DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA(PUNJAB)<br /> <br /> C.C. No. 274 of 12.9.2007 Decided on : 16.1.2008 <br /> <br /> Paramjit Singh Sekhon S/o Sh. Gobinder Singh Sekhon, R/o VPO Jeond, Tehsil & District Bathinda. <br /> .... Complainant<br /> Versus<br /> <br /> 1.ICICI Lombard General Insurance Co. Ltd. (Insurer) through its Branch Manager, R/o Power House Road, Bathinda (Pb.).<br /> 2.Mid Save Health Care Private Limited (T.P.A) R/o F-701-A, Lado Sarai Opposite Golf Course, New Delhi-110 030 through its Branch Manager, Office SCO No. 123-122-123, Ist Floor, Sector 34-A, Chandigarh.<br /> 3.The Sanjivni Trust (Confirming Party) through Registrar Co-operative Societies, through Jeond Co-operative Agricultural Services Society Ltd. through its Secretary, VPO Jeond, Tehsil Phul, District Bathinda.<br /> ..... Opposite parties<br /> <br /> Complaint under section 12 of the Consumer Protection Act, 1986<br /> <br /> QUORUM:<br /> Sh. Lakhbir Singh, President<br /> Sh. Hira Lal Kumar, Member<br /> Dr. Phulinder Preet, Member<br /> <br /> For the complainant : Sh. H.S Dhanoa, Advocate<br /> For the opposite parties : Sh. Vinod Garg, counsel for opposite party No.1<br /> Sh. G.S Sidhu, counsel for opposite party No. 3<br /> Opposite party No. 2 exparte<br /> <br /> O R D E R.<br /> <br /> LAKHBIR SINGH, PRESIDENT:- <br /> 1. Complainant is Member of Jeond Co-operative Agricultural Services Society Limited. It got insured its members with opposite parties No. 1 & 2 vide policy No. 4016-0000968. Card No. 86010200012683-A was issued ( It was received by him after discharge from the hospital). His (complainant's) Identity Card number is 784-426 which was duly issued by opposite party No. 1. As per the scheme, it was specified that if during an year i.e. 14.1.2006 to 13.1.2007 any member covered under it suffers from any ailment and gets treatment from the specified hospital, he would be entitled for free treatment and would not be liable for expenses of medicines. It is further added by him (complainant) that when he became member of the medical-claim insurance policy scheme under the Sanjivni Care Scheme, opposite parties had issued only guide book to him and to the other members. No other document was given. However, some of the members have received Identity Cards through post and remaining members have not so far received Identity Cards. Identity Card was not received by him. Opposite parties were being informed from time to time about the non-issuance of the Identity Card. Despite this, it was not issued. On 19.6.2006, he was suffering from chest pain and was taken to Delhi Heart Institute & Research Centre, Namdev Nagar, 40 Ft. wide road, Bhati Road, Bathinda. He and his family members had apprised the doctor about his membership under the Sanjivni Health Care Scheme. Doctor had demanded Identity Card which is required to be issued under the scheme. It was not with him at that time as opposite parties had assured him that it would be issued after getting it signed from the higher competent authority. During the period of treatment, opposite parties were contacted through Jeond Co-operative Society Ltd. Accordingly, opposite parties ordered departmental inquiry which was conducted upto 22.6.2006. On 23.6.2006, opposite parties No. 1 & 2 directed opposite party no. 3 to issue Identity Card on its letter pad. Accordingly, it was issued by it on its letter pad on 23.6.2007. After he was discharged from the hospital,opposite parties had issued him Identity Card. Identity Card dated 23.6.2006 issued on the letter pad was handed over to the doctor, who had informed that period for cashless facility had expired. Doctor had further told him that as per terms and conditions of the policy, he can send his claim within 30 days from the date of discharge from the hospital for reimbursement. He was discharged from the hospital on 26.6.2006, but his treatment is still continuing. On 8.7.2006, he had sent his claim i.e. summary of final credit bill for Rs. 2,52,725/- + Rs. 15,580/- = Rs. 2,68,305/- duly signed by him and treating doctor through On-Dot Couriers & Cargo Ltd. Till today, nothing has been done. On 10.8.2007, he got served legal notice upon the opposite parties through his counsel. In these circumstances, he alleges deficiency in service on the part of the opposite parties. In these circumstances, this complaint under section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as the Act) has been preferred seeking direction from this Forum to the opposite parties to pay him Rs. 2,68,305/- and Rs. 50,000/- as damages on account of mental and physical harassment including cost of forced litigation.