Haryana

Yamunanagar

CC/755/2013

Dev Dutta Kamboj S/o Kishori Lal - Complainant(s)

Versus

The Manager ,SBI Life Insurance Co.ltd. - Opp.Party(s)

Joginder Bharti

16 Oct 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA   NAGAR AT JAGADHRI.

 

                                                     Complaint No.755 of 2013.

                                                     Date of institution: 10.10.2013.

                                                     Date of decision: 16.10.2017.

Dev Dutt Kamboj, age about 52 years son of Sh. Kishori Lal, resident of H.No.379, Sarojani Colony, Yamuna Nagar, District Yamuna Nagar.

                                                                                                 …Complainant.

                        Versus

1. The Manager, SBI Life Insurance Co. Ltd., SCO No.126-127, Commercial Belt, Sector-17, HUDA, Jagadhri, District Yamuna nagar.
2. Regional Director, SBI Life Insurance Co. Ltd., SCO No.109-110, Ist floor, Sector 17-B, Chandigarh, Haryana.
3. Manager, SBI Life Insurance Co. Ltd., No.113, near Bus Stand, Jind Road, Narwana-126116, Haryana.
4. Administrator (TPA), E-Meditek (TPA) Service Ltd., 208/209, Turf Estate, Office Dr. E. Mases Road, near Maha Laxmi Station, Mahalaxmi, Mumbai-400011.
5. Poonam Kumari, Service Agent, C/o SBI Life Insurance Company Ltd., near Bus Stand, Jind Road, Narwana-12116, Haryana. 

 

….Respondents.

BEFORE     SH. SATPAL, PRESIDENT.

                    SH. S.C.SHARMA, MEMBER.

                    SMT.VEENA RANI SHEOKAND, MEMBER.

 

Present:     Sh. Joginder Bharti, Advocate, for complainant.   

                 Sh. Brijesh Chauhan, Advocate for the OPs.No.1 to 3.

                 Ops No.4 & 5 already exparte.

               

                ORDER

         

(SATPAL, PRESIDENT)

                The complainant-Dev Dutt Kamboj has filed this complaint under section 12 of the Consumer Protection Act 1986, as amended up to date (hereinafter respondents will be referred as OPs). 

2.             Brief facts of the complaint, as alleged by the complainant, are that in the month of January, 2012 the officials of Op No.1 persuaded the complainant to purchase SBI Life-Hospital Cash A Health Insurance Plan and the complainant purchased the said policy and deposited an amount of Rs.13,748/- as Ist premium on 03.02.2012 for a period of 3 years and the Ops issued a policy No.46004280008 which was valid w.e.f. 03.02.2012.  It is alleged that under the said policy, the Ops assured the complainant that they will pay Rs.5,000/- per day for hospitalization of the complainant in case of his admission in the hospital.  It is further alleged that unfortunately, the complainant met with an accident on 27.11.2012 at Radaur Road, Yamuna Nagar and received injuries on his person and his left leg was also fractured.  It is further alleged that he was hospitalized at Vardhman Trauma & Laparoscopy Centre Pvt. Ltd., Muzafarnagar (UP) from 28.11.2012 to 30.11.2012 and again from 09.12.2012 to 19.12.2012.  It is further alleged that the complainant lodged the claim with the Ops and submitted all the necessary documents as required by the Ops but the Ops did not settle the claim of complainant.  So, it is a clear cut case of deficiency in service on the part of Ops and prayed for acceptance of complaint directing the Ops to pay the claim amount of Rs.60,000/- as hospitalization of 12 days of the complainant at the rate of Rs.5,000/- per day and further to pay Rs.2,70,000/- as compensation for harassment and mental agony alongwith Rs.5,000/- as litigation charges.  Hence, this complaint.

3.            Upon notice, the OPs No.1 to 3 appeared, whereas Ops No.4 & 5 did not appear and were proceeded against exparte vide order dt. 04.08.2014.  Ops No.1 to 3 filed their written statement raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant is covered under SBI Life Hospital Cash Policy bearing No.46004280008 with date of commencement as 09.02.2012 for a sum assured of Rs.5,00,000/- and the benefits under the policy are payable only as per the terms and conditions of the policy.  There is no deficiency in service on the part of answering Ops.  On merits, the pleas taken in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             Ld. Counsel for the complainant tendered in evidence affidavit of complainant as Annexure-CW/A and documents Annexure-C1 to Annexure-C27 and closed evidence on behalf of complainant. 

5.             On the other hand, ld. Counsel for the Ops No.1 to 3 tendered in evidence affidavit of Neelam Singh as Annexure-R/A alongwith documents Annexure-R1/1 to Annexure-R1/5 and closed evidence on behalf of Ops No.1 to 3.    

