Punjab

Ludhiana

CC/14/697

Gurmit Kaur - Complainant(s)

Versus

Jalaldiwal Multi Purpose Agri Cooperative Society Ltd - Opp.Party(s)

Naresh Yadav Adv.

22 Aug 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

      Consumer Complaint No: 697 of 07.10.2014

                                                      Date of Decision: 22.08.2016.

 

Gurmit Kaur wife of Sh.Jagroop Singh son of Bhajan Singh, resident of V.P.O.Jalaldiwal, Tehsil Raikot, District Ludhiana.

……Complainant

                                                    Versus          

1.The Jalaldiwala Multipurpose Agri Cooperative Society Limited, VPO Jaladiwal, Tehsil Raikot, District Ludhiana, through its President/Secretary.

2.Bhai Ghanhya Sehat Sewa Scheme, Punjab, Sector 34-A, Chandigarh through its Manager.

3.M.D.India Health Care (TPA) Pvt. Ltd., Max Pro Info Park D-38, Phase-I, Industrial Area, Mohali, through its Manager.

4.United India Insurance Company Limited, registered office at 24, Whites Road, Chennai-600014, through its General Manager/M.D.

5.United India Insurance Company Limited, having its Regional Office at Feroze Gandhi Market, Ludhiana, through its Branch Manager.

                                                                             ……...Opposite Parties

             (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT                                     

MRS.          BABITA, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :          Sh.Naresh Yadav, Advocate

For OP1                         :          Sh.Deepak Ghai, Advocate

For OP2                         :         Sh.Ravinder Sharma, Advocate

For OP3                         :         Ex-parte

For OP4 and OP5          :         Sh.D.R.Rampal, Advocate

 

PER G.K.DHIR, PRESIDENT

 

1.                Complainant, a member of OP1 society got medi claim insurance policy from OP4 and OP5. That policy was started by OP1 for its members with the collaboration of OP2, for the health care insurance policy. OP3 is administrator for implementing the agency of said health care scheme. The policy was purchased by the complainant for self and her husband on the basis of card No.MD-15BGSSS00360774-S(of complainant) and card no.MD-15BSSS00360774-SP (of Jagroop Singh, husband of complainant). Complainant complied with all the requirements of cashless medi claim policy. A list of the hospitals, from which, the treatment can be got under the scheme was also provided to the complainant. Complainant suffered cardiac problem, due to which, she approached Global Heart and Super Specialty Hospital, Ferozepur Road, Ludhiana(mentioned at Sr.No.168 of list of hospitals).Angiography of the complainant was done on 6.6.2014 and she was advised for PTLA and Stent Lad. Thereafter, again complainant admitted in the said Global Heart and Super Specialty Hospital on 12.6.2014, where PTLA and Stent Lad was done. Complainant was discharged from the hospital on 14.6.2014. Medical card was handed over by the complainant in the hospital and said card along with file was sent to OPs through emails on 12.6.2014 and 13.06.2014 at RFI No.4349 and 4497 respectively. Bills of the hospital were not paid by the insurer and as such, the complainant was constrained to pay the sum of Rs.1,50,000/- from her own pocket. That amount included in the medical expenses. Complainant approached OPs several times regarding payment of his treatment expenses and even supplied the medical original card along with required documents, but to no effect. Complainant approached OP3 at Mohali for handing over the documents there, but they refused to pay the amount. By pleading deficiency in service, it is claimed that complainant stood harassed and as such, directions sought to OPs to pay the claimed amount of Rs.3,50,000/- i.e. Rs.1,50,000/- towards medical charges, but Rs.2,00,000/- towards mental pain and agony. Interest @24% p.a. even claimed.

2.                In written statement filed by OP1, it is admitted that the complainant deposited premium amount of Rs.886/- for purchase of medi claim insurance policy for self and her husband Jagroop Singh. A receipt in that respect was issued. Above referred cards were issued to the complainant and her husband. Admittedly, the complainant had to be admitted in the hospital and bear the expenses of medicines and hospital chargers. It is also admitted that despite production of records, the medical expenses not disbursed.

