Orissa

Nuapada

CC/8/2016

Arabind Kumar Agrawal - Complainant(s)

Versus

Sukhesh P. Bhave, Dy. VP Claim - Health, SBI General Insurance Co. Ltd, - Opp.Party(s)

T.C.Soni

26 Mar 2019

ORDER

 

 

 

In the matter of complaint petition U/s 12 of Consumer Protection Act, 1986 filed by the complainant alleging deficiency in service by the opposite parties.

The factual matrix of the case is that:- 

 

          The complainant has purchased SBI General Group Health Insurance Policy bearing Policy No. 0000000002049146  which was valid from 21.08.2014, 00:00 Hrs. to midnight 20.08.2015 from O.P. No. 2  for which the complainant had paid premium of Rs. 3,900/- (Rupees three thousand nine hundred).  On 19.08.2015 at about 11.30 P.M. the complainant felt uneasiness and uncomfortable and he wake up suddenly for nature call.  When the complainant was returning from Bathroom, he all of a sudden sat on the floor of the Bathroom due to headling and called his wife and stood up with the help of his wife and neighbour namely Vivek Joshi and his mother Kamini Joshi for help and immediately they came their and Vivek Joshi took away the complainant in the Nursingh Home of Dr. Ranjit Singh Chhabada at Khariar Road at about 12.30 P.M.  On 20.08.2015 the doctor admitted the complainant in his Nursingh Home at Khariar Road for treatment and inspite of medical treatment and intensive supervision of the said doctor till 11 A.M.   On 20.08.2015, the health position of the complainant could not be recovered rather it became so critical. Ultimately, the doctor decided to refer the complainant  in Fortis Escorts, Heart Centre at Raipur in the state of Chhattisgarh as the blood pressure of the complainant lowdown and was not becoming normal and the complainant was continuing vomiting and on the very day at about 11.15 A.M., the complainant has been taken to the said Heart Centre at Raipur by Road with the help of nurse and compounder and at about 4 P.M. the complainant reached to the said Heart Centre and immediately he admitted in ICU (Intensive Care Unit) for his medical treatment under the supervision of Dr. Santosh Suryavansi there.   On 21.08.2015 at about 2 P.M., the complainant was discharged from the said hospital with a instruction to stay in Raipur for three days for regular checkup and accordingly the complainant stayed in a Hotel for three days i.e. from 21.08.2015 to 24.08.2015.  Thereafter the complainant came back to Khariar Road on 24.08.2015 at about 1 P.M.   The complainant also incurred expenses of Rs. 63,744/- for his treatment from 19.08.2015 at about 11.30 P.M. to 24.08.2015.

 

          Thereafter the complainant came to Khariar Road and narrated the details to O.P. No. 2 and he suggested the complainant to fill-up a claim form and O.P. No. 2 send the same claim form to O.P. No. 1 for claim under Health Policy of SBI Life.  The complainant sent the claim form along with the bills of aforesaid expenses to O.P. No. 1 on 26.02.2015 through post.  After received the claim form by O.P. No. 1, O.P. No. 1 send a letter of rejection of claim to the complainant.  Thereafter the complainant  again approached to O.P. No. 2 for further enquiry about his claim, but he did not respond to him for which the complainant suffered mental agony and harassment  due to negligence and deficiency in service by the opposite parties and as such the complainant claim for relief’s as prayed for.

 

          The complainant has filed the documents in support of his claims as under :- 

1)    Xerox True copy of letter of Policy No. 0000000002049146 issued by O.P. No. 1 on 21.08.2014 to the complainant as (Annexure-1).

2)    Xerox True copy of certificate of insurance issued by SBI, General Insurance vide Certificate No. 0000000002049146 valid from 21.08.2014  00.00 Hrs to Midnight of 20.08.2015 as (Annexure-2).

3)    Treatment prescription of complainant by Dr. Ranjit Singh Chhabada, Khariar Road  on 20.08.2015 at 2 A.M. as (Annexure-3).

4)    Money receipt of Rs. 18,000/- (Rupees eighteen thousand) dt.21.08.2015 received by Dr. Ranjit Singh Chhabada, Khariar Road from complainant as (Annexure-4)

5)    Discharge Summary of complainant  issued by Escort Heart Centre, Raipur on 21.08.2015  as (Annexure-5).

6)    Investigation Report issued by Escort Heart Centre, Raipur as (Annexure-6).

7)    Bill of Rs.  13,744/- (Rupees Thirteen thousand seven hundred forty four) issued by Escort Heart Centre, Raipur (three sheets) as (Annexure – 7, 7/1 & 7/2).