6.             We have heard the ld. Counsel for both the parties and perused the record carefully and minutely.

7.               After hearing the ld. Counsel for both the parties and on perusal of record as-well-as written arguments of Ops No.1 to 3, the foremost question which arises before us for consideration is that whether this Forum has territorial jurisdiction to entertain and try the present complaint or not?

                The plea of the Ops No.1 to 3 is that the complainant had purchased the policy in question from Narwana Branch (Haryana) and as such, this Forum has got no territorial jurisdiction to entertain and try the present complaint.  On the other hand, the version of the complainant is that he is a Haryana Govt. employee and at the time of purchasing of policy in question, he was posted at Narwana but at the time of purchasing of the policy in question, he provided his residential proof mentioning that he is a permanent resident of Yamuna Nagar and as such, this Forum is having territorial jurisdiction to entertain and try the present complaint. 

                We have perused the document Annexure R-1/1 which is welcome letter issued by the Ops-insurance company at the time of issuance of policy bond, wherein the address of complainant is mentioned “Mr. Dev Dutt Kamboj, 379, Sarojni Colony, Yamuna Nagar-135001, Haryana, India”.  Besides this, admittedly, the office of Ops company is situated at Yamuna Nagar and the Ops company work for gain at Yamuna Nagar and as per Consumer Protection Act, 1986, if the office of Ops situated in the territory of the Forum and they work for gain, then the Forum has territorial jurisdiction to entertain and try the complaint.  In view of the aforesaid discussion, the objection raised by the Ops No.1 to 3 is not tenable in the eyes of law and this Forum has got territorial jurisdiction to entertain and try the present complaint.                                            

                Now the second question which arises before us for consideration is that whether the non-settlement of medi-claim of the complainant by the Ops-insurance company is illegal or not?

                The version of the Ops 1 to 3-insurance company is that the complainant had failed to provide the requisite documents as demanded by the Ops No.1 to 3 vide letter dt. 22.01.2013 and followed by reminders dt. 07.02.2013, 11.03.2013 etc. and as such, the claim was not settled due to non-submission of the required documents.  The plea of the complainant is that he had duly sent all the requisite documents which were demanded by the Ops No.1 to 3-insurance company vide letter dt. 18.02.2013 through courier on 19.02.2013 but the Ops No.1 to 3-insurance company illegally withheld the genuine claim of the complainant. 

                We have perused the letter dt. 22.01.2013 (Annexure R-1/3) and followed by the reminders dt. 07.02.2013, 23.02.2013 and 11.03.2013, wherein the Ops No.1 to 3-insurance company had demanded three documents, which are as under:-

“1.    Kindly provide original X-ray/C.T.Scan/MRI Reports, Diagnostic Reports and Films supporting diagnosis.

2.     Kindly provide all investigation reports in support of final diagnosis
3. Kindly provide letter from treating doctor mentioning cause of injury and detailed case history.”

            We have perused the document Annexure C-16, which is a forwarding letter addressed to ‘E-Meditek (TPA) Services Ltd., Mumbai, wherefrom it is clear that the complainant had replied all the quarries of letter dt. 22.01.2013 (Annexure R-1/3) as-well-as enclosed all the required three documents which were demanded by the Ops No.1 to 3-compnay through this letter and sent the same to the TPA through courier on 19.02.2013, which is clear from the receipt of courier (Annexure C-27) as-well-as confirmation for delivery of said courier (Annexure C-21).  From the perusal of aforesaid documents Annexure-C16 (forwarding letter), C-27 (receipt of courier) and Annexure-C21 (delivery report of courier) which reveals that the complainant has provided all the required documents which were demanded the Ops No.1 to 3-insurance company through letter dt. 22.01.2013 (Annexure-R1/3).  Besides this, the complainant has also attached the photo-copy of all these three documents on the file, which are marked as Annexure-C17 to Annexure-C20.  Hence, the plea taken by the Ops No.1 to 3-compnay that the complainant had not submitted the required documents with the Ops No.1 to 3 is not tenable in the eyes of law which amounts to clear cut deficiency on the part of Ops-insurance company.  Hence, the complainant is entitled for relief.

8.             Thus, as a sequel of above discussion, we allow the complaint of the complainant and direct the Ops No.1 to 4 to pay Rs.60,000/- alongwith interest @ 9% p.a. from the date of filing of this complaint till its payment. The Ops No.1 to 4 are further directed to pay Rs.3,000/- as compensation for harassment and mental agony and Rs.3300/- as litigation charges.  Let the order be complied with within 30 days from the date of communication of this order.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.      

Announced in open court:

Dated: 16.10.2017.

                                                          (SATPAL)

                                                          PRESIDENT.

 

 

(VEENA RANI SHEOKAND)         (S.C.SHARMA)

MEMBER                                           MEMBER