Haryana

Fatehabad

CC/358/2019

K.B Chilana - Complainant(s)

Versus

State Bank Of India - Opp.Party(s)

Sube Singh

10 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                      Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                                    C.C.No.358 of 2019.                                                                                            Date of Instt.: 28.08.2019.                                                                                   Date of Decision: 10.01.2024.

K.B. (Kanwar Bhan) Chilana aged 63 years son of Shri Nand Lal, resident of 35-A, Jagjiwanpura, Bigher Road, Fatehabad Tehsil & District Fatehabad.

                                                                        ..Complainant

                              Versus

1.State Bank of India, Branch Fatehabad, District Fatehabad through its Chief Manager.                                                                                                2.Deputy General Manager, State Bank of India, Zonal Office Haryana, Delhi Bypass Road, Rohtak District Rohtak.                                                                           3.Medi Assist Insurance TPA Private Limited Branch 8B, Second Floor, Bahadur Shah Zafar Marg, Next to Times of India Building, Medi Assist, New Delhi-110002 through its Authorized Signatory/Director.                                               4.United India Insurance Company Ltd. Divisional Office, 133, Jahangir Building, First Floor, M.G.Road, Fort, Mumbai-400023 through its authorized signatory.

                                                                   ..Opposite Parties.

Complaint U/S 35 of the Consumer Protection Act, 2019            

Present:                 Sh.Sube Singh Dandiwal, Advocate for complainant.                                            Sh.Sanjiv Mehta, Advocate for Ops No.1 & 2.                                                      Sh.Kaushal Mehta,Advocate for Op No.4.                                                            OP No.3 proceeded against VOD 10.10.2019.

                            

                                                                                               

ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                          Brief facts of the present complaint are that the complainant became the member of SBI REIMBS scheme in October 2015 for health insurance  upto Rs.7 lacs by making premium amount of Rs.62,000/-; that the policy bearing No.1202002818P10372620 was purchased from United India Insurance; that wife of the complainant namely Kamlesh Chilana got hospitalized for pain in knee on 07.10.2018 and operated upon  in IVY Hospital, Mohali; that regarding this information was given to TPA and insurance company; that claim of Rs.2,85,898/- was lodged with the OP/insurance company alongwith relevant documents but the Ops No.3 & 4 only paid Rs.1,75,000/- by withholding the amount of Rs.1,33508/- (Rs.1,10,898 + Rs.22,911/- Post hospitalization expenses); that the complainant requested the Ops to make the balance amount and even got served legal notice upon but all went in vain. The act and conduct of the Ops clearly amounts to deficiency in service and unfair trade practice on their part.

2.                          On notice Ops No.1, 2 & 4 appeared and filed their separate replies.  Ops No.1 & 2 in their reply have taken preliminary objections such as cause of action, locus standi, maintainability, concealment of material facts. It has been further submitted that the replying Ops have been following the terms and conditions of REIMBS scheme from time to time; that as per Police A knee replacement was capped upto Rs.1,75,000/- and no further could be made on the capped disease; that the Mohali city where the operation on the wife of the complainant was done is tier City-3 and knee replacement cap was Rs.1,75,000/- applicable and the said amount has already been paid by the insurance company, therefore, no deficiency in service and unfair trade practice can be attributed towards the replying OP.Other contentions have been contorverted and prayer for dismissal of the complaint has been made.

3.                          OP No.4 in its reply has  taken more or less the same grounds as taken by the Ops No.1 & 2 in their joint reply. It has been further submitted that the claim amount as applicable in the present matter to the tune of Rs.1,75,000/- has already been paid to the complainant  under the policy in question keeping in view the Tier-3 city (as Mohali city falls under Tier-3 City); that since the ailment for which treatment was taken falls under capped limit, hence this claim of Rs.1,33,809/- is not payable as per policy terms and conditions, therefore, the same was rightly denied.  Other contentions have been controverted and prayer for dismissal of the complaint has been made. OP No.3 did not appear before this Commission despite issuance of notice through registered post, therefore, it was pleaded against exparte vide order dated 10.10.2019.

