MRS. NEENA SANDHU, MEMBER

1.         This is an appeal filed by the OP No.2 i.e. National Insurance Company Limited  against order dated 6.4.2010 passed by District  Consumer Disputes Redressal Forum-II, UT, Chandigarh (for short hereinafter to be referred as District Forum) passed in complaint case No. 1067 of 2009.

2.            Briefly stated the facts of the case are that the complainant was insured with Medical Insurance Scheme having policy bearing No. 400104/46/08/85/00000096, Card No.901 1222 45 00020F, Soc Code 2245, with a validity from 1.10.2008 to 30.9.2009 issued under Bhai Ghanhya Sehat Sewa Scheme, by Medsave Healthcare (TPA) Ltd. and National Insurance Co. Ltd. (OPs No.1 and 2). The complainant deposited the premium on 8.9.2008 with Machhli Kalan Co-op Agri. Service Society Limited, Machhli Kalan (Ropar) i.e. OP No.4, which was further forwarded by the said society to the insurer. The complainant suffered acute heart problem on 2.10.2008 and admitted in Dayanand Medical College and Hospital, UNIT – Hero DMC Heart Institute, Ludhiana for treatment. The complainant remained in hospital  for his treatment from 2.10.2008 to 10.10.2008 and he was discharged on 10.10.2008. During this period, the complainant’s heart was operated in the said hospital and the details of the complete medical record of the hospital was attached with the complaint as Annexure C-2. The complainant incurred an expenditure of Rs.1,73,935/- for his treatment.  After his discharge, the complainant lodged his claim with the Ops under their Medical Insurance Scheme for medical expenses. It was submitted by the complainant that cashless medical facility was not afforded by the hospital to the complainant as he was not having his membership card on the date of his admission in the hospital, as the said card was delivered late to the complainant by the insurer itself.  The membership card issued by the insurance company was valid from 1.10.2008 to 30.9.2009 and was received by the complainant on 14.10.2008. and no policy of the insurance was accompanying this card which was handed over to the complainant.  The booklet issued by the Ops “Bhai Kanhaiya Sehat Sewa Scheme Punjab- Guide Book and List of Network Hospital” was given to him at an even later stage.  The complainant after his discharge from hospital duly represented his case with the third party Administrator “Medsave” (OP No.1) acting on behalf of insurer (OP No.2) and lodged his claim for reimbursement of the amount incurred by him on his treatment. The complainant represented his case to the Ops 1 & 2 for re-imbursement of the amount incurred on his treatment under the Medical Insurance Policy but no fruitful result was received from the side of OPs. Ultimately on 7.5.2009 the son of the complainant visited the office of OP No.1, he was shocked to know that the claim of the complainant was rejected and the reason for rejection of the claim was “Rejected as reimbursement allowed in only Government Hospital”.  It was further submitted by the complainant that in the guidebook issued by the Insurer, the name of the DMC Hospital duly mentioned at Serial No.126 in the list of Network Hospitals approved by the insurer for taking treatment under the Medical Insurance Policy. The complainant approached and requested the OPs time and again for the redressal of his grievances but to no avail. The above said act of OPs amounts to deficiency in service and hence, the complaint was filed.

3.         Reply was filed by OPs No.1 and 2 and stated that complainant is not entitled to any reimbursement since all procedures with regard to his medical treatment were carried out in Hero DMC Heart Institute, Ludhiana and they rejected the claim on the ground that for the treatment of Acute Myocardial Infection, the reimbursement was allowed only in Government Hospitals and not in other hospitals where cashless facility was to be given by the empanelled hospitals. The Membership card also issued to the complainant, which the complainant has not presented the card at the time of his treatment and this is a lapse on the part of complainant and not OPs No.1 and 2.  They pleaded that though Hero DMC Heart Institute, Ludhiana is on the panel of the OP No.1 but it was required to give cashless facility to the beneficiaries only if the card was shown to them and as per the scheme, the reimbursement is allowed only in Government Hospitals. They further pleaded that there was no delay on the part of answering OPs in delivery of Membership Card to the complainant and in case, the card cold not receive by the complainant, he contacted the OP No.1 at their Toll Free Number. It was further stated that the complainant could also collect the Policy / Booklet from the Co-operative Society at any time and pleaded that there was no deficiency in service on their part and prayed for dismissal of the complaint.

