Punjab

Ludhiana

CC/21/301

Dilbag Singh - Complainant(s)

Versus

Bhai Ghanhya Sehat Sewa Scheme - Opp.Party(s)

Yogesh Gandhi

09 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  301 dated 11.06.2021.                                       Date of decision: 09.10.2024. 

 

Dalbag Singh son of Sh. Mehar Singh, resident of Kothe Rahlan, Teh. Jagraon, Distt. Ludhiana.                                                                                                                                                                                       ..…Complainant

                                                Versus

1. Bhai Ghanhya Sehat Sewa Scheme, through its Manager/Officer in Charge O/o. Bhai Ghanhya Trust, Punjab State Cooperative Bank, SCO-175-187, Sector 34-A, Chandigarh.
2. MD India Health Insurance TPA Private Limited, Through Officer-in-Charge/Manager, Mohali Towers, Ist Floor, Plot No.F-539, Phase 8-B, Industrial Area, Airport Road, Mohali-160071.
3. MD India Health Insurance TPA Private Limited, Through Officer-in-Charge/Manager, Cabin No.2, Ist Floor, Madhok Complex, Ferozepur Road, Ludhiana-141001.
4. The Jagraon Agwar Dala MPCS Ltd., Through its President/Secretary, Village Agwar Dala, Teh. Jagraon, Distt. Ludhiana-142026.
5. United India Insurance Company Ltd., Through its Regional Manager/Officer-in-Charge, Regional Office 136, Floor No.1, Feroze Gandhi Market, Ludhiana-141001.
6.  Global Heart & Super Speciality Hospital, Ferozepur Road, Near Octroi Post, Lalbagh, Ludhiana.                                                                                                                                                    …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019 as amended up to date.

 

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Yogesh Gandhi, Advocate

For OP1 to OP3             :         Exparte.

For OP4                         :         Sh. Paramjit Singh, Secretary in person.

For OP5                         :         Sh. G.S. Kalyan, Advocate.

For OP6                         :         Sh. Sunil Goel, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant through OP4 availed an insurance policy under Bhai Ghanhya Sehat Sewa Scheme having card No.MD15-BGSSS-00703497-SP vide Form No.282883 against payment of premium of Rs.2181/- and was duly insured with OP5 insurance company. The complainant stated that during validity of said scheme he was admitted with OP6 Global Heart & Super Specialty Hospital on 01.02.2020 due to chest pain and after Coronary Angiography, it came out that the complainant was suffering from Coronary Artery with Triple-Vessel Disease for which he underwent surgery on 03.02.2020. The complainant was discharged on 09.02.2020. The complainant incurred an amount of Rs.1,95,000/- on his treatment etc. The complainant further stated that at the time of admission, he showed his health insurance card at hospital reception who confirmed that the hospital is enrolled with Bhai Ghanhya Sehat Sewa Scheme and assured him that they shall inform MD India Health Insurance TPA Private Limited and the insurance company as well for the insurance claim. After his treatment, the complainant was on bed rest for 45-50 days and even lockdown was imposed in the country due to Covid-19 pandemic and as such, he submitted his insurance claim on 18.05.2020 along with documents with MD India Health Insurance TPA through OP1. However, after waiting for a month the complainant did not receive any communication from the OPs and as such, he again submitted his insurance claim along with documents with OP2 through registered post on 18.05.2020. Even the complainant approached the office of the OPs but nothing fruitful came. The complainant approached OP6 on 18.04.2021 to know about any communication about his insurance claim but to no effect. The complainant further stated that he is aged about 71 years and he approached the OPs time and again with request to disburse the claim amount. The complainant claimed to have suffered mental harassment and agony due to deficiency in service and unfair trade practice on the part of the OPs. Even the complainant served a legal notice dated 19.04.2021 upon the OPs but no reply was given by the OPs. Hence this complaint, whereby the complainant has prayed for issuing directions to the OPs to disburse the claim amount of Rs.1,95,000/- along with compensation of Rs.5,00,000/- and litigation expenses of Rs.55,000/-.

2.                Upon notice, none appeared on behalf of OP1 to OP3 despite service and as such, OP1 to OP3 were proceeded against exparte vide order dated 28.09.2021.

3.                However, OP4 appeared and filed written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; non-disclosure of facts etc. OP4 stated that  the complainant has claimed an excessive and unreasonable amount of Rs.5,00,000/-.

                   On merits, OP4 reiterated the crux of averments made in the preliminary objections. However, OP4 admitted the issuance of insurance policy to the complainant under the said scheme through OP4. OP4 stated that it collected the premium from its members as per instruction of Punjab Government and made demand draft on the name of Bhai Ghanhya Trust. Then the inspector of the cooperative society signed it and forwarded it to the Assistant Registrar of the cooperative society. Assistant Registrar signed it and further moved it to the Deputy Registrar. Finally after the signs of the Deputy Registrar amount of the demand draft was gone to the account of Bhai Ghanhya Trust. After that it was responsibility of the Bhai Ghanhya Trust with which company it wants to insure the members of the society. OP4 further stated that it has no direct connection with the insurance company and cannot do much to disburse the claim of the complainant. According to OP4, it has helped the complainant whole heartedly and provided him every document which he needed. Further it is the duty of OP1 to disburse the claim of the complainant. OP4 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                The complainant filed rejoinder to the written statement of OP4 reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement of OP4.

5.                Sh. G.S. Kalyan, Advocate appeared on behalf of OP5 but instead of filing written statement, OP5 filed an application for deletion of its name from the array of the respondents. However, vide order dated 28.02.2022 the said application ordered to be considered at the time of final arguments.

