Punjab

StateCommission

FA/12/783

Amrit Hospital - Complainant(s)

Versus

Balwinder Kaur - Opp.Party(s)

Parminder Singh

13 Mar 2015

ORDER

2^nd Additional Bench

 

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB

DAKSHIN MARG, SECTOR 37-A, CHANDIGARH

 

First Appeal No.   783 of 2012

                                                           

                                     Date of institution:  8.6.2012  

                             Date of Decision: 13.3.2015

 

Amrit Hospital, Sant Nagar, Amritsar Road, Moga through its Authorised Signatory, namely, Dr. Harjinder Singh Sidhu.

…..Appellant/OP No. 5

                                      Versus

1. Balwinder Kaur widow of sh. Mahinder Singh, resident of Village Khanna, Tehsil Zira, District Ferozepur.

…Respondent No.1/Complainant

2. M.D. India Healthcare Services TPA (Third Party Administrator under Bhai Ghanaya Health Services Scheme), Maxpro Park-D/38, Industrial Area, Phase-1, Mohali, Pb. Through its authorised signatory.
3. Iffco Tokio General Insurance Co. Ltd. 3^rd Floor, Iffco House, 34, Nehru Place, New Delhi through its authorised signatory.
4. The Khanna Nau Abad CASS Ltd. Khanna Tehsil Zira, District Ferozepur, through its authorized signatory.
5. The Deputy Registrar, Cooperative Society, Punjab, Ferozepur. 

…..Respondents No. 2 to 5/ OP Nos. 1 to 4

 

First Appeal against the order dated 13.3.2012 passed by the District Consumer Disputes Redressal Forum, Ferozepur.

 

Quorum:-

 

              Shri Gurcharan Singh Saran, Presiding Judicial Member

              Shri Jasbir Singh Gill, Member

    Shri Harcharan Singh Guram, Member

 

Present:-

 

          For the appellant             :         Sh. Parminder Singh, Advocate

          For respondent No.1        :         None.

          For respondents No.2&3  :         Sh. J.P.S. Singh, Advocate

          For respondent Nos. 4&5:          None.

 

 

Gurcharan Singh Saran, Presiding Judicial Member

ORDER

The appellant/OP No. 5(hereinafter referred as “OP No. 5”) has filed the present appeal against the order dated 13.3.2012 passed by the District Consumer Disputes Redressal Forum, Ferozepur(hereinafter referred as “the District Forum”) in consumer complaint No.549 dated 3.10.2011 vide which the complaint filed by respondent No.1/complainant(hereinafter referred as ‘the complainant’) was allowed with a direction to Op No. 5 to pay a sum of Rs. 1,20,000/- to the complainant alongwith interest @ 9% p.a. from 26.8.2011 till the date of actual payment with liberty to OP No. 5 to lodge his claim with Op Nos. 1 & 2 as per terms and conditions between the hospital and the TPA.

2.                The complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short ‘the Act’) against the opposite parties on the allegations that Government of Punjab under the Punjab Cooperative Societies Act, 1961 had launched a scheme for medical treatment of the Members as well as their family Members of the Cooperative Societies in the State of Punjab. Bhai Ghaniya Trust was a Nodal Agency. The husband of the complainant was an agriculturist and Member of Op No. 3, which was covered under Bhai Ghaniya Sehat Sewa Scheme and accordingly, family of the husband of the complainant was covered under that scheme. The husband of the complainant was holder of MDID No. MD15-BGSSS-00078455-S. It was further alleged that husband of the complainant was suffering from Headache and Vertigo and approached to OP No. 5 for medical check up, after diagnose the Doctor declared that he was suffering from Cerebellum in the left superior cerebellar artery zone and was admitted with Op No. 5 on 7.8.2011 and was discharged on 24.8.2011 but he died on 26.8.2011. At the time of admission in the hospital, the complainant had shown the card issued by Op No. 1 to the husband of the complainant and requested for cashless treatment but Op No. 5 refused to get cashless treatment to the husband of the complainant and ultimately the complainant had to bear an expenditure of Rs. 1,20,000/- on the treatment of her husband from her own pocket. Thereafter the complainant approached Op No. 3 for getting medical treatment claimed under the policy and submitted all the documents with OP No. 3, who assured the complainant that they will send the papers to OP No.1 & 2 for encashment. But lateron they did not give any satisfactory reply. The act and conduct of the Ops, amounts to deficiency in services and unfair trade practice. Hence, the complaint was filed against the Ops with a direction to the Ops to pay a sum of Rs. 1,20,000/- to the complainant alognwith interest @ 18% p.a. from the date it was due till its realisation and Rs. 5500/- as litigation expenses.

3.                The complaint was contested by the Ops. OP No. 1 in its written reply submitted that this OP was a Third Party Administrator (in short ‘TPA’) duly licenced under IRDA Regulations, 2001. Legal objections were taken that the complaint was not maintainable in this Forum as the complainant had no cause of action to file this complaint; the complainant had not lodged any claim with OPs till date; intricate questions of law and facts were involved, which cannot be adjudicated in the summary proceedings, therefore, the parties be relegated to the Civil Court; complainant had not come to the Forum with clean hands and had suppressed the material facts from the Forum and that the complaint was false, frivolous and vexatious to the knowledge of the complainant and it be dismissed with special costs. On merits, it was admitted that this OP had insured the Members of Bhai Ghanhiya Trust Sehat Sewa Scheme(in short ‘BGSSS’). The cashless hospitalization was available only with the network hospital, which were empanelled with the Op as per the terms and conditions of the policy. However, no claim was received from the complainant, therefore, complaint against this Op was without merit and it be dismissed.