<br /> 2. Opposite party No. 1 filed its version taking legal objections that complaint has been filed simply to injure its reputation; complainant has got no locus-standi and cause of action to file it; complainant is not consumer; complaint is not maintainable in the present form; complainant has concealed material facts; he has violated the terms and conditions of the policy and complaint is false and frivolous. It admits that complainant is covered under Group Health Insurance Policy No. 4016/0000968 against Card No. 80010200012693-A. It denies that Identity Card was received by the complainant after discharge from the hospital. There is denial that scheme was effective from 14.1.2006 to 13.1.2007. Rather, it was effective from 31.3.2006 to 30.3.2007. As per terms and conditions of the policy, insured person was allowed to get cashless treatment in private hospitals shown in the list of hospitals covered under the Network of policy upto a sum of Rs. 2,00,000/- on family floater basis per year. Reimbursement is not allowed in case of private hospitals. It denies that insurance policy was not issued to him. Even otherwise, complainant is fully aware of the terms and conditions of the policy as Insurance Policy, Identity Card and guide book were supplied to him. There is no specific denial about the admission of the complainant in Delhi Heart Institute and Research Centre, Bathinda due to chest pain. They deny that complainant and his family members had told the doctor regarding the membership of the complainant under Sanjivni Health Care Scheme. Inter-alia, their plea is that complainant and his family members had not presented the Identity Card or its number for getting authorization for cashless treatment to the hospital authorities nor submitted any application for cashless facility as per the terms and conditions of the policy. He was supposed to submit the request for getting cashless treatment at least 7 days prior to hospitalization and not later than 24 hours after admission in the hospital. Since, complainant has violated the terms and conditions, he is not entitled to reimbursement as it is not allowed regarding private hospitals. Had the Identity Card been not issued, complainant could make request, but he remained silent. It denies that after discharge from the hospital/completion of the treatment, Identity Card was supplied to the complainant. Complainant could not get authorization for cashless treatment due to his own fault. Even the doctor wrote letter dated 10.7.2006 to opposite party No. 2 in this regard. It denies that complainant has sent his claim within time and that he has spent Rs. 2,68,305/- for his treatment. It does not admit the remaining averments in the complaint.<br /> 3. Registered A.D post notice was issued to opposite party No. 2 on 24.9.2007. Till 29.10.2007, neither registered cover not A.D was received. Accordingly, opposite party No. 2 was deemed to have been duly served. No-one came present on its behalf. Hence, it has been proceeded against exparte.<br /> 4. Opposite party No. 3 filed separate reply of the complaint taking legal objections that complaint is not within time; this Forum has got no jurisdiction to entertain and try the complaint and complaint is bad for non-joinder and mis-joinder of parties. On merits, it admits that complainant is the Member of Jeond Co-operative Agricultural Service Society which had got its members insured with opposite parties No. 1 & 2 vide policy No. 4016-0000968. Identity Card number of the complainant is 784-426 which was duly issued by opposite party No. 1. Card No. 86010200012683-A was issued. Scheme was valid from 14.1.2006 to 13.1.2007. According to it, if any member suffers from any ailment and gets treatment from any of the specified hospitals, he is entitled for free treatment. Opposite parties No. 1 & 2 had explained terms and conditions of the insurance to the complainant. No insurance policy has been kept by it (Society). It denies for want of knowledge that complainant got himself admitted in Delhi Heart Institute & Research Centre on 19.6.2006 due to chest pain. No legal notice was received by it (Society). This Society denies the remaining averments in the complaint.<br /> 5. In support of his allegations and averments in the complaint, Paramjit Singh complainant tendered into evidence his own affidavit (Ex.C.1), affidavit (Ex.C.2) of Sh. Jagjit Singh, photocopy of legal notice dated 10.8.2007 (Ex.C.3), postal receipts (Ex.C.4 & Ex.C.5), photocopy of courier receipt (Ex.C.6), photocopies of letters dated 29.6.2006, 10.7.2006 & 23.6.2006 (Ex.C.7, Ex.C.8 & Ex.C.12) respectively, photocopies of claim forms (Ex. C. 9 & Ex.C.10), photocopy of credit bill dated 27.6.2006 (Ex.C.11) & photocopy of Identity Card (Ex.C.13).<br /> 6. On behalf of opposite parties No. 1 & 3, reliance has been placed on affidavits (Ex.R.1 & Ex.R.8) of S/Sh. Mohan Singh, Secretary of opposite party No. 3 & Sat Parkash, Area Head Channels & Authorised Signatory of opposite party No. 1 respectively, photocopies of demand drafts (Ex.R.2 to Ex.R.5), photocopy of Service Level Agreement (Ex.R.6), photocopy of Group Health Insurance Policy (Ex.R.7) & photocopy of Guide Book and list of hospitals in the network of Punjab (Ex.R.9).<br /> 7. We have heard the learned counsel for the complainant and opposite parties No. 1 & 3. Apart from this, we have gone through the record and the written submissions submitted by the complainant and opposite party no. 1.