Punjab

Fatehgarh Sahib

CC/46/2017

Sukhjit Kaur - Complainant(s)

Versus

M D India Health Care - Opp.Party(s)

Sh C P S Cheema

28 Jan 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                            Consumer Complaint No.46 of 2017

                                                        Date of institution:  21.07.2017                        

                                                         Date of decision   :  28.01.2019

Sukhjit Kaur W/o Sh. Charanpal Singh, resident of village Balahra, Post office Khera, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

1. M.D.India Health Care Services,(TPA) Ltd; Max Pro into Park D-38, Phase 1, Industrial Area, Mohali Punjab 160056 through its Regional Manager/Chairman.
2. ICICI Lombard General Insurance Ltd., 4^th Floor, The Statement Building, Plot No.149, Industrial Area Phase-I, Chandigarh, through its Manager/Chairman.
3. The Shamsher Nagar M.P.C.A.S.S. Ltd; Saddo Majra, Sirhind, Tehsil and District Fatehgarh Sahib, through its President/Secretary/Authorized signatory.
4. Bhai Ghaniya Sehat Sewa Scheme Policy, Maxpro.Info.Park, D-38, Industrial Area, Phase-I, SAS Nagar Mohali, Punjab 160056 through its authorized signatory.

…..Opposite parties

Complaint under the Consumer Protection Act

Quorum

Sh. Kuljit Singh, President

Sh. Inder Jit, Member   

                                               

Present :   Sh. C.P.S. Randhawa, Adv.Cl. for the complainant.    

                  Sh. Vinay Sood, Adv. Cl. for Opposite Parties No.1 & 2.

 None for opposite party No.3.

Opposite party No.4 exparte.

 

 

 

ORDER

Kuljit Singh, President

                  Complainant Sukhjit Kaur W/o Sh. Charanpal Singh, resident of village Balahra, Post office Khera, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “OPs”) under the Consumer Protection Act. The brief facts of the complaint are as under:

2.               The complainant is the member of opposite party No.4 through opposite party No.3 and has got herself insured with OP No.2 under the medical policy, which has been issued by the OPs vide Form No.199257 and the OPs also issued identity card No.MD 15BGSS.S00508052SP in the month of January 2016, which was valid for one year. In the last week of March 2016, the complainant suffered from severe joint pain and she was taken to Indus Super Specialty Hospital, Phase I, Mohali for treatment  and ultimately she had to get herself operated in respect of both knees from the concerned doctor of the said hospital. The complainant remained admitted in the said hospital from 20.04.2016 till 26.04.2016 and spent Rs.2,50,000/- for her treatment. Apart from the said amount Rs.50,000/- has also been spent on the medicines. As the said hospital is on the panel of Bhai Ghaniya Sehat Sewa Scheme, the amount of treatment was to be paid by the OPs to the said hospital as per the medical policy.  At the time of admission, the complainant showed her I-card to the doctors of the hospital, which is on the panel list, and requested them to charge the amount of treatment from the OPs as per the medical policy but they refused to admit the claim of the complainant. Thereafter, the complainant sent her treatment chart as well as relevant record of her insurance policy to the OPs but the OPs refused to reimburse the medical charges incurred by the complainant on her treatment from her own pocket. The complainant so many times visited the office of OPs and requested them to refund the said amount to her but all in vain.  The complainant also served a legal notice on the OPs but of no use.  The complainant stated in the complaint that previously she filed a consumer complaint on the same cause of action, which was decided by this Forum vide order dated 23.01.2017 with directions to the complainant to file fresh claim with OPs and OPs were directed to decide the insurance claim within a period of 30 days and permission was also granted to the complainant to file a fresh complaint if she is not satisfied with the decision of the OPs. Accordingly, the complainant filed a fresh claim with the OPs but no response was given by the OPs and they kept mum. The act and conduct of the OPs amounts to great deficiency in service on their part. Hence, this complaint for giving directions to the OPs to pay an amount of Rs.5,00,000/- along with interest, including compensation on account of harassment and mental agony suffered by the complainant.

