Haryana

Panchkula

CC/94/2019

MRS.SWAMI PIARI. - Complainant(s)

Versus

THE DEPUTY GENERAL MANAGER,STATE BANK OF INDIA. - Opp.Party(s)

COMPLAINANT IN PERSON

05 Mar 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PANCHKULA.

 

                                   

Complaint Case No.	:	94 of 2019
Date of Institution	:	07.02.2019
Date of Decision	:	05.03.2021

 

 

 

 

 

Mrs. Swami Piari aged 73 aged wife of late Sh.O.P.Vashisht resident of House No.407, Sector-16, Panchkula, Tehsil and District Panchkula(Haryana)

                                                                                                                                                                                               ….Complainant

Versus

1. State Bank of India, Zonal Office, Sector-5, Panchkula Tehsil and District Panchkula(Haryana) through its Deputy General Manager, Zonal Office, Panchkula.

2.  Medi Assist India TPA Pvt. Ltd. #8B, TEJ Building, 2^nd Floor, Bahadur Shah Zafar Marg, Next to Times of India, Delhi-110002 through the C.E.O. of TPA.

3.  United India Insurance Company Limited, Divisional Office No.8, 133, Jahangir Building, First Floor, M.G.Road, Fort, Mumbai-400023. Through its Chairman-cum-Managing Director.

                                                                                   ….Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Before:       Sh.Satpal, President.   

                  Dr.Pawan Kumar Saini, Member.

                  Dr.Sushma Garg, Member.

 

 

Present:     Complainant in person alongwith Sh.Swarn Singh, Advocate.

Sh. Abhineet Taneja, Advocate for the OP No.1.

                  Ops No.2 already ex-parte vide order dated 29.03.2019.

Sh. Varun Katyal, Advocate for OP No.3.

         

                                                              Order

(SATPAL, president)

 1.     The complainant has filed this complaint with the averments that the husband of the complainant namely late Sh. O.P.Vashisht, was a retired Pensioner of State of India who opted of the SBI Retired Employees Medical Benefit Scheme-II(Modified) policy for retiree officers-Policy #120/200/28/17/P1/0451213 taken by SBI, Policy Holder is State Bank of India Policy-A-Service, Primary Beneficiary: Late Sh.O.P.Vashisht claimant. MAID:5023620173 for which required consideration in the form of money i.e. Insurance Premium had been paid at the time of retirement as per scheme of the Bank. The OP No.1 is Medi Claim policy holder for retiree officers. The C.E.O. Medi Assist India TPA Pvt. Ltd is TPA(Third Party Administrative)- a Medi claims settlement agency on one platform engaged in the business of managing the settlement of claims under the Medi Claim Policy for SBI Retiree officers by the United India Insurance Company Limited, the insurer  of the SBI. All Medi claims, hospitalization bills are enrooted through the OP No.1, to the TPA for settlement of such claims. The OP No.3 is insurer of the Bank who has insured all retired personnel of the bank vide the Mediclaim policy as per Health Insurance Policy for retiree officers of SBI. In this regard, bank has issued Pass book-cum-Identity Cards to all retired employees of the Bank for their Medical Benefits. The husband of the complainant namely late Sh. O.P.Vashisht fell ill and was admitted in Alchemist Hospitals Ltd., Panchkula but realizing the seriousness of the patient there, complainant decided to shift to Fortis Hospital S.A.S. Nagar, Mohali. Late Sh. O.P.Vashisht was admitted by the Fortis Hospital in emergency on 29.10.2017 at 14.51 PM after receiving advance payment of Rs.20,000/- vide receipt no.1002/17/DPtn/-0006736, dated 29.10.2017. Thereafter, the Hospital started treatment immediately in emergency while keeping the patient under observation. Seeing the deteriorated situation of the patient, hospital demanded another advance payment of Rs. 50,000/- as the doctors decided to put the patient on Ventilation for better recovery. Somehow, advance payment of Rs.50,000/- was immediately arranged and deposited vide receipt no.1002/17/DPtn/0007206, dated 29.10.2017. She had borrowed cash from the relatives and deposited Rs.40,000/- and Rs.60,000/- in the difficult situations vide receipt nos. 1002/17/DPtn/ 0007437 dated 01.11.2017 & 1002/17/DPtn/0007671 dated 02.11.2017. Situation of the husband of complainant late Sh. O.P.Vashisht deteriorated further and on 03.11.2017 the patient breathed his last. To take the dead body of the beloved from the hospital, the complainant had to arrange another cash payment of Rs.54,517/- in full and final payment of the hospital which was deposited vide receipt no.1002/17/DPtn/0007742 dated 03.11.2017. The complainant vide letter dated 03.04.2018 addressed to OP No.1, submitted all claim papers of huge medical expenses bill amounting to Rs.2,24,517/- incurred in the Fortis Hospital for early reimbursement of expenses. As required reimbursement claim completing all formalities was logged through OP No.1 which further forwarded the claim papers to the C.E.O. Medi Assist India TPA Pvt. Ltd. for early reimbursement of the medical expenses. The TPA-Medi Assist India TPA Pvt. Ltd. Vide letter dated 03.04.2018 confirmed the receipt of the claim papers and allotted claim no. Our Reference: CCN#15902365 under policy#120/200/28/17/-P1/04512131-policy Holder is State Bank of India-Policy-A- Service. Primary Beneficiary: late Sh. O.P.Vashisht claimant. TPA in their letter further asked for the Consultation bill/pre numbered cash receipts of Rs.2,24,517/-against final bill. As the complainant was in the traumatic situation which arose because of the sudden demise of the Patient Late Sh.O.P.Vashisht while in the ICU, the original Consultation bill/ pre numbered cash receipt of Rs.2,24,517/- in hectic transaction were lost/ misplaced somewhere there in the hospital. However, to comply with TPA’s requirements as required in their letter dated 03.04.2018, certified copies of all the bills/cash receipts duly certified by the Fortis hospital, Mohali itself complete in every respect, were submitted vide letter dated 24.03.2018 to TPA through OP No.1 through speed post. Despite repeated follow up claim of huge medical expenses has not been settled/paid till date. She has also served upon the Ops a legal notice dated 09.06.2018 and 06.07.2018 through counsel for settlement of the medical expenses in reply to which Team Medi Assist through e-mail dated 06.07.2018 replied that the matter is under consideration but never reimbursed the claim. Due to the act and conduct of the Ops, the complainant has suffered a huge financial loss, mental agony and harassment. Hence, the present complaint.

