DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC. No. 84 of 03-04-2007<br /> Decided on : 24-07-2007 <br /> <br /> Dalip Singh alias Sohan Singh S/o Gurdev Singh, R/o V.P.O. Jeond Tehsil Phul, District Bathinda.<br /> ... Complainant<br /> Versus <br /> 1.ICICI Lombard, Power House Road, Bathinda, through its Branch Manager.<br /> 2.MED SAVE HEALTH CARE LIMITED, F-701A, Lado Sarai Opposite Golf Course, New Delhi 110 030.<br /> 3.The Jeonda Co-operative Agricultural Service Society Ltd., VOP Jeond, Tehsil Phul, District Bathinda. <br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer<br /> Protection Act, 1986.<br /> <br /> QUORUM<br /> <br /> Sh. Lakhbir Singh, President<br /> Sh. Hira Lal Kumar, Member<br /> Dr. Phulinder Preet, Member<br /> <br /> For the Complainant : Sh. Hardev Singh, Advocate.<br /> For the Opposite parties : Sh. Vinod Kumar, Advocate for opposite party No. 1.<br /> Sh. Gurcharan Singh, Advocate, 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 a member of The Jeonda Co-operative Agricultural Service Society Ltd., i.e. opposite party No. 3. It (opposite party No. 3) had got insured all its members with opposite parties No. 1 & 2 vide policy No. 4016/0000968. Card Number of the complainant is 86010200121269-A and Code Number is 784-422 which has been duly issued by opposite party No. 1. As per the scheme, it was specified that if during an year i.e. from 1.4.06 to 31.3.07 any member covered under it suffers any ailment and gets treatment from the specified hospital, he would be entitled for free treatment and would not be liable for expenses on medicines. On 2.9.06, he was suffering from high fever due to which he had become unconscious. His brother Inderjit Singh and other relatives brought him to D.M.C. Ludhiana (specified hospital of opposite parties No. 1 & 2). He was provided treatment. After 3-4 days he gained consciousness. He told the doctors about the policy and the fact that he is the member of Sanjivni Health Care Scheme. Concerned doctor obtained his signatures on the relevant documents. An application was obtained from him (complainant). He was told that if he is covered under the scheme, his treatment would be absolutely free. Application was sent by the doctor to Regional Manager, MED SAVE HEALTH CARE LIMITED, F-710A, Lado Sarai, Opposite Golf Course, New Delhi. On 22.9.06 a letter was received from MED SAVE HEALTH CARE LIMITED by Daya Nand Medical College & Hospital, Ludhiana, in which it was mentioned that information regarding illness was not given within 48 hours and as such, medi-claim is rejected. He alleges that claim has been rejected without any sufficient cause or reason. Necessity of giving information within 48 hours has not been mentioned in the guide book nor was it orally conveyed to him. His condition was serious. First priority was to save his life. At the time of his admission, his family members got mentioned his name as Sohan Singh (which is his common name used by the family members) instead of Dalip Singh. Later on it was got corrected on 15.9.06. It is further averred by him that during the period of treatment from 2.9.06 to 7.10.06, a sum of Rs. 1,79,009/- was spent by him. He is legally entitled to receive it. Apart from this, he is entitled to receive Rs. 1.00 Lac as damages on account of mental and physical harassment at the hands of the opposite parties. There is 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 `Act') has been preferred by him seeking direction from this forum to the opposite parties to pay him Rs. 1,79,009/- as expenses of treatment and Rs. 1.00 Lac as damages besides cost of the complaint.<br /> 2. Opposite party No. 1 filed its version taking legal objections that complainant has contravened the terms and conditions of the insurance policy and complaint is pre-mature. As per terms and conditions of the policy and Service Level Agreement dated 24.3.06 among it, Sanjivni Trust and opposite party No. 2, insured is bound to intimate opposite party No. 2 atleast 7 days prior to the date of hospitalisation but in any case not later than 24 hours after hospitalisation and before discharge from the hospital with all the information asked before and as per prescribed form to avail cashless facility. Further complainant was supposed to submit the claim within 30 days from the date of completion of the treatment. Had he submitted the claim within 30 days of completion of treatment, he would have been allowed a claim number. Hence, he is not entitled to any relief. He did not give any intimation to opposite party No. 2 within 24 hours of admission. It was received after more than 48 hours after admission. Therefore, cashless facility for treatment was rejected by opposite party No. 2 vide letter dated 22.9.06. Treatment to the complainant was allegedly completed on 7.10.06 when he was discharged from Dayanand Medical College and Hospital, Ludhiana. Thereafter if so desired, he could submit claim within 30 days. He did not submit such claim with it or opposite party No. 2. Complainant is not consumer. Complaint is liable to be dismissed on account of non-joinder of Sanjivni Trust. Complainant has got no locus standi and cause of action to file the complaint and it is false and