| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.503 of 04-10-2016 Decided on 11-04-2018 Darshan Singh aged about 65 years S/o Arjan Singh R/o Village Assa Buttar, District Sri Muktsar Sahib now residing at Dabwali Road Behind Sheesh Mahal Colony, Bathinda ........Complainant Versus l.Jindal Heart Institute & infertility Centre, # 21373, Power House Road, Bathinda, through its Proprietor/Incharge Dr.Rajesh Jindal Consultant Cardiologist. 2.Dr.Rajesh Jindal Consultant Cardiologist, Proprietor/Incharge of Jindal Heart Institute & Infertility Centre, # 21373, Power House Road, Bathinda. 3.MD India Healthcare Services (TPA) Pvt. Ltd., Bathinda, through its Manager. (Deleted) 4.MD lndia Healthcare Services (TPA) Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali, Punjab, through its Managing Director. 5.The Assa Butter Multipurpose C.A.S.S. Ltd., Assa Butter, through its Secretary. 6.ICICI Lombard General Insurance Co. Ltd., 3039-A, Sharma Complex, GT Road Near Bus Stand, Bathinda. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Sh.Jarnail Singh, Member. Smt.Sukhwinder Kaur Member Present:- For the complainant: Sh.Gurkirat Singh, Advocate. For opposite party Nos.1 & 2: Sh.Naresh Garg, Advocate. Opposite party No.3: Deleted. Opposite party Nos.4 & 5: Ex-parte. For opposite party No.6: Sh.Vinod Garg, Advocate. ORDER M.P Singh Pahwa, President The complainant Darshan Singh (here-in-after referred to as complainant) has filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties Jindal Heart Institute & infertility Centre and Others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that he is an agriculturist. He owns and possesses agriculture land at village Assa Buttar, District Sri Muktsar Sahib. He is member of opposite party No.5. Opposite party No.5 insured almost all its members, including the complainant, under mediclaim policy i.e. Bhai Ghanaya Sehat Sewa Scheme vide an insurance policy. Opposite party Nos.1 and 2 issued card No.MD-15-BGSSS-00962147-S ensuring that the complainant is insured for mediclaim with opposite party Nos.3 and 4. The policy is in the possession of opposite party No.5. The mediclaim policy provides facility to all members of opposite party No.5 to get cashless treatment from the network hospitals and in case of government hospital, the insured is entitled to get the claim from opposite party Nos.3 and 4 after payment. It is alleged that opposite party Nos.3 and 4 conveyed the complainant that they will bear medical expenses in case of pre and post disease from the policy to the tune of Rs.1.5 lakhs per person of the family. Except the card issued by opposite party Nos.3 and 4 and conveying the above facts, no other document or terms and conditions of the policy were supplied to the complainant. It is further alleged that on 15.8.2016, the complainant suffered pain in his chest and his son Veer Singh took him to opposite party Nos.1 and 2 and also informed other relatives. The complainant and his son Veer Singh reached in the hospital of opposite party Nos.1 and 2 and their other relatives also reached directly in the hospital. Opposite party No.2 examined the complainant and told his son that the life of the complainant is in danger and all three vessels of his heart are blocked and stent is to be inserted in his heart immediately. On enquiry by his son with regard to the expenses for inserting the stent, opposite party No.2 disclosed that the total expenses of the total treatment including cost of stent would be Rs.1,50,000/-. Veer Singh informed that the complainant is member of opposite party No.5 and he is insured under mediclaim policy. Opposite party No.2 demanded the card issued under Bhai Ghanaya Sehat Scheme. After sometime, card No.MD-15-BGSSS-00962147-S issued by opposite party Nos.3 & 4 was brought from the house and shown to opposite party No.2. On seeing this card, opposite party No.2 stated that he will give treatment to the complainant free of costs and will get amount from opposite party Nos.3 and 4. It is further alleged that Veer Singh gave his consent for treating the complainant. After 15/20 minutes, opposite party No.2 informed son of the complainant that the stent cannot be inserted in the heart of the complainant because one of the vessel has been leaked. Opposite party Nos.1 and 2 kept the complainant admitted in ICU in their Hospital up to 21.8.2016. He was never taken to the operation theater thereafter. On 21.8.2016, opposite party No.2 informed Veer Singh that the total bill of treatment of the complainant is Rs.1,40,145/- and he should pay this amount. Opposite party Nos.1 and 2 also revealed that they are sending the bills and other documents to opposite party Nos.3 and 4, they will pass the claim of the complainant within 2-3 days and complainant or his son may come to them and they will return amount of Rs.1,40,000/- to the complainant/his son. It is further alleged that on the assurance opposite