BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.409 of 2016

Date of Instt. 21.09.2016

Date of Decision: 21.03.2018

Puneet Madhar son of Sh. Kamal Kumar R/o H. No.1138, Urban Estate-1, Jalandhar.

..........Complainant

Versus

1. Chawla Heart Care Center, Near Guru Nanak Mission Chowk, Jalandhar through its Adm. Officer Sh. Dinesh Sharma.

2. Religare Health Insurance Company Ltd., GYS Global Plot No's.A-3, A-4 & A-5, Sector No.125, Noida-201301, Uttar Pardesh through its Authorized Signatory.

3. Religare Health Insurance Company Ltd. Jalandhar near Oriental bank of Commerce opposite to the Commissioner Jalandhar Division office through its Authorized Signatory.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Harvimal Dogra (Member)

Present: Sh. Vikas Sharma, Adv Counsel for the Complainant.

Sh. TK Badhan, Adv and Sh. BS Bhatia, Adv Counsels for OP No.1.

Sh. RK Sharma, Adv Counsel for the OP No.2 and 3.

Order

Karnail Singh (President)

1. This complaint is filed by the complainant, wherein alleged that the he is serving as Radio Frequency Engineer with Impact Info Tech Pvt. Ltd., 9, Nisigandha Apartments, 17, Navarajasthan Co. Op. Hsg. Society, Senapati Bapat Road, Pune since June 2014. The company has provided the complainant cashless health treatment facility through the Religare Health Insurance Company Ltd. The policy cover No.10524008, which is valid at the time of treatment from the OP No.1 and this fact is specifically mentioned in the offer letter of the appointment of the complainant. The impact Infotech Company is regularly contributing from the salary of the complainant and is remitting the same amount to the Religare Company Ltd. every month. To avail this facility, the Religare Company has given the complainant RHID No.53167864, Member ID IMPTEL 1286. It is pertinent to mention here that the OP No.1 is empanelled with OP No.2 i.e.Religare Health Insurance Company Ltd for the purpose of treatment

