By. Smt. Bindu. R, President:

            This complaint is filed by Joseph. T. T, Thekkumkuzhiyil House, Thariode Post, Wayanad alleging deficiency of service and unfair trade practice from the side of Opposite Parties who are SBI General Insurance and its officials.

            2.  The gist of the complaint is that the Complainant had availed an insurance policy from Star Health and Allied Insurance Company from 2010 onwards.  The 14^th renewal of the Complainant’s Star Health Insurance was on 31.01.2023.  Before the due date the Opposite Party approached the Complainant and explained about their Sureksha Aur Bharaso Dono Policy and requested the Complainant to renew and take the SBI General Insurance Aur Bharaso Dono Policy instead of Star Health and Allied Insurance.  Due to the continuous insistence of Opposite Party No.1, the Complainant renewed his Medial insurance policy with SBI General Insurance Company and paid an amount of Rs.10,502/-.  After the payment of the amount the Opposite Party promised the Complainant that the policy certificate and ID card of SBI General Insurance shall be delivered later.  It is further stated by the Complainant that the Opposite Party had not sent the above documents and after repeated requests the Opposite Party sent photocopy of ID card of SBI General Insurance through whatsapp to the Complainant.  The Complainant was also made to believe that in the event of hospitalization the photocopy of ID would identify the Complainant as an SBI General Insurance Beneficiary and would be valid for cashless hospitalization.

            3.  While thus on 12.04.2023 the Complainant was admitted in Fatima Mata Hospital Kalpetta for a day due to chest pain.  The Complainant had undergone treatment but was charged an amount for Rs.1,86,781/-.  The Complainant had given the ID card and the hospital authorities had sent the claim along with the bills to the Opposite Parties but the Opposite Parties had not settled the claim and therefore the Complainant enquired about it to the Opposite Party and the Opposite Party said that the amount will be reimbursed and the Complainant has to pay the bill and can prefer the claim before Opposite Party for reimbursement.  On getting the assurance from the Opposite Party the Complainant had paid the entire amount of Rs.1,86,781/- and got discharged from the hospital on 17.04.2023.

            4.  Subsequently the Complainant preferred the claim along with the bills and Opposite Party No.1 told that the medical bills are already been submitted to the Opposite Parties through the Opposite Party No.2.  In the meanwhile the Complainant was again admitted in Medical College Hospital, Kozhikode from 03.05.2023 to 11.05.2023.  The Complainant thereafter contacted the Opposite Party No.1 and 2 and Opposite Party No.1 orally informed the Complainant that the Complainant shall get the Medical insurance claim only after three months of completion of maturity period.  Such contention of the Opposite Party is incorrect baseless and against the policy conditions, since this particular policy is not a new policy but a renewed one in continuation of Star Health Policy ie the Star Health policy is ported to SBI General Insurance Policy.  The Complainant was a beneficiary of Star Health policy from 2010 onwards.  The renewal of the policy and the conversion into SBI General Insurance was due to the request of the Opposite Party No.1 which is endorsed through the Complainant’s Bank Account No.10738278442 dated 27.01.2023 prior to the expiry date.  Under the circumstances stated above the Complainant prays the Commission to issue orders to the Opposite Parties to reimburse an amount of Rs.1,86,781/- along with other reliefs.

            5.  Upon notice the Opposite Party No.2 and 3 appeared before the Commission but they had not filed the version within the statutory period, since version had not been filed by Opposite Party No.2 and 3 in time.  Opposite Party No.1 was also not turned up.  Hence Opposite Parties were set ex-parte.  The application filed by Opposite Party No.2 and 3 to set aside the ex-parte Order was also dismissed by the Commission.

            6.  The Complainant had filed proof affidavit and filed Ext.A1 to A5 and there is no evidence from the side of Opposite Parties.

            7.  The following are the main points to be analyzed in this case.

1. Whether there is any deficiency of service or unfair trade practice from the part of Opposite Parties..?
2. If so, whether the Complainant is entitled to get any compensation..?
3. Cost of proceedings if any…?     

8.  On verification of the details stated in the complaint along with the documents produced from the side of the Complainant, it can be seen that the Complainant was a beneficiary of Star Health and Allied Insurance Company Limited as Per Ext.A1 and seen that the date of inception of the first policy is 30.01.2010 and from the enclosure therein it can be seen that the policy is renewed up to 30.01.2023.  The Complainant had produced Ext.A4 to show that the Complainant had subscribed to SBI General Insurance starting from 27.01.2023.  Which is just few days prior to the expiry date of the Star Health Policy.  Ext.A2 is the Copy of Pass book of the Complainant from which it can be seen that an amount of Rs.10,502/- had been deducted  on 27.01.2023 towards the subscription charges of SBI General Insurance Policy.  Ext.A3 is the Original Passbook produced by the Complainant.

9.  Ongoing through the above evidences it can be seen that the Complainant was insured under SBI General Insurance exactly in continuation with the previous policy in Star Health and Allied Insurance Company, since it is endorsed on Ext.A3 against the column dated 27.01.2023 that “Arogya Plus Renewal Premium Joseph. T. T 038967562528 of SBI General Insurance at 70192 Kalpetta” and an amount of Rs.10,502/- is deducted towards the renewal premium.  Normally if it is a new policy of SBI General Insurance the term “renewal” will not be prefixed to the premium and hence it is crystally clear that the amount deducted on 27.01.2023 by the Opposite Parties from the account of the Complainant for renewal of the policy.  It is to be worthy to note at this juncture that the date of expiry of the policy in respect of Star Health Insurance was on 30.01.2023 and the renewal made by the Opposite Parties is on27.01.2023 which justifies the argument of the Complainant that his policy with the previous insurer from 2010 was ported to SBI General Insurance Company and that is why the very word “renewal” is endorsed in the passbook issued by Opposite Parties.  Since things being so the Complainant had proved his case on merit and hence the following orders are passed.

1. The Opposite Parties shall reimburse an amount of Rs.1,86,781/- (Rupees One Lakh Eighty Six Thousand Seven Hundred and Eighty One Only) being the treatment expenses paid by the Complainant to the Complainant with interest @ 8% per annum.
2. The Opposite Parties are directed to deliver the original policy certificate and ID card of SBI General Insurance to the Complainant.
3. The Opposite Parties shall pay an amount of Rs.25,000/- (Rupees Twenty Five Thousand Only) as compensation to the Complainant.
4. The Opposite Parties shall pay an amount of Rs.5,000/- (Rupees Five Thousand Only) towards costs to the Complainant.

Needless to say that the above Order is to be complied with by the Opposite Parties within 30 days of receipt of copy of this Order otherwise the Opposite Parties will be liable for interest for the amount stated @ 6% p.a except for the amount awarded as costs.

Hence Consumer Case is partly allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 15^th day of February 2024.

Date of Filing:-19.09.2023.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Joseph. T. T.                                     Gunman.

Witness for the Opposite Parties:-

Nil.

Exhibits for the Complainant:-

A1.                  Copy of Medi Classic Insurance Policy (Individual) Schedule for the

period of 31.01.2022 to 30.01.2023.

A2.                  Copy of SBI Bank Passbook.

A3.                  SBI Bank Passbook.

A4.                  Copy of ID Card of SBI General Insurance.

A5.                  Copy of Final Bill.                                                    Dt:17.04.2023.

Exhibits for the Opposite Parties:-

                        Nil.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-