Punjab

Sangrur

CC/645/2014

Jarnail Singh - Complainant(s)

Versus

Kotak Mahindra Bank - Opp.Party(s)

Jagtar Singh Kaler

14 May 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    645

                                                Instituted on:      05.12.2014

                                                Decided on:       14.05.2015

 

Jarnail Singh aged 38 years son of Niranjan Singh, resident of Village Bhojowali, Tehsil Dhuri, District Sangrur.

                                                        ..Complainant

                                        Versus

1.             United India Insurance Company Limited, Divisional Office; Dhuri Road, Sangrur through its Divisional Manager.

2.             M.D. India Health Care Services Private Limited, MAX Pro Info Park, D-38, Phase-I, Industrial Area, Mohali 160 056 (Punjab) through its authorised signatory.

3.             Cooperative Agriculture Sewa Society, Bhojowal, through its Secretary.

                                                        ..Opposite parties

 

 

For the complainant    :       Shri Jagtar Singh, Adv.

For OP No.1              :       Shri Ashish Kumar, Adv.

For OP No.3              :       Shri G.S.Toor, Adv.

For OP No.2              :       Exparte.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

 

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Jarnail Singh,  complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant purchased a medical insurance policy from OP number 1 through OP number 3, according to which the complainant along with his parents  and children were entitled for the medical insurance. The card number of the father of the complainant is MD15-BGSSS-00304466-F.  It is further averred in the complaint that father of the complainant suffered from right ureic stone, as such he was admitted in A.P. Health Care and Trauma Centre, Bhadson Road Patiala on 5.6.2014 for operation and he spent an amount of Rs.18,887/- on the treatment of his father in the hospital. Further case of the complainant is that the OP number 1 did not provide identity card to the complainant and his family members at the time of admission , as such the complainant could not submit the identity card of his father to the hospital. It is further stated that after the operation, the complainant submitted his claim to the Sub Registrar of OP number 3 and submitted all the necessary documents, but the OP number 1 sent a cheque for Rs.1800/- only instead of reimbursement of the full claim. Thus, alleging  deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the amount of Rs.18,887/- along with  @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1 and 2, it is averred that on the request of the Bhai Ghanhya Trust, the OP number 1 issued a group medical policy w.e.f. 16.5.2014 to 15.5.2015 and ID card along with guide book was sent to the beneficiaries. It is stated further that OPs have already paid an amount of Rs.1800/- as per package for private hospitals. It is stated further that charges incurred at hospital primarily for diagnostic, x-ray or laboratory examinations not leading to indoor treatment are not covered, therefore, the complainant is not entitled to claim more than Rs.1800/- from the OPs. It is wrong that the complainant spent an amount of Rs.18,887/- as alleged by him in the complaint.  It is stated that the amount of claim has already been paid as per rules. Any deficiency in service on its part has been denied.

 

3.             In reply filed by OP number 3, it has been admitted that the complainant had purchased the medical insurance policy from the OPs and paid the premium. It is also admitted that the complainant is the main beneficiary and as per the scheme the parents and children of the beneficiary are entitled for the medical benefits. It has been further stated that OP number 3 gave the identity card to the complainant on 6.6.2014. The other allegations levelled in the complaint have been denied.

 

4.             Record shows that OP number 2 did not put appearance despite service, as such OP number 2 was proceeded exparte on 14.01.2015.

 

5.             The learned counsel for the complainant has produced Ex.C-1 copy of ID card, Ex.C-2 to Ex.C-4 copies of booklet, Ex.C-5 discharge slip, Ex.C-6 to Ex.C-13 copies of bills, Ex.C-14 copy of cheque, Ex.C-15 copy of application, Ex.C-16 affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP1/1 copy of policy, Ex.OP1/2 copy of guide book, Ex.OP1/3 copy of letter, Ex.OP1/4 copy of agreement, Ex.OP1/5 affidavit, Ex.OP1/6 copy of application of enrolment and closed evidence. On the other hand, the learned counsel for the OP number 3 has produced Ex.OP3/1 copy of resolution dated 15.1.2015 and Ex.OP3/2 affidavit and closed evidence.