frivolous. Claim of the complainant is not maintainable as per special condition of the policy. As per them, only cash less hospitalisation is covered in private hospitals and reimbursement is allowed in case of government hospital. In this case, treatment is alleged to have been taken from Dayanand Medical College & Hospital, Ludhiana, which is a private hospital. He was supposed to intimate opposite party No. 2 for getting the treatment. He was also supposed to get authorisation for cashless treatment. Neither he gave intimation to opposite party No. 2 well in time nor did he get authorisation. It does not deny the fact that complainant is member of opposite party No. 3 which got its employees insured for the period from 1.4.06 to 31.3.07. Complainant and his family members covered under the policy were fully aware of the condition of the policy that intimation regarding illness is to be given to the opposite party atleast 7 days prior to and not later than 24 hours after hospitalisation for getting authorisation for cashless treatment in private hospital. Intimation was given more than 48 hours after admission. Thereafter authorisation for cashless treatment was rejected vide letter dated 22.9.06. It denies that claim has been rejected without any sufficient cause. There is denial that a sum of Rs. 1,79,009/- has been spent by him for treatment. Complainant did not submit the claim in prescribed form and alongwith medical bills and relevant record as per Clause 4 with heading Basis of Assessment of Claim in part II of the Schedule of the Policy. Each and every expenditure is not covered under the policy. Payment of expenditure is to be decided as per terms and conditions of the policy. As per special condition at Sr. No. 14 of Part I of Schedule of Policy under Clause 9 and also as per Part II of Schedule, expenditure of any investigation, evaluation and observations is not covered. It denies the remaining averments as well as the allegation that treatment has been taken as per guide book.<br /> 3. Registered A.D. notice of the complaint was issued to opposite party No. 2 on 9.4.07, Neither registered cover nor A.D. was received back. 30 days had elapsed. Accordingly opposite party No. 2 was deemed to have been duly served. No one came present on its behalf. Hence, it was proceeded against exparte.<br /> 4. Opposite party No. 3 filed separate reply taking legal objections that complaint is not filed within limitation; this forum has got no jurisdiction to entertain and try it and that it is bad for non-joinder of necessary parties. It admits that complainant is resident of village Jeonda and he is member of it (opposite party No. 3). He and his family members were got insured from opposite parties No. 1 & 2. Insurance Policy No. 4016/000968, Card No. 86010200121269-1 and Code No. 784-422 were issued. Insurance was valid from 1.4.06 to 30.3.07. If any member covered under the scheme suffers any ailment during this period, he was to get free treatment. According to it, complainant was informed at the time when his insurance was got done that in case of any illness, it is necessary to give intimation within 48 hours to opposite parties No. 1 & 2. It is averred by it that complainant is not entitled to recover any medical expenses, damages and cost etc., as insurance was done by opposite parties No. 1 & 2. It denies the remaining averments in the complaint.<br /> 5. In support of his averments contained in the complaint, complainant has produced in evidence Guide Book of Sanjivni Health Care Scheme (Ex. C-1), his original I Card (Ex. C-2), photocopy of Pre-Authority letter (Ex. C-3), photocopy of his application (Ex. C-4), photocopy of letter dated 22.9.06 (Ex. C-5), photocopy of Note dated 15.9.06 (Ex. C-6), medical bills (Ex. C-7 to Ex. 157), his affidavit (Ex. C-158), affidavit of Sh. Pardeep Singh (Ex. C-159), Medical Certificate dated 9.6.06 (Ex. C-160), photocopy of letter dated 19.9.06 (Ex. C-161) and affidavit of Sh. Inderjit Singh (Ex. C-162).<br /> 6. In rebuttal, on behalf of opposite party No. 1 affidavit of Sh. Sat Parkash, Area Head Channels and authorised signatory (Ex. R-3), photocopy of Group Health Insurance Policy (Ex. R-4), photocopy of service level agreement (Ex. R-5) and on behalf of opposite party No. 3 affidavit of Sh. Mohan Singh (Ex. R-1) and photocopy of demand drafts (Ex. R-2) have been tendered in evidence.<br /> 7. We have heard learned counsel for the parties. Besides this, we have gone through the record and written briefs of arguments submitted on behalf of complainant, opposite party No. 1 and opposite party No. 3.<br /> 8. Opposite party No. 3 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. 