Hon’ble Mrs. Rumpa Mandal, Member.
The non-payment of claim of group mediclaim has dragged the Complainant, before this Commission for redressal of her grievance. The O.P. No.1 is the Branch Manager of SBI General Insurance Company Ltd., Siliguri and O.P. No.2 is the Chief Executive Officer of SBI General Insurance Company Ltd., O.P. No.3 is the Director of the said TPA of SBI General Insurance Company Ltd., at Bangalore and O.P. No.4 is the Branch Manager of Medi Assist Insurance TPA Pvt. Ltd., at Kolkata. Being allured by the advertisement Published and displayed at various places, Complainant Smt. Chandana Barman took up group Health Insurance policy of SBI General Insurance Company Ltd., being policy No.10430307. As per proposal of O.P. No.1 & 2 the Complainant paid yearly premium of Rs.6,200/- against such policy. The Complainant was initially taken for the period 01.08.2018 to midnight of 31.07.2019 for her family consisting of three persons viz. herself Chandana Barman, her husband Ajoy Sarkar and her daughter Ayushi Sarkar and later on the same policy was renewed and was valid through the period 01.08.2019 to 31.07.2020. Against such renewed policy all the insured members viz. Chandana Barman, Ajoy Sarkar and Ayushi Sarkar were also issued separate cards by the TPA Medi Assist Insurance TPA Pvt. Ltd effective from 01.08.2019. The O.P. No.1 assured that under the policy, throughout the policy period, the Complainant would get medical expenses incurred by her for medical treatment on account of illness and/ or accident on the advice of a Medical Practitioner. During subsistence of the said policy on 10.08.2019 due to serious illness of the Complainant was taken firstly to Subham Hospital emergency as she detected with hypertension, forthwith she was taken to Dr. P.K. Saha Hospital Pvt. Ltd., Cooch Behar wherein she was admitted for her treatment and she incurred a sum of Rs.43,820/- towards her treatment. The Complainant remained in the said nursing home on and from 10.08.2019 till 14.08.2019 which was intimated to the O.Ps for formality of the group mediclaim and on the basis of her request one claim being No.99090012 has been raised by the O.Ps. Such claim being No.99090012 the O.Ps sought for required documents. In spite of submitting all the relevant documents as asked by the O.Ps, O.Ps up till now did not settle the valid claim of the Complainant. Therefore, Complainant furnished a certificate from her attending doctor vide certificate dated 14.10.2019 and also duly informed the Branch Manager, SBI General Insurance Company Ltd., Siliguri vide her letter dated 15.10.2019. She has no more documents with her to submit before them. After receiving her reply the same letter sent to the Medi Assist Insurance TPA Pvt. Ltd., (O.P. No.3 & 4) for payment of the said amount. Complainant had no previous history of any ailment and on 10.08.2019 the Complainant suddenly became ill. Having found no other alternative, Complainant served notice to the O.P. No.1 to 4 through his Ld. Advocate, Sri Kumerdip Mukherjee, Cooch Behar on 26.12.2019 through speed post with A/D. On 04.01.2020 the SBI General Insurance Company Ltd. through their Ld. Advocate Smt. Nidhe Singha, New Delhi replied evasively reiterating the same to provide prescriptions/ treatment papers related to the disease prior to the hospitalization of the Complainant which also yielded nothing causing the Complainant to face hardship and suffering from mental pain and agony. Thus by such wilful act of omission and Commission in non settling of the aforesaid claim amount of the Complainant, the O.Ps have caused a deficiency in service and unfair trade practice and such act of the O.Ps made them liable to be prosecuted under the Consumer Protection Act. The cause of action of the present case arose on 01.08.2018 and on subsequent dates on 10.08.2019 and it is still continuing. The Complainant therefore prayed for an award for a sum of Rs.43,820/- which was wrongly and illegally deducted from the account of the Complainant and pay sum of Rs. 1 Lakh for mental pain and agony and pay a sum of Rs. 1 Lakh for unfair trade practice and Rs.20,000/- for cost of proceeding in favour him.
