BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 7th October 2016
PRESENT
SMT. C.V. SHOBHA : HONBLE PRESIDENT
SMT.LAVANYA M. RAI : HONBLE MEMBER
COMPLAINT NO.261/2012
(Admitted on 09.08.2012)
Mr. Percy Noel Pais,
S/o. Mery Pais,
Aged 45 years,
Residing at Jakribettu House,
Mother Theresa Road,
Bantwal D.K. Dist, Mangalore.
……… Complainant
(Advocate for Complainant: Sri AKM)
VERSUS
The Branch Manager,
S.B.I. Life Insurance Limited,
1st Floor Fr Hospital Mullers Hospital
Opp. Doctors Quarters,
Kankanady, Mangalore 02
…. Opposite Party
(Advocate for the Opposite Party: Sri. KSUN)
ORDER DELIVERED BY HONBLE PRESIDENT
SMT. C.V. SHOBHA
- 1. This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service as against the opposite party claiming certain reliefs.
2. The complainant prays for the order for reliefs directing the opposite party to pay the sum of Rs. 45,000/, and to pay Rs. 25,000/ to the complainant in respect of expenses incurred and tension, mental agony and hardship suffered by the complainant, to the interest at 21% from 05.02.2012 till realization.
The brief facts of the case are as under:
That the complainant is the life insurance policy holder of the opposite party and he was obtained two D.H.C.B. insurance policies valid since 19.10.2011 and 20.10.2012 with a premium of Rs. 5,050/ and 4,160/ per year respectively from the opposite party. Hence the complainant is a consumer as defined under the Consumer Protection Act 1986.
That the complainant was admitted in Community Health Centre, Bantwal, D.K. on 05.02.2012 for the injuries and sustained fracture of his left foot and there was severe pain and swelling and that he was admitted as an inpatient from 05.02.2012 to 13.02.2012.
That the complainant was admitted in the above said hospital for 9 days which is covered the policies of insurance issued by the opposite party and he is entitled to get Rs. 3,000/ and Rs. 2,000/ per day respectively which amounts, to Rs. 45,000/ and that he had sent his claim for Daily Hospital Cash Benefit with in the stipulated period along with all relevant documents to the opposite party. But inspite of that till now the opposite party not cared to reply or settled the claim amount of Rs. 45,000/ as per the terms of the policies as referred above.
Further submitted that due to the deficiency in service of the opposite party the complainant has suffered mental agony and loss and he had suffered monetary loss also which is moderately estimated at Rs. 75,000/-. Hence the complainant was left with no option, but constrained to send the lawyers notice dated 12.05.2012 to the opposite party demanding his claim of amount of Rs. 45,000/ which was entitled by the complainant from the opposite party.
II. Further, on observation by us of the order sheet maintained in the case by this Forum, the necessary notice sent to the opposite party by RPAD with copies of the complainant. The opposite party appear through their counsel and also filed version.
Opposite Party submitted that SBI Life has not received any annexures along with the complaint. Hence, the documents which are the basis for the present complaint are not available to the opposite party to examine the same and reply properly.
The opposite party submit that the complaint is premature and hence should be dismissed without further proceedings because the opposite party should first get an intimation about the claim with the necessary requirements for it to examine the admissibility or otherwise of the claim. If the complainants are not satisfied with the decision, then he/she may seek legal remedies.
As per the email received from Third Party Administrator (TPA), E Meditek dated 14.09.2012 they had received a phone intimating the claim and they had sent an SMS to the complainant requesting him to submit claim form and other documents. A copy of the e mail dated 14.09.2012 is appended as Annexure A.
