Punjab

Sangrur

CC/453/2016

Gurmail Kaur - Complainant(s)

Versus

ICICI Lombard General Insurance Company Ltd. - Opp.Party(s)

Shri Rajan Kapil

10 Jan 2017

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR

                             

                                                                   Complaint no. 453                                                                                        

                                                                    Instituted on:  14.07.2016

                                                                   Decided on:    10.01.2017

 

Gurmail Kaur aged 55 years wife of Nahar Singh r/o Village Shadihari, District Sangrur.   

                                                …. Complainant.      

                                         

Versus

 

1.       ICICI Lombard General Insurance Company Limited Branch Office, Gaushalla Road, Sangrur through its Branch Manager.

2.       M.D. India Health Care Services ( TPA) Pvt. Limited Maxpro Info Park, D-38, Industrial  Area Phasse 1, Mohali through its Director/ Authorized Signatory Global Heart and Super Specialty Hospital, Near Chungi Ferozpur Road, Ludhiana.

3.       Global Heart and Super Specialty Hospital near Chungi Ferozpur Road Ludhiana.

4.       The Co-operative Agriculture Services Society Ltd. Shadi Hari Tehsil Sunam District Sangrur through its Secretary.

5.       Deputy Registrar, Co-operative Societies, Sangrur.

      ….Opposite parties.

 

 

FOR THE COMPLAINANT:      Shri Rajan Kapil,  Advocate                           

 

FOR OPP. PARTIES No.1&2:    Shri G.S.Shergill, Advocate                   

 

 

 

FOR THE OPP. PARTY NO.3:            Shri G.S.Nandpuri Advocate                          

 

FOR OPP. PARTIES NO.4&5:            Shri B.S.Phumanwal Advocate                          

 

 

Quorum

         

                    Sukhpal Singh Gill, President

Sarita Garg, Member

Vinod Kumar Gulati, Member

 

 

 

ORDER:  

 

Sukhpal Singh Gill, President

 

1.             Gurmail Kaur, complainant has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that she is a member of Bhai Ghaniya Sehat Sewa Scheme-Punjab after depositing Rs.300/- with OP no.4. The complainant was suffering from Heart Problem and approached the OP no.3. The complainant admitted in the said hospital  vide serial number 6951 dated 29.02.2016 and deposited Rs.400/- but OP no.3 refused to treat the complainant as OPs no.1 and 2 are not making the payment  and as such  the complainant admitted in Sadbhavana Medical and Heart Institute Patiala . The complainant spent an amount of Rs.90600/- approximately. The complainant so many times requested the OPs to reimburse the medical claim but all in vain. Thus, alleging deficiency in service on the part of OPs, the complainant has sought following reliefs:- 

i)      OPs be directed to pay  all the expenses to reimburse  the medical bills of the complainant amounting to Rs.90600/- approximately,

ii)     OPs be directed to pay to the complainant a sum of Rs.10000/- as compensation   on account of mental agony and also to pay Rs.10,000/- on account of deficiency in service,

iii)     OPs be directed to pay Rs.5500/- on account of litigation expenses.

2.             In reply filed by the OPs no.1&2, it is submitted that  OP no.3 sent the pre-authorization  request for an amount of Rs.1,50,000/-  with date of admission as 01.03.2016. After getting the pre-authorization request OP no.2 sent letter dated 29.02.2016 who provide 1) ECG of patient which has been repoted as AF with CHB on Holters Main Page 2) Sympthomatology and current medication of patient 3) Indication of pace maker in this patient along with other additional documents but the OP no.3 failed to provide the documents and consequently the claim of the complainant was closed  vide letter dated 22.03.2016.  It is wrong  that the OPs ever refused for the treatment. The claim  of the complainant is not payable as the complainant took the treatment at Sadbhawna Hospital, Patiala  which is not on the panel of under the scheme. Therefore as per the policy treatment taken at non-panel hospital is not payable.

3.             In reply filed by the OP no.3, it is submitted that in order to provide treatment to the complainant the case of the complainant was sent to OP no.2 for approval but no reply was received so the patient  requested the hospital to cancel her case. Therefore, a cancellation letter dated 23.03.2016 was sent to the OP no.2to cancel the request of the complainant. It is further stated that  even in the present complaint there is not even a single allegation against the OP no.3.