8)     Letter issued  to complainant  on 30.09.2015 by OP No.1.

Being noticed, O.P. No. 1 appeared through their Advocate and filed their written version and challenged the complaint of complainant in this case .OP  No.1 has also filed the documents  in support of  his claims as belows:-

A)   Xerox copy  of certificate of insurance dated 21.08.2014 as Annexure-A.

B)   Xerox copy of Claim Form of Complainant dated 21.08.2015 as Annexure-B .     

After received the notice, O.P. No. 2 has not appeared in this case so he set exparte.

          In the above pleadings, the following issues are framed and considered :-

I)             Whether the complaint is maintainable in the eye of law  ?

II)           Whether the Forum has jurisdiction to adjudicate upon  and there is cause of action  ?

III)          Whether any negligence and deficiency in service on the part of the opposite parties  ?

IV)         To what relief, the complainant is entitle to  ?

            ISSUE No. I to III :-

          Since the issues are very much linked up with each other, those are taken up for jointly discussion and findings.

          On perusal of case record as well as the documents filed by the complainant, it is found that the complainant has purchased SBI, General Group Health Insurance Policy bearing Policy No. 0000000002049146, which was valid from 21.08.2014, 00:00 to Midnight  20.08.2015 from O.P. No. 2 for which the complainant had paid premium of Rs. 3,900/- (Rupees three thousand nine hundred).  On 19.08.2015 at about 11.30 P.M. the complainant felt uneasiness and uncomfortable and he wake up suddenly for nature call.  When the complainant was returning from Bathroom, he all of a sudden sat on the floor of the Bathroom due to headling and called his wife and stood up with the help of his wife and neighbours and immediately they came there and the neighbour Vivek Joshi took away the complainant in the Nursingh Home of Dr. Ranjit Singh Chhabada at Khariar Road at about 12.30 A.M.  On 20.08.2015 the doctor admitted the complainant in his Nursingh Home at Khariar Road for treatment and inspite of medical treatment and intensive supervision of the said doctor till 11 A.M. on 20.08.2015, the health position of the complainant could not be recovered rather it became so critical. Ultimately, the doctor decided to refer the complainant  in Fortis Escorts, Heart Centre at Raipur in the state of Chhattisgarh as the blood pressure of the complainant lowdown and was not becoming normal and the complainant was continuing vomiting and on the very day at about 11.15 A.M., the complainant had taken to the said Heart Centre at Raipur by Road with the help of Nurse and Compounder and at about 4 P.M., the complainant reached to the said Heart Centre and immediately admitted in ICU (Intensive Care Unit) for his medical treatment under the supervision of Dr. Santosh Suryavansi there.  

          Thereafter on 21.08.2015, at about 2 P.M. the complainant was discharged from the said hospital with an instruction to stay in Raipur for three days for regular medical checkup and then he came back to Khariar Road on 24.08.2015 at about 1 P.M. and he incurred expenses of Rs. 63,744/- (Rupees sixty three thousand seven hundred forty four) for his treatment.

          Thereafter the complainant narrated the details to O.P. No. 2 and as per the advised of O.P. No. 2, the complainant filled-up the claim form and submitted before O.P. No. 2 and accordingly O.P. No. 2 send the said claim form to O.P. No. 1 but O.P. No. 1 failed to settle the claim of complainant which is squarely absurd by them.

          In such an uncongenial situation and without any option,   the complainant knocked the door of this Forum.

          As per the Consumer Protection Act, 1986, Section 2 (d)(ii) explain consumer means :-  Any person  “Who hires or avails of any service for a consideration which has been paid or promised or partly promised or any system of deferred payment and includes any beneficiary of such services other than commercial purpose”  So  the status of consumer cannot be deniable and thereby the maintainability.

          So far as the point of jurisdiction, it is seen that the complainnt is a resident of village Khariar Road, Ward No. 8, District Nuapada and Branch Office of opposite parties is situated in this district so the complaint is within the jurisdiction of this Forum and this Forum has wide jurisdiction to adjudicate the present dispute and there is cause of action.

          In another factual aspect is that in SBI, General Insurance Policy in Annexure-2, it is specifically reflected in clause-6 “Day Care Expenses - Insurer shall Pay for Day Care Expenses incurred on Advanced technological surgeries and Procedures requiring less than 24 Hours of Hospitalisation as per Attached list and subject to the condition that prior approval is obtained by the Insured Person/Insured from the Administrator/ Insurer for such a Day Care Procedure/Expenses.”