4.                OP No. 2 in its reply submitted that it is insurance company and took the legal objections that the complaint was not maintainable as the complainant had no cause of action against this OP to file the complaint as the complainant had not lodged any claim with this OP; intricate questions of law and facts were involved, which cannot be decided in summary procedure and the matter be relegated to the Civil Court and that the complaint was false, frivolous and vexatious to the knowledge of the complainant, therefore, it be dismissed with special costs. On merits, it was admitted to the extent that this OP had insured the Members of BGSSS subject to the agreement entered in between the Trust and the TPA. The cashless hospitalization was available only with the Network Hospital, which were empanelled with this OP. No claim was lodged with Op No. 1 either by the complainant or by Op No. 5, therefore, no one can take benefits from its own wrong. Since no claim was lodged, therefore, question of deficiency does not arise. Complaint was without merit and it be dismissed.

5.                OP Nos. 3 & 4 in their reply admitted that Members of Cooperative Societies were covered under ‘BGSSS’ adopted by Iffco Tokio General Insurance Co. and that the husband of the complainant was Member of OP No. 3 and card holder of TPA. However, the complainant had not filed any claim with the Ops. Therefore, the complaint against these OPs was without merit and it be dismissed.

6.                OP No. 5 in its written reply took the preliminary objections that the complaint filed by the complainant was false, frivolous and vexatious to his knowledge, therefore, it be dismissed with special costs; complainant had not come to the Forum with clean hands; there was no cause of action against this Op to file the complaint and that this Op as a gesture of goodwill had advised the complainant that their hospital was not covered under ‘BGSSS’ for the facility of medicines and that their hospitals was covered only for the surgery, therefore, he was advised to go to some other hospital but he insisted for the treatment in this hospital. On merits also, the same averments were reiterated and it was submitted that the charges were charged from the complainant for the treatment given to the complainant. Complaint was without merit against this Op and it be dismissed.

7.                The parties were allowed by the learned District Forum to lead their evidence.

8.                In support of his allegations, the complainant had tendered into evidence her affidavit Ex. C-1, death certificate of Mahinder Singh Ex. C-2, Health Card Ex. C-3, receipts Exs. C-4 to 15, Bill/receipts Exs. C-16 to 41, discharge card and test reports Exs. C-42 to 45. On the other hand, opposite party No. 1 had tendered into evidence affidavit of Amrinderjit Singh Ex. R-1, affidavit of Dr. Geeta Bhardwaj Ex. R-2, affidavit of Srikanth Charan Ex. R-3, booklet copy Ex. R-4, affidavit of Dr. Harjinder Singh Sidhu Ex. R-5.

9.                After going through the allegations in the complaint, written replies filed by the OPs, evidence and documents brought on the record, complaint was allowed against Op No. 5 as referred above.

10.              In the appeal, it was contended by the counsel for the appellant that no doubt the husband of the complainant being Member of Op No. 3, was a Member of TPA OP No. 1 and was insured with Op No. 2 but this Op hospital was empanelled only for the purpose of Surgery. The Booklet, which was issued to the Members for the empanelled hospital is Ex. C-45 and in District Moga, Amrit Hospital is one of the panel hospital. There is no averment in this booklet that this hospital is empanelled only for Surgery purpose, therefore, the view taken by this appellant/OP No. 5 is not corroborated by any documentary evidence on the record and was an empanelled hospital and the complainant had approached this hospital being member of BGSSS and was entitled to cashless treatment from his hospital on the basis of insurance policy given by OP No. 2, therefore, the hospital was under obligation to move the papers of the husband of the complainant to the TPA for cashless treatment but no such action was taken by this Op to send the papers, rather, took the money from the complainant for the treatment given to her husband.

11.              It was contended that the claim was not raised by the complainant against Op Nos. 1 & 2 and without raising the claim how the responsibility can be imposed only upon OP No. 5. In case we go to the scheme, the procedure has been given under the Booklet Ex. C-45 wherein it has been provided that first it is to verify whether the hospital from where the treatment is to be taken is approved Network Hospital and then the identity card, he is required to be shown to the hospital and pre-authorisation form is to be supplied to the hospital and the treating Doctor after completion the form was to send it to the TPA. Therefore, once husband of the complainant had shown that he had the insurance cover under BGSSS, had shown the card to the concerned Doctor then it was the duty of the hospital to get pre-authorisation for cashless treatment from the TPA. However, instead of getting pre-authorisation from the TPA, this OP took a false plea that it is approved only for the purpose of Surgery and not for other treatment, which is not corroborated on the record. Therefore, deficiency is clear on the part of this OP to take a false plea and not to send pre-authorisation for cashless treatment of the complainant and take the treatment expenses from the complainant i.e. wife of the DLA. In these circumstances, we are of the opinion that the District Forum was justified to order OP No. 5 to pay this payment and then to recover this amount from the TPA according to the terms and conditions of the policy. In case any assistance is required from the complainant to sign any documents, she will provide the same.

12.              In view of the above circumstances, we do not find any merit in the appeal and the same is dismissed with no order as to costs.

13.              The appellant had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to respondent No. 1 by way of a crossed cheque/demand draft after the expiry of 45 days, subject to stay, if any, by the higher Fora/Court.

14.              Remaining amount shall be paid by the appellant to respondent No. 1 within 30 days from the receipt of the copy of the order.

15.              The arguments in this appeal were heard on 9.3.2015 and the order was reserved. Now the order be communicated to the parties as per rules.

16.              The appeal could not be decided within the statutory period due to heavy pendency of Court cases.

 

 (Gurcharan Singh Saran)

Presiding Judicial Member

 

                                                                            (Jasbir Singh Gill)

                                                                                                    Member

 

March 13, 2015.                                                      (Harcharan Singh Guram)

as                                                                                                Member