3.                In separate written statement filed by OP2, it is pleaded interalia as if complaint is not maintainable against OP2 because the complainant is not a consumer of OP2; there is no deficiency in service in providing services on the part of OP2; complaint alleged to be false, frivolous and vexatious; complainant has no cause of action and this Forum has no territorial jurisdiction because Bhai Ghanhya Trust has its registered office at Chandigarh. Besides, it is claimed that at the time of enrolment of the complainant, the terms and conditions of the scheme were supplied to the complainant, which she read over and understood the same. The complainant undertook to abide by all the terms and conditions of the insurance scheme by agreeing that Courts at Chandigarh will alone have jurisdiction in respect of the matter qua benefits under the scheme. Beneficiaries have been informed clearly that complete financial and legal liabilities, if any, arising consequent to the operation of the scheme or the policy will rest with M D India Health Care Services (TPA) Ltd, i.e. Op3 and United India Insurance Company i.e. Op4 during the scheme period of 16.5.2014 to 15.5.2015. Op4 has been appointed as insurer by Bhai Ghanhya Trust, but OP3 has been appointed as TPA for implementing the scheme. OP3 had to issue the identity cards and even to inspect the hospitals and thereafter, make recommendation to the trust for their empanelment. OP3 to grant authorization and settle the claim for making payments to the empanelled hospitals for providing cashless services. OP2 is neither necessary nor a proper party because it is not a service provider and nor the complainant is its consumer. As TPA and insurer are the service providers and as such, complaint against OP2 prayed to be dismissed. Admittedly, Global Heart & Super Specialty Hospital is an approved hospital under the scheme. If the claim of the complainant has not been settled by the OP3 and OP4, then they alone may be held liable.

4.                In joint written statement filed by OP4 and OP5, it is pleaded interalia as if complaint in the present form not maintainable; complaint is bad due to non-joinder and mis-joinder of necessary parties; complainant due to suppression of material facts has not approached this Forum with clean hands; intricate question of law and facts requiring elaborate evidence are involved,   due to which,Civil Court is competent to decide the matter. Besides, it is claimed that complaint is not verified. OP4 and OP5 are administrative and governing offices of United India Insurance Company Limited and they are not issuing any insurance policies. The insurance policies are issued by the Divisional Offices and Branch Offices, but they have not been impleaded as parties. No assurance was ever given by the offices of OP4 and OP5 that expenses on medical treatment will be provided under the cashless policy scheme. Each and every other averment of the complaint denied by claiming that the complainant is not entitled to any amount of compensation, particularly when OP3 after scrutinizing the claim of the complainant,disallowed the claim.Claim of the complainant is neither payable  nor entertainable. Complainant was suffering from pre-existing disease and that is why claim of the complainant was treated as ‘No Claim’ by OP3. Due and proper services have been rendered by OPs, but despite that claim alleged to be filed with malafide intention for harassing the OPs.

5.                OP3 was proceeded ex-parte in this case vide orders dated 23.12.2014.

6.                Complainant to prove her case tendered in evidence her affidavit Ex.CA along with documents Ex.C1 to Ex.C13 and thereafter, closed the evidence.

7.                On the other hand, counsel for OP1 tendered in evidence     affidavit Ex.RA1 of Sh.Gurmail Singh, Secretary of OP1 along with documents Ex.R1 to Ex.R3 and then closed the evidence.

8.                Counsel for the OP2 tendered in evidence affidavit Ex.RA2 of Sh.H.S.Sidhu, Chief Executive Officer of Bhai Ghanhya Trust and even tendered documents Mark A, Mark B and Ex.R2/1 and then closed the evidence.

9.                Counsel for the OP4 and OP5 tendered in evidence affidavit Ex.OP4/A of Sh.Baljit Singh, Manager of United India Insurance Co.Ltd along with documents Ex.OP4/1 to Ex.OP4/6 and then closed the evidence on behalf of OP4 and OP5.

10.              Written arguments submitted by the complainant. Written arguments also submitted by OP2 as well as OP1 only. Oral arguments of counsel for the parties heard and records gone through minutely.