          Here, the complainant admitted in ICU (Intensive Care Unit) of Fortis Escorts, Heart Centre at Raipur (Chhattisgarh) at 4 P.M. on 20.08.2015 and he discharged from the said Hospital on 21.08.2015 at about 2 P.M.  So it is asserted that the hospitalisation of the complainant is less than 24 Hours and as such the complainant is entitled for the benefit of the insurance.

          Supporting to the above findings, we quote a decision of Hon’ble Supreme Court of India in the case of D. SRINIVAS . Vrs. . SBI, LIFE INSURANCE CO. LTD. AND OTHERS in CIVIL APPEAL No. 2216 of 2018.  Decided on 16.02.2018.

          In another factual aspect is that the insurance contract of utmost good faith and the insurer person takes the insurance policy by keeping faith on the company.  But, his hopes and dreams shattered by the attitude of insurer when the issue of claim arises.  The Insurance Company find several ways how to repudiate the claim even it is genuine one and harass the claimant and make him to run from pillar to post.  It is just unfair and unacceptable.

          Here, the Consumer Protection Act is social legislation and there is need to strike down such practices and need to give proper redressal to the consumers.

          In fact, the Insurance Company should be magnanimous, enough generous to award the claims at single window, without any hassle and with full co-operation.

          So from the perusal of the provisions of Consumer Protection Act, 1986, applied to all type of goods, and all type of services availed by the consumer against the consideration paid, or promised.  Section 1 (iv) of the Consumer Protection Act, 1986 is of wide connotation.

          Perused the documents of complainant as well as OP No.1 and we found that the claim of complainant is genuine and relevant and as such taken in consideration.

          In this case, the Advocates for both the parties have argued and advocate  for OP No.1 has filed a written argument in support of their claims.

          The advocate for OP No.1  has also filed citations as under:-

1.          M/S SURAJMAL RAM NIWAS OIL MILL(P) LTD

VRS

            UNITED INDIA INSURANCE CO.LTD & ANOR

           SUPREME COURT OF INDIA CIVIL APPEAL NO.1375 OF 2003

 

2.          ORIENTAL INSURANCE CO. LTD

                        VRS

      SAMAYANALLUR PRIMARY AGRICULTURAL COOP.BANK

      SUPREME COURT  OF INDIA APPEAL (CIVIL) 8716

      OF   1997,DATE OF JUDGEMENT 02/11/1999

 

3.          EXPORT CREDIT GUARANTEE CORPN OF INDIA LTD

                               VRS

      GARG SONS INTERNATIONAL

      SUPEME COURT OF INDIA CIVIL APPEAL NO.1557 FO 2004

 

4.         UNITED  INDIA INSURANCE CO.LTD

                 VRS

     M.K.J.CORPORATION

     SUPREME COURT OF INIDIA 21/08/1996

 

5.         GENERAL ASSURANCE  SOCIETY  LTD

                  VRS

     CHANDUMULL JAIN AND ANOR

     SUPREME COURT OF INDIA 07/02/1996

 

            Here, the citations filed  by Advocate  for  OP No.1 are neither applicable nor related  in this case.

          Here, we assessed that the complainant is a consumer of opposite parties and it is the duty of opposite parties to provide proper service and proper information to the complainant.  But the opposite parties have failed to do the same in this case.

          Hence, it is apparent from the above issues that there is a deficiency of service by the opposite parties as not provide proper service to the complainant for which the complainant is suffering financial loss and mental agony due to negligence and deficiency of services by the O.Ps.

          So, we are of considered opinion that there is a deficiency in service by the opposite parties.  Thus, opposite parties are liable for deficiency in service.

ISSUE No. IV :-

          It is clear crystal that the complainant has proved his case and he is entitled to get relief in this case.  Hence, order.

O  R  D  E  R.

          In the aforesaid matrix of facts and circumstances, the complaint is allowed and we direct U/s 14 (d)(ii) of the Consumer Protection Act, 1986 as below :-

 

1)    We direct the opposite parties to pay Rs. 63,744/- (Rupees sixty three thousand seven hundred forty four) to the complainant as expenses for his medical treatment within 45 (forty five) days from the date of order, failing which the opposite parties shall pay @  9%  (Nine percent) interest  on the above said amount from 20.08.2015 till payment.

2)    We further direct the opposite parties to pay Rs.7,000/- (Rupees Seven thousand) to the complainant as compensation towards mental agony and harassment and again to further pay as Rs.3,000/- (Rupees three thousand) towards litigation cost within 45 (forty five) days from the date of order.

3)    Failing which the above order, the complainant is at liberty to take steps as per process of law.

 

          Judgement pronounced in the Open Court of the District Consumer Disputes Redressal Forum, Nuapada, this the 26^th      day of March 2019.