Punjab

StateCommission

A/10/326

NIC Ltd. - Complainant(s)

Versus

Balwinder Kaur - Opp.Party(s)

Vandanaa Malhotra

27 Feb 2015

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,  PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

                                     

                             First Appeal No.326 of 2010

 

                                                          Date of Institution: 03.03.2010  

                                                          Date of Decision : 27.02.2015

 

National Insurance Company Limited, Divisional Office, Barnala through its Divisional Manager through National Insurance Company Limited, Regional Office-1, Sector 34-A, Chandigarh

 

                                                                                                                                               …..Appellant/Opposite Party No.2

         

                                      Versus

 

1.       Smt.Balwinder Kaur wife of Sh.Sukhdev Singh s/o Jarnail Singh          resident of House No.232, Village Vadhate Tehsil Tappa, District       Barnala.

                                                                                                                                                        Respondent no.1/complainant.

 

2.       The Chugh Jadid Cooperative Agriculture Services Society Ltd.,          Chungan, Tehsil Tapa District Barnala.

3.       Assistant Registrar, Cooperative Societies, Barnala

4.       Registrar, Cooperative Societies Punjab, Chandigarh.

 

                                                                                                                                                     ….Respondent no.2 to 4/OP No.3 to 5

                                

5.       Medsave Healthcare (TPA) Ltd., SCO 121-122-123, Second Floor,

          Sector 34-A, Chandigarh through its Manager.

 

                                                          ..Performa Respondent/OP No.1

First Appeal against order dated 15.01.2010 passed by the District Consumer Disputes Redressal Forum, Barnala

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

          Shri Harcharan Singh, Guram, Member    

Present:-

 

          For the appellant              :         Sh.Rajneesh Malhotra, Advocate

          For the respondent no.1   :         Sh.Meera Bansal, Advocate

          For the respondent no.2  :         None

          For the respondent no.3&4        None

          . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

                            

J. S. KLAR, PRESIDING JUDICIAL MEMBER:-

                                     

           The appellant National Insurance Company through its Divisional Manager (opposite party no.2 in the complaint) has directed this appeal against the respondents of this appeal (respondent no.1 Balwinder Kuar, being complainant in the complaint and respondent no.2 to 5 being OPs no.1,3 to 5 in the complaint), assailing the order dated 15.01.2010 of District Forum Barnala, accepting the complaint of the complainant  and directing the OPs to pay the amount of Rs. 68,533/- to the complainant with 7 ^1/2 interest from the date of order till its actual payment and to pay further amount of Rs.3000/- for mental harassment. The instant appeal has been preferred against the same by the OP No.2 now appellant before us.

