FINAL ORDER / JUDGEMENT

Sri. Apurba Kr. Ghosh............President.

The Complainant has filed this case against the OPs and prays for the following orders/reliefs:-

1. Direction against the OPs to returned back the entire cost of treatment i.e. a sum of Rs. 17,735/- only to the complainant together with 18 % interest accrued thereon, on and from 18.09.2017 till its realization.
2. A direction against the OPs to pay a sum of Rs. 50,000/- to the complainant for her mental pain, agony and harassment.
3. Direction against the OPs to pay a sum of Rs. 15,000/- to the complainant on account of punitive damages.
4. Direction against the OPs to pay sum of Rs.20,000/- to the complainant on account of her litigation cost.
5. Any other relief / reliefs to which the complainant is legally entitled. 

BRIEF FACT OF THE COMPLAINT

1. That the complainant is a peace loving and law abiding citizen of India and OP No. 1 is a banking organization and has introduced themselves in the field of general insurance under the name and style SBI General Insurance company limited. The OP No. 2 has engaged themselve in the business of general insurance and OP No. 3 is the branch as well as Head Office of the OP No. 2 for the territory of Siliguri and the OP No. 4 is a Branch Office of the OP No. 1 and OP No. 5 is the Branch Head of the OP No. 2 and 3 and OP No. 5 is liable and responsible for the day to day works and affairs of the OP No. 2 and 3 for the territory of Siliguri. The OP No. 6 is a third party administrator and they used to play a role of settlement of claim of insured person.

2. That the husband of the complainant has opened a saving bank account with the OP No. 4 being A/C No. 34803737563 and in the month of March 2015 the employees of the OP No. 3 after collecting the details of the husband of the complainant as well as complainant contacted with them and requested them to insure themselves under the mediclaim policy of the OPs and accordingly her husband as well as the complainant had insured themselves with the OPs under the product type of “Family Floater”, after making payment of requisite premium. That after taking premium and considering the proposal form of the husband of the complainant as well as the complainant the OP No. 2 and 3 have agreed to insured the husband of the complainant as well as complainant under the said mediclaim policy of the OPs and accordingly they issued one Group Health Insurance Policy being No. 0000000002774279-02 on 29.03.2015 and the said mediclaim policy was issued covering total insured sum of Rs. 1,00,000/- each and the said policy was valid from 29.03.2015 to 28.03.2016. That the policy was valid till the midnight of 28.03.2018 and subsequently the policy was again renewed by the OPs, after taking premium and presently the insurance policy was valid till the midnight of 28.03.2019.

3. That the complainant as well as her husband insured themselves under the said policy which having the facility of cashless      benefit         and    the OPs have time to time issued cashless benefit card to the husband of the complainant as well as the complainant separately for obtaining the benefit of cashless hospitals benefits/ service under the listed network hospitals of the OPs bearing  member ID no. SBIG4024751.

4. That for the purpose of her treatment the complainant went to Apollo Hospitals Chennai and after consulting Dr. Prakash K.C., Consultant Nephrologist of Apollo Hospitals, Chennai the complainant went for some pathological test as advised by Dr. Prakash K.C. That for the purpose of her treatment the complainant had to take admission in the said Apollo hospital Chennai from 05.09.2017 to 07.09.2017 vide bed no. 4452 and for which the complainant has to incur an expenditure of a sum of Rs. 13,735/- only. That at the time of taking admission in the said hospital the complainant has produced her cashless benefit/ service card with the administration of the Apollo Hospital, Chennai. That the authority of Apollo Hospitals, Chennai has consulted with the OPs and thereafter they have denied the cashless benefit to the complainant and they have also instructed the complainant to deposit a sum of Rs. 20,000/- only prior to take admission and for which the complainant has deposited the said sum of Rs. 20,000/- with the Apollo Hospitals, Chennai and after deducting the said expenses of the complainant i.e a sum of Rs. 13,735/- only the balance amount of Rs. 6,265/- was refunded to the complainant by the Apollo Hospitals, Chennai authority.

5. That subsequently the complainant has also incurred expenses for a sum of Rs. 600/- for consultation , Rs. 750/- for follow up visit and Rs. 2,650/- for the said treatment at Apollo Hospitals, Chennai and the complainant has compelled to incur expenses altogether a sum of Rs. 17,735/- only due to denial of cashless service/ benefit by the OPs though at the time of issuance of first policy the OPs have firmly assured/ declared and promised to provide cashless service/ benefit to the husband of the complainant as well as the complainant in any case of health complication and hospitalization under the listed network hospitals of the OPs.

