BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 389 of 2015
Date of Institution: 12.6.2015
Date of Decision: 1.06.2016
Gurjit Singh son of Harbhajan Singh resident of Quampur, Tehsil Ajnala District Amritsar
Complainant
Versus
- Bhai Ghanhya Sehat Sewa Scheme through its M.D. India Healthcare Service (TPA) Pvt.Ltd., Maxpro Info Park D-38, Industrial Area, Phase I, Mohali, Punjab
- Deputy Registrar Cooperative Societies, Amritsar
- Assistant Registrar Cooperative Societies, Ajnala District Amritsar
- The Quampur Multipurpose Coop.Agri.Service Society Ltd., Quampur Tehsil Ajnala District Amritsar through its Secretary
- Sh.Chuni Lal Memorial Gulati Hospital Chamyari Road, Near Gurdwara Jiwan Singh, Ajnala District Amritsar through Dr. Sanjay Gulati
Opposite Parties
Complaint under section 12/13 of Consumer Protection Act, 1986
Present: For the Complainant : Mrs.Kirpal Kaur,Advocate
For the Opposite Party No.1 : Sh.S.S.Batra,Advocate
For Opposite Parties No.2 ,3 &4 : Sh.Sukhbir Singh,Rep.
For Opposite Party No.5 : Sh.Vipan Bhasin,Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Sh.Anoop Sharma,Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Gurjit Singh complainant has brought the instant complaint under section 12 and 13 of the Consumer Protection Act, 1986 on the allegations that the complainant is member of opposite party No.4. Opposite party No.1 launched the mediclaim insurance scheme under the name and style of Bhai Ghanaya Sehat Sewa Scheme for the members of the cooperative societies . As such the complainant also obtained the said scheme /policy and he was insured by opposite party No.1. Card bearing No. MD15-BGSSS-00370986-S was issued in his favour , copy of the card is Ex.C-1. The complainant obtained the services of opposite party No.1 and as such he fell under the definition of Consumer Protection Act and is entitled and competent to file the present complaint. Unfortunately complainant suffered from GE Hyponolacmic Shock and he was admitted in Shri Chuni Lal Memorial Gulati Hospital, Chamyari Road, Near Gurdwara Jiwan Singh, Ajnala District Amritsar on 5.8.2014 with aforesaid disease and he remained admitted upto 10.8.2014 in the said hospital. Dr. Sanjay Gulati of the said hospital treated the complainant, copy of the admission and discharge cards are attached. The aforesaid hospital is duly authorized hospital of opposite party No.1 and at the time of admission in the hospital, complainant had given the information to the hospital authorities regarding his insurance policy under the scheme of Bhai Ghanhya Sehat Sewa and also submitted his identity card to the hospital authorities. The complainant incurred Rs. 28000/- on his treatment/hospital expenses. Opposite party No. 5 illegally claimed the said amount from the complainant, whereas everything was disclosed to opposite party and he also showed the card issued by opposite party No.1 but in the claim form opposite party No.5 in order to get the amount encashed, wrongly mentioned that the patient never showed or disclosed about the BGSSS card with him. As a matter of fact the claim form is filled up by the opposite party and the complainant has just signed the same . It was the duty of opposite party No.5 to submit the claim directly to opposite party No.1 . The complainant made the payment of the amount in dispute to opposite party and submitted his claim vide dispatch No.2298 dated 25.8.2014 to the Assistant Registrar Cooperative Societies Ajnala Amritsar, who raised some objections and after removal of the said objections, complainant again submitted the treatment bill/claim vide dispatch No. 4090 dated 15.9.2014 to Deputy Registrar Coop.Societies,Amritsar. The complainant submitted the claim immediately after the discharge from the hospital but till date reimbursement has not been made to the complainant and they have told him that claim of the complainant was time barred. Thereafter the complainant got issued legal notice upon opposite parties No.1 to 3 through counsel. But the opposite parties have failed to comply with the said legal notice . Copy of the legal notice is attached. Vide instant complaint, complainant has prayed for the following reliefs:-
(i) The opposite parties be directed to reimburse the medical claim amount to the complainant immediately;
(ii) A compensation of Rs. 50000/- on account of mental pain, agony and harassment suffered by the complainant may also be grated in his favour .
(iii) Costs of the proceedings Rs. 11000/- may also be granted.
Hence, this complaint.
2. Upon notice, opposite parties No.1 to 5 appeared and contested the claim. Opposite party No.1 and 5 filed separate written statements while opposite parties No.2,3 & 4 filed collective written statement contesting the claim of the complainant.