6.                OP6 appeared and filed written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; the complainant has not come with clean hands and is guilty of suppression of material facts; the complainant being bad for mis-joinder of the necessary parties; lack of cause of action; the complainant being estopped by his act and conduct etc. OP6 stated that it never made any assurance to the complainant. Rather it received an Email dated 14.08.2019 from Mr. Arun Chaudhary of MD India Health Insurance TPA Pvt. Ltd. stating that any admission after midnight 11:59 PM on 14.08.2019 will not be considered as eligible under Bhai Ghanhya Sehat Sewa Scheme. OP6 further stated that it never made any confirmation or assurance to the complainant for reimbursement of his claim.

                   On merits, OP6 reiterated the crux of averments made in the preliminary objections. OP6 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

7.                The complainant filed rejoinder to the written statement of OP6 reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement of OP6.

8.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 to Ex. C30 and closed the evidence.

9.                On the other hand, the counsel for the OP5 tendered affidavit Ex. R5/1 of Ms. Lipi Moitra, Authorized Signatory of OP5 along with documents Ex. R5/1A and closed the evidence.

                   The counsel for OP6 tendered affidavit Ex. RA of Dr. Brajesh K. Badha, Proprietor of M/s. Global Heath Hospital  along with documents Ex. R1 and Ex. R2 and closed the evidence.

                   OP4 failed to tender any evidence despite grant of sufficient opportunities including last and final chance and as such, evidence of OP4 was closed by order vide order dated 25.07.2023.

10.              We have heard the arguments of the counsel for the parties and also gone through the complaint, rejoinders, affidavit and annexed documents as well as written statements, affidavits and documents produced on record by the parties.

11.              The complainant, a senior citizen, being a member of OP4 Cooperative Society, was enrolled with Bhai Ghanhya Sehat Sewa Scheme being run by OP1. Under this scheme, an amount of premium was being paid by the member of Cooperative Society to its Society who in turn transmitted the consolidated amount of premium of all members to OP1 which had a tie up with insurance companies. The insurance companies had engaged OP2 as TPA for administration of third party claim. In November 2018, the complainant himself and his wife became a member of the said scheme by paying a premium of Rs.2182/- for each member and accordingly, ID Cards having a validity of one year were issued. According to the complainant, he got same renewed in November 2019 and renewed cards were also issued to him as well as his wife. OP4 in his written statement has admitted this fact and also relied upon consolidated society wise enrolment report Ex. C2 where it has been shown that a total amount of premium of Rs.73,653/- collected from members including the complainant was remitted to OP1 on 09.09.2019.

12.              The complainant was admitted with OP6 hospital and underwent Coronary Angiography. During the period of hospitalization i.e. 01.02.2020 to 09.02.2020, the complainant incurred expenses of Rs.1,95,000/- and attached the supporting documents ex. C3 to Ex. C10. The complainant remained bed ridden and due to Covid-19 conditions, he was able to submit his claim till May/June 2020. Since the issue remained unresolved, he also issued a legal notice dated 19.04.2021 Ex. C14 upon the OPs and also made representations to various public authorities Ex. C21, Ex. C23 and Ex. C25 but to no avail. Hence the present complaint was filed.

13.              From the evidence lead by the respective parties, it became noticeable that as per Ex. R1, United India Insurance Company Limited had tie up with OP1 w.e.f. 15.08.2018 to 14.08.2019. It has also been conceded by OP6 Global Hospital that vide Email Ex. R1, OP2 informed that their tie up with Bhai Ghanhya Sehat Sewa Scheme is expiring on 14.08.2019 midnight and after 11:59 PM on 14.08.2019, any admission will not be considered as eligible under the said scheme. Further as per Ex. C30, the New India Assurance Company Ltd. had tie up with OP1 from 16.03.2020 to 15.03.2021. Therefore, it is evident that the complainant remained admitted in the hospital 01.02.2020 to 09.02.2020  and incurred expenses of Rs.1,95,000/- when in fact OP1 could not engage any insurance company for providing insurance coverage to its enrolled members. As such, the insurance companies or its TPA cannot be held liable for non-settlement of the claim of a member of Bhai Ghanhya Sehat Sewa Scheme. Further the other OPs except OP1 had due diligently discharged its duties and liability cannot be fastened upon it. Undeniably, OP1 had received huge amount of premiums from different Cooperative Societies on behalf of its enrolled members and it was duty bound to ensure that the insurance coverage is extended to them continuously and uninterruptedly. As per enrolment report Ex. C2, the premium was forwarded to the trust on 09.09.2019 and the trust unjustly retained the same and was able to engage the services of New India Assurance Company Limited only after a break of six months. No explanation has been assigned for this delay despite the fact that the claim was submitted to them vide claim file No.62 dated 18.05.2020. Had OP1 acted promptly and efficiently, the complainant could have become entitled to lodge cashless claim as well as reimbursement of claim with the insurance company. This clearly amounts to deficiency in service on the part of OP1 and as such, it would be just and appropriate if OP1 is burdened with composite costs of Rs.50,000/- to the complainant.

14.              As a result of above discussion, the complaint is partly allowed with direction to OP1 to pay a composite costs of Rs.50,000/- (Rupees Fifty Thousand only) to the complainant within 30 days from the date of receipt of copy of order failing which the complainant shall be further held entitled to interest @8% per annum from the date of filing of the complaint till date of actual payment. However, the complaint as against OP2 to OP6 is hereby dismissed. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.  

15.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

Announced in Open Commission.

Dated:09.10.2024.

Gobind Ram.