6. That after coming back from Chennai the complainant has submitted claim form duly signed and attested by the treating doctor of the complainant viz. Dr. Prakash K.C along with all original copy of discharge summary, bills, photocopy of prescriptions and other treatment related documents on 18.09.2017 with the OP No. 6 and the OP No. 6 has duly received the same from the complainant on the even date i.e on 18.09.2017 by putting their original seal and signature and also acknowledging receipt of the treatment related document of the complainant in original. That since 18.09.2017 all the treatment related documents are lying under the custody of OP No. 6 and in the month of August i.e on 02.08.2017 the complainant went to Dr. Sandeep Saha with problem of swelling of legs/Edema and thereafter the complainant went to Dr. Deepak Tomar and Dr. Vishal Golay as per the advice of Dr. Sandeep Saha and lastly the complainant went to Chennai for the purpose of treatment at Apollo Hospitals, Chennai.

7. That in spite of completion of all required formalities for getting the benefit of said insurance policy the OPs have neither reimburse the expenditure made by the complainant for her treatment purpose nor they have bothered to make any response to the complainant for their illegal and unlawful gain and with an ill intention to frustrate the legal, valid and genuine claim of the complainant.

8. That on 26.09.2017 the OPs have asked / raised some questions with the complainant and in reply on 04.10.2017 the complainant has answered those questions satisfactorily in written to the OPs and the said letter was duly received by the OP No. 6 on 04.10.2017 by putting their original seal and signature.

9. That on 20.11.2017 the OPs again asked for documents by issuing a letter to the complainant in spite of getting sufficient reply along with all original documents too earlier, which clearly proves the evil plan of the OPs not to reimburse the legal, valid and genuine claim of the complainant.

10. That till today the OPs did not reimburse the legal, valid and genuine claim of the complainant nor made any positive reply from their ends which clearly proves that the intention of the OPs not to reimburse the legal, valid and genuine claim of the complainant but to unnecessarily linger the process of settlement of the claim to frustrate the insured from her legal, valid and genuine claim which establishes that there was great deficiency in service and also illegal and unfair trade practice on the part of OPs towards discharging their official duties. 

10. That due to the illegal acts and conducts of the OPs the complainant has suffered immense mental pain, agony, trauma and harassment and for which the OPs are liable and responsible severally and jointly to pay the adequate compensation thereof.

11. That the cause of action for this case arose on and from 05.09.2017 when the cash less service/ benefit was denied by the OPs to the complainant and thereafter on each and every date and the same is still continuing within the jurisdiction of this Commission.   

In order to prove the case the complainant has annexed the following documents:

1.  Photocopy of Bank passbook, bearing Savings Account No. 34803737563 standing in the name of the husband of the complainant.
2. Photocopy of Health Insurance Policy bearing No. 0000000002774279-02.
3. Photocopy of Cashless Benefits Card (3Nos) be3ing member ID No. SBIG4024751.
4. Photocopy of prescription of the Complainant issued by the Dr. Sandip Saha.
5. Photocopy of prescription of the Complainant issued by the Dr. Deepak Tomar.
6. Photocopy of prescription of the Complainant issued by the Dr. Vishal Golay.
7. Photocopy of prescription of Apollo Hospitals, Chennai issued by Dr. Prakash K.C.
8. Photocopy of Discharge issued by the Apollo Hospitals, Chennai dated 07.09.2017.
9. Photocopy of Final Bill of the complainant amounting to Rs. 13,735/- issued by Apollo Hospitals, Chennai.
10. Photocopy of Bill of the complainant for consultation with Dr. Prakash K. C amounting to Rs. 600/-
11. Photocopy of Bill of the complainant for follow up visit with Dr. Prakash K. C amounting to Rs. 750/-.
12. Photocopy of Bill of Pathological Test of the Complainant viz. ‘VASCULTITIS PACKAGE’ amounting to Rs. 2650/-.
13. Photocopy of claim Form of the Complainant duly attested by the Dr. Prakash K.C. of Apollo Hospital, Chennai dated 18.09.2017 received by the O.P. No. 6.
14. Photocopy of reply letter of the complainant dated 04.10.2017 received by the OP No 6.
15. Photocopy of letter issued by the O.P No. 6 to the complainant dated 20.11.2017