11.              From the evidence produced on record namely affidavit Ex.CA of complainant Smt.Gurmit Kaur, copy of membership enrolment form Ex.C2, certificate issued by OP1 Ex.C4=Ex.R2, affidavit Ex.RA1 of Sh.Gurmail Singh, Secretary of OP1, copy of dispatch list prepared by OP1 and sent to OP3 placed on record as Ex.R1, copy of policy schedule Ex.OP4/1, it is established that  complainant along with her husband Sh.Jagroop Singh, being members of OP1 purchased the medi-claim health insurance policy on the basis of identity card Ex.C1 issued by OP1. Premium of Rs.886/- was collected from the complainant and same deposited by OP1 after collection from its members through certificate Ex.R2 and by submitting dispatch list Ex.R1. Even repudiation letter Ex.OP4/6 establishes as if medi-claim policy No.112100/48/14/41/00000029 of patient Gurmit Kaur was rejected due to receipt of claim documents after 60 days of date of discharge of the complainant from the hospital. That rejection through Ex.OP4/6 claimed to be according to the terms and conditions of the policy. No other ground of rejection of the claim is mentioned in letter Ex.OP4/6. So from the perusal of Ex.OP4/6 also it is made out that denial of purchase of the policy not made by OP4 and OP5. Even lodging of claim qua treatment of complainant from Global Heart & Super Specialty Hospital, Ferozepur Road, Ludhiana during period from 12.6.2014 to 14.6.2014 as indoor patient is admitted through repudiation letter Ex.OP4/6 itself. In view of this submissions advanced by Sh.D.R.Rampal, Advocate representing OP4 and OP5 has no force that the complainant failed to prove that he is entitled to the benefit of mediclaim policy in question. These arguments advanced on the basis of policy schedule Ex.OP4/1, in which, mention of collection of premium from 1,80,966/- families made. Even if in Ex.OP4/1, names of the families covered by the policy schedule not mentioned, despite that above referred evidence enough to establish as if the complainant being member of OP1 society availed the medi-claim health insurance policy through OP2 from OP4 and OP5, for which, OP3 is the TPA.

12.              It is also contended by Sh.D.R.Rampal, Advocate representing OP4 and OP4 that this Forum has no jurisdiction because on Ex.OP4/1, seal of Mohali Office of OP4 and OP5 is there and even TPA i.e. OP3 has its office at Mohali and the policy issued through Mohali and as such, complaint could have been lodged in District Consumer Forum situate at Mohali only. That submissions of counsel for OP4 and OP5 has no force because the premium amount as per the admission of Secretary of OP1 collected from the complainant in village Jalaldiwala, Tehsil Raikot, District Ludhiana and thereafter, list of members of OP1 seeking enrolment under the mediclaim health insurance policy Ex.R1 was sent from Jalaldiwala itself. Complainant is resident of said village Jalaldiwala, Tehsil Raikot, District Ludhiana and even OP4 has its regional office in Feroze Gandhi Market, Ludhiana and as such, not only cause of action accrued to the complainant in territorial jurisdiction of this Forum, but even due to existence of branch of United India Insurance Company Limited at Ludhiana, this Forum has territorial jurisdiction. Besides, the treatment got by the complainant from Global Heart and Super Specialty Hospital, Ferozepur Road, Ludhiana and payment for medical expenses of treatment made at Ludhiana and as such, cause of action accrued to the complainant in the territorial jurisdiction of this Forum.

13.              As per law laid down in case of Sh.Narayan Singh vs. New India Assurance Company Limited-IV(2007)CPJ-289(N.C.), if complainant resides at Muzaffarpur and insurance company has branch office there, then the District Forum of Muzaffarpur will have territorial jurisdiction to adjudicate the consumer dispute. Even as per law laid down in case of Life Insurance Corporation of India vs. Kewal Krishan Kampani-I(2007)CPJ-34(Punjab State Consumer Disputes Redressal Commission, Chandigarh), case can be filed by a person at a place, where OP has branch office. On the analogy of law laid down in above cited cases and by keeping in view the facts that United India Insurance Company Limited has its regional office at Ludhiana, it is obvious that this Forum has territorial jurisdiction.