Notice were served upon the O.Ps. Despite service of the notice the O.P. No.3 & 4 did not turned up before this Commission to contest the case. So, the case was decided to be heard ex-parte by the Commission vide its Order No.23 dated 17.08.2022. The O.P. No.1 & 2 contested the case by filing written version, evidence on affidavit and advanced his oral argument. The O.P. No.1 & 2 in their defence plea stated that O.P. No.1 & 2 has invoked the jurisdiction of the Hon’ble Commission. These O.Ps processed the claim of the Complainant only after due perusal of all documents received and within the precincts of terms and conditions of the policy. So, the complaint deserves to be dismissed in limini for want of cause of action. Complainant has failed to produce any substantial evidence or specific averments worth its salt to prove the claim admissible under the terms and conditions of the insurance policy. So, the instant complaint is liable to be dismissed at the threshold. The O.P. No.1 & 2 clearly stated in their written version that Smt. Chandana Barman is the insured and the policy holder of the Floater Group Health Insurance policy No. 1043030701 for the period between August, 01, 2019 and July, 31, 2020. The said policy had been continuing for the second year, the previous policy (Being No. 10430307) had been for the period of August 01, 2018 and July 31, 2019 (Annexure- A & B). Complainant was admitted to Dr. P.K. Saha Hospital Pvt. Ltd., Cooch Behar on August 10, 2019 on account of hypertrophy of uterus (gynaecological disorders). The insured was thereafter discharged from the said hospital on August 14, 2019. The claim was intimated to the TPA (Third Party Administrator) Medi Assist Insurance TPA Pvt. Ltd., i.e. O.P. No.3 & 4 on September 04, 2019 and the letter was issued by the concerned TPA (O.P. No.3 & 4) to the Complainant for the submission of certain documents for proper evaluation of the reported claim (Annexure-C). The O.P. No.1 & 2 sent two reminder letters to the Complainant dated 17.09.19 and 27.09.19 after not receiving any documents from the TPA (O.P. No.3 & 4) (Annexure-D). Thereafter Chandana Barman submitted certain documents to the O.P. No.3 & 4 to evaluate the claim based on the documents submitted certain documents were not submitted and based on the same findings the O.P. No.3 & 4 had sent another requirement letter dated 05.10.19 followed by four requirement letters dated 16.10.19, 21.10.19, 29.10.19 and 09.11.19 (Annexure-E). The Complainant promoted by the said letters again submitted few more documents to the O.P. No.3 & 4. On account of which the claim was re-evaluated again certain documents necessary for proper claim evaluation was not submitted on account of which the O.P. No.3 & 4 sent another query/ requirement letter to the Complainant on November 15, 2019 (Annexure-F). Not receiving any response from the Complainant/ insured O.P. No.3 & 4 sent three reminder letters on 23.11.2019, 04.12.2019 and 15.12.2019 (Annexure-G). The Complainant did not submit the requisite documents within the due time frame provided by the O.P. No.3 & 4 despite several follow-ups which had promoted the O.P. No.1 & 2 to close the claim vide closure dated 02.01.2020 (Annexure-H).
As the claimant did not comply with the order of the TPA so the claim remained unsettled. So, the O.Ps acted proactively in the whole matter so the question of deficiency in service or unfair trade practice on the parts of the O.Ps does not arise. So, the instant case is liable to be dismissed for these O.Ps.
Perused the case record and documents filed by both the parties. Heard, the arguments advanced by the Ld. Advocates of both the parties at length. The following point need to be discussed for adjudicating the case.
Points for Determination
- Is the case maintainable in its present form and prayer?
- Is there any deficiency in service on the part of the O.Ps?
- Is the Complainant is entitled to get any relief?
Decision with reasons
Point No.1.
The Complainant purchased the mediclaim policy i.e. Floater Group Health Insurance policy being No.10430307 for her family consisting of three persons viz. herself Chandana Barman her spouse Sri Ajoy Sarkar and her daughter Ayushi Sarkar for which a sum of Rs.6,200/- as a premium for the year 2019-2020 had been deducted from his account by the O.P. No.1 & 2. The abovesaid premium was deposited to the S.B.I General Insurance who later engaged Medi Assist Insurance TPA Pvt. Ltd., as third party administrator or for the same and at the time of claim insurance, the same was submitted to the O.P. No.1 & 2 who later forwarded it to the O.P. No. 3 & 4. Thus, it is clear from the above facts that there is a Consumer service provider relation among the parties.
The O.Ps raise the point that the case has been filed under section 12 of C.P. Act, 1986. In this respect the order has been passed vide its Order No.23 dated 17.08.2022.