As per policy documents bearing No. 46002791804 and 46002219903, point No. 10, claims, the policy holder/nominee/legal heir or any of the life assured should intimate the claim in writing stating at least the policy number and the nature of the illness/claim. We will require the following documents copy of policy document, claim form, treating Doctor’s Certificate, Discharge Card and copy of all medical documents related to hospitalizations, any other documents as the TPA/ company may require depending on type cause of claim, identity proof of the policy holder, age proof of the Life Assured, Pan card copy of the policy holder (for online policies), Direct credit mandate of the policy holder. Any hospitalization should be intimated to us before the hospitalization in case of preplanned hospitalization or within 24 hours in case of emergency.
The opposite party will be able to decide the admissibility or otherwise of the claim only after the receipt of the above said requirements. All claims shall be subject to requirements as stipulated by the company. The company reserves the right to call for any additional information and documents required to satisfy itself as to the validity of a claim.
The opposite party SBI Life Insurance Company Ltd, here under gives its Para wise comments to the complainant filed by Shri Percy Noel Pais without prejudice to what is stated above. Opposite party No.1 SBI Life Insurance company Ltd, all the contents of the referred complaint should be treated as denied. The answering opposite party emphatically denies all that is contained in the complaint which is contrary to or inconsistent with what is stated by the opposite party No.1 herein. Unless any averment of the complaint is specifically admitted by the answering respondent herein, irrespective of whether a specific traverse is made or not and non-dealing with any particular averment may not be taken as implied admission.
That the contents of Para No.2 are accepted to the extent that the complainant was the holder of policies bearing No. 46002219903 and 46002791804. The details of the policies
Policy Number | 46002219903 | 46002791804 |
Date of commencement | 19.10.2011 | 09.11.2011 |
Premium | 5571 | 4159 |
Periodicity of Premium | Annually | Annually |
It is specifically denied that the date of commencement of the policy bearing No. 46002791804 is 20.10.2011. The date of commencement is 09.11.2011. That the contents of para No.3 are denied for want to information. That the contents of Para No.4 are accepted in the sense that TPA/E Meditek has received a phone intimating the claim. As per the terms and conditions of the policy, the claim has to be intimated in writing with relevant documents. The answering opposite party has neither received any claim intimation nor any documents to check the admissibility or otherwise of the claim as alleged. All the allegations are denied in toto.
That the contents of Para No.5 are denied. The answering opposite party has neither received any claim intimation nor any documents to check the admissibility or otherwise of the claim. The opposite party will be able to decide the admissibility or otherwise of the claim only after the receipt of the requirements. All claims shall be subject to requirements as stipulated by the company. The company reserves the right to call for any additional information and documents required to satisfy itself as to the validity of a claim. It is humbly submitted that the opposite parties reserve their right to decline the claim benefit for any other reasons as per the terms and conditions of the policy.
That the contents of Para No.6 and 7 are denied. It is specifically denied that there is deficiency in service on the part of the Answering opposite party the complainant has not suffered any mental agony and hence not eligible for any compensation, monetary loss etc. Further submitted that the admissibility or otherwise of the claim can be decided only on receipt of the aforesaid requirements. Hence the opposite party does not have any liability to pay the claim. It is denied that the complainant had suffered mental agony and hardship and is entitled for the compensation of Rs. 25,000/. The complainant is not entitled to any relief whatsoever as prayed for. The complaint is nothing but an abuse of the process of law. It is specifically submitted that the opposite party has a right to examine the admissibility or otherwise of the claim and to repudiate for any reason, as per the terms and conditions of the policy.
Further submitted that mere submission of requirements does not entitle the complainant to the claim. The opposite party may decline a claim if the claim is not genuine or the contract per se is vitiated by suppression of material facts or for any other valid reason.
Further submitted that the relief prayed for in the complaint under prayer clause of the complaint are unjust, illegal and unfair on the part of the complainant and the present complaint is frivolous, vexatious and is an abuse of the process of law. Hence it is humbly prayed that this Forum be pleased to dismiss the complaint with costs to the company. Then that on 15.11.2012 complainant (CW 1) filed evidence by way of affidavit and got marked the documents as Ex C1 to C5. And prays for it’s allow.
