| ORDER | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA (PUNJAB)
CC No. 534 of 01-11-2011 Decided on : 29-02-2012
Surinder Singh aged about 54 years S/o Sh. Sadhu Singh R/o Village Danewala, District Sri Mukatsar Sahib. ... Complainant
Versus IFFCO TOKIO GENERAL INSURANCE CO LTD., Corporate Office 4th & 5th Floors, IFFCO Tower, Plot No. 3, Sector 29, Gurgaon 122001 (Haryana), through its Managing Director/Chairman. MD India Health Care Services (TPA) Private Ltd., Maxpro Info Park, D-38, Industrial Area Phase-I, Mohali (Punjab) 1600056 through its MD/CMD/GM/President/Chairman The Danewala Multipurpose Co-operative Agricultural Society, VPO Danewala, Tehsil Malout, District Sri Mukatsar Sahib through its Secretary/President Jason Hospitals Pvt. Ltd., Street No. 1, Bhagu Road, Bathinda. Deputy Registrar, Co-operative Societies, Sri Mukatsar Sahib. Punjab Co-operative Society, Chandigarh (Punjab), through its Registrar. ..... 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. Arvinder Singh, counsel for the complainant For the Opposite parties : Sh. Varun Gupta, counsel for opposite party Nos. 1 & 2. Sh. Harraj Singh, counsel for opposite party No. 3. Sh. K S Dabrikhana, counsel for opposite party Nos. 5 & 6. Opposite party No. 4 exparte
O R D E R
VIKRAMJIT KAUR SONI, PRESIDENT The instant complaint has been filed by the complainant under Section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as 'Act'). Briefly stated the case of the complainant is that he is a member of The Danewala Multipurpose Co-operative Agricultural Service Society, Danewala, District Mukatsar. The MD India Healthcare Services (TPA) Pvt. Ltd., introduced a scheme under the name of Bhai Ghanhya Sehat Sewa Scheme Policy and induced the members of the Co-operative societies to be the members of the said scheme for cashless hospitalization. The complainant also purchased the said policy of Bhai Ghanhya Sehat Sewa Scheme by depositing the requisite fee with opposite party Nos. 1 & 2 through opposite party No. 3. The opposite party Nos. 1 & 2 issued Card No. MD 15-BGSSS000041337-S to the complainant and as such the complainant and his family members are duly insured for medical insurance under Bhai Ghanhya Sehat Sewa scheme with opposite party Nos. 1 & 2 through opposite party No. 3, but no copy of policy was supplied to the complainant. The policy is valid from 2011 to 2012. The complainant met with an accident and sustained multiple grievous injuries and was got admitted in the Jason Hospitals Pvt. Ltd., opposite party No. 4, on 31-7-2011. At the time of admission in the said hospital, it was disclosed by the complainant to opposite party No. 4 that he is having the card under Bhai Ghanhya Sehat Sewa Scheme Policy and opposite party No. 4 also assured the complainant that their hospital is authorized for providing cashless hospitalization under the said scheme. The complainant remained admitted in the hospital w.e.f. 31-7-2011 to 10-08-2011 and is still under treatment. The complainant spent more than Rs. 60,000/- on account of medicines, hospital charges, bed charges and surgery charges etc., The complainant submitted the claim forms and bills to opposite party No. 3 who forwarded the same to opposite party Nos. 1 & 2 for payment of the claim amount of Rs. 60,000/- but the opposite party Nos. 1 & 2 have been putting the matter off under one pretext or the other. Hence, the complainant has filed the present complaint. The opposite party No. 1 in its separate written statement pleaded that complainant lodged the claim with opposite party No. 2 which is Third Party Administrator, through Jason Hospital Pvt. Ltd., Bathinda, which was received on 7-8-2011. The opposite party No. 2 on the same day raised some queries from opposite party No. 4 hospital, but it gave reply on 26-8-2011, but the patient was discharged on 10-08-2011 after treatment and as such, the claim was not considered and denied by opposite party No. 2. The cashless facility is to be extended before commencement of treatment and in this case the opposite party No. 4 failed to comply with the requirement of the policy terms and conditions. The opposite party No. 1 has pleaded that opposite party No. 2 received pre-authorization letter from opposite party No. 4 for providing cashless treatment to the complainant on 7-8-2011. On receipt of said pre-authorization letter, the opposite party No. 2 asked opposite party No. 4 to provide some other documents vide letter dated 7-8-2011, but the opposite party No. 4 failed to send the required documents nor gave reply to the query raised by opposite party No. 2 till 26-08-2011 whereas the complainant was discharged from the said hospital on 10-08-2011. Therefore, the opposite party No. 2 has declined the claim for cashless vide letter dated 26-08-2011. Under the scheme, the opposite party has to make the payment to opposite party No. 4, if the treatment cost was admissible in policy terms and conditions and for cashless facility all the desired documents and information are submitted by the treating network hospital on time as prescribed