14.              It is contended by Sh.Deepak Ghai, Advocate representing OP1 and Sh.Ravinder Sharma, Advocate representing OP2 that complaint against OP1 and OP2 is not maintainable because OP2 after collecting the premium from the members of OP1 through OP1transmitted the same to the insurance company and thereafter, contract arrived at between the complainant and United India Insurance Company Limited. The claim was to be processed by OP3 as TPA and as such, it is vehemently contended that there is no deficiency in service on the part of OP1 and OP2. These submissions advanced by counsel for OP1 and OP2 each has force because the documentary evidence produced on record as Ex.R1 and contents of affidavit Ex.RA1 of Sh.Gurmail Singh, Secretary of OP1 and contents of affidavit Ex.RA2 of Sh.H.S.Sidhu, Chief Executive Officer  of OP2 establishes that mediclaim insurance policy purchased by the Trust or OP1 for the benefit of members after collection of premium amount from the members of OP1. The collected premium amount was transmitted by OP1 under scheme of OP2 to OP4 and OP5 and as such virtually the contract of insurance came in existence between the complainant and OP4 and OP5 with OP3 as TPA.

15.              In cases titled as Sanjvni Trust(Regd.) Office of Registrar, Cooperative Societies, Punjab vs. Surinder Singh and others, decided on 19.09.2010 through First Appeal No.77 of 2007 by the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh and Bhai Ghanya Trust (Regd.), vs. Mehal Singh and others, decided on 29.05.2013 through First Appeal No.323 of 2012 by the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh, it has been specifically held that when Trust like OP2 purchased the insurance policy for the members of co-operative  society, then liability of paying the medical claim as per the terms and conditions of the policy will remain of insurer on processing of claim by TPA and not by the Trust or of co-operative society. Ratio of both these cases fully applicable to the facts of the present case and as such, OP1 being the collecting agent and OP2, as Trust, not liable to pay the insurance claim to the complainant under the Group Mediclaim Health Insurance policy purchased from United India Insurance Company Limited for the benefit of members of OP1.

16.              Moreover, after going through page 21 of Guide Book Ex.C3 issued by OP2, it is made out that after commencement of the mediclaim insurance scheme for the members of co-operative society, neither Bhai Ghanya Trust and nor co-operative society will be responsible in any way because liability of paying the insurance amount to the beneficiary to remain of insurance company, which is in this case is United India Insurance Company Limited as revealed by perusal of page no.12 of Ex.C3. At page no.12 of Ex.C3 itself it has been mentioned that OP3 will be the TPA. In view of assertions      at page no.21 of Ex.C3, it is obvious that neither co-operative society i.e. OP1 and nor the Trust i.e. Op2 liable to pay the claimed insurance amount. Rather, the liability to pay the claimed insurance amount will remain of United India Insurance Company Limited after processing of the claim by OP3, the          TPA. So, certainly the complaint against OP1 and OP2 is not maintainable because deficiency in service on their part is not at all proved. Rather, OP1 and OP2 after transmitting the collected premium amount from the members of OP1 society discharged their obligation by purchasing the policy Ex.C4/1 from United India Insurance Company Limited.

17.              Global Heart & Super Specialty Hospital situate at Ferozepur Road, Ludhiana is mentioned in the list of empanelment of OP3 to OP5 as revealed by entry No.168 at page 31 of Guide book Ex.C3 and by entry No.169 of page no.44 of Ex.OP4/3 (Also the guide book and list of network hospitals of OP2).

