Sardana, Adv. for OP No.1.

                     Sh. Rajbir Singh, Adv. for OP No.2.

 

ORDER:

 

Saroj Bala Bohar, Presiding Member:

 

1.                 In brief, facts of this case are that complainant is widow of late Sh. Jai Krishan Dahiya, Ex-Staff Clerk, who retired from service on 31.08.2016 from the bank branch of OP No.1. During his service tenure, he had purchased a Health Insurance Policy for a period from 01.10.2016 to 31.10.2017.  It is submitted that her husband suffered  from kidney disease and  remained  admitted  in  Ivy  Hospital  Super Specialty   Healthcare, Chandigarh as  well  as Surya  Kidney Care,   Mohali   and after      discharged also remained outdoor patient  from March 2017 to September 2017 and Rs.1,27,290/- were incurred on his treatment. It is stated that her husband died on 11.09.2017 and thus she being legal heir of insured person lodged claim with OP No.1 by submitting all necessary documents but the same was declined alleging various objections, vide letter dated 15.01.2018. Legal notices dated 29.01.2018 and 19.05.2018 were sent to the OPs but of no avail.  Hence, the present complaint has been preferred by complainant seeking directions against the Ops to pay Rs.1,27,290/- alongwith interest @ 18 upto date. Further to pay Rs.10,000/- towards negligent act & conduct of OPs besides Rs.50,000/- as compensation for harassment. Also to pay Rs.5000/- as cost of complaint. Any other relief, to which this Commission deems fit, has also been sought.

2.                 Upon notice, OPs appeared through their respective counsels. OP No.1 file WS raising preliminary objections qua maintainability of complaint, deficiency in service, locus standi & cause of action and suppression of material facts. On merits, it is submitted that Jai Kishan Dahiya was employee of the OP No.1 and retired from service on 31.08.2016 and he was insured from OP No.2 for medical insurance scheme for retirees. The policy expired on 31.10.2017. Medical reimburse claim w.r.t Sh. Jai Krishan Dahiya from March 2017 to September 2017 so submitted by complainant were sent to the Zonal office of OP No.1 on 15.01.2018, however, it was not their duty to send the same whereas complainant can directly submit her claim to them. Since, the claim of complainant was not within time period for reimbursement of medical bills as well as for want of claim form, it was returned. Complainant submitted claim form and it was again sent to the zonal office but the same was declined by TPA Dedicated Healthcare Services on the grounds that policy has expired on 30.09.2017 and as per policy conditions, claim documents were to be submitted within 30 days of discharge or post hospitalization or from the date of OPD treatment taken but the documents were sent by zonal office of OP No.1 on 19.04.2018. As such, this OP denied any deficiency in service on its part and prayed for dismissal of the complaint qua it.

3.                 OP No.2 filed its written statement raising preliminary objections that the complaint is not maintainable, complaint is false and frivolous, locus standi and bad for want of non-joinder of necessary parties. On merits, it is admitted that Jai Krishan Dahiya was insured under the policy for a period from 01.11.2016 to 31.10.2017.  It is urged that the claim form and documents etc. were to be submitted within 30 days of discharge, or post hospitalization or from the date of OPD treatment. However, the employee who could not submit the documents as above were given following time lines: 1. On or before 25.12.2017 or 30 days from the date of discharge or 30 days from the post hospitalization or OPD treatment have been taken, whichever ever falls later. This notice was brought into notice of all banks including OP No.1 who was insured under the Group Health Policy in advance on 04.10.2017 followed by reminder dated 27.10.2017. Since, the claim of complainant was not within the time limit, therefore, claim documents were returned to the OP No.1. In the end, denied for any deficiency in service on its part and prayed for dismissal of the complaint with costs.

4.                 In evidence of complainant, her affidavit Ex.CW1/A alongwith documents Annexure C-1 to Annexure C-15 were tendered and then closed the evidence.

5.                 In evidence of OP No.1, affidavit Ex. RW2/A of Mr. Mohammad Azad., Chjief Manager of OP Bank alongwith documents Annexure R-5 to Annexure R-14 were filed and then closed the evidence.

6.                 In evidence of OP No.2, affidavit of Ms. Priyanka, A.O. of OP company documents Annexure R-1 to Annexure R-4 were filed and then closed the evidence.

7.                 We have heard learned counsels for the parties and perused the record carefully.

8.                 At the outset, it is admitted by OP No.2 insurance company that during the period of treatment, husband of complainant was under cover of insurance policy and it is also not in dispute that Rs.1,27,290/- were incurred on his treatment. The claim has been denied to the complainant on the ground as it was submitted beyond of time limit of 30 days, detailed mentioned above.  OP No.1 has averred in its written statement that the claim was to be submitted directly to OP No.2 insurance company as it had no concern in process of the claim whereas the OP insurance company has said that since the policy was a Group Health Insurance Scheme, therefore, involvement of OP No.1 bank was necessary and they were also informed from time to time about timeline for taking the medical claim reimbursement documents from such persons. It is also not in dispute that husband of complainant taken treatment from March 2017 to September 2017 & that he died on 11.09.2017.  As per OP No.2 insurance company it had informed vide letter dated 04.10.2017 to the OP bank for timely submission of all the claim of concerned person and it was also reminded vide letter dated 27.10.2017 but despite that the OP no.1 bank has not intimated the complainant for submission of claim form as per the letter of OP No.2 insurance company. OP No.1 bank has not mentioned in its written statement that as to when it had received the claim documents from complainant rather he has said the claim was returned by their zonal office vide letter dated 15.01.2018.

9.                 We have perused the  policy terms and conditions (Annexure R-4), condition no.5.5 of it says that All supporting documents relating to the claim must be filed with the office of the Bank dealing with the claims or Third Party Administrator  within 30 days from the date of discharge from the hospital. In case of post hospitalization, treatment (limited to 90 days), as mentioned in para 2.32) all claim documents should be submitted within 30 days after completion of such treatment.

10.               After hearing learned counsels for the parties and going through the record, we are of the considered opinion that the OPs are negligent and deficient in providing proper services to the complainant because of which she has to suffer a lot of mental pains and physical harassment in her old age besides huge monetary loss. Further, it was also the moral responsibility of the OP Bank knowing that husband of complainant was their employee so to get processed the claim timely and to make efforts for its reimbursement. But despite doing so, the OP no.1 bank absolving from its liability saying that it has no concern with the present claim of complainant.

11.               In totality of the facts and circumstances of the present case, we observe that the claim of complainant was well within time period, however, the delay, if any, was on the part of OP bank. It is also worthwhile to mention here that for the wrongs of OP No.1 bank, complainant should not be suffered for any monetary loss or otherwise. Therefore, we fasten liability upon OPs jointly and severally to satisfy the claim of complainant.  OP No.1 is further at liability to pay compensation for harassment to the complainant besides legal expenses fee. Accordingly, the complaint is allowed and directions mentioned below be complied with within 40 days from the date of the order:-

(i)       OPs, jointly and severally, to pay a sum of Rs.1,27,290/- (Rs. One lac twenty seven thousand two hundred ninety) to the complainant alongwith simple interest @ 9% per annum from the date of filing this complaint till actual realization.

(ii)      OP No.1 to pay Rs.50,000/- (Rs. Fifty thousand) as compensation for harassment to the complainant.

(ii)      OP No.1 further to pay Rs.11,000/- (Rs. Eleven thousand) as litigation expenses to the complainant.

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    The complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite parties may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 30.07.2024