3.               The complaint is contested by OPs No.1, 2 & 3 but OP No.4 chose not to appear to contest this complaint despite service. Hence, it was proceeded against as exparte.

4.               In reply to the complaint OPs No.1 & 2 raised certain preliminary objections, inter alia, that the present complaint is false, vexatious and has been filed with a malafide intention to harass the OPs by misusing the process of law; the present complaint is not maintainable and this forum has got no jurisdiction to try and entertain the present complaint; the complainant has not come to this Forum with clean hands; the complainant is stopped by his own acts and conducts from filing the present complaint; no cause of action has been arose to the complainant to file the present complaint; the complainant is not a consumer within the definition of Section 2(d) of the Consumer Protection Act and the present complaint is bad for mis-joinder and non-joinder of necessary parties. As regards the facts of the complaint, OPs No.1 & 2 stated that complainant had submitted the bills and treatment record to OP No.2 and as per the terms and conditions of the policy the coverage of the policy for treatment for knee replacement is Rs.1,00,000/- and further more knee replacement is allowed beyond the age of 60 years. In the present case the complainant had not completed the age of 60 years, which is clear cut violation of the terms and conditions of the policy. Hence, after seeking the opinion from OP No.1, the claim of the complainant was rightly repudiated.  Hence, there is no deficiency in service on the part of OPs No.1 & 2. After denying the other averments made in the complaint, OPs No.1 & 2 prayed for dismissal of the complaint.

5.               In reply to complaint OP No.3 stated that Charanpal Singh is the Member of Bhai Ghaniya Sehat Sewa Scheme and the complainant Sukhjit Kaur is the dependent of said Charanpal Singh. It is admitted that the hospital Indus Super Specialty, Phase-1, SAS Nagar is on the panel of the said scheme. Rest of the paras are denied by OP No.3 for want of knowledge. The OP No.3 prayed for deciding the present complaint in the interest of justice.

6.               In order to prove the case, the complainant tendered in evidence copies of documents Ex. C-1 to C-20 and her affidavit Ex. C-21 and closed the evidence. In rebuttal OPs No.1 & 2 tendered in evidence affidavit of Sh. Apurava Sharma, Manager Legal, as Ex.OP1/1 and true copy of documents i.e. repudiation letter Ex. OP1/2, policy Ex. OP1/3 and closed the evidence. OP No.3 tendered in evidence affidavit of Taranjit Singh as OP3/1 and closed the evidence.

 7.               Ld. counsel for the complainant stated that the reimbursement of medical expenses incurred on the knee replacement has not been done by the OPs. He further argued that reimbursement to the tune of Rs.1,50,000/- is available for a family and that no claim has been filed by any other member of the family. Hence, Rs.1,50,000/- be ordered to be reimbursed to the complainant alongwith adequate compensation and litigation charges. The Ld. counsel also cited a judgment of this Forum dated 02.09.2016 passed in Consumer Complaint titled as Raj Kumar Vs. M.D.India & others in which Rs.1,50,000/- was ordered by this Forum.

8.               On the other hand the Ld. counsel for the OPs stated that as per terms and conditions of the policy(Ex. C-3), only Rs.1,00,000/- is reimbursable for knee replacement  and that too after the age of 60 years. Ld. counsel pleaded for dismissal of complaint.

9.               We have gone through the documents placed on record by the Ld. counsel for both the parties and also heard their oral submissions. We are of the opinion that the complainant, who had achieved the age of 60 years on 20.04.2016( her date of birth being 24.03.1956 as per Ex. C-2) is entitled to Rs.1,00,000/- towards medical reimbursement for her knee replacement as per terms and conditions of the policy(Ex. C-3). Accordingly, we accept this complaint and OPs No.1 & 2 are directed to pay Rs.1,00,000/-(Rupees one lakh) along with interest @ 8 % p.a. from the date of aforesaid payment became due to her till its actual payment. Complainant is also held entitled to Rs.10,000/- for compensation on account of mental agony together with litigation charges. The order be complied with within 45 days from the date of receipt of certified copy of this order.

10.                       The arguments on the complaint were heard on 14.01.2019 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.       

Pronounced                                                                                                    Dated: 28.01.2019