4.             In reply filed by the Ops no.4&5, it is submitted that the husband of the complainant namely Nahar Singh recorded  in the sr. no.1 of list of members and he deposited Rs.1006/- as premium the same was sent along with other document to the higher authority and Op no.4 sent the premium amount alongwith list of members to the higher authority vide cheque number 243664 for the amount of Rs.36466/-  It is wrong that complainant and her husband issued any letter to the OP no.5.  The OPs issued the list of the hospital from where the any member of the scheme can take the treatment.  

5.             The complainant has tendered documents Ex.C-1 to Ex.C-17 and closed evidence. On the other hand, OPs have tendered documents Ex.OPs1&2/1 to Ex.OPs1&2/4,Ex.OP.3/3 to Ex.OP3/5, Ex.OPs.4&5/1 to Ex.OPs4&5/6 and closed evidence.

6.             It is not disputed that the complainant is a member of Bhai Ghaniya Sehat Sewa Scheme Punjab  under which she was insured with OP no.1.  The complainant has alleged that she was suffering  from heart problem and was admitted in the hospital OP no.3  vide serial number 6951 dated 29.2.2016 and deposited Rs.400/- as requisite fee but OP no.3 refused to treat her on the excuse that OPs no.1 and 2 are not making the payment and thereafter admitted in Sadbhavana Medical and Heart  Institute Patiala  and spent an amount of Rs.90600/- on surgery. On the other hand OP no.3 has stated that in order to provide treatment  to the complainant the case of the complainant was sent to OP no.2 for approval but no reply was received, so the patient requested the hospital to cancel her case. The OPs no.1 and 2 have also stated that after getting pre-authorization request OP no.2 sent a letter dated 29.02.2016 to OP no.3 to provide some required documents but OP no.3 failed to provide the same and as such the claim of the complainant was closed vide letter dated 22.03.2016.

The claim of the complainant is not payable as the complainant took the treatment at Sadbhawana Hospital Patiala which is not on the panel of under the scheme.

7.             Now, the only question which arises for determination before us is  whether the Sadbhawana Hospital Patiala is the panel  hospital under the scheme or not ? Further, whether the OP no.1 is liable to make the payment of expenses spent by the complainant on her treatment taken from Sadbhawana Hospital Patiala or not?

8.             From the perusal of the Guidebook and list Network Hospitals under Bhai Ghanhiya Sehat Sewa Scheme, Punjab Ex.OPs1&2/2, it is clear that Sadbhawana Hospital Patiala is not mentioned in the list of network hospitals, so we feel that the OPs no.1 and 2 are not liable to pay the expenses spent by the complainant on her treatment taken from Sadbhawna Hospital Patiala which is a non-panel hospital as  it has been specifically mentioned under the scheme that the complainant is entitled to take treatment from the hospitals which are fully covered under the scheme. Learned counsel for the complainant has cited a ruling namely Surjeet Kumar Vs.  Union of India and other, 2014 (1) PLR 152: 2015 ACJ 198 wherein  Hon'ble Punjab and Haryana High Court has held that  terms and conditions of mediclaim policy  and averments taken by the insurance company would make it clear that the attempt on the part of the respondent company was only to defeat the genuine claim of the petitioner.  Further it does not behove the respondent insurance company to deny even the genuine and reasonable claim of the petitioner, expenses for which were incurred on account of treatment for cancer and the treatment was availed  only from a Government Hospital. It was further held that  petitioner was a bonafide claimant and was entitled for reimbursement of the medical expenses incurred by him on his treatment for cancer availed from PGIMS, Rohtak, being a government hospital.  We feel that the present ruling is not applicable to the facts of the instant case as  the complainant has taken treatment from Sadbhavana Hospital Patiala which not a Govt. hospital like  PGIMS in Punjab.     

9.             In view of the facts stated above, we find no merit in the  complaint of the complainant and as such the same is dismissed however with no orders as to costs. Copy of the order be supplied to the parties free of charge. File be consigned to records in due course.                  

                Announced

                January 10, 2017

 

 

( Vinod Kumar Gulati)  ( Sarita Garg)               (Sukhpal Singh Gill)                                                                                       Member                   Member                         President

 

 

 

 

 

BBS/-