Karnataka

Chitradurga

CC/243/2018

Ramesh.B.E - Complainant(s)

Versus

Service Manager,SBI Life Insurance Co,Ltd., - Opp.Party(s)

Sri Dheerendra Prasad

26 Jul 2019

ORDER

                                                       COMPLAINT FILED ON:28/11/2018

DISPOSED      ON:26/07/2019

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHITRADURGA.

CC.NO:243/2018

 

DATED: 26^th JULY 2019

PRESENT :-         SRI.T.N.SREENIVASAIAH      :   PRESIDENT                                                    B.A., LL.B.,

SMT. JYOTHI RADHESH JEMBAGI

BSc.,MBA., DHA.,         :     LADY MEMBER

                             SRI. SHIVAKUMAR.K.N         :     MEMBER

                                      M.Com., LL.B.,

……COMPLAINANT/S	Ramesh B.E. Aged about 45 years, Professor, R/o Dyamalamba Nilaya, Tarala Balu Nagara, 1st Block, Ist Cross, Chitradurga. (Rep by Sri.Dheerendra Prasad, Advocate)
V/S
…..OPPOSITE PARTIES	Service Manager/Agency, Manager /Branch Manager, SBI Life Insurance Co., Limited, 2nd Floor, Block No.1 Swanthal Plaza, B.D. Road, Chitradurga.   (Rep by Sri.C.J. Lakshminarasimha, Advocate )

ORDER

SRI. T.N. SREENIVASAIAH:   PRESIDENT

The above complaint has been filed by the complainant u/Sec.12 of the C.P. Act, 1986 for the relief to direct the OP to settle the medical bills of Rs. 70,000/- and interest from the date of 31/08/2018 and mental agony and financial loss.

2.      The brief facts of the case of the above complaint wife Smt. Manjula M.S. aged about 38 years she was hospitalized in Appolo hospital Bennergatta Road, Bangalore on 31/08/2018 for pain while passing stools and muss per rectum chronic constipation for that she was taking treatment as a in patient for 6 days. That expenditure final bill is Rs. 70,000/- at that time complaint approaching OP to need medical claim then OP told to complainant  first clear the bill in hospital and after submit the all document with claim form. As per OP guidelines complainant  clear the final bill in hospital.

On 11/09/2018 complaint submit all the documents with claim form, from that date complaint wait 1 month for OP response but OP not inform any this from that date complaint visiting OP office several time but OP giving irresponsible answer and OP not guide properly. As per OP policy terms and conditions OP are failed to comply the same, it shows deficiency of service.

The OP had not repudiate/Refused the claim but just keep quite without any reasons. This is deficiency of service.

This attitude on OP part indicates that OP intentionally and purposefully in order to give a trouble harassment and to make a wrongful gain by deceitful means for made complaint a member in OP  life insurance company limited and cheated, OP giving false assurance.

The complainant submits that due to non-settling the claim, the complainant has taken steps to file this complainant due to this complainant has incurred heavy financial loss, suffered metal agony and distress for having taking Insurnace Policy from Ops which cannot be compensated in any terms. For all, OP have to liable to pay compensation to the complainant. Hence the complainant has filed this complaint for, seeking reliefs from this Hon’ble Forum.

The cause of action for the complaint has arise at Chitradurga District, whitin the jurisdiction of this Hon’ble Forum, 24/11/2018 when the Op has received the clime form and legal notice complied for the same with valid reason and this Honble forum has got jurisdiction to entertain the complaint. The complaint with in the time of this Forum and prayed for allow the complaint.

 3.     On service of notice, OP No.1 appeared through Sri. C.J. Lakshminarashima, Advocate and filed version. 

According to the version filed by the OP the complainant was the older of policy bearing no. 46004631601 with date of commencement as 31/03/2012 with daily Hospital cash benefit of Rs. 2,000/-, ICU benefit of Rs. 4,000/- and family care benefit of Rs. 10,000/-. This policy provides for the fixed daily hospitalization cash benefit as state above and further submitted that complainant regarding hospitalization in Apollo  hospital for the period 31/08/2018 to 02/09/2018.

As per policy document, clause no.2, definitations, point no.12 day it is defined as “in the context of this policy and for the calculation of DHCB and ICU benefits,     a    Day in    hospital   and/or in ICU means a period

of confinement of full and complete 24 hours. The first cycle of 24 hours i.e one day shell commence at the time of admission to the hospital ICU and each subsequent day of 24 hours shall be reckoned from the time of completion of previous cycle of 24 hours. In the event that at the time of discharge of the life assured from hospital/ICU, the life assured spends more than 12 hours, but less than 24 hours from the time of reckoning, then the day of discharge shall be regarded as a Day. A stay of 12 hours or less shall not be counted as a day. In the instant case, hospitalization in Apollo Hospital was from 31/08/2018 @ 10:21 am to 02/09/2018@12:54 p.m.

Complainant was admitted in the hospital for 2 days hence the daily hospital Cash benefit for 2 days was Rs. 4,000/-. The Ops have settled the claim of Rs. 5,081/- including interest. The above said amount was paid vide transfer to complainant account bearing no. 522162107 in Indian Bank, Chitradurga branch on 20/11/2018 vide UTR No. SBIN418324397317 the same was convide vide letter dated 22/11/2018.

Further the complaint filed by the complainant is not maintainable either in law or on facts and the same is liable to the dismissed in limine.