2.      The complainant Balwinder Kaur has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that she is member of the Chugh Jadid Cooperative Agriculture Society Ltd, Chungan, Tehsil Tappa, District Barnala. That she received her membership under Bhai Ghanaya Health Services Scheme.  That Bhai Ghanaya Health Services Scheme has been working in collaboration with OPs of this complaint rendering health insurance coverage of Rs.2 lac, vide receipt no. 8343 dated 9.8.08. That membership card was issued to complainant, to her husband and to her children under the above scheme, undertaking to reimburse the medical expenses, if required to be incurred. The card, as issued was valid from 1.10.2008 to 30.9.09,  with the endorsed policy no.400104/46/08/85/00000096, SCO Code 2331, as detailed in the card. The complainant took the treatment provided by the networked hospital as per guidebook of the Scheme. The complainant got herself treated in the hospital of the R.G Stone and Super Specialty Hospital , 510 L Model Town, near Post Office Ludhaina and she incurred the expenses of Rs. 21,130/-, vide bill no.09-10C-2967 dated 20.7.09, the amount was paid by her in cash, vide receipt no.16585 dated 20.7.09 for Rs.16130/- and vide advance receipt cash bill no.9-10/16493 dated 17.7.2009 for Rs.5000/-, the amount Rs.42,828/-, out of Rs.42,828/- vide bill no.09-10B2227 dated 10.8.09, OPs approved the small amount of Rs.10,800/- for her treatment only in favour of the above hospital instead of approving the incurred expenses on her treatment. That complainant also incurred the amount of Rs.15,375/- on the purchase of the medicines, vide bill no. 3048 dated 20.7.09. That the hospital R.G Stone and Super Specialty Hospital, Ludhiana kept on record of the treatment/bills, on the pretext that they would get the whole amount refunded from OPs and they also obtained the signatures of the complainant on the blank and printed forms by assuring that they would be filled up and sent to the OP No.1 after completing the formalities. That the OP No.2 had allowed only Rs.10,800/- for this treatment to the complainant and refused to disburse the remaining amount spent by her on her treatment. That OPs are guilty of unfair trade practice and they are liable to pay the remaining amount of the treatment to complainant besides compensation for mental harassment and litigation expenses. The complainant has further averred that photocopy of card No.90101233100011C of the complainant and also her husband card no.90101233100011Z , showing ration card of the complainant along with her family, visitors pass was duly issued by the treating hospital authority, vide receipt no.8343 dated 9.8.09 issued by Chugh Jadid Cooperative Agriculture Service Society, Chughan, vide bill no.09-10C2967 dated 20.7.09, receipt no.16585 dated 20.7.09, cash bill no.9-10/16493 dated 17.7.09, bill no.09-10B2227 dated 10.8.09 , vide receipt no.17916 dated 10.8.09, authorization letter for approved amount of Rs.10,800/- medicine receipt no.3048 for Rs.15,375/-, hospital discharge letter dated 20.7.09. The complainant has, thus, prayed that OPs be directed to pay the remaining amount of the expenses to the tune of Rs.68,533/- and compensation of Rs.30,000/- for mental harassment and litigation expenses to her.

3.      Notice of this complaint was served upon OP No.1 and 2 and they contested this complaint by filing the joint written reply raising legal objections that District Forum Barnala has no territorial jurisdiction to decide the case. The complainant has not come to the Forum with clean hands.  On merits, OP No.1 and 2 admitted that at instance of the Bhai Ghanhya Trust , the National Insurance Company Ltd issued a Group Medical Policy regarding persons w.e.f 1.10.2008 to 30.09.2009, subject to terms and conditions of the policy. That on the card along with guidebook was also issued by  Bhai Ghanhya Trust to the complainant forthwith. The policy was under the scheme of cashless treatment and the list of hospitals were mentioned in the guidebook issued by Bhai Ghanhya Trust. It was admitted that Balwinder Kaur complainant took the treatment from R.G Stone and Super Specialty Hospital Ludhiana from 17.7.09 to 20.7.09. That she was admitted in the above hospital on depositing of Rs.5000/-, as advance as a non-insured without producing the ID Card issued by the OP No.2. That insured Balwinder Kaur had not produced the ID Card to the hospital within 24 hours as per the terms and conditions, described in the Member Enrollment Form, hence, she is not entitled to the reimbursement of expenses incurred by her in the networked hospital. That she is not entitled to amount of Rs. 21,130/- regarding hospital bills of medicines for Rs.15,375/-, as alleged by her in para no.3 of the complaint. That hospital did not request OP No.1 to make the payment regarding treatment of the patient Balwinder Kaur. That the claim of Rs.10,800/- was approved to the complainant under the negotiated package rates of Bhai Ghanhya Sehat Sewa Scheme by the OPs. The amount of Rs.10,000/- was included in the final bill no.0910B2227 dated 10.8.09 regarding private room charges, which are not permissible as per terms and conditions of the scheme. OP No.1 and 2 prayed for dismissal of the complaint.