under the policy terms and conditions. But, opposite party No. 4 did not send the documents and claim within the specified time, rather discharged the complainant after receiving entire expenses of treatment from the complainant and in this way, the opposite party no. 4 has violated the terms and conditions of the agreement executed between opposite party No. 2 and 4. Once the cashless request is turned down by opposite party No. 2, the insured beneficiary is supposed to claim the reimbursement of treatment cost from opposite party No. 2. The opposite party No. 2 in its separate written statement stated that it received pre-authorization letter from opposite party No. 4 for providing cashless treatment to the complainant on 7-8-2011. On receipt of the said pre-authorization letter, the opposite party No. 2 asked opposite party No. 4 to provide some other documents, but opposite party No. 4 failed to send the required documents nor gave reply to the query raised by opposite party No. 2 till 26-08-2011 but the complainant was discharged from the said hospital on 10-08-2011. Under the scheme, the opposite party No. 2 has to make payment to opposite party No. 4, but it did not send the documents and claim rather discharged the complainant after receiving entire expenses of treatment from him. The complainant has not lodged any claim with opposite party No. 2 till date. The cashless hospitalization expenses are to be paid by opposite party No. 2 as per terms and conditions contained in the Guide Book which is in possession of main member of family. The opposite party No. 3 has pleaded in its separate written reply that it has nothing to do with providing the cashless treatment to the complainant. The complete financial and legal liabilities, if any, arising consequent to the operationalization of the scheme or the policy, rests exclusively and unconditionally with the TPA and the Insurance Company i.e. opposite party Nos. 1 & 2 and opposite party No. 3 has nothing to do with providing any cashless facility to the complainant. The role of opposite party No. 3 is only confined to the passing on the premium paid by the members to the Insurer on their behalf. The opposite party No. 4 filed separate written statement. It has been pleaded that the complainant was admitted in the hospital on 31-07-2011 as a case of RASA with fractures of multiple ribs with surgical emphysema chest and diabetes melitus. The patient was admitted under Dr. Harinder Pal Singh MS (General Surgery) working on regular basis in the hospital. At the time of admission, the patient did not inform about his insurance. He only informed about his insurance after a few days. The opposite party No. 4 admitted that complainant remained admitted in the hospital from 31-7-2011 to 10-08-2011. The hospital did not have any reply to the genuine queries of the insurance company as regarding the alcohol status of the patient at the time of the accident, as the patient was admitted with a gap of one day between injury and admission. As per guidelines of MD India, the procedure followed for cashless hospitalization is that hospital concerned forwards the PAL Form (Preauthorization letter) alongwith relevant documents to MD India when the patient produces the MD India Card and the required documents and only on the approval of the MD India for the same, cashless hospitalization can be given. All the required documents which were handed over to the hospital were forwarded to the insurance company in the present case. The hospital has not received or claimed any payment from MD India against the treatment of the complainant. The opposite party Nos. 5 & 6 filed their joint written reply. It has been pleaded that the Bhai Ghanhya Trust is a Registered Trust and the Trust has appointed M/s. IFFCO TOKIO General Insurance Co. Pvt. Ltd., opposite party No. 1 as Insurer w.e.f. 16-5-2011. M/s. IFFCO TOKIO, General Insurance Company has appointed opposite party No. 2 as Third Party Administrator to implement the scheme w.e.f. 16-5-2011 onwards. 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, to make the payments to empanelled hospitals for providing cashless services to the beneficiaries of the scheme. The members and employees of co-operative Societies and the co-operative department can become members of the scheme. The opposite party No. 4 is an approved hospital to provide cashless health care services under the scheme and opposite party Nos. 1 & 2 are the competent authorities under the scheme to settle the claim of the beneficiaries as per provisions of the scheme. The opposite party Nos. 5 & 6 have further pleaded that in case a beneficiary produces his card and the hospital denies the cashless then clause 6.4.7 of the Service Level Agreement makes the insurer liable. The insurer and the TPA are the service providers and the claim settling authorities under the scheme. Parties have led their evidence in support of their respective pleadings. Arguments heard. Record alongwith written submissions submitted by the parties perused. These are undisputed facts between the