The OPs have followed the terms and conditions of the policy the claiming of the complainant for amount of Rs. 70,000/- is out side the scope of terms and conditions of the policy. The Ops have not committed any deficiency of service in this case. And further submitted that complainant is claiming expenses incurred during hospitalization. The policy is not a Mediclaim policy as per the policy schedule page no.9 of policy documents. The claim of the complainant is very much against the terms and conditions of the policy. Further the complainant have not filed this complaint with in the limitation of the time as per the CP Act as well as limitation act. In this regard Ops have relied upon nearly 10 Judgments passed by the Hon’ble Supreme court, and Hon’ble National Commission.  

The cause of action is in the year 2012 while the complaint has been filed in the year 2018 i.e after 6 years from the date of cause of action. Hence complainant is barred by limitation. The complainant was not filed any application for condone the delay. Hence pray for dismissal of the complaint.

      4. Complainant himself has examined as PW-1 by filing affidavit evidence and the documents Ex.A-1 to A-12 were got marked and closed his side. On behalf of OPs side  one Sri.Dhanya K.P. authorized representative of OP company, as DW-1 by filing the affidavit evidence and Ex.B-1 to Ex.B-6 documents have been got marked and closed his side.  

 

5.      Arguments heard.

6.      Now the points that arise for our consideration for decision of above complaints are that;

(1)  Whether the complainant proves that the OP has committed deficiency of service in settling the claim under the said insurance policy and entitled for the reliefs as prayed for in the above complaint?

              (3) What order?

         7.       Our findings on the above points are as follows:-

                   Point No.1:- Negative

Point No.2:- As per final order.

 

REASONS

8.      Point No.1:- There is no dispute between the parties that, the complainant wife by name Smt. Manjula was hospitalized in Apollo hospital Bhanneragatta Road, Bangalore on 31/08/2018 for paying while passing stools and muss per rectum chronic constipation for that she was taking treatment as  inpatient for 6 days and expenditure bill is of Rs. 70,000/- . The complainant is obtaining fimily benefit policy from the OP and paid premium amount regularly from 2012 to 2018. After discharge the complainant has submitted all the necessary documents to the OP for claiming the hospital bill through his insurance policy. The Op has collected all the necessary documents from the complainant andpaid sum of Rs. 5081/- to the complainant on 20/11/2018 the same has been accepted by the complainant. The complainant has taken the contention in his complaint that the complainant wife was admitted to the Apollo hospital on 31/08/2018 to 02/09/2018. Accordingly the complainant has claim a hospital expenditure for Rs. 70000/- But the Op has stated in his version as well as arguments that the complainant was having  a  non medical claim policy. The complainant policy is not a medical claim policy. As per the  policy schedule page no.9 the Op as paid daily hospitalization expenditure for Rs. 2000/- accordingly the OP has paid Rs. 4000/- to the complainant and also paid sum of Rs. 1000/- towards non claim bonus and penal interest of Rs. 81/- in total the OP was already paid Rs. 5081/-. As per the documents produced by the OP it is a clearly shows that the complainant policy is a non claim medical policy. Accordingly the OP has paid the amount to the complainant. The OP have not committed any deficiency of service. The amount claimed by the complainant is not correct.

As per the terms and conditions of policy the complainant has paid hospital expenditure to the complainant.

We have gone through the entire documents, affidavit and Written Arguments filed by the both sides and the arguments addressed by the  complainant advocate that the complainant is having family benefit policy from the OP and the complainant has paid premium amount to the policy the annual premium amount of Rs. 5,754/- the policy commencing from 31/03/2012 it is a SBI life duly hospital cash benefit policy.

Accordingly the complainant was paid the above said premium every year regularly. In this case complainant wife was admitted to the hospital on 31/08/2018 and taking treatment for two days i.e. up to 2/09/2018 in Apollo hospital and the complainant claiming the hospital expenditure the OP is bounded duty to pay the same. Sri. C.J. Lakshminarasimha, Advocate appeared on behalf of OP and submitted his arguments. It is true the complainant was obtained policy from the OP it is a non medical claim policy. According to this policy the complainant is entailed daily hospital expenditure not for treatment charge. Accordingly the complainant wife admitted to the hospital for two days. As per the terms and conditions of the policy the OP has already paid a sum of Rs. 5,081/- including non claim bonus and penal interest. The Documents produced by the OP it clearly shows that the OP has already clearly the entire hospital expenditure. In any angle shows that the OP have not committed any deficiency of service. Hence Point no. is held negative and  pass the following  order.

                                                             ORDER

The complaint filed by the complainant U/s 12 of CP Act 1986 is hereby is dismissed. No cost.

 (This order is made with the consent of Member after the correction of the draft on 26/07/2019 and it is pronounced in the open Court after our signatures)        

 

                                     

LADY MEMBER           MEMBER          PRESIDENT

-:ANNEXURES:-

Witnesses examined on behalf of Complainant:

PW-1:  Complainant by way of affidavit evidence.

Witnesses examined on behalf of OPs:

DW-1:  Sri.B. Shamanna, the Administrative Officer of OP No.1 to 3 by way of affidavit evidence. 

Documents marked on behalf of Complainant:

01	Ex-A-1 & 2:-	Copy of notices
02	Ex-A-3:-	Postal receipts
03	Ex-A-4:-	Policy
04	Ex-A-5:-	Claimants statement
05	Ex-A-6:-	Certificate by employer

Documents marked on behalf of OPs:

01	Ex-B-1:-	Policy
02	Ex.B-2:-	Proposal form
03	Ex.B-3:-	Letter of authorization
04	Ex.B-4:-	Endorsement dated 20.04.2018 by BEO, Chitradurga
05	Ex.B-5:-	Medical attendants certificate
‘06	Ex.B-6:-	Copy of premium ledger

 

 

 

LADY MEMBER           MEMBER                      PRESIDENT

Rhr**