III. In view of the above said facts, the points now that arise for our consideration in this case are as under:
- Whether the complainant proves that, there is a deficiency of service by the opposite party?
- If so, for what quantum and from whom the complainant in entitled?
- What order?
We have considered the notes/oral arguments submitted by the learned counsel and also considered the materials that was placed before this Forum and answer the points are as follows:.
Point No. (i) and (ii): As per Affirmative
Point No. (iii): As per the final order.
REASONS
V. POINTS No. (i) and (ii): For the convenience and to avoid the repetitions of the matter, we assigned the reasons for its consideration we conclude the same together for both the points as below.
The main reason in raising dispute in the complaint against opposite party that even with regard to admission by opposite party in the case, regarding the complainant was obtained two insurance policies under mediclaim benefit and the scheme of D.H.CB (Daily Hospital Cash Benefit). Such as (1) dated 22.10.2011 by remitting the premium amount of Rs. 4,160/ for the sum assured is Rs. 2,00,000/ and (2) on dated 08.10.2011 by remitting the premium amount of Rs. 5,572/ sum assured is Rs. 3,00,000/. Accordingly, both are under a product plan/ SBI Life Hospital Cash. Under the circumstance of the case both the said policies in original produced in the case by the complainant in his evidence and got marked as Ex C1 and C2. On perusal of the same, it clearly goes to show that Joining SBI Life Family will give you access to best customer service and large range of products which caters to most of your life insurance needs this reveals that, it is the assurance put by opposite party to all the Consumers like complainant too. That has been done admittedly during the primary stage, and tackling the innocent public including like the complainant by the opposite party. In particular, such a tack ticks used by opposite party in all, for attracting into the schemes which involved in the case and collecting such a huge amount by way of the premium and issued the policy as per the Ex C1 and C2, because in the dispute arised before us that when the claim made by the complainant against the opposite party on the basis of Ex C1 and C2, by the time for one reason or the other, as best known to the opposite party, opposite party totally denied all the liability of it as per the said policies. Because, even as per Ex C1 and C2, it is the contract between there in order to discharge the liability of the opposite party is the prime motive, in the event of claim and demand arises. But in the case it was not done hence, invariably the complainant raised the dispute before us. On the ground that even as per Ex C1 and C2 clearly goes to show that at page 16 and 17 under serial No. 04 policy benefits, is very clear in serial No. 4.1 under the same 4.1.1 to 4.1.3 are very much necessary and essential, in order to conclude this case, that the opposite party is always covering the deficiency of service to the complainant throughout. Because, the said important items reads that:
4.1.1: We will pay this benefit in the event of any of the life assured being hospitals for a medical treatment for any illness/ailment/ disease or injury for a continuances period of a day or more……
4.1.2: A daily hospital cash benefit (DHCB), as referred in the policy schedule of this policy document, will be payable for each completed day of hospitalization and
4.1.3: The maximum number of days of regular hospitalization covered in a policy year will not exceed 100 days.
The above mentioned items clearly applies for both Ex C1 and C2. But with regard to claim benefit is concerned as shown in both Ex C1 and C2 at page of under the head of base plan for Vive (S) assured shown under BHCB benefit is Rs. 2,000/ and is Rs. 3,000/ respectively.
Such being so even as per the claim made by the complainant under the both Ex C1 and C2 that, admittedly the complainant took treatment at Taluk level government Hospital Bantawal, D.K. as an inpatient from 05.02.2012 at 5.00 PM till 13.02.2012 at 07.00 PM. Further, it is also case of the complainant that he sustained fracture injury on his left foot in is scooter fall on 04.02.2012, in the result he took treatment so, as per Ex C3 inpatient ship and discharge summary of the concerned. As remanded there in he took treatment as inpatient for 08 days 02.00 hours. Further, on the day only the complainant informed the fact to the opposite party even after his discharge and so also sent the documents pertaining into his claim. Later when not considered by the opposite party 1 the Ex C4, legal notice sent on 15.05.2012 and it was duly served on 17.05.2012 as per Ex C5. On those basis, it is clear that the complainant made all his efforts duly, for claiming the legal benefit of his mediclaim, which entitled under Ex C1 and C2.