parties that the complainant purchased the Insurance policy of Bhai Ghanhya Sehat Sewa Scheme for cashless hospitalization by depositing the requisite premium with opposite party Nos. 1 & 2 through opposite party No. 3. The opposite party Nos. 1 & 2 issued Card No. MD 15-BGSSS000041337-S Ex. C-2 to the complainant and accordingly the complainant and his family members are duly insured for medical insurance under Bhai Ghanhya Sehat Sewa scheme with opposite party Nos. 1 & 2 through opposite party No. 3. The policy is valid from 2011 to 2012. The procedure followed for cashless hospitalization is that the hospital concerned forwards the PAL Form (Preauthorization letter) alongwith relevant documents to MD India when the patient produces the MD India Card and the required documents and on the approval of the MD India for the same, cashless hospitalization can be given. The complainant met with an accident and sustained multiple injuries and was got admitted in the Jason Hospitals Pvt. Ltd., opposite party No. 4, on 31-7-2011, which is a network hospital of opposite party Nos. 1 & 2. The complainant remained admitted in the said hospital w.e.f. 31-7-2011 to 10-08-2011. The complainant submitted the claim forms and bills to opposite party No. 3 who forwarded the same to opposite party Nos. 1 & 2. The complainant paid the amount as per receipts Ex. C-5 to Ex. C-26 to opposite party No. 4 for the treatment. Neither the cashless treatment was provided to the complainant nor any amount on this account was reimbursed to him by the opposite parties. The learned counsel for the complainant submitted that the complainant met with an accident and he was admitted in hospital opposite party No. 4. At the time of admission, he told opposite party No. 4 regarding his insurance and provided his ID card. Despite this, the opposite party No. 4 charged treatment expenses from the complainant, which he was not liable to pay. On the other hand, the learned counsel for opposite party Nos. 1 & 2 submitted that as per MOU executed between the net hospital i.e. opposite party No. 4 and opposite party Nos. 2, the opposite party No. 4 was bound to treat the patient after approval of opposite party No. 2. He submitted the Pre-authorisation letter on 7-8-2011 whereas the complainant was admitted on 31-7-2011 and discharged from the hospital on 10-08-2011. After receipt of PAL, some queries were raised. As per MOU opposite party No. 4 was bound to reply the query within 1 hour. The opposite party No. 4 did not reply the queries till 26-8-2011 whereas the complainant was discharged from the hospital on 10-08-2011. The submissions of the learned counsel for opposite party No. 3, 4 & 5 is that the complete financial and legal liabilities, if any, arising consequent to the opertionalization of the scheme or the policy, shall rest exclusively and unconditionally with the TPA and the Insurance company i.e. opposite party No. 1 & 2. Dr. Geeta Bhardwaj, General Manager, Operations, MD India Health Care Services (TPA) Pvt. Ltd., has deposed in para No. 3 of her affidavit Ex R-7 that :- “........opposite party No. 2 received pre-authorization letter from opposite party No. 4 for providing cashless treatment to the complainant on 7-8-2011. On receipt of the said pre-authorization letter, the deponent/opposite party asked opposite party No. 4 to provide some other documents but opposite party No. 4 failed to send the required documents nor gave any reply to the query raised by the deponent/opposite party till 26-08-2011 but the complainant was discharged from the said Hospital on 10-08-2011. Under the scheme, the deponent/opposite party has to make payment to opposite party No. 4, but however opposite party No. 4 did not send the documents and claim, rather discharged the complainant after receiving entire expenses of treatment of the complainant from the complainant.” Ex. R-11 is the Memorandum of Understanding (MOU) executed between MD INDIA Health Care Services (TPA) Pvt. Ltd, and Network Hospital (Provider) for implementation of “Bhai Ghanhya Sehat Sewa Scheme (BGSSS). Under the heading Definitions it has been mentioned :- “ -Cashless Service : It is a credit arrangement wherein the PROVIDER will treat the patients without charging any fees and MD INDIA will settle the bills of the PROVIDER directly subject to terms, conditions and provisions of this MOU.” Clause No. 2.9 of the the said MOU reads as under :- “2.9 On confirmation of the beneficiary, the PROVIDER will fax the filled Pre Authorization Letter (PAL) and copy of ID card within one hour of receipt of ID Card from the beneficiary to the MD INDIA office at Mohali and follow up with MD INDIA for obtaining authorization letter. It shall be responsibility of the PROVIDER to reply back to the TPA within one hour of receipt of any query regarding PAL/line of treatment from the TPA. The clause No. 41.5 of MOU is reproduced hereunder :- “PROVIDER shall not take any advance deposit, reimbursable security deposit or cash amount on any other account like service charge/surcharge/administration charges from