3. In reply filed on behalf of opposite party No.1, it took preliminary objections therein inter-alia that the complainant has not approached this Forum with clean hands as various material facts have been concealed by him from this Forum. It is stated that the complainant had obtained the mediclaim policy of opposite party No.1 through opposite party No.2 under settled terms and conditions. This fact was very much in the knowledge of the complainant and in this regard terms and conditions were settled and guide book of the same was provided to the complainant as well as to opposite party No.2 by opposite party No.1. In the said guide book, it has been specifically stated at page 16 that “Members will be provided a cashless facility in the hospital/nursing homes, as per the list attached. This would mean that a patient can avail the treatment in any one of the network hospitals without actually having to pay the bills. In case a patient chooses to go to Government Hospital, the expenditure shall be reimbursed provided the beneficiary submit the claim to TPA within 45 days of discharge.” It is further clarified at page 23 of the guide book that “claim from the provider hospital may not be settled and processed by the TPA, if received after 45 days from the date of discharge from the hospital” & “no claim from the beneficiary shall be entertained for processing and settlement by the TPA, if received after 45 days from date of discharge from Govt.Hospital”. The complainant has undergone the treatment from Shri Chuni Lal Memorial Gulati Hospital of opposite party No.5 w.e.f. 5.8.2014 (date of admission) to 10.8.2014 (date of discharge) under the said policy. But he put forwarded his claim before opposite party No.1 on 11.10.2014, which is after the lapse of 62 days and as such claim of the complainant has been rejected by opposite party No.1 ; that the complaint of the complainant is not maintainable in the present Form ; that complainant is stopped by his own act and conduct to file the present complaint as he himself filed his claim after the lapse of 62 days from the date of discharge from the hospital , otherwise, it was the duty of the complainant to follow up his bills/claims from the office of opposite party No.2 and confirm the receiving of the opposite party No.1 within the prescribed period, as such the complaint of the complainant is liable to be dismissed . On merits, facts narrated in the complaint have been specifically denied and a prayer for dismissal of the complaint with cost was made.
4. In their collective written reply on behalf of opposite parties No.2 ,3 & 4 , preliminary objections to the effect that the complaint is not legally maintainable against the replying opposite parties . Opposite parties are only concerned to issue card which has correctly been issued and there is no complaint regarding the genuineness, legality and validity of the said card. Further , when the complainant approached the replying opposite parties, they also submitted his claim to opposite party No.1 and as such it was and is duty of opposite party No.1 to pass or reject the claim and the present complaint is not legally maintainable against the replying opposite parties. There is no negligence or deficiency on the part of opposite parties 2 to 4 ; that complainant is not consumer of replying opposite parties and as such the present complaint against the replying opposite parties is not legally maintainable. On merits, facts narrated in the complaint have been specifically denied . It is stated that when the complainant approached the replying opposite parties, they immediately submitted the claim of the complainant without any delay and there is no deficiency on the part of the replying opposite parties.
5. In written statement on behalf of opposite party No.5, preliminary objections to the effect that the complaint is not maintainable against the replying opposite party No.5 either on facts alleged or under the law, hence is liable to be dismissed ; that no case of negligence or unfair trade practice or any deficiency in service has been made out against the replying opposite party No.5 ; that either at the time of admission or during treatment or after at the time of discharge, complainant never disclosed the fact that he is a member and card holder of Bhai Ghanhya Sehat Sewa Scheme . So he was treated in routine like other patients. The complainant made payment of the hospital bill without any objection or demur and without disclosing that he was the member of Bhai Ghanhya Sehat Sewa Scheme, hence is stopped from filing the present complaint ; that the complainant has not placed complete and correct facts before this Forum and has intentionally with-held the material information from this Forum in order to get undue advantage ; that complainant has no cause of action to file the present complaint. On merits facts narrated in the complaint have been specifically denied and a prayer for dismissal of the complaint with cost was made .
6. In his bid to prove Smt.Kirpal Kaur,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.CW1/A, copy of identity card of Gurjit Singh Ex.C-1, copy of admit and discharge card Ex.C-2, copy of claim form for Bhai Ghanhya Sehat Sewa Scheme Ex.C-3, copy of legal notice dated 1.4.2015 Ex.C-4, copies of medicine bills Ex.C-5 to Ex.C-10, copies of the receipts Ex.C-11 to Ex.C-14, copy of patient bill dated 10.8.2014 Ex.C-15 and Ex.C-16, copy of Lab report Ex.C-17,C-18,C-18A and Ex.C-19, copy of discharge card alongwith essentialities Ex.C-20 and closed the evidence on behalf of complainant.
7. To rebut the aforesaid evidence Sh.S.S.Batra,Adv.counsel for opposite party No.1 tendered affidavit of Sh.Surinderrn Singh,Divisional Manager Ex.OP1/1, copy of letter dated 23.7.2015 Ex.OP1/2, copy of list of network hospitals Ex.OP1/3 and closed the evidence on behalf of opposite party No.1.
8. On the other hand Sh.Vipan Bhasin,Adv.counself for opposite party No.5 tendered affidavit of Dr.Sanjay Gulati, Prop. Ex.OP5/1 and also relied upon document Ex.C-3 claim form and closed the evidence on behalf of opposite party No.5.
9. Opposite parties No.2,3 & 4 did not appear to lead any evidence, as such opposite parties No.2,3 & 4 were ordered to be proceeded against ex-parte vide order dated 6.1.2016. But later on Sh.Sukhbir Singh, authorized representative on behalf of opposite parties No.2,3 & 4 appeared and he was permitted to join the proceedings at that stage vide order dated 22.4.2016.