In spite of it the opposite party still under total denial on the ground that they have not having any information and documents regarding the claim. To that extent, we go through the oral and documentary evidence with the pleadings of either the side. Wherein the detailed version of the opposite party as well as reply to the interrogatories and affidavit evidence of opposite party No.1 all reveals that they have in the habit of saying lie, pertaining s even to the said Ex C4 and C5, Ex C5 is a document of postal acknowledgement of the opposite party only, on the same the said Ex C4 was duly served. Such being so it is enough to conclude, even on the receipt of it and so also the information and documents pertaining to the claim of the complainant was denied by opposite party by saying a lie, even the same in their duly sweared affidavit, before this forum. It shows even the conduct of the opposite party is so, to the extent of the said lie, only with an intention to escape from its liability as per Ex C1 and C2 to the complainant. Hence, in totality it is a case of a pure deficiency in service done by opposite party to the complainant in all angle.
Further regarding the medical claim under the policy is concerned as stated above the said treatment as inpatient in the hospital by the complainant, for only a period of 8 days 2 hours. Hence it is rounded to only 08 days. Hence, as discuss above regarding the benefit, as per Ex C1 it is per day a sum of Rs. 2,000/. Accordingly the said period of 8 days is Rs. 16,000/ and as per Ex C2 it is per day a sum of Rs.3, 000/ . Accordingly the said period of 8 days is Rs. 24,000/ . In both it is Rs. 16,000/ plus Rs.24, 000/. Therefore in total under this head the complainant is entitled only for Rs. 40,000/ as per Ex C1 and C2 from the opposite party.
Hence, we hold that, both the points held in the affirmative. Since, it is so, it was happened due to the fault and deficiency of opposite party till the day and caused harassment, suffering and mental agony, the opposite party is also liable to pay the interest at the rate of 10% p.a on the said entire sum of Rs. 40,000/ from the date of his discharge from the hospital dated 13.02.2012 till the date of realization in fall. As it was also happened under the violation of fair trade practice. In this regard the complainant also entitled for a compensation of Rs. 10,000/ and also Rs. 3,000/ towards cost and litigation expenses incurred by the complainant so far.
POINTS No. (iii): As per the order below.
ORDER
The complainant is allowed in part. The opposite party is responsible and liable to pay for a sum of Rs. 40,000/ (Rupees Forty thousand only) with accrued interest at the rate of 10% p.a from 03.02.2012 till realization. Further opposite party is also liable to pay Rs. 10,000/ (Rupees Ten thousand only) towards compensation and Rs. 3,000/ (Rupees Three thousand only) towards cost and litigation expenses incurred by the complainant, payment shall be made within 30 days from the date of receipt of copy of this order.
Copy of this order as per statutory requirements, be forwarded to the parties and therefore the file shall be consigned to record room.
(1 to 8 pages dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 7th day of October 2016)
MEMBER PRESIDENT
(SMT. LAVANYA M.RAI) (SMT. C.V.SHOBHA)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore. Mangalore.
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW 1: Mr. Percy Noel Pais,
Documents marked on behalf of the Complainant:
Ex.C1: 10.11.2011: Original Policy of Rs. 4159/.
Ex.C2: 29.10.2011: Original Policy of Rs. 5571/.
Ex.C3: 13.02.2012: Original Discharge Summery issued by Primary Health Center Bantwal.
Ex.C4: 12.05.2012: Office copy of the lawyer s notice.
Ex.C5: 18.05.2012: Original Postal Acknowledgement.
Witnesses examined on behalf of the Opposite Party:
RW1: Mr.V.Srinivas.
Documents marked on behalf of the Opposite Party:
Nil
Dated: 07-10-2016 PRESIDENT