 

6.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             It is an admitted fact that the complainant purchased a medical insurance policy from OP number 1 through OP number 3 by paying the requisite premium for the period from 16.5.2014 to 15.5.2015 under which the parents and children of the complainant were entitled to claim the medical expenses incurred in the empanelled hospital of the OPs number 1 and 2.  It is the specific case of the complainant that his father Shri Niranjan Singh was suffering from ureic stone, as such he was got admitted in the A.P. Health Care and Trauma Centre, Bhadson, which is an empanelled hospital of the OPs, where he spent an amount of Rs.18,887/-.  It is further admitted that the claim for reimbursement was lodged with  OPs number 1 and 2 through OP number 3, but the OP number 1 paid an amount of Rs.1800/- only instead of full claim. It is worth mentioning here that the complainant did not get the cheque of Rs.1800/- encashed.  On the other hand, the learned counsel for OPs number 1 and 2 has contended that the OPs have paid an amount of Rs.1800/- as per package for private hospitals regarding DJ Stenting Unilateral and as per Bhai Ghanhya Sehat Sewa Scheme terms and conditions, URS (ureteroscopy) is a diagnostic procedure and not the primary treatment.  It is stated further that the charges incurred at hospital primarily for diagnostic, x-ray or laboratory examinations are not leading to indoor treatment, as such, the same are not covered under the policy. 

 

8.             We have very carefully perused the whole case file and after hearing the arguments of the learned counsel for the parties, we find that the father of the complainant, Shri Niranjan Singh took treatment from AP Healthcare and Trauma Centre, Bhadson, which is an empanelled hospital, as per list of network hospitals, which is on record as Ex.C-4.  The learned counsel for the complainant has contended vehemently that the Ops have illegally and intentionally did not pay the full claim of Rs.18,887/- as the same amount was spent on the treatment taken by Shri Niranjan Singh in the empanelled hospital as mentioned above.  On the other hand, the learned counsel for the OPs number 1 and 2 has contended that as per document Ex.OP1/2 Bhai Ghanhya Sehat Sewa Scheme Punjab guidebook and List of Network Hospitals, charges incurred at hospital or nursing home primarily for diagnostic, xray or laboratory examinations not leading to indoor treatment, as such no amount is payable.  Assuming that such charges are not payable by the OPs, but there is no justification that why the Ops did not pay the other amount spent by the complainant on medicines and treatment etc. as per Ex.C-6 bill for medicines for Rs.307/-, Ex.C-7 bill for medicines for Rs.375/-, Ex.C-8 bill for medicines for Rs.1385/-, Ex.C-10 bill of laboratory for Rs.750/-, Ex.C-11 bill of AP Healthcare and Trauma Centre for Rs.13,340/, Ex.C-13 bill for medicines for Rs.731/-, the total of which comes to Rs.16,888/-.  There is no explanation from the side of the OPs number 1 and 2 on the file that why the amount of Rs.16,888/- spent by the complainant on the treatment of Shri Niranjan Singh was not paid.  Further it is on the file that the identity card of Shri Niranjan Singh was only delivered by OP number 3 to the complainant on 6.6.2014, whereas the treatment was taken on 5.6.2014, meaning thereby the identity card in question was delivered to the complainant only after taking the treatment.  This fact that the OP number 3 delivered the identity card to the complainant on 6.6.2014 is also mentioned in the affidavit of Shri Ram Sarup, Secretary of the Cooperative Agriculture Sewa Society, Bhojowali, which is on record as Ex.OP3/2.   In the circumstances, of the case, we feel that the complainant is entitled to get an amount of Rs.16,888/- from the OP number, which has been spent by him on the treatment of Shri Niranjan Singh in an empanelled hospital.

 

9.             In view of our above discussion, we allow the complaint and direct OP number 1 to pay to the complainant an amount of Rs.16,888/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 5.12.2014 till realisation.  OP number 1 is further directed to pay to the complainant an amount of Rs.5000/- in lieu of litigation expenses.

 

10.            This order of ours be complied with within a period of thirty days of its communication. A copy of this order be supplied to the parties free of cost. File be consigned to records.

                Pronounced.

                May 14, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                          

                                                                (Sarita Garg)

                                                                   Member