4.      OP No.3, 4 were set exparte before the District Forum.

5.      The complainant tendered in evidence affidavit of Balwinder Singh Ex.C-1, affidavit of Sukhdev Singh Ex.C-2, copy of I-Card Ex.C-3, copies of I-Card of family members of the complainant Ex.C-4 to C-6, copies of voter card Ex.C-7 to Ex.C-8 , copies of other documents Ex.C-9 to C-21. .  As against it, OP No.1 and 2 tendered in evidence copy of membership form Ex.R-1, policy Ex.R-2, guidebook Ex.R-3, letter Ex.R-4, receipt Ex.R-5, authority letter Ex.R-6, affidavit of Dr.Roli Aggarwal, Regional Manager, Medsave Healthcare TPA Ltd, affidavit of Sat Pal Hira, Divisional Manager, National Insurance Company Ex.R-8 and copy of order of District Forum Sangrur Ex.R-9 thereafter. On conclusion of evidence and arguments, the District Forum, Barnala accepted the complaint of the complainant and directing the OP No.1 and 2 to pay the amount of Rs. 68,533/- to the complainant along with interest @7^1/2 p.a from the date of order till it actual payment besides compensation of Rs.3000/- for mental harassment. Dissatisfied with this order dated 15.1.2010 District Forum, Barnala, the instant appeal has been preferred  against the same by the OPs now appellant. 

6.      We have heard learned counsel for the appellant and counsel for  the respondent no.1, as rest of the respondents of this appeal are exparte in this appeal. We have also examined the record of the case. The submission raised by counsel for the appellant before us is that the I-Card issued to the complainant under the scheme was not produced by her at the time of her admission in the R.G Stone and Super Specialty Hospital , 510 L. Model Town, near Post Office, Ludhaina. That the amount of Rs.5,000/- was deposited at the time of her admission by her as non-insured and she was treated like an uninsured person. This point has been highlighted by the counsel for the appellant during the arguments. That on account of non-production of the above-referred I-Card, the case cannot be treated under the above-referred scheme. We find that complainant has categorically pleaded in the complaint regarding production of I.D Card and other documents in the hospital. There is also affidavit of the complainant Balwinder Kaur on the record in support of her averments. Vide Ex.C-1, she has categorically deposed that the requisite I-Card and other documents were produced in the hospital and they were kept in the hospital, as treating hospital promised her to take up the case with the insurer. We further find that the appellants have approved the amount of Rs.10,800/- to the complainant for the treatment, instead of repudiating the entire claim of the complainant on this score. We, thus, find that there is no cogent evidence on the record in the shape of any affidavit of the hospital authority concerned to prove this fact that no such card was produced thereat by the complainant. Consequently, we find no merit in this contention as referred before us by the counsel for the appellant. Ex.C-3 is copy of I-Card under the scheme issued to the complainant Balwinder Kaur, Ex.C-4 to Ex.C-6 are copies of I-Card issued under the above scheme to her family members. Ex.C-7 is the photocopy of the voter card of Balwinder Kaur complainant and Ex.C-8 is copy of voter card of her husband. Ex.C-9 is copy of ration card, Ex.C-10 is copy of visitor's pass of the above hospital. The final bill details Ex.C-12 showing the amount of Rs.16130/- as net balance , Ex.C-13 is copy of receipt in cash dated 20.7.09 of the above treating hospital. Another final bill (detail) Ex.C-15 showing the total bill amount of Rs. 42828/- from the complainant by the above hospital on 10.8.09 for her treatment. Ex.C-16 is receipt regarding of cash amount of Rs.32,028/-. Ex.C-17 is copy of Authorization letter for treatment and guarantee of payment for Bhai Ghanhya Sehat Sewa Scheme issued to Balwinder Kaur complainant. Ex.C-18 copy of bill of medicines, Ex.C-19 and Ex.C-20 are Hospitals Discharge Letters, Ex.C-21 is guidebook of the empanelled hospital, admittedly this hospital is also recorded as one of the networked hospitals at serial no.117 in it.