2.               Upon notice, OP  No.1 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable being frivolous and baseless; the complainant does not falls under the definition of the consumer; no locus standi; the complaint is bad for mis-joinder of necessary parties; no cause of action, the complainant has not come with clean hands. On merits, it is stated that the OP bank is engaged in the business of banking. Being the employee oriented organization, the OP Bank entered into an agreement with OP No.3 so that the retired employees of the bank and their families may not face any difficulty at the time adversity and may get medical treatment without any financial difficulty. Further, in order to expedite the process of claim, the insurance company i.e. OP No.3 has a tie-up with the OP No.2(settlement agency) so that the claims can be settled in a hassle free manner. The Ops No.2 & 3 are entirely the different and separate bodies and their functioning is also entirely different and independent from the functioning of Ops No.1. The OP No.1 has no control over the functioning of Ops no.2 & 3. The OP No.2 is a Private Limited Company and OP No.3 is a Public Limited Company. As per the procedure, the claim of the retired employees or their family members is given to the OP No.2(agency of OP No.3) which further forwards and pursues the matter with OP No.3 for settlement of the claim. In case of any query, the OP No.2 deals with the insured and insurer directly and the OP No.1 has no role to play in the said correspondence. Further, as per the scheme opted by the husband of the complainant and after the initial contribution(one time payment) of Rs.7,764/- he or his family members were entitled to the medical benefit of Rs.2.00 lakhs. The said benefit can be availed by them only one in a lifetime. It is pertinent to mention that out of the total sum of Rs.2.00 lakhs, the sum of Rs.59,186/- has already been paid and as of now, she is eligible for the sum of Rs.1,40,814/-. It is further submitted that as per the procedure, when the complainant gave her request to the OP No.1, her request was forwarded to the OP No.2 for its necessary action. Although, the answering OP had no role to play in this matter.

                  Notice was issued to the OP No.2 through registered post vide registered post No.CH036309757IN on 25.02.2019 to OP No.2 which was not received back either served or unserved despite the expiry of 30 days from the issuance of notices to OP No.2; hence, it was deemed to be served and thus, due to non appearance of Op No.2, he was proceeded ex-parte by this Forum vide its order dated 29.03.2019.

                  Upon notice, OP No.3 appeared through counsel and filed written statement raising preliminary objections qua complaint is not maintainable being frivolous and baseless; no jurisdiction; no cause of action. On merits, it is stated that the perusal of the notice (Annexure P-21 and P-22) makes it clear that the same has never been sent to the OP No.3. The complainant should have contacted the grievance cell of the OP No.3 or Insurance Ombudsman. Thus, there is no deficiency in service on the part of the OP and prayed for dismissal of the present complaint.

3.               Replication to the written statement of the OPs No.1 & 3 were filed by the complainant reiterating the contents of the complaint while controverting the contentions of the OPs No.1 & 3.

