| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA. CC. No. 153 of 04-04-2012 Decided on 19-10-2012
Jasmail Kaur wd/o Maghi Singh, aged about 60 years R/o Village Ram Nagar, Tehsil Talwandi Sabo, District Bathinda. ........Complainant Versus ICICI Lombard (Health Insurance), Bawa Tower, Bandra Kurla Complex, Mumbai, through its Managing Director. Senior Branch Manager, ICICI Lombard (Health Insurance), Opposite 100' Road, Bathinda. MD India Healthcare Services (TPA) Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali, Punjab 165 056, through its MD/ GM/ Chairman. The Ram Nagar Cooperative Agricultural Society, VPO Ram Nagar, through its Secretary Punjab Cooperative Society, Punjab Chandigarh, through its Registrar. Delhi Heart Institute and Research Centre, 40 ft Road, Namdev Nagar, Bathinda, through its owner/partner/MD Dayanand Medical College & Hospital (UNIT HERO DMC Heart Institute), Ludhiana, through its MD/Chairman/G.M./ Partner/ Prop./ Authorized Signatory
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986.
QUORUM Smt. Vikramjit Kaur Soni, President Sh. Amarjeet Paul, Member Smt. Sukhwinder Kaur, Member
For the Complainant : Sh. Ish Kumar, counsel for the complainant For the Opposite parties : Sh. Vinod Garg, counsel for opposite party Nos. 1 & 2. Opposite party Nos. 3,4 & 7 exparte Sh. K S Dabrikhana, counsel for opposite party No. 5. Sh. Jasbir Singh, authorised representative of opposite party No. 6. O R D E R
VIKRAMJIT KAUR SONI, PRESIDENT The instant complaint has filed by the complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). In brief the case of the complainant is that she is a widow of deceased Maghi Singh who was member of The Ram Nagar Cooperative Agricultural Society, VOP Ram Nagar (opposite party No. 4). The opposite party Nos. 4 & 5 are running Health Welfare Scheme for farmers throughout Punjab. As per scheme, if member of society gets policy by paying membership fee, he and his family members become beneficiary of policy and in case of any mishap, member could get cashless treatment from hospitals including opposite party Nos. 6 & 7. The scheme is known as Bhai Ghanaiya Sehat Sewa Scheme. The deceased Maghi Ram became the member of the said scheme and cashless card bearing policy No. 4016/00004117, MDID No. MD15-BGSSS-00005725/FL was issued to the complainant by opposite party Nos. 1 & 2 through opposite party No. 3. The policy was valid 1-2-2010 to 31-01-2011. The deceased Maghi Singh suddenly suffered heart attack on 29-10-2010 and was immediately taken to opposite party No. 6 wherein he was admitted. Maghi Singh shown the relevant documents in original to opposite party No. 6 but it refused to provide cashless treatment and compelled to pay an amount of Rs. 35,650/-. Maghi Singh was discharged on 30-10-2010. After the treatment and discharge of Maghi Singh from the hospital of opposite party No. 6, he did not felt relief and accordingly he was taken to opposite party No. 7 on 30-10-2010. Maghi Singh was admitted with opposite party No. 7. The attendants of said Maghi Singh again requested the authorities of opposite party No. 7 for cashless treatment, but to no effect. The authorities of opposite party No. 7 got deposited Rs. 4700/- in advance on 30-10-2010 and Rs. 59,410/- on 31-10-2010, but the said Maghi Singh could not survive and died on 31-10-2010. The complainant alleged that she spent Rs. 99,760/- on the treatment of Maghi Singh and Rs. 20,000/- on transportation etc., She filed the claim with the opposite parties and completed the entire formalities, but her claim has not been decided so far. Ultimately, the complainant got served legal notice upon opposite party No. 3 for settlement and payment of claim, but to no effect. Hence, the complainant has filed the present complaint seeking directions to the opposite parties to pay Rs. 1,20,000/- on account of treatment expenses alongwith cost and compensation. The opposite party Nos. 1 & 2 filed their joint written statement and pleaded that complainant has concealed the fact that they never refused approval for treatment with opposite party No. 6 as opposite party No. 6 itself refused cashless treatment for the reasons best known to it. The opposite party No. 6 did not seek any approval from opposite party Nos. 1 to 3. The opposite party No. 7 is not on the panel of approved list of hospitals, hence they are not liable to reimburse the amount spent in opposite party No. 7. Registered notice of the complaint was sent to opposite party No. 3, but none appeared on its behalf and as such, exparte proceedings were taken against it. The opposite party No. 4 filed its separate written statement and admitted deceased Maghi Singh was member of Society and insured vide aforesaid policy as per their record. The opposite party No. 5 in its separate written statement pleaded that Bhai Ghanhya Trust is a registered Trust and is meant for providing Health Care Services to the members and employees of the Cooperative Societies and Cooperative Department Punjab. The opposite party Nos. 1 & 2 were appointed as Insurer by the Trust for implementation of the scheme and the insurer further appointed opposite party No. 3 as Third Party Administrator to implement the scheme. Third Party Administrator was to issue Identity Cards, to inspect hospitals and recommend to the Trust for their empanelment, to grant authorization, to settle the claims of hospitals/beneficiaries, to make the payments to the empanneled hospital for providing cashless services to the beneficiaries of the scheme. The opposite party No. 5 is neither the service provider nor the complainant is a consumer of it. It is the Insurer and the TPA who are the