4.                          In evidence, the complainant has tendered affidavit Annexure CW1/A with documents Annexure C1 to Annexure C22. On the other hand the appearing Ops have tendered affidavits Ex.RW1/A, Ex.RW4/A and documents Annexure R1 to Annexure R14, Annexure R4/1 to Annexure R4/2.

 5.                         We have heard oral final arguments from both sides. We have also perused the case file minutely.

6.                          The fact regarding making the payment of Rs.1,75,000/- to the complainant on account of ailment of the wife of the complainant (being replacement of knees) is not disputed.  The complainant has come with the plea that bill amounting to Rs. 2,85,898/- were submitted to the Ops for reimbursement, as the operation for knee replacement was done on the person of his wife, during the currency of the policy in question, but the Ops have only paid Rs.1,75,000/- withholding the remaining amount of Rs.1,33,508 ( Rs.1,10,898 + Rs.22,911/- post hospitalization expenses) without any rhyme and reason. Learned counsel for the complainant further argued that the Ops have failed to redress the grievance of the complainant despite requests and serving of legal notice upon them.

7.                          On the other hand, learned counsel for the Ops have argued that the complainant was only entitled for the reimbursement of Rs.1,75,000/- as per the terms and conditions of the policy as well as the fact that the place Mohali where the operation for knee replacement was conducted falls within tier-3 city, therefore, the cap upto Rs.1,75,000/- only was applicable and thus, the said amount was paid to the complainant. In support of his contentions learned counsel for the Ops drew the attention of this Commission towards document Annexure R1/8 i.e. Family Floater Group Medi-claim Policy wherein it has been mentioned as under:

Disease wise cap
Type of disease	Limits (Amount in Rs.)
	Tier 1	Tier 2	Tier 3
Angioplasty	-	-	-
CA BG	-	-	-
Cholecystectom,y	-	-	-
Hernia	-	-	-
Knee Replacement Unilateral	1,75,000	150,000	100,000
Knee Replacement Bilateral	2,50,000	2,25,000	1,75,000

 

It is not disputed that the knee replacement was done at Mohali but perusal of this Annexure R1/8 shows that the Mohali city does not fall within the purview of Tier-1 and Tier-2 cities and the same is shown as Tier-3 city. Since the amount of Rs.175000/- has already been paid to the complainant keeping in view the terms and conditions of the policy keeping in view the eligibility criteria for tier-3 city, therefore, the complainant is seized to raise the plea that the rest of the amount has been withheld by the Ops wrongly and illegally.

8.                          So far as the plea of the complainant qua winding up the scheme in question, it is worthwhile to mention here that the complainant himself has signed the declaration form (Annexure R1/2) wherein it has been mentioned that We have read and understood the terms and conditions of the SBI REMBS and undertake to abide by the same.  The complainant also agreed to the point mentioned at Sr. No.(v) which is as under:

We also note that in case the Bank decides to wind up the scheme and dispose off the contributions/fees received from them in a manner deemed fit we shall have no legal claim against the bank or the managing Committee or the Trust.

On one hand, the complainant himself has given his consent for not taking any legal action against the concerned bank in case it closes/winds up the scheme in question but on the other hand has filed the present compliant against the said institution for winding up/closing the scheme in question.  It is a settled principle of law that he who seeks equity must do equity with others but in the present case the complainant is trying to back out from the  promise which was made by him in the shape of declaration made in Annexure R1/2, therefore, this plea is hereby rejected. Since the complainant has already received the amount to the tune of Rs.1,75,000/- as per the eligible criteria made for Tier-3 city, therefore, the present complaint is not maintainable before this Commission and deserves dismissal.

9.                          On the basis of above mentioned discussion, we are of the considered opinion that there was no deficiency in service at all or any unfair trade practice, on the part of any of the Ops, as alleged, so as to make any of them liable to any extent in this matter. Hence, the complaint is dismissed in view of the facts and circumstances stated above.  All the parties are left to bear their own costs. A copy of this order be supplied to both the parties free of cost as per rules.  This order be uploaded, forthwith, on the website of this Commission as per rules for the perusal of the parties. File be consigned to record room, as per rules, after due compliance.

Announced in open Commission.                                                                   Dated: 10.01.2024

                    

                                                                                     

(K.S.Nirania)                      (Harisha Mehta)                (Rajbir Singh)                                Member                                  Member                                              President