4.         Notice served upon OP No.3 but despite notice, nobody appeared on behalf of OP No.3. Hence, OP No.3 was proceeded against exparte on 6.10.2009.

5.         Reply filed by OPs No.4 and 5 and submitted that the complainant had deposited the premium amount as prescribed by Ops 1 & 2 with the answering OP no.5 and further submitted that the insurance cards were received by the answering OPs, after the date of commencement of the insurance policy, from the OPs. The said car was received and distributed by the answering OP No.5 and distributed among its members on 6.10.2008. It was pleaded that since the complainant was not available in the village on the said date, due to which his card could not be delivered to him on the said date. It was further submitted that since the Guide Book mentioned herein were not supplied by the OPs to the distributed along with the insurance cards and cards alone were distributed. However, the complainant along with other members of the society were duly made aware about all the terms and conditions of the policy. There is no cause of action against the answering OPs as the OPs No.1 and 2 were the only insurers of the claim and pleaded that there was no deficiency in service on the part of answering OPs and prayed for dismissal of the complaint.

6.         The parties led their evidence in support of their contentions.

7.         The learned District Forum allowed the complaint and direct the OPs 1 and 2 to reimburse the entire amount of Rs.1,73,935/- incurred by the complainant on his treatment at DMC Hospital, Ludhiana as per treatment chart (Annexure C-3), to pay a sum of Rs.50,000/- as compensation for mental agony and harassment and also Rs.5000/- as costs of litigation. The Ops 1 & 2 were directed to comply with the above order within a period of six weeks from the date of the receipt of the order, failing which the Ops 1 & 2 liable to pay interest @ 18% p.a. on the amount of Rs.2,23,935/- from the date of this order till the actual date of realization. As there was no deficiency in service on the part of the Ops No. 3,4 and 5, the complaint qua them also dismissed.

8.            Aggrieved by the order passed by the learned District Forum, the present appeal has been filed by the OP No.2 i.e. National Insurance Company Limited. Sh.Gaurav Bhardwaj, Advocate has appeared on behalf of appellant and nobody has appeared on behalf of OPs.

9.         In appeal, the appellant submitted that the stand of the appellant as well as Medsave health Care (TPA) Ltd. i.e. respondent No.2 was that the reimbursement sought by respondent No.1 was admissible to him only if he had obtained treatment in a Government Hospital. It was further stated that the membership card which was issued to respondent No.1 was not presented at the time of treatment. This was lapse on the part of respondent No.1. It was also stated that Hero DMC Heart Institute, Ludhiana was on the penal of respondent No.2 but it was required to give cashless facility to the beneficiaries only if the card was shown to the hospital at its OPD Desk and there was no delay in delivery of the membership cards to the beneficiaries and in case the respondent No.1 had not received the membership card from his respective society, he could have contacted the respondent No.2 at its toll free number. In the reply of respondents No.4 and 5 it was submitted that since respondent No.1 was not available in the village on the said date, therefore, the card could not be delivered to him. It stands admitted that the appellant had sent the card to the beneficiaries in time and since the respondent No.1 was not available, the card sent to the society could not be delivered to respondent No.1. At the time of availing the treatment, the respondent No.1 did not show the card at the OPD desk of the respondent No.3 hospital and as such there was no question of providing him with cashless treatment. The learned District Forum has ignored the submissions of the appellant and has arbitrarily burdened it with a total sum of Rs.2,23,935/- with interest @ 18% p.a. from the date of order till actual realization. It has been submitted by the appellant that the maximum limit which could have been granted to the respondent No.1 was Rs.1,50,000/- only and the learned District Forum has in a most arbitrary manner awarded a sum of Rs.1,73,935/- to respondent No.1 being the expenditure incurred by him on his treatment. The respondent No.1 was not entitled to any compensation because the lapse was absolutely on he part of respondent no.1. It is the basic ingredient of the policy issued to respondent No.1 and which comes out from the terms and conditions of the policy that ‘No Card’ ‘No Cashless Service’. In the present case, the learned District Forum has ignored the terms and conditions of the policy. Hence, it is prayed that the appeal may kindly be allowed and the impugned order passed by the learned District Forum may kindly be set aside.

