DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/129/2019

Date of Institution : 04.09.2019

Date of Decision : 09.03.2020

Pritam Kaur aged about 62 years wife of Gurcharan Singh resident of Maur Nabha-148108, Tehsil Tapa, District Barnala. …Complainant

Versus

1. Bhai Ghanya Trust, Punjab State Co-op Bank, SCO 175-187, Sector 34-A, Chandigarh-160022 through its Managing Director/Chairman.

2. Bhai Ghanya Sehat Sewa Centre, Punjab State Co-op Bank, SCO 175-187, Sector 34-A, Chandigarh-160022 through its Managing Director/ Chairman.

3. United India Insurance Co. Ltd., Regd. and Head Office: 74, Whites Road, Chennai-600014 through its Managing Director.

4. MD India Health Insurance TPA Pvt. Ltd., Maxplro Info Park, D-38, Industrial Area, Phase-1, Mohali-160055 through its Managing Director.

5. Orthonova Joint and Trauma Hospital (P) Ltd., Nakodar Road, Near Nari Niketan, Jalandhar City-144040 through its CEO.

6. The Secretary, The Mouran MPCASS, Maur Nabha-148108, Tehsil Tapa, District Barnala. 

…Opposite Parties

Complaint Under Consumer Protection Act, 1986.

Present: Sh. JS Dhaliwal counsel for the complainant.

Opposite parties No. 1, 2 and 4 exparte. 

Sh. AK Jindal counsel for opposite party No. 3. 

Sh. RS Mehta counsel for opposite party No. 5.

Sh. JS Mann counsel for opposite party No. 6. 

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

(ORDER BY SHRI KULJIT SINGH, PRESIDENT):

    The complainant namely Pritam Kaur has filed the present complaint under the Consumer Protection Act 1986 (hereinafter referred as Act) against Bhai Ghanya Trust, Chandigarh and others. (hereinafter referred as opposite parties). 

2. The facts leading to the present complaint are that she is the member of opposite party No. 6 and purchased insurance policy from opposite party No. 1 through opposite party No. 6 and ID Card No. MD15-BGSSS-11128504-M has been issued to her. 

3. It is further alleged that the complainant got herself treated from opposite party No. 5 and she remained admitted from 28.10.2018 to 31.10.2018 and was operated upon during the said period. She further submitted that an amount of Rs. 1,52,492/- was spent by the complainant on her treatment. At the time of admission in the hospital of the opposite party No. 5 she showed her ID card to the opposite party No. 5 upon which opposite party No. 5 told the complainant that the said ID card was not in proper form upon which the complainant approached the opposite party No. 6 who assured the complainant about the genuineness of the said card and advised the complainant to file her claim with the concerned authority, so the complainant paid the said amount.

4. It is further alleged that the complainant lodged her claim with opposite party No. 4 for refund of the amount of Rs. 1,52,492/- spent by her on her treatment upon which the complainant was asked to submit the original bills. Accordingly, the complainant submitted the original bills with the opposite party No. 4 but till today no amount has been refunded to the complainant by the opposite party No. 4 which amounts to deficiency in service and unfair trade practice on the part of the opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to refund Rs. 1,52,492/- spent by the complainant on her treatment alongwith interest at the rate of 15% per annum.   

2) To pay Rs. 1,00,000/- as compensation on account of mental agony and harassment.

3) To pay Rs. 20,000/- as litigation expenses.  

4) Any other relief this Forum deems fit. 

5. The opposite parties No. 1, 2 and 4 not appeared before this Forum despite service through RC AD so the opposite parties No. 1, 2 and 4 were proceeded against exparte vide order dated 21.10.2019. 

6. Upon notice of complaint, opposite party No. 3 filed written version taking legal objections on the grounds that the complainant never approached the answering opposite party nor lodged/submitted requisite documents with the answering opposite party, so the complaint is premature. Further, the complaint is objected on the grounds of no locus standi or cause of action, concealment of material facts and no jurisdiction.  