party Nos.1 and 2 to return the amount, Veer Singh paid them an amount of Rs.1,00,000/-. They handed over the discharge summary, copies of color doppler Echo cardiography report, Angiography report and other reports to Veer Singh. They also gave two CDs of Angiography, but the same do not play when tried to be open. It is also alleged that Veer Singh approached opposite party Nos.1 and 2 on 25.8.2016 to get refund of Rs.1,00,000/- paid for treatment of the complainant. Opposite party Nos.1 and 2 told Veer Singh that they have received only Rs.50,000/- from opposite party Nos.3 and 4 and balance claim has been rejected. They returned an amount of Rs.10,000/- only to Veer Singh. The complainant was not feeling well. As such, Veer Singh took him to DMC & Hospital, Ludhiana for check up and further treatment. The complainant was examined by Dr.G.S Wander, Cardiologist of the Hospital. After seeing the reports given by opposite party Nos.1 and 2, Dr.G.S Wander diagnosed that the heart of the complainant is working only 25% and heart is weak. He prescribed certain medicines and orally stated that no such surgery can be conducted on the person of the complainant. Opposite party Nos.1 and 2 have given medicines and nothing was done. It is further alleged that opposite party Nos.1 and 2 in the Angiography report have described that RCA is 100% block, S1 is 100% block, D1 is 70%-80% block and D2 is 80-90% block, but Dr.G.S Wander in his report has described the working of the heart to the extent of 25%. As per Angiography report, no such leakage of any vessel has been described by opposite party Nos.1 and 2. It is also alleged that opposite party Nos.1 and 2 have squeezed Rs.1,40,000/- from the complainant and his son. Opposite party Nos.3 and 4 have only passed the claim regarding treatment of the complainant to the extent shown in the medical record submitted by opposite party Nos.1 and 2. The complainant lodged the claim with opposite party Nos.3 and 4 for making payment of the balance amount of Rs.90,000/-, but they refused on the pretext that they have already paid the genuine claim to opposite party Nos.1 and 2 and amount paid by the complainant to opposite party Nos.1 and 2 is beyond the treatment. In the bill, opposite party Nos.1 and 2 have described charges of Rs.65,000/- as POBA, Rs.10,000/- as TPI and Rs.27,000/- as IABP, but however opposite party Nos.3 and 4 have not passed the claim. Opposite party Nos.1 and 2 have taken away Rs.90,000/- from the complainant, though he was fully insured for the mediclaim with opposite party Nos.3 and 4. The complainant has claimed refund of Rs.90,000/- with interest @ 18% p.a. from 21.8.2016 till payment from opposite party Nos.1 to 4. It is also alleged that opposite party No.6 is insurer under Bhai Ghanhya Sehat Sewa Scheme. All opposite parties jointly and severally are liable to pay the claim amount to the complainant. On this backdrop of facts, the complainant has alleged that due to wrong and illegal act of opposite party Nos.1 to 4, he remained under mental shock and agony. For these sufferings, he has claimed compensation to the tune of Rs.2 lakhs and cost of litigation to the tune of Rs.20,000/- in addition to Rs.90,000/- with interest @ 18% per annum. Hence, this complaint. Upon notice, opposite party Nos.1, 2, 5 and 6 appeared before this Forum and contested the complaint by filing their written version. The name of opposite party No.3 was deleted and opposite party No.4 was proceeded against ex-parte. In the joint written version, opposite party Nos.1 and 2 have raised the legal objections that the complaint is not maintainable qua them in its present form. The complainant has not come with clean hands and not disclosed true facts to this Forum as he never paid single penny to opposite party Nos.1 and 2 till date and total treatment done by opposite party Nos.1 and 2 under BGSSS (Cashless Scheme). It is further mentioned that the complainant Darshan Singh admitted on 15.8.2016 with opposite party Nos.1 and 2 with sudden on set chest pain for last two hours. On evaluation, he was found to be suffering from Massive Heart Attack with Heart Rhythm going into heart blocks. Necessitating urgent intervention with Pacemaker and Reperfusion Therapy (Coronary Angioplasty/Stenting of Culprit Vessel). Darshan Singh was so serious that very high risk consent was duly explained in vernacular language to his son Veer Singh and other relatives present at the spot at that time. It was also explained that in case of worsening scenario, he will also be required to put on ventilator and other life support measures. Subsequently, the patient was taken into the cath lab and immediately, temporary pacemaker was inserted and coronary angiography was done, which revealed blockage in all three major heart vessels. His condition and treatment provided are detailed in the written version, reference of which is not necessary for disposal of