4.               To prove her case, the complainant has tendered affidavit as Annexure C/A along with documents Annexure C-1 to C-25 in evidence and closed the evidence by making a separate statement. On the other hand, the ld. counsel for OP No.1 has tendered affidavit Annexure R-1/A alongwith documents Annexure R-1/1 & R-1/2 and closed the evidence. The ld. counsel for the OP No.3 has tendered affidavit Annexure R3/A and closed the evidence.

5.               We have heard learned counsels for the complainant as well as OP No.1 and OP No.3 and also gone through the entire record available on record including the written arguments filed by the learned counsels for the complainant, OP No.1 and OP No.3, minutely and carefully.

6.               It is evident that the complainant’s husband namely Sh. O.P.Vashisht being a retiree official/officer of OP No.1 i.e. SBI opted to avail the benefits under the SBI Retired Employees Medical Benefit Scheme-II(Modified) Policy by making one time contribution of Rs.7,764/-. As per pass book cum identity card (Annexure C-24), he was allotted the membership no.110100354. It is an admitted fact that the said Sh. O.P.Vashisht or his family members were entitled to the medical benefits of Rs.2,00,000/- under the said policy. The case of the complainant is that her husband late Sh.O.P.Vashisht, remained hospitalized in the Fortis Hospital in Mohali w.e.f. 29.10.2017 and he breathed his last on 03.11.2017 and the complainant incurred the expenses of Rs.2,24,517/- during the treatment and aforesaid hospitalization of her husband in the hospital. The grievances of the complainant are that the Ops have not reimbursed the aforesaid despite the fact that she had lodged the complaint with OP No.1 alongwith necessary documents including medical bills, discharge summary etc. death certificate, treatment record on Fortis hospital etc. It is contended that all the necessary papers/documents were handed over by the OP No.1 to Sh.Naman Handa an official on behalf of the Medi Assist on 03.04.2018 as acknowledged by him vide Annexure C-7 & Annexure C-8. It is contended that the OP No.2 insisted upon the submissions of  original consultation bill/pre numbered cash receipt of Rs. 2,24,517/- against the final bill. In this regard, it is contended that pre-numbered cash receipt/bill duly stamped, signed and certified by Fortis hospital had been delivered to CRM executive Sh.Naman Handa. It is further contended that the complainant pursue the matter with OP No.2, through various e-mails conversation followed by legal notice sent vide dated 09.06.2018 (Annexure C-21 & Annexure C-22). However, the OP No.2 expressed his inability to process the claim for want of original bill vide e-mail (Annexure C-20) dated 05 July,2018.

7.               The OP No.1 while denying its liability to reimburse the claim amount has admitted that it is a master policy holder of the insurance policy issued by the OP No.3 to late Sh.O.P.Vashisht. It is/its retiree was beneficiary under the said scheme. As per the scheme opted by the husband of the complainant and after the initial contribution (one time payment) of Rs.7,764/- he or his family members were entitled to the medical benefit of Rs.2.00 lakhs. The said benefit can be availed by them only once in lifetime. Further, stated that out of the total sum of Rs.2.00lakhs, the sum of Rs.59,186/- has already been paid and as of now, she is eligible for the sum of Rs.1,40,814/- only. A copy of the statement of accounts showing the payment of Rs.59,186/- is on record as per Annexure, OP-1/1. 

It is further contended that the OP No.1 has well performed its duty in the matter by duly forwarding the papers/documents etc., as received from the complainant, to CRM Executive of OP No.2. It is strongly contended that there is no lapse and deficiency on the part of the OP No.1.

8.               The OP No.2 did not appear to contest the claim of the complainant and preferred to be proceeded ex-parte, for which adverse inference is liable to be drawn against him. The non-appearance of the OP No.2 despite notice shows that he has nothing to say in his defence or against the allegations made by the complainant. Therefore, the assertions made by the complainant go unrebutted and uncontroverted.

9.               The OP No.3 i.e. United India Insurance Company Limited, who had issued the master insurance policy insuring the various retirees/employees has resisted the complaint on various grounds, which  may be mentioned as under:-

1. That the Commission lacks territorial jurisdiction.
2. That the complainant does not falls under the category of consumer.
3. That the claim has been repudiated by OP No.2 and thus, the complaint is not maintainable against it.

We take up the above objections for discussion as under:-

1. The first objection regarding territorial jurisdiction is rejected in view of the fact that the OP No.1 is the master policy holder whose office is located in the territorial jurisdiction of this Commission. Further, various correspondence made by the complainant regarding lodging of the claim in the office of OP No.1 clearly negates the contention of the OP No.3.
2. The second objection disputing the status of the complainant as consumer is rejected in view of the fact that the complainant including her husband, namely, Late Sh. O.P. Vashisht  is entitled to medical benefit of Rs.2,00,000/- vide master policy issued by OP No.3 in favour of OP No.1.  Admittedly, Late Sh.O.P.Vashisht was a member vide no. 110100354 of the insurance policy.
3. The third ground also deserves rejection in view of the fact that claim has not been repudiated so far as alleged. The OP No.2 has stopped the processing of the claim for want of original medical bills etc.