7. On merits, the opposite party No. 3 submitted that without lodging the requisite documents with the answering opposite party they cannot settle the claim of the complainant and cannot filed a detailed reply. The answering opposite party never received the claim of the complainant. When the complainant failed to submit requisite documents with the answering opposite party then question of deficiency of service and unfair trade practice on the part of the opposite party does not arise. Lastly the opposite party No. 3 prayed for the dismissal of the present complaint with costs. 

8. The opposite party No. 5 filed written reply in which they submitted that patient got admitted in this hospital and present Bhai Ghanya Sehat Sewa Scheme Card No. MD-15-BGSS-11128504 on 26.10.2018 but as the hospital is not on the list of Bhai Sehat Sewa Scheme so they intimated to MD India TPA vide claim ID No. MD100010804 on 26.10.2015 for approval of procedure immediately. It is admitted that complainant is having the card of Bhai Ghanya Sehat Sewa Scheme. Lastly, the opposite party No. 5 prayed for the dismissal of the present complaint.

9. The opposite party No. 6 also filed written reply taking legal objections on the grounds of not maintainable, no cause of action and locus standi, complainant is not a consumer and complaint being time barred. 

10. On facts the opposite party No. 6 submitted that complainant neither informed the answering opposite party nor she ever was in touch with the answering opposite party regarding the payment. She never contacted answering opposite party and not specific allegation is made against the answering opposite party. Lastly, they prayed for the dismissal of the present complaint with costs.

11. In support of her complaint, the complainant tendered into evidence her affidavit Ex.C-1, copy of ID card Ex.C-2, copy of bills  Ex.C-3 to Ex.C-16, copy of legal notice Ex.C-17, postal receipts Ex.C-18 to Ex.C-23, copy of Aadhaar Card of Pritam Kaur Ex.C-24, copy of Guide Book Ex.C-25, copy of complete guide book Ex.C-26, copy of Member Enrollment Form Ex.C-27, copy of Dispatch list Ex.C-28 and closed the evidence.

12. To rebut the case of complainant, opposite party No. 3 tendered in evidence copy of mail dated 17.10.2019 Ex.OP-3/1, affidavit of Baldev Singh Ex.OP-3/2 and closed the evidence. The opposite party No. 5 tendered in evidence affidavit of Dr. Harpreet Singh CEO Ex.OP-5/1 and closed the evidence. Opposite party No. 6 tendered in evidence affidavit of Lachhman Singh Ex.OP-6/1, resolution Ex.OP-6/2 and closed the evidence.

13. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by the complainant and opposite parties No. 3, 5 and 6. 

14. It is admitted fact between the parties that the complainant that the complainant is the member of the Bhai Ghanya Sehat Sewa Scheme vide her Card No. MD15-BGSSS-11128504-M Ex.C-2 and she was insured under this scheme. From copy of Guidebook and List of Network Hospitals Ex.C-26 it is proved on the file that under this scheme family of the  member of the Cooperative Society Maur Nabha was insured for Rs. 2,00,000/- per year on the basis of floater. Further, from copy of Member Enrollment Form Ex.C-27 the complainant Pritam Kaur is the mother of the main member of the family Jagsir Singh who paid the premium of Rs. 3,481/- for this insurance scheme. 

15. The opposite party No. 5 admitted in their written version that patient got admitted in hospital bearing card No. MD15-BGSSS-11128504 which belongs to the complainant. The opposite party No. 5 denied in their written version that hospital is not on the list of Bhai Sehat Sewa Scheme but from the copy of Guide Book and List of Network Hospitals Ex.C-26 it is proved on the file that the hospital of opposite party No. 5 Orthonova Joint and Trauma Hospital Private Limited, Nakodar Road, Near Nari Niketan, Jallandhar is the hospital under the network hospitals at Jallandhar under Bhai Ghaniya Sehat Sewa Scheme for 2018-2019. In this way, it is proved on the file that opposite party No. 5 concealed true facts from this Forum. However, they admitted that they intimated the opposite party No. 4 on 26.10.2018 for approval of procedure immediately. 