controversy involved in this complaint. Further legal objections are that the complaint is not maintainable under 'Act' against opposite party Nos.1 and 2 as the services are free of cost. There is no negligence on their part. The complaint is bad for mis-joinder of necessary party. The complainant is not entitled for any relief as he never paid any single penny of his treatment to opposite party Nos.1 and 2. On merits, opposite party Nos.1 and 2 have controverted all the material averments of the complainant. It is reiterated that the complainant took treatment from opposite party Nos.1 and 2 under BGSSS i.e. Cashless Insurance Scheme and he never paid them single penny. Opposite party Nos.1 and 2 filed the complaint against BGSSS, Insurance Company and TPA for not releasing the treatment bills of the complainant. It is also asserted that opposite party No.1 discharged the complainant without any amount under BGSSS and submitted the final bill of Rs.1,40,145/- alongwith all the treatment papers to opposite party Nos.4 and 5 as per scheme of BGSSS, but they again passed the part payment of Rs.46,190/- on 22.8.2016. In this way, they passed the part payment of Rs.3810/- and Rs.46,190/- i.e. total Rs.50,000/- against the final bill of Rs.1,40,145/-. An amount of Rs.90,145/- is still due towards against the complainant and opposite party Nos.3 to 5 and insurance company. After controverting all other averments of the complainant, opposite party Nos.1 and 2 have prayed for dismissal of complaint. In the written version, opposite party No.5 has also raised the legal objections regarding locus standi; cause-of-action and non-joinder of the necessary party. On merits, it is stated to be matter of record that the complainant is member of opposite party No.5 and members of opposite parties are insured under mediclaim policy i.e. Bhai Ghanaya Sehat Sewa Scheme (opposite party Nos.3 and 4). All other averments of the complainant are denied mainly for the reason for want of knowledge. It is relevant to mention that when case was fixed for evidence, none appeared on behalf of opposite party No.5. As such, ex-parte proceedings were taken against it vide order dated 3.8.2017. In the written version, opposite party No.6 has also raised the legal objections the intricate questions of law and facts are involved in the complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act'. The appropriate remedy, if any, lies only in the civil court. That another complaint titled Dr. Rajesh Jindal Vs. ICICI Lombard has been filed by opposite party Nos.1 and 2 qua same cause-of-action wherein Dr.Rajesh Jindal has claimed payment of Rs.90,145/- whereas Darshan Singh is claiming this amount on the ground that he has paid amount on account of medical treatment to opposite party Nos.1 and 2. There is interse dispute between the complainant and Dr.Rajesh Jindal of Jindal Heart Institute. Opposite party No.6 will make the payment as per order of this Forum in case, amount is held to be payable by it. The complainant has concealed the material facts and documents from this Forum and opposite party No.6. He has concealed the fact that opposite party Nos.1 and 2 are claiming the same amount by filing a separate complaint, which is still pending in this Forum. The complainant has no locus-standi or cause-of-action to file the complaint. On merits, terms and conditions of the policy are not denied. The maximum liability under the scheme is Rs.1,50,000/- per member, but on family floater basis. Other averments relating to opposite party No.6 are denied mainly for want of knowledge. After controverting all other averments of the complainant, opposite party No.6 has prayed for dismissal of complaint. Parties were asked to produce the evidence. In support of his claim, the complainant has tendered into evidence his affidavit dated 10.12.2017, (Ex.C1); photocopy of certificate, (Ex.C2); photocopy of insurance card, (Ex.C3); photocopy of PAL details, (Ex.C4); photocopy of beneficiary feedbook report, (Ex.C5); photocopy of discharge summary, (Ex.C6); photocopy of colour doppler report, (Ex.C7); photocopy of mitral valve, (Ex.C8); photocopy of triscupid valve, (Ex.C9); photocopies of reports, (Ex.C10 to Ex.C14, Ex.C17 and Ex.C22); photocopy of OPD card, (Ex.C15) photocopy of dispatch list, (Ex.C16); photocopies of bills, (Ex.C18 to Ex.C21) and submitted written arguments. To rebut the claim of the complainant, opposite party Nos.1 and 2 have tendered into evidence affidavit of Dr.Rajesh Jindal dated 4.9.2017, (Ex.OP1/1); photocopy of medical file, (Ex.OP1/2); CDs of treatment, (Ex.OP1/3 and Ex.OP1/4) and photocopy of policy, (Ex.OP1/5) and submitted written arguments. Opposite party No.6 has tendered into evidence affidavit of Aman Singh dated 29.7.2017, (Ex.OP6/1); photocopy of complaint, (Ex.OP6/2); photocopy of endorsement schedule, (Ex.OP6/3); photocopy of group health insurance mass, (Ex.OP6/4); photocopy of