10. We have heard the ld.counsel for the parties and have also gone through synopsis of written arguments submitted on behalf of the parties and have carefully gone through the record on the file.
11. Ld.counsel for the complainant has vehemently contended that the complainant was the member of Bhai Ghanhya Sehat Sewa Scheme and card was also issued by opposite party No.1 in his favour which is bearing No.MD15-BGSSS-00370986-S which is Ex.C-1. It is also not disputed that complainant suffered GE Hyponolacmic Shock and he was admitted in Shri Chuni Lal Memorial Gulati Hospital Chamyari Road, Near Gurdwara Jiwan Singh Ajnala District Amritsar on 5.8.2014 with the aforesaid disease. The complainant remained admitted in the abovesaid hospital upto 10.8.2014 and he was discharged on 10.8.2014. The admission card as well as discharge card is Es.C-2 on record. It is the case of the complainant that he informed the hospital authorities about the policy under the scheme of Bhai Ghanhya Sehat Sewa and submitted his identity card to them. The complainant incurred Rs. 28000/- on his treatment/hospital expenses . But,however, the hospital authorities illegally got the amount from the complainant in cash, whereas the medical treatment was required to be cashless. Opposite party No.5 in order to get the amount in cash wrongly mentioned that the complainant never showed or informed about BGSSS card with him. Whereas opposite party No.5 filled the claim form and signed the same. It was the duty of opposite party No.5 i.e. Chuni Lal Memorial Gulati Hospital, Chamyari Road, Ajnala to submit the claim directly to opposite party No.1 , but they did not do so. The complainant made the payment to the hospital authorities and submitted his claim. Claim was submitted by the complainant vide despatch No. 2298 dated 25.8.2014 to Assistant Registrar Cooperative Societies, Ajnala Amritsar, copy of the same is attached. The Cooperative Societies Ajnala raised some objections and after removal of the objections, complainant again submitted the treatment bill/claim vide despatch No. 4090 dated 15.9.2014 to Deputy Registrar Cooperative Societies, Amritsar within 36 days. But till date no reimbursement has been made and the claim has been dismissed on the plea that it was time barred. Copy of the repudiation letter accounts for Ex.OP1/2. The complainant has also produced on record copy of legal notice Ex.C-4, cash memos of Gulati Drug Store Ex.C-5 to Ex.C-10, copies of two bills dated 10.8.2014 Ex.C-15 & Ex.C-16,and Lab receipts dated 6.8.2014, 7.8.2014 and 9.8.2014 Ex.C-11, Ex.C-12 ,Ex.C-13 & Ex.C-14 respectively alongwith test reports dated 7.8.2014, 9.8.2014 and 5.8.2014, copies whereof are Ex.C-17, Ex.C-18,Ex.C-18A and Ex.C-19. It is further contended that complainant is entitled to get the amount of Rs. 28000/- reimbursed and his complaint may be allowed accordingly.
12. But , however, from the appreciation of the facts and circumstances of the case, the complainant has not adduced on record copies of claims sent vide despatch No.2298 dated 25.8.2014 and despatch No. 4090 dated 15.9.2014 allegedly sent to Deputy Registrar Cooperative Societies, Amritsar for proving the fact that claim was sent within time. However, the opposite parties have led evidence to prove that case for mediclaim reimbursement was sent by the complainant after 45 days from the date of discharge from the hospital. As per guide book at page 23, it is clearly stated that “claim from the provider hospital may not be settled and processed by the TPA, if received after 45 days from the date of discharge from the hospital” and “no claim from the beneficiary shall be entertained for processing and settlement by the TPA, if received after 45 days from the date of discharge from Govt.Hospital”. Copy of the guide book accounts for Ex.OP1/1. In the case in hand, the complainant has put-forward his claim before opposite party No.1 on 11.10.2014 which is after a lapse of 62 days from the date of discharge from the hospital. The complainant could very well produce the best evidence in his possession. But for the reasons best known to him, the complainant has purposely with-held this document from the scrutiny of the Forum. In such a situation adverse inference will have to be drawn against the complainant that had he submitted that record, it would have gone against him. The complainant has tried to place reliance on claim form dated 16.9.2014 Ex.C-3 to prove the fact that the claim was sent within the prescribed period. But mere signing the claim form on 16.9.2014, will not make out the case of the complainant that the claim was within time. Rather it was imperative to show that the claim form must reach the TPA within 45 days from the discharge of the patient from the hospital. There is nothing on record to prove the said factum and in such a situation, the stand of the opposite parties that the claim reached them after a lapse of 62 days from the discharge of the complainant from the hospital shall have to be believed. As per letter of repudiation Ex.OP1/2 the claim file reached TPA on 11.10.2014 i.e. after a lapse of 62 days of discharge of the complainant from the hospital whereas the mandatory period was 45 days. As such, opposite party No.1 has rightly repudiated the claim of the complainant. Consequently, instant complaint fails and the same is ordered to be dismissed accordingly. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated : 01.06.2016
/R/ ( S.S.Panesar )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
Member Member