Notice was issued from this commission upon the OPs which had duly served upon them and on receipt on notice the OP No. 1 to 4 have appeared through Vokalatnama, filed written version and denied all the material allegation of the complainant. In the written version the OP No. 1 to 4 have stated that the complaint is not maintainable both in law and facts against the OPs/ the case is barred by law of estoppels and waiver/ the complaint is not maintainable for mis-joinder and non joinder of necessary parties/ the complainant has claimed relief against the OPs which is beyond the scope of the Consumer Protection Act/ the complainant cannot be construed as a consumer disputes as per the provisions of the CP Act / the complainant has filed this case against the OPs with an intention to harass them and to derive undue advantage as well as unlawful gain from the OPs. The OPs have further stated that that the complainant had an saving account being no. 34803737563 with the answering OPs (OP no. 1 & 4) and the contents of para no. 1 of the complaint is matter of record and para no. 2 is partially correct. It is further stated that, the OP no. 1 is not introduced themselves in the filed of General Insurance business, and the OP No. 1 The State Bank of India and SBI General Insurance Company limited is not the same and the answering OPs belongs separate and legal identity from the SBI General Insurance Company Limited and the OP No. 1 and 4 are state owned organization and SBI General Insurance is joint venture organization. It is further stated by the OP no. 1 and 4 that the contents of para no. 3 of the complaint is purely false and just a cock and bull story and fabricated just to entangled them in this case. And the contents of para no. 4 to 14 does not implicate them in any way. The OP No. 1 and 4 have further stated that no cause of action arose against them and the complainant is not a consumer and the OPs does not come within the territorial  jurisdiction of the Forum as the OP no. 1 falls in the state of Maharashtra and OP No. 4 comes under the jurisdiction of Jalpaiguri District. By filing the written version the OP No. 1 and 4 praying for dismissal of this case.

In the written version the OP no. 2, 3 & 5  have stated that the complainant has no cause of action to file this case against them/ the complaint is not maintainable in law as well as in facts/ the claim petition is barred by principle of waiver, estoppels and acquiescence, / the case is barred by law of limitation / the case is barred for mis-joinder and unnecessary parties / the statements made in para  no. 1, 2 and 3 are matter of record / statement made in para no. 4 and 5 of the complaint are disputed and challenged as the husband of the complainant was not eligible for getting cashless facilities of his treatment due to delay of first information and also non supply of necessary documents of his treatment  and therefore the TPA Service India Pvt. Ltd. (OP No 6) intimated the Apollo Hospital Chennai is being denied the claim of the cashless facilities on account of the DOCUMENTS NOT RECEIVED WITHIN 72 HOURS from the date of commencement of ailment certified by the treating doctor duly signed with registration Number in proper format and not provided the first consultation prescription when the diseased was first detected and all the past prescription related to treatment. The OP No. 2, 3 & 5 have further stated with regard to statement made in para no. 6 and 7 of the complaint are also disputed and denied by them and the TPA (OP No. 6) intimated the complainant by its letter dated 26.09.2017 asking some documents but as per their requirement the complainant did not supply those documents and also asked the complainant to provide Hospital Bill details break up  for the hospital amount of Rs. 13,735/- and all investigation report during hospitalization period and attending physician to certify the cause of ailment and all past treatment papers related to the disease and histopathology / biopsy report. It is further stated in the W/V of the OP No. 2, 3 & 5 that on 31.10.2017 again the OP No. 6 requested the complainant to provide the certificate of attending doctor to certify the cause of ailment but the complainant did not provide the same and the OP No. 6 on several occasions by their letter dated 31.10.2017, 10.11.2017, 20.11.2017, and 06.12.2017 requested the complainant to provide the documents of i) Attending doctor to certify the cause of ailment ii) certificate of the attending doctor to certify the duration of the ailment. But the complainant did not provide the same and they further stated in the W/V that the statement made in para no. 8  to 17 are not correct. By filing the W/V the OP No. 2,3 & 5 praying for dismissal of this case.

In support of the W/V Ld. Advocate of OP No. 1 and 4 filed the following documents:

1. List of members of Board of Director of SBI.
2.    List of members of Board of Director of SBI General.

Having heard the Ld. advocate of both the side and on perusal of the complaint, written version as well as documents filed by the parties the following points are taken to be considered/decided by this Commission.

POINTS FOR CONSIDERATION

1. Whether the complainant is a consumer as per the provision of C.P. Act. ?
2. Whether the case is maintainable in its present form and prayer under the provision of the C.P. Act. ?
3. Whether there is any cause of action to file this case by the complainant?
4. Whether there was deficiency in service on the part of the OP as alleged by the complainant?
5. Is the complainant has able to prove this case and entitled to get any relief as prayed for?

