DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: BHADRAK
Dated the 29th day of January, 2021
C.D Case No. 25 of 2019
1. Shri Basanta Kumar Mallick, Presiding Member
2. Afsara Begum, Member
1. Mamata Nayak
W/o Sujit Kumar Nayak
At/Po: Gelpur,
Ps: Bhadrak (R),
Dist: Bhadrak, Odisha
2. Sujit Kumar Nayak
S/o Late Rabi Narayan Nayak
At/Po: Gelpur,
Ps: Bhadrak (R),
Dist: Bhadrak, Odisha
……………………. Complainant
(Versus)
1. The Chief Manager, State Bank of India, Bhadrak Main Branch
At: Kacheri Bazar,
Po/Ps/Dist: Bhadrak, Pin- 756100
2. S.B.I General Insurance Company Ltd.
Padmalaya Complex, 3rd Floor,
Opposite Bus Stand, At/Po: Sahadevkhunta,
Dist: Balasore, Odisha 756001
3. Medicare TPA Services (I) Pvt. Ltd.
At: Paul Mansions, 6, Bishop Lefroy Road
Kolkata- 700020
4. SBI General Insurance Company Ltd.
Corporate & Registered Office
At: Junction of Western Express Highway & Andheri Kurla Road, Andheri East, Mumbai- 400069
5. MEDICARE, Thapar House (7th, 8th, 9th Floor)
25 Brabourne Road, Kolkata- 700001
……………………..Opp. Parties
Counsel For Complainant: Santosh Kumar Nayak, Adv & Others
Counsel For the OP No. 1: Jaminikanta Nayak, Adv
Counsel For the OP No. 2 & 4: P. Kanungo, Adv & Others
Counsel For the OP No. 3 & 5: Set Ex-parte
Date of hearing: 06.01.2020
Date of order: 29.01.2021
BASANTA KUMAR MALLICK, PRESIDING MEMBER
This dispute arises out of a complaint filed by the complainant alleging deficiency of service and unfair trade practice against the O.Ps.
The facts of the case as narrated in the complaint are to the effect that the complainant No. 2 is a savings bank account holder under OP No. 1 was transacting the account regularly. OP No. 1 motivated the complainant No. 2 to take up a health insurance policy under the SBI General Insurance Company Ltd. and narrated in details about the benefits of the said insurance scheme which was very much alluring. The complainant No. 2 agreed to the proposal of OP No. 1 and taken up Health Insurance Policy for cashless hospitalization in TPA Network Hospitals in the name of his wife (the complainant) on payment of required premium by way of debiting his SB account and accordingly, on the advice of OP No. 1, issued a standing instruction authorizing OP No. 1 to debit the account on the due dates for renewal of said policy as and when necessary to keep the policy alive. The said Health Insurance Policy was intended to cover the spouse and their son and daughter. From the date of opening of policy in the year 2014, OP No. 1 has been debiting the SB account of complainant No. 2 for payment of insurance premium continuously for more than four years. Initially the policy bearing No. 000000000 1886827 having member ID SBIG2282351 was issued commencing from 27.06.2014. It was the responsibility of OP No. 1 to deduct the insurance premium from the SB account of complainant No. 2, but unfortunately in the year 2015 the policy number and member ID was changed to 0000000003100380 and member ID- SBIG4500254 which is different from the first insurance policy even though OP No. 1 has been debiting the SB account of complainant No. 2 matching the amount of premium for renewal of the policy in every year. During the continuance of aforesaid Health Insurance Policy, the complainant No. 1 suffered from cholelithiasis and was admitted at KAR CLINIC & HOSPITALS (P) Ltd. Bhubaneswar from 09.06.2016 to 11.06.2016 and under gone surgery. For payment of the treatment cost, the complainant No. 2 exhibited the cashless hospitalization card to the hospital authorities which was not accepted by them and demanded for payment of cash. As the treatment was going on, under such unavoidable situation the complainant availed hand borrowings from his local friends to meet the medical expenses and other costs incurred during their stay in Bhubaneswar. After being discharged from KAR CLINIC the complainants staked claim with OP No. 1 & 2 along with required documents and relevant papers pertaining to the treatment in the said hospital. But the O.Ps refuted to settle the claim because of break and discontinuation of said Health Insurance Policy which is not a mistake of complainant as he has issued standing instruction to OP No. 1 for deduction of required premium from his SB account bearing No. 33053767369 maintained with OP No. 1. Such act of the O.Ps not deducting the amount in time, amounts to deficiency of service and unfair trade practice.
