BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI

                                  Consumer Complaint No.194 of 2015

                                 Date of institution:          29.04.2015

                                                    Date of Decision:            15.09.2015

Gurvin Singh son of V.S. Malhotra resident of H.No.2164, Sector 71, Mohali.

                                                                         ……..Complainant                                   Versus

1.     Ivy Health & Life Sciences Pvt. Ltd., Sector 71, Mohali through its Chairman/Managing Director/Principle Officer Service through its Medical Superintendent.

2.     United India Insurance Company Limited its Chairman/Managing Director/Principle Officer Service through its  Branch Office at B.O. II, SCO 357-358, Sector 35-B, Chandigarh 160 035 through its Branch Manager.

        (Name of OP No.2 deleted from the array of the OPs vide order dated 04.08.2015).                                                                                                             ………. Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

CORAM

Mrs. Madhu. P. Singh, President.

Mrs. R.K. Aulakh, Member.

Present:    Complainant in person.

                Opposite Party No.1 exparte.

                OP No.2 already given up.

(Mrs. Madhu P. Singh, President)

ORDER

                The complainant has filed the present complaint seeking following direction to Opposite Party (for short ‘the OP’) No.1 to:

(a)    pay him compensation to the tune of Rs.10.00 lacs.

(b)    pay him adequate cost of litigation.

                The case of the complainant is that he took his deceased mother Smt. Jasinder Kaur to OP No.1 for medical treatment where she remained admitted from 09.01.2014 to 11.01.2014 as inward patient. The mother of the complainant was covered under medical indemnity insurance from OP No.2 and the indemnity insurance was presented to OP No.1 for approval and payment of medical expenditure to be incurred during stay of mother of the complainant with OP No.1. Accordingly on request of OP No.1 OP No.2 made pre approval of Rs.40,000/- and the balance amount, if any, is to be paid by OP No.2 after presentation of final treatment bill. The total treatment cost of mother of the complainant at the time of discharge came to be Rs.83,417/- and OP No.1 assured the complainant that it will raise the balance bill to the  OP No.2 and also adjust pre authorization amount and meanwhile OP No.1 took cheque No.093935 as security from complainant in case of less payment by OP No.2. To the utter surprise and shock to the complainant, OP No.1 initiated proceedings under Section 138 of Negotiable Instruments Act against the complainant vide complaint No.240/14 on the basis of aforesaid cheque given to OP No.1 as security cheque. The complainant approached OP No.1 and was shocked to know that OP No.1 did not prefer the balance bill of medical treatment of Rs.43,417/- with OP No.2 and neither utilized/claimed the pre authorised amount of Rs.40,000/- from OP No.2 and instead presented the cheque in the account of complainant which is not payable by the complainant. In order to get the proceedings under the NI Act against him, the complainant made the balance payment of said cheque to OP No.1.The complainant approached OP No.2 who informed the complainant that OP No.1 did not prefer any balance amount claim against the medical indemnity policy and not even utilized/claimed the pre authorization amount of Rs.40,000/-. Aforesaid act of OP No.1 in not claiming the balance medical treatment bill and utilizing the pre approved amount by OP No.2, is an act of deficiency in service and unfair trade practice. With these allegations the complainant has filed the present complaint.

2.             After admission of the complaint, notice was sent to the OP No.1.  None appeared for it despite service. Therefore, OP No.1 was proceeded against exparte vide order dated 18.06.2015. Shri G.D. Gupta, advocate appeared for OP No.2 but on 04.08.2015 the complainant made a statement that he has no grievance against OP No.2 and his name be deleted from the array of the OPs. Accordingly, the name of OP No.2 was deleted from the array of the OPs vide order dated 04.08.2015.

3.             To succeed in the complaint, the complainant tendered in evidence his affidavit Ex.CW-1/1 and copies of documents Ex.C-1 to C-12.

4.             We have heard the complainant and have also gone through the written arguments submitted by him.

5.             The complainant was holder of Individual Health Insurance Policy-2010 bearing policy No.110201/48/ 13/97/00000013 and the policy was valid from 01.04.2013 to 31.03.2014. The complainant’s mother being the dependant was also entitled to benefits of the policy and as per the complainant on 09.01.2014 his mother Smt. Jaswinder Kaur, now deceased, took treatment from OP No.1 as indoor patient and remained in the hospital from 09.01.2014 to 11.01.2014. The patient was entitled to cashless benefit of the policy and OP No.1 has taken pre-authorization of medical expenses of Rs.40,000/- from OP No.2 i.e. the insurer and further assured the complainant to get the reimbursement of the over and above expenditure of medical treatment from OP No.2. During the treatment as an indoor patient, the total expenditure on treatment was Rs.83,417/-. At the time of discharge, OP No.1 has taken one post dated cheque No.93935 from the complainant. The said cheque has been issued as a security with OP No.1 by the complainant with the clear understanding mentioned on the overleaf of the cheque “Security cheque valid only if insurance claim rejected by TPA. To be returned after claim paid to hospital.”  OP No.1 has not sent the bills to the insurance company though under the cashless policy it is the duty of the empanelled hospital to provide the details of treatment, bills raise against the treated patient and get the claims recovered from the insurance company. Instead OP No.1 has chosen to present the cheque issued as a security in the month of March, 2014 and the same cheque has been returned by the banker and, thereafter OP No.1 has issued legal notice to the complainant and even filed a complaint under Section 138 N.I. Act before the court of JMIC, Mohali as complaint No.179 of 12.05.2014 Ex.C-12. The said matter has been compromised in the Lok Adalat between the parties as OP No.1 has withdrawn the complaint. In this regard the complainant present in person states that the OP No.1 has failed in its duty of presentation of the bills to OP no.2 for raising the claim against the treatment of his mother and on this account, OP No.1 has failed to render proper and effective services to the complainant and, therefore, the act of OP No.1 is an act of deficiency in service. Further as per complainant, the presentation of post dated cheque No.93935 given by the complainant to OP No.1 as a security with clear instructions   to present the cheque only if insurance claim is rejected by TPA and return the same after the claim is paid to OP No.1. OP No.1 has failed deliberately to adhere to the instruction of security cheque and wrongly presented the same for encashment with the bank of the complainant. The act of OP No.1 in the presenting the cheque against the instructions is an act of unfair trade practice causing mental agony and harassment of unwarranted litigation which the complainant is forced to make before the Illaqa Magistrate.

5.             The fact that OP No.1 has withdrawn the complaint under Section 138 N.I. Act vide orders dated 06.12.2014 and honouring of claim by the insurance company vide claim settlement memo dated 17.03.2015 by the TPA and the full and final settlement receipt issued by OP No.1 Ex.C-9 clearly shows that OP No.1 has failed to present the claim to the insurance company and further has wrongly presented the security cheque for encashment. Therefore, on both the accounts, the complainant has proved his case against OP No.1 i.e. deficiency in service and unfair trade practice having been indulged by OP No.1 for which the complaint deserves to be allowed and the complainant deserves to be compensated.

6.             In view of above discussions, the complaint is allowed with the following direction to OP No.1 to:

(a)    pay to the complainant Rs. Rs.25,000/- (Rs. Twenty five thousand only) as lump sum compensation for mental agony, harassment and costs of litigation.

(b)    OP No.1 is further directed to discontinue the unfair trade practice being a service provider and empanelled hospital it must honour the obligations arising out of the memorandum of understanding signed between the insurance company, TPA and service provider for the interest and welfare of consumers.

                Compliance of this order be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.

Pronounced.                           

September 15, 2015.    

                        (Mrs. Madhu P. Singh)

                                                                        President

(Mrs. R.K. Aulakh)

Member