DECISION WITH REASONS

All the points are taken up together for discussion to avoid unnecessary repetition and for the sake of convenience and brevity of this case.

The complainant was given opportunity to prove her case by filing evidence as well as by filing supportive documents. In order to prove this case the complainant has adduced written evidence in the form of an affidavit. She also filed several documents by a firisty.

In the written evidence the complainant has specifically corroborated the contents of the complaints by stating that, she was medically checked up by several doctors and subsequently she was compelled to take admission in the Apollo Hospital at Chennai for her treatment. In the written deposition the complainant has stated that, no cashless benefit was provide to the complainant for her treatment and that’s why she was compelled to pay the entire expenditure amount to the hospital authority. The complainant has further corroborated that, after getting back from Chennai she raised claim with the OP no. 6 and produced all the medical related documents in original along with the certificate of the doctors for reimbursement of the claim. The Complainant has further stated in her evidence that, on several occasions she wrote letter to the OPs for early settlement of the claim but the OPs have denied the claim by assigning reasons which are not at all correct and only to harass the complainant they did not settle the claim of reimbursement.

Ld. Advocate of the complainant by filing written notes of argument argued that, the complainant has been able to prove her case to the effect that, within the validity period of the insurance policy the complainant was admitted in the Apollo Hospitals, Chennai where she was denied by the OPs for providing cashless benefits. Further argument of the ld. Advocate of the complainant that not only the OPs have denied to provide the cashless benefit to the complainant but also they take no initiative for settlement of claim raised by the complainant. It is further argued on the side of the complainant that, on 18.09.2017 the OP No. 6 had received the entire original medical related documents along with the claim form duly signed and attested by the treating doctor of the complainant including the discharge summary, bills, photocopy of prescription and other treatment related documents on 18.09.2017 and by putting signature with seal the OP No. 6 acknowledged the receipt of the treatment related documents of the complainant in original but they falsely stated in their W/V as if the complainant did not provide those documents to the OP No. 6 which is a blatant lie. At the time of hearing of argument Ld. Advocate of the complainant referred one decision of Om Prakash Ahuja VS Reliance General Insurance Co. Ltd reported in 2023  Live Law (SC) 509 and also referred decisions reported in CPJ 2013 Vol II page no. 345 (NC)  and submits that the complainant has been able to prove the case and she is entitled to get the relief as prayed for.

To falsify the case of the complainant the OPs have filed separate deposition in chief in the form of an affidavit alleging that the complainant has filed this case on some false allegation and there was no deficiency in service on the part of the OPs. In their written deposition they has also stated that the complainant has filed the case knowing fully well that she has no cause of action for filing of the same and only to extort compensation amount she filed this case on some false allegations.

At the time of hearing of argument Ld. Advocate of the OP No. 1 and 4 have stated that, the complainant is not a consumer and her husband is an account holder of their bank and the complainant purchased a mediclaim policy from the OP No. 2, 3 and 5 and as per request of the husband of the complainant the premium of the said mediclaim policy was deducted from the savings account of the husband of the complainant and there was no negligence/ deficiency in service  on the part of OP No. 1 and 4  and no claim was made before the OP No. 1 and 4 for reimbursement by the complainant. They further argued that no cause of action arises against the OP No. 1 and 4 and the OP No. 1 and Insurance Australia Group jointly introduced themselves in the field of General Insurance Business as SBI General Insurance Company Limited and it is a joint venture project and the OP No. 1 and 2 are not the same and the  legal entity of the OP No. 1 and 2 are different and the Board of Management is also different. Ld. Advocate of the OP No. 1 and 4 at the time of argument submits that, the complainant has failed to prove its case against them.

At the time of hearing of argument Ld. Advocate of the OP No. 2, 3 & 5 argued that, the complainant has failed to prove its case against them and due to non supply of relevant documents required for the disbursement / settlement of the claim of the complainant was not provided though the OP No. 6 by sending several letters in favour of the complainant requires medical documents which she did not provide the same to the OP and based on non supply of those documents the cashless benefits as well as reimbursement of the medical expenditure was not provided to the complainant rightly. It is further argument of the Ld. Advocate of the OP No. 2, 3 & 5 that the TPA (OP No. 6) intimated the Apollo Hospital, Chennai that the complainant did not provide the required medical documents and that’s why the cashless benefit was denied and the reason to decline the request of the Apollo Hospital for availing cashless facilities is absolutely based on documents / information provided by the Hospital and denial of the cashless authorization does neither imply denial of treatment nor does it in any prevent the hospital authority from extending necessary medical attention as there was every scope for reimbursement with necessary documents for review. It is further argument of the ld. Advocate of the OP No 2, 3 & 5 that the complainant has claim excess amount which she incurred for her medical treatment.