10.             As mentioned above, the OP No.2 has been proceeded ex-parte and thus, we have no version in the shape of reply or its written statement. However, e-mails correspondence between it and the complainant is available on record as Annexure C-11 to C-20 which clearly point out that it has stopped the process of the claim for want of original consultation bill/pre numbered cash receipt. The receipt of claim papers from the complainant is not disputed. In this regard, Sh.Naman Handa its CRM Executive has clearly acknowledged about the receipt of documents vide Annexure C-7 & Annexure C-8. The OP No.2 further confirmed the receipt of claim vide its letter (Annexure C-8(Colly)) which is for the sake of convenience and clarity, the same may be re-produced as under:-

 We confirm the receipt of your claim as per the reference given above. On scrutiny of the documents submitted by you, the following documents/ information would be required for further processing of your claim. We request you to furnish the following at your earliest convenience:-

SI No.	Documents Required
1.	Bills Related .Consultation bill/pre numbered cash receipt-(of Rs.224517/- against Final Bill(original receipts are needed)

 

However, the OP No.2 desired the Pre-numbered cash receipt in original vide its e-mail dated 24.05.2018(Annexure C-14) and upon the failure of the complainant to furnish the same stopped the processing of the claim and informed the complainant vide e-mail dated 05.07.2018 (Annexure C-20) as under:-

Dear Sir/Madam,

Thank you for writing to Medi Assist.

We regret to inform you that we are unable to process the claim in the absence of required documents. As per insurer’s instructions we need the bills/receipts in original only. We are unable to process the same as per insurer’s norms.

Regards,

Medi Assist Support Tem

 

11.             From the above discussion, it is clear that OP No.2 has not processed the claim for want of original bills and original pre numbered cash receipts. In  this regard it is pertinent to mention here that the complainant has duly informed vide her e-mail correspondence (Annexure C-11, C-12, C-14 & C-20) etc. that original bills/receipts have got misplaced and thus, requested the OP No.2 to get the bills verified at their own level from the Fortis Hospital. Further, to clear any doubts about the genuineness of bills and treatment record, the complainant vide her e-mail (Annexure C-20) has further stated that neither she has taken any claim from any other agency nor she would claim in future against these misplaced original documents.

12.            In view of the consistent and categorical version of the complainant that she had lost the original bills because of the traumatic situation which had arisen due to the sudden demise of her husband, it was incumbent upon the OP No.2 to take further necessary action on the basis of duly certified and signed receipt bills etc. issued by the Fortis hospital.

13.             In our considered opinion there was no impediment in getting the desired bills/documents verified from the Fortis Hospital. The aforesaid discussion leaves no scope of any doubt with regard to the gross lapse and deficiency on the part of OP No.2 while insisting upon the submission of original bills/documents etc.

14.             Now, coming to the liability of Ops to reimburse the expenses incurred by the complainant, admittedly, the group insurance policy, vide which the complainant has been held entitled to the claim amount, has been issued by OP No.3, thus, the OP No.3 cannot avoid its liability. The OP No.2, who has been found deficient in rendering the services to the complainant, is also liable to compensate the complainant. Thus, both the OPs No.2 & 3 are liable to compensate the complainant jointly and severally.  The present complaint is dismissed qua OP No.1 as no deficiency has been found on its part. 

15.             Now coming to the relief, admittedly, the complainant has already availed the benefit of Rs.59,186/- out of total insured sum of Rs.2,00,000/- and thus, the complainant is entitled to the release of Rs.1,40,814/-.

16.             As a sequel to above discussion, we partly allow the present complaint with the following directions to the OPs No.2 & 3:-

1. To refund the amount of Rs.1,40,814/- to the complainant along with interest @ 9% per annum from filing of the complaint till its realization.
2. To pay an amount of Rs.25,000/- to the complainant on account of mental agony and harassment.
3. To pay an amount of Rs.7,500/- as cost of litigation charges.

 

17.             The OPs No.2 & 3 shall comply with the order within a period of 30 days from the date of communication of copy of this order failing which the complainant shall be at liberty to approach this Commission for initiation of proceedings under Section 71 of CP Act, 2019 against the OPs No.2 & 3. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance.

Announced on: 05.03.2021

 

 

           Dr.Sushma Garg          Dr. Pawan Kumar Saini       Satpal

                    Member                  Member                                President

 

Note: Each and every page of this order has been duly signed by me.

 

                                              Satpal

                                             President