16. The complainant deposed in her affidavit Ex.C-1 that she spent Rs. 1,52,492/- for her treatment for the replacement of joint and to support this version the complainant tendered in evidence copies of bills and receipts Ex.C-3 to Ex.C-16. But as per copy of Guide Book Ex.C-26 for joint replacement treatment the insured amount is Rs. 1,00,000/- subject to the age of member should be more than 60 years. In the complaint and affidavit of complainant Ex.C-1 the age of the complainant is mentioned as 62 years which fact is not denied by any of the opposite parties. 

17. From the copy of the email dated 17.10.2019 Ex.OP-3/1 which was written by the opposite party No. 4 to opposite party No. 3 it is mentioned that case of Pritam Kaur Card No. MD15-BGSSS-11128504 was reported to our office from opposite party No. 5 for Bipolar Hip Arthroplasty procedure on 26.10.2018 at 2.51 PM. It is further mentioned in this email Ex.OP-3/1 that our office processed the cashless request from hospital at 26.10.2018 at 4.10 PM and asked for following documents i.e. Clear X-ray report of Pritam Kaur and Consultation letter of Pritam Kaur by treating doctor which were necessary to process cashless request. But they did not receive any reply from the hospital against required documents due to which cashless request was closed due to no response from opposite party No. 5 even after raising the query on designated web portal for one year. It is also mentioned in this report that cashless request was later closed on 14.10.2019 after policy expiry. The opposite party No. 3 also filed copy of query which was sent to opposite party No. 5 for required documents. The opposite party No. 5 never disclosed any fact about this query and concealed the same from this Forum. It is admitted by the opposite party No. 5 in written arguments that thy replaced the joint of the complainant in their hospital. In these arguments they admitted that they have charged the amount from the complainant and this thing is also clear from the copies of bills and receipts Ex.C-3, Ex.C-5, Ex.C-6, Ex.C-13, Ex.C-14 and Ex.C-16. From all the documents on the file one thing is clear that the complainant had replaced her joint from the opposite party No. 5 by paying the amount to them and has not received any amount from the insurance company. But from the copy of email Ex.OP-3.1 that cashless request of the complainant cannot approved due to the fault and greed on the part of the opposite party No. 5 who had not sent the required documents to the opposite party No. 4 for approval of cashless request even up to the policy expiry. So, in our view in the present complaint the opposite party No. 5 is deficient in providing service to the complainant and they play unfair trade practice with the complainant for which they are liable. 

18. In view of the above discussion and copy of email dated 17.10.2019 Ex.OP-3/1 the present complaint is partly allowed against the opposite party No. 5. Accordingly, the opposite party No. 5 i.e. Orthonova Joint and Trauma Hospital Private Limited, Jalandhar is directed to pay Rs. 1,00,000/- (One Lac Only) to the complainant on account of deficiency in service and unfair trade practice on their part due to which the cashless request of the complainant was closed by the opposite parties No. 3 and 4. However, the opposite party No. 5 can recover this amount from the opposite party No. 3 i.e. United India Insurance Company Limited, Chennai by due course of law, if so advised. The opposite party No. 5 is also directed to pay Rs. 7,000/- to the complainant as consolidated amount of compensation for mental tension, harassment and litigation expenses. The opposite party No. 5 is also directed to pay Rs. 3,000/- as costs in the Consumer Legal Aid Account maintained by this Forum. Compliance of the order be made within the period of 30 days from the date of the receipt of the copy of this order, failing which the opposite party No. 5 is directed to pay the above mentioned amount of Rs. 1,00,000/- alongwith interest at the rate of 6% per annum from the date of order till actual realization. Copy of this order be supplied to the parties free of costs. The file be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN FORUM:

  9th Day of March 2020

 

 

            (Kuljit Singh)

            President

              

(Tejinder Singh Bhangu)

Member