Having heard the Ld. Advocate of both the side and on perusal of the entire record including the documents filed by the complainant as well as the OPs it is admitted fact that, the complainant has purchased mediclaim policy along with her husband. From the documents submitted by the complainant it is proved that, the mediclaim policy was valid when the complainant was admitted in the Apollo Hospitals, Chennai for her medical treatment. It is also admitted fact by all the parties that, the cashless benefit was not provided to the complainant though the complainant was given cashless benefit card which she gave to the hospital authority for getting the facility/ benefit of cashless treatment. It is not the case of the OP that, no premium was given for renewal of the existing of the mediclaim policy rather it is admitted fact that, policy was effective/ valid when complainant was admitted in the hospital. From the documents submitted by the complainant, it further proves that, the complainant sustained medical expenses of Rs. 13,735/- which was given to the Apollo Hospital Authority and she also sustained a sum of Rs. 600/- for consultation and Rs. 750/- for follow up visit and Rs. 2,650/- for treatment at Apollo Hospital Chennai and she incurred expenses altogether a sum of Rs. 17,750/- . From the list of document serial no. 13 and 14 it is proved that, the claim form of the complainant duly attested by the Dr. Prakash K. C of Apollo Hospital Chennai dated 18.09.2017 was received by OP No. 6 along with the reply letter of the complainant dated 04.10.2017.

From the written complaint as well as from the evidence of the complainant it is the case of the complainant that, she was admitted in the Apollo Hospital Chennai for her medical treatment but in the written version the OP No. 2, 3 & 5 submits that, the husband of the complainant was not eligible for getting cashless benefits for his treatment due to delay of first information and for supply of necessary documents of his treatment.

From the decision reported in 2023 Live Law (SC)509 referred on the side of the complainant it is settled provisions of law that, in the case of medical insurance once there is a valid insurance policy in favour a person, the claim for reimbursement of the expenses incurred must be paid.

In the case in hand it is admitted fact that, within the effective policy period the complainant was admitted in the Apollo Hospital Chennai for her treatment and that’s why she was compelled to pay expenses for her treatment to the hospital authority as the OPs have denied to provide the cashless benefit. It is needless to mention here that, the complainant and her husband have availed insurance from the OPs and inspite of providing cashless benefit card in favour of the complainant the OPs did not provide cashless services to the complainant, nor they have reimburse the expenses to the complainant during existence of valid insurance policy of mediclaim and for which the complainant is entitled to get the relief.

Moreover in the petition of complaint and in the written evidence the complainant has state that the OP no. 1 has introduced themselves the filed of General Insurance under the name and style SBI General Insurance Co. Ltd. But the said evidence of the complainant has not been challenged by the OPs either through putting questionnaires or by producing relevant documents.

Considering all, we are of the view that, there was deficiency in service as well as restrictive trade practice on the part of the OP No. 1 to 5. We are also of the view that, the complainant has also able to prove her case against the OP No. 1 to 5 and they are liable to pay the awarded amount jointly as well as severally.

Hence, it is

O R D E R E D

That the instant Consumer Case being no. 47/2018 is allowed on contest against the OP No. 1 to 5. All of them are liable to pay the awarded amount jointly as well as severally. The OPs are directed to pay a sum of Rs. 17,735/-(Rupees Seventeen Thousand Seven Hundred Thirty Five) only to the complainant towards reimbursement of medical expenses along with interest @7% per annum w.e.f. 18.09.2017 till the date of making payment of entire amount.

 The OPs No. 1 to 5 are further directed to pay a sum of Rs. 20,000/-(Rupees Twenty Thousand) only to the complainant for causing mental pain, agony and harassment by the OPs No. 1 to 5  and they are further directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only to the complainant towards the cost of legal proceedings. The OPs No. 1 to 5 are further directed to pay a sum of Rs. 10,000/- (Rupees Ten Thousand) only in the Consumer Legal Aid Account of this Commission.

The OPs No. 1 to 5 are directed to pay the awarded amount within 45 days from this day failing which the complainant is at liberty to take steps against them.

Let a copy of this order be given to the parties free of cost.