2. That on 08.03.2016 at about 04:00 P.M., the complainant felt unwell and came for checkup and treatment was given by the OP No.1. The complainant complained of palpation and chest heaviness. Dr. Raman Chawla of OP No.1, after examining the complainant, vide OPD 15181 advised him for admission to the hospital and he was admitted on 09.03.2016. Since the complainant was entitled for cashless treatment, accordingly RHID card No.53167864 was produced to Shri Dinesh Sharma Adm. Officer of the Chawla Heart Care Center. As desired by him copies of the Card and the Aadhar Card were also given to him. However, inspite of giving all these documents, the complainant was flatly refused cashless treatment by the OP No.1 and complainant was insisted upon to firstly deposited Rs.10,000/- as a security with the hospital and accordingly, the complainant deposited the said amount i.e. Rs.9781/- in advance for the treatment taken from the empanelled hospital as per law because the complainant has no other alternative. Thereafter, the complainant was kept in ICU by the OP No.1 for about three hours and thereafter, he was shifted to the Railing Lounge, where no regular medical officer/attendant were provided. On 10.03.2016 at about 10:00 A.M., the complainant was discharged from the hospital, vide IPD No.2025. On that day, the father of the complainant again requested the OP No.2 to refund the amount of Rs.9781/-, but the said request of the complainant was refused by the OP No.1, by saying that the case of the complainant is to be sent to M/s Religare Health Insurance Company Ltd. for approval and only if the approval is accorded, then the amount will be credited in the hospital account, the advance amount taken from the complainant by the OP No.1 shall be refunded to the complainant thereafter, but after that the father of the complainant number of times visited the hospital of the OP No.1, but they lingering the matter on one pretext or the other and then on 13.03.2016, the father of the complainant again went to hospital of OP No.1 to get refund the amount, the father of the complainant was told by Sh. Gajanand Gupta that necessary approval has been received and in the meanwhile, Shri Dinesh Sharma also came there, who stated that the moment amount is credited in hospital account by the Religare Health Insurance Company, the amount of the complainant shall be refunded. He further stated that it will still take 30 to 45 days time. The complainant contacted the branch office of M/s Religare Health Insurance Company Ltd., Jalandhar ,near Oriental Bank of Commerce, opposite to the Commissioner Jalandhar Division Office. The matter was brought to the notice of concerned person Mr. Khanna, who told that the OP No.1 had sent a bill of Rs.26,660/- to the company for approval, but the company has given the guarantee approval of Rs.15,000/- only vide AL No.80068176 dated 12.03.2016 to the hospital. Mr. Khanna also called Shri Dinesh Sharma Adm. Officer on telphone in the presence of the complainant and his father and called upon him to refund the amount collected from the complainant as per company's MOU and the approval granted. But inspite of all this, the OP No.1 failed to refund the amount collected from the complainant. It is also pertinent to mention here that when the OP No.1 was asked as to on what basis the OP No.1 has sent an inflated bill of Rs.26,660/- to the company for approval, whereas the original bill amount was much less, no satisfactory reply was given by the OP No.1. Thereafter, the complainant brought the whole matter to the notice of Head Office of M/s Religare Health Insurance Company, Noida twicely, vide email dated 16.03.2016 and 24.04.2016, but even then the genuine and legitimate grievance of the complainant was not redressed by the OPs. Then on 04.05.2016, the complainant again contacted the customer care centre of the OP No.2. The dealing hand Mr. Ankur told him that Rs.5950/- has been credited to the hospital on 29.03.2016 and asked him to collect the same from the OP No.2. Accordingly, the complainant went to hospital, but the OP No.2 paid only Rs.5050/- to the complainant finding foul play being played by Mr. Dinesh Sharma, the complainant sent an email on 10.05.2016 to the customer care centre of the OP No.2 with a request to supply him a detail of actual amount sanctioned. The company on 23.05.2016 mailed the letter dated 30.03.2016, vide which they settled the amount of Rs.5355/- only against the actual amount of Rs.9781/- spent by the complainant. Thus, in the spirit of the aforesaid letter the complainant again came to the OP No.1 on 25.05.2016 to collect the remaining amount of Rs.305/-. As per law, the OPs were bound to provide cashless treatment to the complainant, but the OPs failed to provide the said facility to the complainant to top it, the OPs did not even refund the full amount spent by the complainant on his treatment, which is clear cut deficiency in service on the part of the OPs and and as such, necessity arose to file the present complaint the complainant and prior to that a legal notice was served to the OP, but all in vain and ultimately, this complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to admit the claim of the complainant pertaining to the medical expenses borne by the complainant to a total sum of Rs.4800/- and to release the same to the complainant and OPs be also directed to pay compensation for harassment, to the tune of Rs.2,00,000/- with interest and litigation expenses of Rs.11,000/-.

3. Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared and filed written reply, whereby contested the complaint by taking preliminary objection that the complainant has no locus-standi to file the present complaint against answering OP. It is further averred that the complainant has suppressed and concealed the material facts from the Forum and therefore, the complaint is liable to be dismissed. On merits, the taking of insurance policy from Religare Health Insurance Company is not denied even the matter in regard to admission of the complainant in the hospital and getting a treatment, is also admitted, but the other averments as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.

4. OP No.2 and 3 filed its separate written reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable against the answering OPs and further alleged that the present complaint on receipt request of pre-authorization for cashless treatment from the hospital on 11.03.2016, the answering OP immediately, vide letter dated 12.03.2016, authorized the hospital for the cashless treatment of the complainant to the extent of Rs.15,000/-, but as per record, by that time, the complainant had been discharged from the hospital and hospital had received the charges of the treatment. However, on the basis of the documents submitted, the answering OPs had credited an amount of the Rs.5355/- in the account of the OP No.1 through NEFT on 29.03.2016 and the OP No.1 was informed, vide letter dated 30.03.02016 alongwith Annexures I and II showing the details of payment and deductions. The answering OPs are still ready to consider the remainder claim of the complainant as if any subject to submission original receipts of the expenses on treatment with explanation for delayed submission and on submission of such original documents, the OPs No.2 and 3 shall process the claim, if any as per terms and conditions of the insurance policy and further alleged that there is no deficiency in service or unfair trade practice on the part of the answering OP No.2 and 3. On merits, the taking of insurance policy as well as getting a treatment from OP No.1 and submitting a medical claim, is admitted, but the remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

5. In order to prove the case of the complainant, complainant himself tendered into evidence his duly sworn affidavit Ex.CW1/A alongwith some documents Ex.C-1 to Ex.C-12 and then closed the evidence.