4016/000968 was issued. Copy of the insurance policy is Ex. R-4. As per this document, name of the insured is M/s. The Sanjivni Trust and mailing address of the insured is Punjab Institute of Co-op Training, SCO No. 16, Sector 7-C, Chandigarh (Punjab). Details of the person insured are as per Annexure. Principal Members insured were 169473 and Dependent Members 350666. Policy was valid from 31.3.06 to 30.3.07. Card No. 860 1020 01 21269 A under MedSave Group was issued. Copy of guide book of Sanjivni Health Care Scheme was issued, copy of which is Ex. C-1. Code A/c No. 784-422 was issued to the complainant, copy of which is Ex. C-2. Opposite party No. 3 pleads that complainant was made fully aware that in case of any ailment , it is necessary to give information within 48 hours to opposite parties No. 1 & 2. Ex. C-4 is the copy of application of the complainant to the Regional Manager of Med Save which is undated. According to him, it was given to the doctors for getting cashless hospitalisation in network hospital i.e. Dayanand Medical College and Hospital. In other words, it was moved for getting free treatment. Opposite party No. 2 vide letter dated 22.9.06, copy of which is Ex. C-5, refused to issue an authorisation for cashless treatment on the ground that pre-authorisation letter has been received after 48 hours of admission. Complainant got treatment from Dayanand Medical College & Hospital from 2.9.06 to 7.10.06.<br /> 9. Contention of the learned counsel for the complainant is that if according to letter dated 19.9.06, opposite parties are ready to entertain and reimburse the claim of the complainant, complainant is ready to file fresh claim although this letter was not received by him before filing of the complaint and that it has been received after filing of the complaint. In the written arguments of opposite party No. 1 plea has been taken that in the alternative if this forum comes to the conclusion that complainant is entitled to any relief, only in that case he may be directed to submit his claim alongwith medical record and bills so that it may be decided in accordance with the terms and conditions of the policy.<br /> 10. After considering the submission and pursuing the record, we are of the view that complaint merits part acceptance. There is Service Level Agreement among the opposite parties i.e. opposite party No. 1, MedSave Health Care Private Limited (TPA) and The Sanjivni Trust (Confirming Party) as is evident from Ex. R -5. So far as the prayer of the complainant for authorisation for cashless treatment is concerned, it has already been rejected as is evident from Ex. C-5. Opposite party No. 2 had sent letter dated 19.9.06, copy of which is Ex. C-161 addressed to Dayanand Medical College & Hospital, Ludhiana . It is regarding denial of cashless facility for treatment to the complainant. Through this letter, request has been made to the hospital to collect the expenses from the insured person i.e. Mr. Dalip Singh. It has further been observed that he may submit hospitalisation papers for reimbursement and the claim would be settled after investigation and gathering more information if found admissible as per policy terms and conditions. Complainant alleges that he has spent a sum of Rs. 1,79,009/- for his treatment. Without touching other aspects of the case, we find that there is no evidence according to which complainant has lodged his claim for reimbursement. Had he submitted the claim for reimbursement, opposite parties No. 1 & 2 could consider it keeping in view the terms and conditions of the policy and various other aspects of the case particularly in view of the letter Ex. C-161 issued by opposite party No. 2. We do not want to touch various other aspects of the matter because complainant's case is required to be considered after proper claim is lodged by him for reimbursement with opposite parties No. 1 & 2.<br /> 11. Now, question arises as to which relief should be accorded to the complainant. Direction deserves to be given to opposite party No. 2 to handover the claim form to the complainant under proper acknowledgement within 10 days from the date of receipt of the copy of this order. After claim form is delivered to the complainant, he would submit it alongwith medical record and bills etc., within 15 days from the date of receipt of claim form. Opposite parties No. 1 & 2 would consider the complainant's claim regarding reimbursement on merits within two months from the date the claim form and other documents are submitted to them by the complainant and convey the decision to him. In the facts and circumstances, no case is made out for damages claimed by the complainant.<br /> 12. In view of our foregoing discussion, complaint is partly allowed with no order as to costs. Complainant and opposite parties No. 1 & 2 are directed to do as under :-<br /> i)Opposite parties No. 1 & 2 to handover the claim form to the complainant under proper acknowledgement within 10 days from the date of receipt of copy of this order.<br /> ii)Complainant may submit claim form alongwith medical record, bills etc., within 15 days from the date of receipt of claim form to opposite party No.2 for consideration of his claim for reimbursement.<br /> iii)Opposite parties No. 1 & 2 would consider the claim of the complainant for reimbursement in accordance with law, terms and conditions of the policy within 2 months from the date of receipt of the claim form and other documents and convey the decision to the complainant.<br /> Copy of this order be sent to the parties concerned and file be consigned to record room. <br /> Pronounced :<br /> 24-07-2007 (Lakhbir Singh )<br /> President<br /> <br /> <br /> ( Hira Lal Kumar )<br /> Member<br /> <br /> <br /> (Dr. Phulinder Preet)<br /> Member <br />