The case is maintainable in its present form and prayer under C.P. Act, 1986. So, the Complainant rightly filed the present case under the C.P. Act, 1986.
Therefore, Point No.1 is decided in favour of the Complainant.
Point Nos. 2 & 3.
Both the point Nos. 2 & 3 are closely related. Therefore, in deciding these are taken up together for discussion.
From the documents and evidence, it is crystal clear that the Complainant paid premium. This is established through his supported documents and O.P. No.1 & 2 admitted in their written version and evidence in chief.
The Complainant in order to substantiate the case proved the following documents.
- BHT, Treatment Sheets, Discharge Certificate etc. of Dr. P.K. Saha Hospital Pvt. Ltd. (Annexure- A1 to A11).
- Health card issued by S.B.I General Insurance and Medi Assist Insurance TPA Pvt. Ltd. (Annexure-B).
- Legal notice dated 26.12.2019 (Annexure-C1 to C5).
- Copy of speed post receipts and postal tracking report of consignment, both four in number (Annexure-C6 to C10).
- Payment acknowledgment of S.B.I. General (Annexure-D).
- Certificate from Dr. Subhas Chandra Saha (Annexure-E).
- Reply to legal notice dated 04.01.2020 (Annexure-F to F6)
- Request for information/ document of Medi Assist (Annexure-G to G5).
- Letter dated 15.01.2019 by Complainant (Annexure-H).
After perusing the said documents and the evidence on affidavit, it is crystal clear that the Complainant submitted the documents to the OP for realisation of insurance claim. It is proved according to the legal notice dated 26.12.2019 being the Annexures- C1 to C5 and Complainant sent letter to the OP dated 15.10.2019 being Annexure-H.The OP could not discard the specific evidence. Moreover, the Complainant during the trial of the case filed the copy of the said document. It signifies that after submitting the original documents the Complainant kept the copy of the said documents with her. There is no cross-examination discard the said particular evidence of the Complainant.
The O.Ps i.e. Insurance Company took the defence plea that the Complainant has suppressed her previous disease.
Ld. Advocate for the Complainant rightly argued that it was not within the knowledge of the Complainant that she had any previous disease. Accordingly, she had never medically treated before any doctor save and except the current ailment. So, the documents called for by the O.Ps regarding her previous ailment could not be supplied by the Complainant.
That apart at the time of registering the insurance the O.Ps medically checked up the Complainant-insured after setting up the medical board. So, the defence plea that the Complainant had pre-disease could not be proved by the O.Ps.
The case law referred by the Complainant in Civil Appeal No. 2709-2770 of 2023 SC Om Prakash Ahuya Vs Reliance General Insurance Company Ltd., is relied on in this case.
Accordingly, the Complainant has fulfilled all the conditions for getting the insurance claim. But refusal to the said claim by repudiating the claim of the Complainant caused mental pain and agony.
Thus, having assessed the entire evidence in the case record and on the basis of aforesaid discussion, the Commission finds that the Complainant successfully proved the case.
So, from the aforesaid discussion it is crystal clear that Complainant left no stone unturned to get her claim of group mediclaim policy at the earliest as she was in urgent need of money for her treatment. But she could not get her claim for O.Ps till date. Therefore, the Commission opines that there is gross unfair trade practice on the part of the O.Ps. So, the Complainant is entitled to get relief for their gross unfair trade practice and mental pain and agony.
Hence, the Point Nos. 2 & 3 are decided in favour of the Complainant.
In the result the instant case succeeds on contest.
Hence, it is
Ordered
That the complaint case No. CC/16/2020 be and the same is allowed on contest with cost.
So, the O.P. No.1, 2, 3 & 4 are directed to pay mediclaim amount of Rs.43,820/- to the Complainant jointly and/ or severally. They are also directed to pay Rs.30,000/- for mental pain and agony and Rs.30,000/- towards unfair trade practice and Rs.5,000/- towards cost of proceeding to the Complainant jointly and/or severally within 30(thirty) days from the date of this Order failing which the total sum of Rs.1,08,820/- (Rupees One Lakh Eight Thousand Eight Hundred Twenty only) will carry an interest @ 6% per annum till its realisation.
D.A. to note in the trial Register.
Let a plain copy of this Order be supplied to the concerned party by hand/by Registered Post with A/D forthwith, free of cost, for information & necessary action as per rule.
The copy of the Final Order is also available on www.confonet.nic.in.
Dictated and corrected by me.