the Beneficiaries/ MD India /ITGIC over and above the rate list.” Article 7.1 under the heading 'Billing Procedure' reads as under :- “7.1 PROVIDER will submit all the original medical bills, discharge summary, investigation reports alongwith the claim documents of hospitalization and the treatment carried on in the hospital within 7 days from the date of discharge of the patient.” The opposite party No. 2 after receipt of Pre-authorization Letter from opposite party No. 4 raised some queries and demanded some documents vide letter Ex. R-9. The relevant portion of the said letter is reproduced hereunder :- :..This is with reference to the above mentioned request for Authorization letter (PAL) received on 7-8-2011, we desired the following information at the earliest to process the PAL further. 1) Kindly provide clear photograph taken at the time of admission 2) Reason for delay in sending the Request for Authorization Letter 3) Detail circumstances of injury or trauma sustained with date and time. 4) Is the trauma/injury caused directly/indirectly due to use of alcohol ? Kindly provide alcohol status at the time of accident. 5) Copy of MLC/FIR 6) Clear MDI ID Card Xerox copy 7) All indoor papers with detail notes till date 8) Approximate expenses with detail break-up” The opposite party No. 4 has admitted in para No. 9 of his written reply that the opposite party No. 2 raised some queries. The said para reads as under :- “9. The hospital did not have any reply to the genuine queries of the Insurance Company as regarding the alcohol status of the patient at the time of accident, as the patient was admitted with a gap of one day between injury and admission. There was no valid reason for explaining the delay of informing the company regarding his admission as the lapse was on the part of the complainant.” Hence, it is proved on the record that after receipt of PAL, the opposite party No. 2 raised some queries which were not furnished by opposite party No. 4. However, the opposite party No. 4 has admitted in para No. 6 of his written reply that he has forwarded all the documents to the Insurance Company, which were submitted by the complainant to him. The opposite party No. 4 has pleaded in para No. 5 of his written reply that patient did not inform him about his insurance at the time of admission or within 24 hours of admission as is done in all emergency cases. He informed about his insurance after few days. If the version of opposite party No. 4 is believed that complainant told about his insurance after few days even then also, the aforesaid version of opposite party No. 4, regarding the queries raised by opposite party No. 2, makes the position crystal clear that opposite party No. 4 did not take the matter of insurance of the complainant seriously and did not reply to the queries. He discharged the complainant on 10-08-2011 and charged the total treatment charges from him and did not bother to get the approval to provide cashless treatment to the complainant. The opposite party No. 2 has pleaded that opposite party No.2 did not reply the queries till 26-08-2011 whereas as per clauses of MOU, reproduced above, the opposite party No. 4 was bound to provide cashless treatment to the complainant and reply to the queries within 1 hour. The opposite party No. 1 in para No. 5 of its written statement has stated that the opposite party No. 4 failed to send the required documents nor gave reply to the query raised by opposite party No. 2 till 26-8-2011, therefore, the opposite party No. 2 has declined the claim for cashless vide letter dated 26-08-2011. Hence, the act of opposite party No. 4 amounts to deficiency in service on his part. As discussed above, the complainant was entitled for cashless treatment according to aforesaid Insurance policy. The complainant has prayed that he spent Rs. 60,000/- on his treatment but the record reveals that he paid Rs. 46,339/- to opposite party No. 4 vide receipts Ex. C-5 to Ex. C-26 for which he was not liable. Therefore, keeping in view the facts, circumstances and the evidence placed on file by the parties, this complaint is accepted with Rs. 15,000/- as compensation and cost against opposite party No. 4 and dismissed qua opposite party Nos. 1 to 3 and 5 & 6. The opposite party No. 4 is directed to pay Rs. 46,339/- to the complainant. The opposite party No. 4 has admitted that he has forwarded all the documents of the complainant to opposite party No. 2. Thus, he may get the reimbursement of the treatment expenses of the complainant from the Insurance Company as per MOU. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance within the stipulated period, the opposite party No. 4 would be liable to pay interest @ 9% P.A. on the amount of Rs.46,339/- from the date of institution of this complaint i.e. 01-11-2011 till realization. A copy of this order be sent to the parties concerned free of cost and the file be consigned to record.
Pronounced
29-02-2012 (Vikramjit Kaur Soni) President
(Amarjeet Paul) Member
(Sukhwinder Kaur) Member
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