10.       It is an admitted fact that the complainant was insured with medical insurance scheme issued under Bhai Ghanhya Sehat Sewa Scheme, by Medsave Healthcare (TPA) Ltd. And National Insurance Company Limited with a validity from 1.10.2008 to 30.9.2009. The first premium was deposited by the complainant on 8.9.2008 with OP No.4. On 2.10.2008 the complainant suffered acute heart problem and was admitted in DMC Heart institute, Ludhiana for treatment. He remained in the hospital for his treatment from 2.10.2008 to 10.10.2008 and complainant incurred an expenditure of Rs.1,73,935/- for his treatment but when the complainant lodged his claim with the OPs, the OPs repudiated the claim and stated that “Rejected as reimbursement allowed in only Government Hospital”. The learned District Forum allowed the complaint and directed Ops no.1 and 2 to reimburse the entire amount of Rs.1,73,935/- incurred by the complainant on his treatment, Rs.50,000/- as compensation for mental agony and harassment and Rs.5,000/- as costs of litigation.

11.       Even we are of the opinion that there is a definitely deficiency in service on the part of OP by repudiating the claim of the complainant. In this case as per the guide book issued by the insurer the name of the DMC Hospital, Ludhiana is at the serial No. 126 of the list of the Network hospital approved by them for taking treatment under the medical insurance policy.  Hence, the appellant/OP No.2 is at fault and there is a deficiency in service on their part by repudiating the claim of the complainant and the learned District Forum has directed to reimburse the entire amount of Rs.1,73,935/- incurred by the complainant on his treatment at DMC Hospital, Ludhiana as per treatment Chart Annexure C-3. During the course of arguments, the learned counsel for the appellant/OP No.2 drew our attention to Clause No. 1.9 of the Guide Book Punjabi translation of which runs as follows.

1.9               Sub limit of the total insurance amount.

S.No.           Bimari/Illaj                       Fixed Sub Limit

Serial No.1 to 4 are not relevant.

5.                 Heart Operation              Rs.1,50,000/- and 50% of the                                                                       expenditure in excess of Rs.1.5                                                                    lacs to Rs.2 lacs.

Then comes clause No.1.9.5 the Punjabi translation of which is as follows.

1.9.5            In case of treatment/operation of the heart problems the beneficiary of this scheme is entitled upto a sum of Rs.1,50,000/- and if the expenses incurred for the said treatment is more than Rs.1.5 lacs then the member would be entitled to 50% of the amount in excess of Rs.1.5 lacs to Rs.2 lacs. The entire expenditure in excess of Rs.2 lacs would be borne by the beneficiary.

            In the present case the expenses incurred by the complainant on the treatment are more than Rs.1.50 lacs and less than Rs.2 lacs, hence as per Clause 1.9.5 the complainant is entitled for the reimbursement of the amount of Rs.1,50,000/- plus half of the amount of Rs.23,935/- i.e. Rs.11967.50 paise say Rs.11,968/- i.e. a total of Rs.1,61,968/-. In our opinion the learned District Forum has erred in awarding the full amount of Rs.1,73,935/-

12.       After considering the issue regarding the quantum of compensation as agitated by the appellant, we are of the opinion that total expenses incurred by the complainant on the treatment is Rs.1,75,935/- , out of which the OP No.2 is entitled to reimburse an amount of Rs.1,61,968/- as per Clause 1.9.5. Hence, relatively the compensation to the tune of Rs.50,000/- for mental agony and harassment to the complainant seems to be on the higher side. The law has already been settled on this point that compensation should be in proportionate to the amount of claim.  Therefore, with this reason we are of the opinion that in this case the compensation of Rs.20,000/- will be appropriate to meet the ends of justice.

13.       In view of the foregoing discussion, we set aside the order to the extent as discussed above and partly allow the appeal filed by the OP No.2 i.e. National Insurance Company with the following directions:-

1.         To reimburse an amount of Rs.1,61,968/- along with interest @ 8% p.a. from the date of repudiation of the claim till its realization.

2.         To pay a sum of Rs.20,000/- as compensation to the complainant along with litigation expenses of Rs.5,000/-.

            The appellant is directed to comply with the aforesaid order within 30 days from the date of receipt of copy of this order, failing which interest @ 12% p.a. will be charged w.e.f the date of filing of the complaint before the learned Diatrict Forum i.e. from 29.7.2009 till its payment to the complainant.

14.       Copies of this order be sent to the parties, free of charge.

Pronounced.                                                                           

12^th October, 2010.