<br /> 8. Jeond Co-operative Agricultural Service Society Ltd. admits that complainant is its Member. According to it, complainant and his family members were got insured from opposite parties No. 1 & 2 and insurance policy No. 4016-0000968 was issued. Copy of the insurance policy is Ex.R.7. As per this document, name of the insured is M/s. The Sanjivni Trust and mailing address is Punjab Institute of Co.op Training, SCO No.16, Sector 7-C, Chandigarh (Pb.). Details of the persons insured are as per annexure. Principal members insured were 169473 and dependents members 350666. Policy was valid from 31.3.2006 to 30.3.2007. Complainant admits that Guide Book of Sanjivni Health Care Scheme was issued, copy of which is Ex.R.9. According to the complainant, Identity Card was subsequently issued with No. 784-426 and copy of the Identity Card is Ex.C.13.<br /> 9. As per copy of the Identity Card, policy has been shown valid from 14.01.2006, whereas as per copy of the Group Health Insurance Policy (Ex.R.7), insurance is valid from 31.3.2006 to 30.3.2007. Copy of the Service Level Agreement is Ex.R.6.<br /> 10. Arguments pressed into service by Mr. Dhanoa, learned counsel for the complainant are that when complainant and other persons had become members of the medi-claim insurance policy under the Sanjivni Health Care Scheme, only Guide Book, copy of which is Ex.R.9, was issued. No other document was supplied. As per page No. 8 of Ex.R.9, production of Identity Card for availing cashless facility from the hospital authorities is essential. There is nothing in Ex.R.9 that members are bound to give information seven days prior to hospitalization or within 24 hours from the date of admission in the hospital. Members of the scheme did not receive Identity Cards till July, 2006. Ex.C.2 is the affidavit of Jagjit Singh according to which he received the Identity Card in the first week of July, 2006. Policy came into existence on 31.3.2006 and agreement on 24.3.2006, whereas scheme has been shown to have commenced on 14.1.2006. Identity Card was not issued to the complainant till 23.6.2006 although complainant had made efforts for getting the same issued. It is only on 23.6.2006 opposite party No. 3 had issued it on its letter pad and copy of the same is Ex.C.12. There is nothing in Ex.R.6 & Ex.R.7 as to how the matter would be adjudicated in case of deficiency. On 8.7.2006, complainant had submitted his claim accompanied by all the documents including medi-claim original bills of Rs. 2,68,305 through On-Dot Couriers Cargo & Ltd.,Bathinda to opposite parties No. 1 & 2 as is evident from Ex.C.6 to Ex.C.11. Opposite parties have not furnished any information. Even legal notice, copy of which is Ex.C.3, sent by him through his counsel proved futile. In these circumstances, complainant is entitled to receive the amount of Rs. 2,68,305/- spent by him for his treatment from 19.6.2006 to 26.6.2006.<br /> 11. Mr. Vinod Garg, learned counsel for opposite party No. 1 argued that complainant has taken treatment in the network hospital without getting any authorization from the competent authority for cashless facility and as such, question of reimbursement of the amount upto the permissible limit of Rs. 2,00,000/- is not available. Complainant was fully aware of the scheme and procedure for getting treatment as is clear from paras No. 2 to 4 of the complaint. His next argument is that complainant has failed to establish that Identity Card was not issued to him before he got himself admitted in the network hospital. He has not proved that he was not aware that seven days prior information from the date of admission or within 24 hours from the date of admission in the hospital was to be given.<br /> 12. We have considered the rival arguments. Complainant admits that guide book of Sanjivni Health Care Scheme was supplied to him. On its page No. 8, it has been recorded that before getting admission in the network hospital for treatment, production of Identity Card is essential. Question is as to whether Identity Card was not issued to the complainant before he got himself admitted in Delhi Heart Institute & Research Centre, Bathinda on 19.6.2006 and that he was not aware of the terms and conditions of the policy, copy of which is Ex.R.7. According to the policy, insured-beneficiary is required to intimate to opposite party No. 2 at least seven days prior to the date of hospitalization, but in any case not later than 24 hours after hospitalization and before the discharge from the hospital with all the information asked for as per the prescribed format, where this hospitalization may give rise to any claim and/or liability for the company under the policy. <br /> 13. As per policy, cashless hospitalization in network hospitals is permissible, whereas reimbursement/cashless hospitalization in Govt. hospitals is covered under the policy. Onus to prove the version in the complaint is upon the complainant. He is required to stand on his own legs. He is