guidebook of insurance scheme, (Ex.OP6/5); affidavit of Apurva Sharma dated 15.9.2017, (Ex.OP6/6); photocopy of calculation sheet, (Ex.OP6/7) and submitted written arguments. We have heard learned counsel for parties and gone through the file as well as written arguments submitted by learned counsel for parties. Learned counsel for complainant and opposite party Nos.1 and 2 have reiterated their stand as taken in their respective pleadings and detailed above. It is further submitted by learned counsel for complainant that the main dispute involved in this complaint is regarding Rs.90,000/-, which is paid by the complainant to opposite party Nos.1 and 2. This amount was to be paid by the insurance company i.e. opposite party No.6 as the complainant was covered under the policy. It is further submitted by learned counsel for complainant that although, in the written version, opposite party Nos.1 and 2 have asserted that they have to receive a sum of Rs.90,145/- from the complainant/insurance company, but during the pendency of complaint, opposite party Nos.1 and 2 have already suffered statement that they have no objection, if amount be paid to the complainant. In this way, they have already supported the claim of the complainant. It is also submitted by learned counsel for complainant that opposite party No.6 has tendered into evidence affidavit of Apurva Sharma, (Ex.OP6/6) whereas opposite party No.6 has agreed to release only Rs.58,094/- after adjusting an amount of Rs.50,000/- already paid to opposite party Nos.1 and 2. The complainant is entitled to total outstanding amount of Rs.90,145/-. Opposite party No.6 has unnecessarily delayed to release this amount, which necessitated the complainant to file this complaint. Therefore, he is also entitled to compensation and cost of litigation. On the other hand, learned counsel for opposite party No.6 has submitted that the complainant is entitled to reimbursement only as per terms and conditions detailed in the policy. A sum of Rs.50,000/- was already released to opposite party Nos.1 and 2 and this fact is admitted by them also. A sum of Rs.58,094/- is payable as per terms and conditions of the policy. The details of the calculation is also brought on record as Ex.OP6/7. The complainant has not impugned this detail also. Opposite party No.6 could not release this amount due to interse dispute of the complainant and opposite party Nos.1 and 2. As such, there is no delay on the part of opposite party No.6. We have given careful consideration to these rival submissions. Some facts are not in dispute. It is not disputed that the complainant was covered under Bhai Ghanaya Sehat Sewa Scheme. It is also not disputed that he took treatment from opposite party Nos.1 and 2. Opposite party No.2 has charged Rs.1 lakh, out of which, a sum of Rs.10,000/- was returned on 25.8.2016. The main claim of the complainant is for compensation amount of Rs.90,000/-. Although in the written version, opposite party Nos.1 and 2 have asserted that the complainant was provided treatment free of cost being covered under the policy. They have also raised the claim of remaining amount of Rs.90,145/- from the complainant and insurance company. Subsequently, learned counsel for opposite party Nos.1 and 2 has suffered statement that opposite party Nos.1 and 2 have no objection, if this amount is released to the complainant. Therefore, now, dispute is between the complainant and opposite party No.6 only. The complainant has alleged a sum of Rs.90,000/- is payable being medical charges. Opposite party No.6 has pleaded that as per terms and conditions, total amount payable to the complainant is Rs.1,08,094/-, out of which, Rs.50,000/- has been paid and a sum of Rs.58,094/- is payable. Opposite party No.6 has placed on record calculation to show that amount is paid/denied as per policy terms and conditions. The complainant has not disputed this calculation. Therefore, he is entitled to this amount of Rs.58,094/- from opposite party No.6. Opposite party No.6 has unnecessary delayed to settle the claim, which necessitated the complainant for filing this complaint. As such, he is also entitled to cost of litigation. For the reasons recorded above, the complaint is partly accepted with cost of Rs.10,000/- in favour of the complainant and against opposite party No.6 and dismissed qua opposite party Nos.1, 2, 4 and 5. Opposite party No.6 is directed to pay an amount of Rs.58,094 to the complainant. The compliance of this order be made within 30 days from the date of receipt of copy of this order. In case of non-compliance, thereafter the interest @ 12% per annum will yield on the amount payable to the complainant till realization. The complaint could not be decided within the statutory period due to heavy pendency of cases. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 11-04-2018 (M.P Singh Pahwa) President (Jarnail Singh) Member (Sukhwinder Kaur) Member
| |