service provider and claim settling authorities. The opposite party No. 6 also filed its separate written statement and pleaded that complainant has wrongly complained that Maghi Singh had shown relevant documents in original to it and opposite party No. 6 refused to provide cashless treatment. Mr. Maghi Singh neither had shown his BGSSS ID Card towards obtaining cashless facilities of treatment nor had informed about the same to hospital authorities. Therefore, he was to pay the treatment expenses as per bills. The opposite party No. 6 has further pleaded that Maghi Singh did not get relief from treatment as complainant has stated he should have reported back to treating doctor for further investigation and remedy which he did not do. Since Maghi Singh at the time of his admission did not produce BGSSS ID card, cashless treatment was not provided to him. The opposite party No. 7 in its separate written statement admitted that patient Maghi Singh was got admitted with it on 30-10-2010 at about 9.42 p.m. with the complaint of chest pain and other ailments alongwith Disponea. He was intubated and managed accordingly. The patient had cardiac arrest at 2.30 p.m. on 31-10-2010, but despite of best efforts, could not be revived and was declared dead. The opposite party No. 7 has pleaded that it is not liable to provide the facility of cashless treatment until and unless a specific authorization to this effect is given by opposite party No. 3. As per Clause 2.9 of the agreement executed between it and opposite party No. 3, it is the primary responsibility of each and every beneficiary (patient) to inform opposite party No. 7 regarding his/her insurance and availability of the cashless treatment by any insurance company/authority by producing the ID. In the present case, when the patient was got admitted on 30-10-2010 with opposite party No. 7, as well as attendants never disclosed the fact to it that he is insured under Bhai Ghaniya Sehat Sewa Scheme and is entitled to get the cashless facility. The opposite party No. 7 has further pleaded that in the absence of any information regarding insurance of the patient and his entitlement for cashless treatment facility, it was not possible for it to provide the cashless treatment facility. If the husband of the complainant was having valid insurance, she can claim the reimbursement of the treatment cost of her husband as per his eligibility according to the terms and conditions of the insurance policy. The opposite arty No. 7 has no role in the reimbursement of any amount to the complainant. Parties have led their evidence in support of their respective pleadings. Arguments heard. Record alongwith written submissions submitted by the parties perused. During the pendency of the complaint on 21-09-2012, learned counsel for opposite party No. 1 & 2 offered a sum of Rs. 90,000/- in lumpsum to the complainant as full and final payment of his claim against opposite party Nos. 1 to 3. He stated that the payment will be made within one month from 21-09-2012 failing which the opposite party Nos. 1 & 2 will pay interest @9% p.a. from the date of filing of this complaint. The learned counsel for the complainant accepted this offer and both the counsel got recorded their statements separately on 21-09-2012. Accordingly, the learned counsel for the complainant withdrew the complaint against opposite party Nos. 1 to 3. Now, so far as complaint against the remaining opposite parties is concerned, the opposite party No. 4 & 5 are the Societies which runs Health Welfare Scheme for farmers vide which the husband of the complainant was insured. A perusal of file reveals that no deficiency in service has been alleged against the said opposite parties. The main allegation of the complainant is that she had shown the relevant record to opposite party Nos. 6 & 7 but they did not provide cashless treatment to her husband Maghi Singh. The pleadings of opposite party Nos. 6 & 7 is that neither the complainant nor any of the attendant of Maghi Singh shown the record of insurance and hence cashless treatment could not be provided to him. A perusal of file reveals that complainant has not produced any document on file to prove that actually she had shown the card in question to opposite party nos. 6 & 7. Moreover, Maghi Singh, insured suffered heart attack on 29-10-2010 and complainant filed this complaint on 04-04-2012 i.e. after more than one and a half year. During this period, she has not written any letter or made any complaint to the Society (insured) regarding not providing cashless treatment to her husband. In such circumstances, the version of the opposite party Nos. 6 & 7 seems to be correct that at the time of admission, complainant or her husband or his attendants did not show the insurance card to them and hence they did not provide cashless treatment to the husband of the complainant. The claim was to be paid by the Insurance Company i.e. opposite party Nos. 1 to 3 and in the present case, as discussed above, the complainant has already received an amount of Rs. 90,000/- from them and she has withdrawn the complaint against opposite party Nos. 1 to 3. Keeping in view the facts, circumstances and the evidence placed on file by the parties, this Forum is of the considered view that there is no deficiency in service on the part of the opposite party Nos. 4 to 7. Hence, this complaint fails and is hereby dismissed without any order as to costs. A copy of this order be sent to the parties concerned and the file be consigned to record.
Pronounced 19-10-2012 (Vikramjit Kaur Soni)
President
(Amarjeet Paul) Member (Sukhwinder Kaur)
Member
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