7.      The OPs relied upon Ex.R-1 the copy of Member Enrollment Form of Bhai Ghanhya Sehat Sewa Scheme on the record. Ex.R-2 is National Insurance Company Ltd under  Bhai Ghanhya Sehat Sewa Scheme, Ex.R-3 is terms and conditions of the Bhai Ghanhya Sehat Sewa Scheme, Ex.R-4 is also in connection with the same in the record of the hospital, Ex.R-5 is claim status of Balwinder Kaur complainant approving the amount of Rs.10800/- for treating Balwinder Kaur by the appellant, Ex.R-6 is authorization letter for treatment and guarantee of payment for Bhai Ghanhya Sehat Sewa Scheme, Ex.R-7 is affidavit of Dr.Roli Aggarwal , Regional Manager Medsave Healthcare TPA Ltd, Ex.R-8 is affidavit of Sat Pal Hira, Divisional Manager National Insurance Company Limited, Ex.R-9 is copy of order of  District Forum Sangrur in some other case, but this order in its different case with different facts and has no concern in the case in hand.

8.      We have come to the this conclusion that it is a proved fact that complainant was covered under the Bhai Ghanhya Sehat Sewa Scheme and she was issued I-Card therein, in addition to her husband and family members. There is no dispute regarding depositing of premium in this case on her part. She is fully covered under the Bhai Ghanhya Sehat Sewa Scheme, she received treatment from networked hospital. These points are not disputed in this case. We find that the complainant spent a total amount of Rs.42828/-, vide final bill of the above hospital, Ex.C-15 in addition to that she spent Rs.7448/- for purchase of the medicines, which was indispensable for her treatment. The submission of the appellants is that above items are not covered under the terms and conditions of the scheme. The total annual amount  is of Rs.2 lac per member under the above scheme, vide Ex.C-21 on the record. The exclusion clauses are recorded in the scheme, vide Ex.R-3 on the record. It is not disputed that the disease of the complainant did not fall in any exclusion clause of the policy. This fact is admitted that the disease of the complainant had not fallen in any exclusion clause. The complainant duly informed the treating hospital within 24 hours, as per her pleading and affidavit on the record that she is a member under the above scheme and is insured. The OP only approved the amount of Rs.10800/-, which is deficient in service on its part beside unfair trade practice only. Balwinder Kaur opted this Bhai Ghanhya Sehat Sewa Scheme, just to cover her family and herself from attacks of the diseases. It is sheer malpractice on the part of the insurer not to disburse the amount, when the treatment has been taken from the networked hospital and expenses, which are directly incurred on the treatment are liable to be reimbursed to the complainant. The counsel for the appellant could not point out that any of the expenses were not essential for her treatment.

9.      The next contention of the counsel for the appellant is that territorial jurisdiction of the District Forum Barnala is barred in this case. We are of this view after considering the pleadings of the parties that complainant is resident of village Vadhate, Tehsil Tappa, District Barnala. She became member under the above-said scheme at her village. The requisite premium either by her us or on behalf of her by the cooperative society was paid thereon. The cause of action thus partly accrued, where she was member of cooperative society and was enrolled under the above scheme. Consequently, any agreement specifically entered into between the parties to exclude the jurisdiction of the statutory body, as conferred by the law on it is of no consequence.

10.    As a result of our above discussion, we find that the order of the District Forum under appeal in this case is sustainable. Accordingly, the order of the District Forum under challenge in this appeal is upheld. Finding no merit in the appeal, the same is hereby dismissed. 

11.    The appellant had deposited an amount of Rs.25000/- at the time of filing the appeal. This amount with interest, if any, accrued thereon, be refunded by the registry to the complainant  by way of crossed cheque/demand draft after 45 days from receipt of copy of this order. Remaining amount as per the order of the District Forum shall be paid by the OPs now appellant to the complainant within 45 days from the receipt of the copy of this order.

12.     Arguments in this appeal were heard on 25.02.2015 and the order was reserved. Now the order be communicated to the parties.

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

 

                                                                          (J. S. KLAR)

                                                             PRESIDING JUDICIAL MEMBER

                       

                                                           (HARCHARAN SINGH GURAM)

                                                                          MEMBER

 

February, 27    2015.                                                               

(ravi)