18.              From perusal of documents Ex.C7 to Ex.C11, it is made out that complainant got the treatment from the empanelled hospital namely Global Heart and Super Specialty Hospital situate at Ferozepur Road, Ludhiana not only on 6.6.2014, but even during admission period from 12.6.2014 to 14.6.2014. Specific reference to discharge summaries Ex.C7 and Ex.C10 in this respect can be made. Amount of Rs.1,12,978/- was paid for this treatment during period of admission of complainant from 12.6.2014 to 14.6.2014 is a fact borne from receipt Ex.C11. No evidence produced on record to show that the complainant got heart treatment for PTLA and Stent to LAD on account of pre-existing disease because insurance company has not produced any evidence in that respect. Had complainant suffered from pre-existing disease of heart ailment, then repudiation of claim would have been made on that account also through repudiation letter Ex.OP4/6. No reference of rejection of medical claim owing to pre-existing disease of the complainant made by OP4 and OP5 in Ex.OP4/6 and as such, certainly submissions advanced by Sh.D.R.Rampal, Advocate has no force that the complainant was not entitled for the insurance claim owing to pre-existing disease. Even as per law laid down in case National Insurance Company Limited vs. Suraj Parkash-II(2005)CPJ-3(Punjab State Consumer Disputes Redressal Commission, Chandigarh), when no evidence produced in support of claim that complainant knew about disease at the time of purchase of the insurance policy, then repudiation of the claim on ground of suppression of factum of pre-existing disease is illegal. In the case before us, insurance company failed to produce on record any evidence to establish that the complainant suffered from heart ailment prior to June 2014 because no documentary or oral evidence in that respect produced and as such, in view of the fact that repudiation of claim through letter Ex.OP4/6 is not on account of pre-existing disease, it has to be held that arguments of counsel for OP4 and OP5 has no force that the claim rightly repudiated due to pre-existing disease of the complainant.

19.              Besides, perusal of clause 1.3 of Ex.C3=OP4/3 reveals that pre-existing disease and first year exclusions are covered under the policy. No waiting period applicable in such cases as per clause 1.3 of Ex.C3=OP4/3. So, claim for pre-existing disease even covered by medi-claim insurance policy in question and as such, repudiation of claim on that account cannot be ordered. The documentary evidence produced above along with contents of affidavit Ex.CA of complainant enough to establish as if the complainant got the treatment from empanelled hospital for heart ailment during period from 12.6.2014 to 14.6.2014 as an indoor patient. So, hospitalization of the complainant was for more than 24 hours. As per the contents of page 18 of Ex.OP4/3, a patient can go to any of the network hospital/nursing home of his choice, the name of which is mentioned in the list. That has been done by the complainant by visiting the empanelled hospital for treatment as discussed above.

20.              As per clause no.4 at page No.19 of Ex.OP4/3, the member will obtain Preauthorization Form from the IPD Reception of the empanelled hospital, get it filled from the treating doctor and submit it back to the IPD reception. The officials of IPD reception of the empanelled hospital to send the filled preauthorization form to OP3 at regional office at Mohali for ensuring that authorization for cashless treatment got from TPA within 24 hours of admission of the patient. It is contended by counsel for OP4 and OP5 that compliance of this condition no.4 at page no.19 has not been done and as such, the complainant not entitled to the benefit of the policy in question. However, the complainant has produced on record copy of email correspondence Ex.C12 to establish as if intimation through email by empanelled hospital namely Global Heart & Super Specialty Hospital qua admission of complainant was sent to OP3 vide RFI-No.4349 dated 12.6.2014 and RFI-No.4497 dated 13.6.2014. So for getting the cashless treatment benefit, the officials of empanelled hospital sent the intimation to OP3 within 24 hours of admission of complainant. It was thereafter the responsibility of OP3 to process the claim and forward the same  to the insurer. No documentary evidence produced by OPs to prove the incorrectness of Ex.C12 and nor any attempt made by OP4 and OP5 to ascertain from the empanelled hospital that contents of Ex.C123 are false and as such, reliance on Ex.C12 has to be placed for holding that in fact the empanelled hospital from where the complainant got treatment, during admission period of 12.6.2014 to 13.6.2014, sent intimation to TPA of OP4 and OP5 qua treatment of complainant. If after getting such intimation from the officials of empanelled hospital, OP3 did not do anything, then complainant cannot be blamed for     that.