relying upon Identity Card, copy of which is Ex.C.13. He has not proved on which date it was received by him. In para no. 4 of the complaint, he pleads that he had informed the opposite parties from time to time that Identity Card has not been received by him. Dates and months of lodging the information with the opposite parties to this effect have not been disclosed by him. It is not known that the information was in black and white or oral. As per averments in the complaint, some of the members of the scheme had received their Identity Cards through post. It is not known when all those members had received the Identity Cards. If those members had received the Identity Cards, complainant could send the request in writing and keep the record with him. Had he done so, the matter could stand clinched. His bald version that he got the Identity Card after he got discharged from the hospital and after the Society had issued him Identity Card on the letter pad, cannot be believed. Affidavit Ex.C.1 of the complainant stands amply rebutted with the affidavit Ex.R.8 of Sh. Sat Parkash, Area Head Channels and authorised signatory of opposite party No. 1. According to it, complainant was fully aware of the terms and conditions of the policy and that Identity Card and Guide Book were supplied to him. In the affidavit Ex.R.1 Sh. Mohan Singh, Secretary of Jeond Co-operative Agricultural Service Society Ltd. has stated that terms and conditions of the policy were explained to the complainant. Fact that complainant was aware of the terms and conditions of the policy is supported from para No. 5 of the complaint in which he has got recorded that on 19.6.2006 he had chest pain and he was taken to Delhi Heart Institute & Research Centre, Bathinda and that he and his family members had told the concerned doctor about his membership under Sanjivni Health Care Scheme. This shows that he was fully aware that intimation within 24 hours after hospitalization for availing cashless facility was required. When para no. 5 is considered, contention of the learned counsel for the complainant is not tenable. Merely on the basis of the averment that Society issued Identity Card on its letter pad on 23.6.2006, complainant cannot wriggle out of the situation by saying that Identity Card was not issued to him and that he was not aware about the terms and conditions of the policy, particularly when stance of the opposite party no. 3 is that terms and conditions were fully explained to him. Plea of opposite party No. 1 is that policy, guide book and Identity Card were issued to him. If doctor had demanded the Identity Card on 19.6.2006 and complainant could not produce the same on account of the fact that it was not issued to him by the opposite parties, he would not have sit folded handed. He was to avail cashless facility. He could immediately apply to the opposite parties for getting it issued. There is no record that such like application was moved by him immediately to opposite parties No. 1 & 2 intimating that he has been admitted in the hospital and doctor is demanding the Identity Card. Plea of the complainant is that he submitted claim forms dated 8.7.2006 alongwith credit bills through the doctor on 10.7.2006 through On-Dot Courier as is clear from Ex.C.6 & Ex.C.8 to Ex.C.11. In other words, he is basing his medi-claim on the basis of letter dated 10.7.2006 of Dr. Naresh Goyal of Delhi Heart Institute & Research Centre. It reveals that complainant and his relatives informed them about their Sanjivni membership only after the treatment was over and on that account pre-authorization could not be sent. As discussed above, complainant was aware about the terms and conditions of the policy as is clear from para No. 5 of the complaint. He was to give intimation to opposite party No. 2 as mentioned above either personally or through letter which was not given by him or his family members. Information as per Ex. C.8 was supplied to the doctor after the treatment was over. On this score, pre-authorization from opposite party No. 2 for cashless facility could not be obtained. Admittedly, Delhi Heart Institute & Research Centre is one of the specified hospitals/network hospitals. In such like hospitals, only cashless hospitalization is permissible. Reimbursement regarding treatment obtained from such hospitals is not covered under the policy, copy of which is Ex.R.7.<br /> 14. Keeping all these facts and circumstances in view, no deficiency in service on the part of the opposite parties in not reimbursing the amount to the complainant, is proved, particularly when facts and circumstances allude the violation of the terms and conditions of the policy by the complainant.<br /> 15. In the result, complaint is dismissed. Parties are left to bear their own costs. Copy of this order be sent to the parties free of cost. File be<br /> consigned.<br /> Pronounced (Lakhbir Singh)<br /> 16.01.2008 President<br /> <br /> <br /> (Dr. Phulinder Preet) (Hira Lal Kumar)<br /> Member Member<br /> 'bsg'<br /> <br /> <br /> <br /> <br />