O.Ps objected the claim of the complainant and contested the case. OP No. 1, in submitting written version, has stated that the complaint filed against the answering OP N0. 1 is not sustainable and liable to be dismissed as the said OP has no role to play for settlement of claim and OP No. 1 is not the insurer of the Health Insurance of the complainant. The role of OP No. 1 is limited to the extent of transmitting the insurance premium by debiting complainant’s SB account under the instruction of the complainant. Hence impleading the answering OP is absolutely unnecessary. OP No. 2 & 4 in submitting written version have raised objection to the effect that the complainant is not a consumer within the meaning of CP Act and is not coming within the scope and purview of the policy conditions issued by the insurer. It is also further mentioned that the policy bearing No. 0000000003100380 was issued covering the risk period from 22.07.2015 to dt. 21.07.2016, subject to terms and condition. It is further raised that the insure was treated at Kar Clinic and Hospital Pvt. Ltd. for the period from 09.06.2016 to 11.06.2017 for cholelithiasis and therefore laparoscopic cholecystectomi was done as per record the insured was hospitalized for treatment on 09.06.2016 where as the policy was commenced from 22.07.2015 and thereby it is ascertained that the said policy was in its first year operation. According to the terms and condition of the policy the treatment expenses incurred during first year of the policy cannot be settled. Therefore the claim raised by the complainant for hospitalization falls beyond purview of the policy and as such the same is not payable. OP No. 3 & 5 did not appear before the Commission nor submitted any written version for which both the O.Ps were set ex-parte.
The contention of the complainant with regards to settlement of the claim is to the effect that under the instigation of OP No. 1 the complainant initiated the policy on 27.06.2014 and issued standing instruction to OP No. 1 for deduction of subsequent renewal premiums from the SB account No. 33053767369 held with the branch of OP No. 1. But OP No. 1 has grossly neglected in deducting the renewal insurance premium on or before the due date of renewal regularly as a result of which the policy could not continue as per the policy condition. The due date for renewal of the policy was 22.06.2015 whereas due to negligence of OP No. 1 the policy has been renewed on 22.07.2015 instated of 22.06.2015 resulting discontinuation of policy as claimed by the O.Ps. The settled provision of law is that for the mistake of insurer and the banker the insured should not suffer. Had the policy renewed in due time, the complainant could have got the claim instantly when was under the treatment under the treatment. Such act of the O.Ps amounts to deficiency of service and it is believed that the O.Ps have intentionally and deliberately done the mischief to repudiate the claim of the complainant. It is also a fact that there was sufficient balance in the SB account of complainant No. 2 as against the required premium of Rs 7,400/-. Therefore it is crystal clear that the OP No. 1 has, in collusion with OP No. 2, intentionally and deliberately not deducted the renewal premium amount from the SB account as mentioned above for which OP No. 1, 2 & 4 are liable to pay the claim to the complainants.
Heard both the parties and perused materials on record. It is evident that there was sufficient balance in the SB account of the complainants maintained with OP No. 1 bank which could have been deducted in time but OP No. 1 has grossly neglected in discharging it’s legitimate duties as a result of which the complainants suffered from mental agony and harassment and also from financial front. Hence it is ordered;
ORDER
In the result, the complaint be and the same is allowed against the O.Ps No. 1, 2 & 4 with cost and compensation. The said O.Ps are directed to pay the claim amount as raised in the claim of Rs 1,00,900/- together with interest @ 7% P.A on quarterly rests from the date of staking the claim. Further the aforementioned O.Ps are directed to pay compensation of Rs 20,000/- for mental agony and harassment and Rs 10,000/- towards cost of litigation. This order must be complied within 30 days from the date of receipt of this order failing which additional interest on the claim amount @ 7% shall be charged from the date of order till the date of payment.
This order is pronounced in the open Forum on this day of 29th January, 2021 under my hand and seal of the Forum.