21.              Perusal of clause No.2 of page no.21 of Ex.OP4/3 reveals that all bills/ documents/ claim form to be submitted to the offices of District Coordinators of OP3 within 45 days from the date of discharge from the hospital by the patient, but those were not submitted even until 10.9.2014 as revealed by copy of claim form Ex.C13, bearing date of receipt of OP3 office at Mohali. Benefit of this clause no.2 or of miscellaneous clause nos.1 and 2 at page no.23 and 24 of Ex.OP4/3 can’t be got by the counsel for the OP4 and OP5 because after submission of intimation through email Ex.C12, it was the responsibility of OP3, the TPA to collect the documents and pass order as to whether cashless treatment to be provided or not? Decision in that respect not given by OP3 even after submission of the intimation qua admission of complainant through RFI-No.4349 of 12.6.2014 and RFI-No.4497 of 13.6.2014 and as such, repudiation of claim improper on ground that documents not received within 60 days from the date of discharge. Rather, the above referred clauses at page nos.23 and 24 of Ex.OP4/3 or at page nos.28 and 29 qua submission of claim form along with documents within 45 days, not applicable to the present case because treatment not got by the complainant from Government hospital, but from the empanelled hospital, who sent intimation of admission of complainant on 12.6.2014 and 13.6.2014 as revealed by Ex.C12 referred above.

22.              After taking us through Ex.C13, it is contended by Sh.D.R.Rampal, Advocate that claim form was received on or before 10.09.2014, despite the fact that the complainant was discharged from the empanelled hospital on 14.6.2014 and as such, claim was not lodged within 45 days. Besides, mention of the documents consisting of bills and treatment record not made in Ex.C13 and as such, it is contended that documents were sent after 10.9.2014 only and not before that, due to which, that repudiation of claim through letter Ex.OP4/6 is proper. That submission of counsel for OP4 and OP5 again has no force  because if intimation qua authorization for cashless treatment sent by the officials of empanelled hospital to TPA on 12.6.2014 and 13.6.2014 that is within 24 hours of admission of complainant, then TPA must have decided as to whether benefit of cashless treatment to be given to the complainant or not? In view of non taking of decision in that respect by OP3, husband of the complainant had to pay from his own pocket to the empanelled hospital and as such, the complainant was put to mental harassment and agony unnecessarily. So, complainant entitled to compensation for mental agony, harassment and sufferings from OP3 to OP5 i.e. TPA and insurer.

23.              Even if the insurance policies are issued by the branch office, despite that impleadment of head office of United India Insurance Company Limited and Regional Office as OP4 and OP5 is quite appropriate because insurer is United India Insurance Company Limited and not the particular branch of it. Head office of United India Insurance Company Limited along with Regional office concerned has been impleaded as OP4 and OP5 and as such, submissions of Sh.D.R.Rampal, Advocate has no force that complaint bad due to mis-joinder and non-joinder of necessary parties. No complicated question of law and facts are involved and as such, this Forum has jurisdiction to decide the complaint. Complainant also entitled to litigation expenses because he has been dragged in litigation due to in action of OP3 in not processing the cashless treatment claim, even after getting the information through Ex.C12 from the officials of empanelled hospital within time.

24.              As a sequel of the above discussion, complaint allowed in terms that OP3 to OP5 will process the claim of the complainant at earliest and will adjudicate the same within 45 days from the date of receipt of copy of this order. After such adjudication, OP4 and OP5 will make the payment of the adjudged amount within 30 days of settlement of claim along with interest @8% per annum from today onwards till payment. OP3 to OP5 also directed to pay compensation of Rs.8000/- for mental harassment, but litigation expenses of Rs.2000/- to the complainant. Complaint against OP1 and OP2 is dismissed. Liability of paying compensation for mental harassment and litigation expenses will be joint and several of OP3 to OP5. Copies of order be supplied to the parties free of costs as per rules.

25.                        File be indexed and consigned to record room.

 

                   (Babita)                                          (G.K. Dhir)

          Member                                          President

Announced in Open Forum

Dated:22.08.2016

Gurpreet Sharma.