BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 91 of 2018
Date of Institution: 8.2.2018
Date of Decision: 11.2.2019
Amrik Singh son of Sh.Ujjagar Singh aged 73 years, resident of Village Roran Wala Kalan, District Amritsar, Punjab 9981363290
Complainant
Versus
- M.D.India Health Insurance TPA Private Limited, through its Managing Director having office at Mohali Towers, Ist Floor, Plot No. F-539, Phase 8-B, Industrial Area, Airport Road, Mohali 160071
- Reliance General Insurance Co.Ltd. through its MD, having its registered office at H-Block, Ist Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai 400710
- Corporate Hospital, Batala Road, Tehsil & District Amritsar
Opposite Parties
Complaint under section 12 & 13 of the Consumer Protection Act.
Present: For the Complainant: Sh.G.S. Randhawa, Advocate.
For Opposite Party No.2: Sh.R.P.Singh,Advocate
For Opposite Parties No.1 & 3 : None
Coram
Sh.Charanjit Singh, President
Mr.Anoop Sharma, Member
Ms.Rachna Arora, Member
Order dictated by:
Sh.Charanjit Singh, President
1. Sh. Amrik Singh complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, on the allegations that the complainant availed Bhai Ghanhya Sehat Sewa Scheme by paying Rs. 2000/- to opposite party No.2 and opposite party No.2 insured the complainant for various diseases . The complainant felt severe pain in his left knee in the month of October 2017 and consulted the doctor at “Corporate Hospital” at Amritsar , who referred the complainant for knee replacement surgery. The complainant asked the Corporate Hospital ,Amritsar about the cost of the surgery and told the said hospital that he is medically insured through Insurance policy of opposite party No.2 and also told the hospital authorities that their hospital is on the panel of hospitals of opposite parties No.1 & 2 . The complainant also asked the hospital authorities to get approval of the treatment of the complainant from opposite party No.1 and 2 for the surgery of the knee of the complainant. The hospital authorities applied for the approval of the treatment of the complainant through complainant by calling the representative of opposite parties NO.1 & 2 at the hospital. Opposite parties No.1 & 2 assured the complainant as well as hospital authorities that the approval will be given by them within 10 days , but inspite of repeated request , opposite parties did not give any approval and the treatment of the complainant could not be undertaken, as such the complainant had to suffer severe pain due to non replacement of knee and treatment of the knee. Complainant also served upon legal notice dated 8.1.2018 upon opposite party No.1, but no reply was given by opposite party No.1 . The act of the opposite parties by not giving approval for the treatment of the complainant amounts to deficiency in service. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite parties be directed to approve the treatment of the complainant through the Insurance policy scheme immediately ;
(b) Compensation to the tune of Rs. 20000/- alongwith litigation expenses to the tune of Rs. 10000/- may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party No.2 appeared and filed written version in which it was submitted that there is violation of the terms and conditions of the agreement. As per article 8 of the terms and conditions of the agreement, the hospital was required to give the intimation of 7 days prior to hospitalization for all the cases of joint replacement and cataract surgeries and 3 days prior to the planned admission for all the planned surgeries but in this case, the hospital issued letter dated 3.7.2017 informing the date of surgery for (Right TKR) 4.7.2017, whereas seven days prior intimation was required to be given, therefore, approval was not given. Thereafter till date neither the complainant informed regarding the surgery nor filed any reimbursement claim. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh.G.S.Sandhu,Adv.counsel for the complainant tendered into evidence affidavit of complainant Ex.C-1, copy of I.card issued by opposite parties No.1 & 2 Ex.C-2 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for opposite party No.2 tendered into evidence affidavit of Sh.Surya Deep Singh Thakur Ex.OP2/A, copy of letter dated 3.7.2017 Ex.OP2/1, copy of agreement Ex.OP2/2 and closed the evidence on behalf of opposite party No.2.
5. We have heard the Ld.counsel for the complainant as well as Ld.counsel for opposite party No.2 and have carefully gone through the record on the file.
6. Ld.counsel for the complainant has vehemently contended that the complainant availed Bhai Ghanhya Sehat Sewa Scheme by paying Rs. 2000/- to opposite party No.2 and opposite party No.2 insured the complainant for various diseases and also issued Insurance card Ex.C-2 on record. It was the case of the complainant that due to severe pain in his left knee in the month of October 2017 he consulted the doctor at “Corporate Hospital” at Amritsar , who advised the complainant for knee replacement surgery. The complainant requested the hospital authorities that as he was fully insured under any type of ailment with opposite party No.2 and the hospital is on the panel of Insurance company, as such the complainant asked the hospital authorities to get approval of the treatment of the complainant from opposite party No.1 and 2 for the surgery of the knee of the complainant. The hospital authorities applied for the approval of the treatment of the complainant but till the filing of the present complaint, opposite parties did not give any approval for the treatment of the complainant . Ld. Counsel for the complainant conteded that the act of the opposite parties by not giving approval for the treatment of the complainant amounts to deficiency in service due to which the complainant suffered pain due to non replacement of knee and also suffered mental agony and harassment in the hands of the opposite parties.
7. Whereas Ld.counsel for the opposite party No.2 has contended that as per article 8 of the terms and conditions of the agreement, the hospital was required to give the intimation of 7 days prior to hospitalization for all the cases of joint replacement and cataract surgeries and 3 days prior to the planned admission for all the planned surgeries but in this case, the hospital issued letter dated 3.7.2017 informing the date of surgery for (Right TKR) 4.7.2017, whereas seven days prior intimation was required to be given, therefore, approval was not given. But, we are not agreed with this plea of the opposite party No.2 as the hospital from where the complainant wants to avail treatment is on the panel of the opposite parties and opposite party No.2 only to escape themselves from the liability of paying the treatment expenses has been taking such types of pleas . Moreover the complainant has been seeking approval before taking the treatment from the empaneled hospital of the opposite party No.2 and has not lodged claim of the treatment expenses, as such opposite party No.2 cannot take this plea that the complainant has violated any of the terms and conditions of the opposite parties. Moreover it is usually seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
Moreover due to non approval of the opposite party No.2 for the treatment of knee replacement, complainant has suffered physical pain as well as harassment in the hands of the opposite parties, as such the complainant is entitled to compensation as well as litigation expenses.
surgery nor filed any reimbursement claim.
8. In view of the above discussion, the complaint is disposed of with the directions to the opposite party No.2 to give approval for the treatment of knee replacement of the complainant to the hospital i.e. opposite party No.3 ,which was on the panel of opposite party No.2 . The opposite party No.2 is also directed to pay compensation to the tune of Rs. 3000/- while litigation expenses are assessed at Rs. 2000/-. Compliance of this order be made within 30 days from the date of receipt of copy of the order ; failing which complainant shall be entitled to get the order executed through the indulgence of this Forum. 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.
