Jharkhand

Bokaro

CC/17/71

Ranjit Kumar Singh - Complainant(s)

Versus

Branch Manager, SBI General Insurance Co. Ltd. - Opp.Party(s)

sanjay kapoor

10 Mar 2023

ORDER

District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-29-04-2017

Date of final hearing-10-03-2023

 Date of Order-10-03-2023

Case No. 71/2017

  Ranjit Kumar Singh, S/o- Late D.N. Singh

  R/o- Sector-12/B, Qr.No.- 3253, Bokaro Steel City,

  District- Bokaro, Jharkhand.

 

Vs.

1.Branch Manager, SBI General Insurance Co. Ltd.

      Kadru Argora Road, Maple Plaza, Ashok Nagar, Ranchi.

  2. Branch Manager Medicare TPA Service Pvt Ltd.

     6B, Bishop Lefroy Road, Kolkata

 3. The Branch Manager, S.B.I.

Sector-12 Branch, District, Bokaro, Jharkhand.

 

 Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

 

1.   Complainant has filed this case with prayer for direction to O.Ps. for payment of Rs. 2,43,180.96/- on account of medical expense incurred during his treatment at CMC, Vellore and for grant of compensation Rs. 1,00,000/- and for Rs. 15,000/- as legal expense.

2.  Complainant’s case in brief is that he obtained SBI General Insurance Policy No. 0000000002884989 in the year 2015 which was renewed time to time and was valid till 16.03.2017 for sum assured Rs. 5,00,000/-. Further case is that due to uncomfort in the chest complainant obtained online consultation with the Doctor of the CMC, Vellore on 11.05.2016 thereafter went there in the month of June 2016 who was consulted by the Doctor on 13.06.2016 thereafter, as per advice of the doctor he was admitted in the hospital on 11.08.2016 where Angiography was done on 13.08.2016 meanwhile he sustained stomach pain due to stone hence he was referred to the concerned department for consultation and discharged from the hospital on 14.08.2016 whose cashless facility was not approved. Further case is that again complainant was admitted in the CMC, Vellore hospital on 02.10.2016 and discharged on 09.10.2016 after surgery and at that very time also his cashless request was refused, hence he paid Rs. 2,43,180.96 for incomplete treatment and its claim has been refused by the O.P. hence legal notice was issued having no impact. Thereafter, this case has been filed with above mentioned prayer.

3. O.P. No. 3 has filed W.S. mentioning therein that he is not liable to pay any medical expense, only he has provided banking facility to the complainant hence case is liable to be dismissed against him.

4.  W. S. has been filed by O.P. No.2 SBI General Insurance Co.  in which there is no comment on the facts mentioned at para 1 to 5 of the complaint petition and facts mentioned at para 6 & 7 have been admitted. Only ground for rejection of the claim is that complainant has deliberately and knowingly misrepresented  the fact related to non disclosure of pre existing disease i.e. Renal Calculus since three years, Ischemic Heart disease since four years, Diabetes and Hypertension since 15 years which was not disclosed during obtaining the policy. Further reply is that as per discharge summary issued by CMC, Vellore complainant has suppressed so many facts related to pre-existing  disease. Hence claim has been repudiated.

5. Question for determination is whether complainant is entitled to get relief as prayed?

6. Ld. Counsel for the O.P. has drawn attention of this Commission on discharge summary issued by the Hospital and submits that complainant was having pre-existing disease to which he has not disclosed during opening of the insurance policy.

   7. Contrary to it Ld. Counsel for the complainant submits that  the opening form of insurance policy itself is very much clear as it has been filed by the O.P. as annexure of his defense that in the column related to personal health details of the complainant it has been left blank which is very much clear that complainant disclosed all the details to the O.P. who has left the column blank and issued the policy knowing well about all facts.

8. We have gone through the materials available on record. Complainant has filed photo copy of the first page of the bank passbook (Annexure-1), photo copy of policy paper (Annxure-2 & 3),photo copy of medical report dt. 13.06.2016 (Annexure-4), photo copy of discharge summary dt. 14.08.2016 (Annexure-5), photo copy of pre authorization repudiation letter dt. 14.08.2016(Annxure-6), photo copy of discharge summary dt. 09.10.2016 (Annxure-7), photo copy of pre authorization repudiation letter dt. 05.10.2016 (Annxure-8), photo copy of claim form (Annxure-9), photo copy of claim form dt. 15.11.2016 (Annxure-10) , photo copy of letter written by the complainant to the Insurance co. (Annxure-11), photo copy of bills etc. (Annxure-12), photo copy of letter dt. 14.03.2017 (Annxure-13) , photo copy of letter dt. 14.08.2016(Annxure-14)  and photo copy of legal notice dt. 07.04.2017 (Annxure-15) have been filed.

9. Complainant has been examined as witness during which he has stated in cross-examination that he has disclosed at the time of opening of the policy regarding pre-existing disease like Diabetes, Heart disease and operation for stone problem.

10. Facts related to issuance of Mediclaim policy, treatment of the complainant during relevant period at CMC, Vellore are not in dispute. Only it has been disputed by the O.P. that since complainant has not disclosed about pre-existing disease at the time of opening of the policy hence on this ground reimbursement of the medical expense has been refused. To prove it O.P. has brought photo copy of the proposal form related to opening of the present Mediclaim policy as annexure to  which O.P. has filed on 23.07.2018. On careful perusal of the photo copy of proposal form it is very much clear that in the column related to personal health details all information have been left blank. It shows that there is no latches on the part of the complainant and knowing well about all the facts O.P. insurance co. has issued the insurance policy. Therefore, insurance co. cannot be permitted to say anything contrary to its own records. It is important to mention here that by Annxure-9 complainant has prayed for imbursement of Rs. 59,659/- related to treatment for admission in the hospital from 11.08.2016 to 14.08.2016. Through Annexure-10 complainant has claimed reimbursement of Rs. 1,53,926/- for treatment related to his admission in the hospital from 02.10.2016 to 09.10.2016. It is important to note here that this case has been filed with prayer for reimbursement of second claim as it has been cleared by the Ld. Counsel for the complainant. Therefore, we are of the view that there is deficiency in service by the O.P. and complainant is entitled to get reimbursement of Rs. 1,53,926/- only related to his treatment from 02.10.2016 to 09.10. 2016 with pre hospitalization expense. Accordingly this point is being decided in favour of the complainant.

10 Accordingly prayer of the complainant is being allowed in the following manner:-

         O.P. No. 1 & 3  the Branch Managers of SBI General Insurance  Co. Ltd., Kadru, Argora Road, Mapal Plaza, Ashok Nagar, Ranchi or the at present address where Branch is existing and Sector-12 Branch, B.S.City, Bokaro are directed to pay Rs. 1,53,926/- to the complainant within 60 days from receipt/production of the copy of this Judgment, failing which they will pay interest @ 10% per annum  on that very amount from 29.04.2017 (i.e. the date on which case was filed). Further O.P. No.1 & 3 are directed to pay compensation of Rs. 15,000/- for various types of harassment caused to the complainant for his genuine claim and also to pay Rs. 5000/- as litigation cost within above mentioned period.

 

J.P.N. Pandey)

                                                                                      President

 

 

(B.P.L Das)

   Sr. Member

                                                                            

                  

                                                                               (Baby Kumari)

                                                                                       Member