6. Similarly, the Attorney of the OP No.1 tendered into evidence his own affidavit Ex.OPA1 along with some documents Ex.OP1/1 to Ex.OP1/7 and closed the evidence.

7. Similarly, counsel for the OP No.2 and 3 tendered into evidence affidavit of Sh. Rajdeep Khurana as Ex.OP2/A along with some documents Ex.OP2/1 to Ex.OP2/12 and closed the evidence.

8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

9. After considering the over all circumstances as came out from the pleadings of the party, that the complainant had admittedly obtained an insurance policy from OP No.2 and 3 and it is also not denied that the OP No.1 is an empanelled hospital of the Insurance Company No.2 and 3 and further it is also not in dispute that the complainant remained admitted in the hospital of OP No.1 from 09.03.2016 to 10.03.2016 and at the time of admission, the complainant alleged that he submitted a copy of insurance policy card along with Aadhar Card for cashless health treatment from the OP No.1 and accordingly, the OP No.1 got deposited an amount of Rs.2000/- on 09.03.2016 as a security amount, it cannot be considered as treatment charges and further complainant purchased some medicines on 09.03.2016 for a sum of Rs.981/- and admittedly, as per documentary report, the medical insurance claim of the complainant was sent by OP No.1 on 11.03.2016 to the OP No.2 and 3 and accordingly, the OP No.1 was allowed and gave surety for payment of the treatment upto Rs.15,000/-, that assurance was given on 12.03.2016, but before that date, the complainant was discharged from the hospital i.e. on 10.03.2016 and as such, the OP No.1 has no other alternative except to receive the medical charges and accordingly, the OP No.1 got deposited a sum of Rs.6800/- on 10.03.2016 and thereafter, number of written complaints as well as personal visit was given by the complainant or his father for getting refund of the said amount from OP No.1 and ultimately, the OP No.2 and 3 settled the medical claim of the complainant on 30.03.2016, vide letter Ex.C-7, to the tune of Rs.5355/- and the said amount was paid by the OP No.1 by way of two installments i.e. at the first instance Rs.5050/-, then Rs.350/- and as such, we are of the considered opinion that there is no negligence or deficiency in service on the part of the OP No.1, therefore, complaint of the complainant qua OP No.1 is dismissed.

10. Admittedly, there is a negligence and deficiency in service on the part of the OP No.2 and 3, who despite getting a detail of treatment, obtained by the complainant from OP No.1, settled the medical insurance claim of Rs.5355/-, whereas the complainant has paid from his own pocket a sum of Rs.9781/-, vide photostat receipt of the same Ex.C-3 dated 09.03.2016 for Rs.2000/- Receipt Ex.C-4 dated 09.03.2016 for amounting to Rs.981/- and Receipt Ex.C-5 dated 10.03.2016, for amounting to Rs.6800/-, in total Rs.9781/-. We are considered opinion that the complainant is entitled for the aforesaid amount, which was paid by him from his own pocket and produced the receipts, issued by hospital as well as Medical Store, but despite the receipts of the aforesaid amount, the said amount has not been given by the OP No.2 and 3 rather settled the claim in a lesser amount of Rs.5355/- and as such, we find that the complainant is entitled for the remaining amount of Rs.4026/-. As the complainant has already received Rs.5355/- ,out of the total deposited amount of Rs.9781/-. The complainant is also entitled for interest on the aforesaid amount as well as for compensation and litigation expenses.

11. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OP No.2 and 3 are directed to pay the remaining medical expenditure amount of Rs.4026/-, to the complainant with interest @ 9% per annum from the date of discharge from the hospital i.e. 10.03.2016, till realization and further OP No.2 and 3 are directed to pay compensation for harassment to the complainant, to the tune of Rs.20,000/- and also directed to pay litigation expenses of Rs.5000/-.The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Harvimal Dogra Karnail Singh

21.03.2018 Member President