Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  : 78 of 2016

Date of Institution                      :01.11.2016

Date of Decision               : 14.3.2019

Buta Singh son of Sadhu Singh resident of village Kot Jaspat Tehsil and District Tarn Taran                                                 ...Complainant

Versus

1. M.D. India Health Care Services (TPA Pvt. Ltd.) through M.D, having its head office at Maxpro Info Park, D-38, Industrial Area, Phase I, Mohali, Punjab 160056
2. ICICI Lombard General Insurance company Ltd. 401-402, Interface Bldg. No. 11, Link Road Malad (West) Mumbai-400064 through M.D.

…Opposite Parties.

Complaint Under Section 12 and 13 of the Consumer Protection Act.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

                             Sh. Jatinder Singh Pannu, Member

For Complainant                     Sh. H.S. Sandhu Advocate

For Opposite Party No.1                  Exparte on 20.12.2016

For Opposite Party No. 2                 Sh. Amit Bhatia Advocate

ORDERS:

Charanjit Singh, President;

1        The complainant Buta Singh has filed the present complaint under Section 12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against M.D. India Health Care Services (TPA Pvt. Ltd.) through M.D, having its head office at Maxpro Info Park, D-38, Industrial Area, Phase I, Mohali, Punjab 160056 and another (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to direct the opposite parties No. 1 and 2 to release the insurance claim/ reimbursement of Rs. 23,000/- to the complainant and the complainant also prayed Rs. 10,000/- as compensation and Rs. 20,000/- as litigation expenses.

2        The case of the complainant in brief is that he is a farmer and is a member of Farmer Cooperative Society, The Kot Jaspat, multi- purpose Society Ltd. and this society got medically insured him with the Opposite Parties No.1 & 2 being the member and as per the scheme of the Punjab Government commonly known as "Bhai Ghanhya Sehat Sewa Scheme". The complainant suffered severe pain in his abdomen and for that he approached Guru Nanak Dev Super specialty Hospital, Tarn Taran on 13.06.2016 and was diagnosed with Stone in his Gall Bladder i.e. [Pita] and was admitted in the Hospital on the same day. The complainant told the hospital authorities that he is medically insured with opposite parties No.1 & 2 and as per the information provided to him this Hospital is on the penal/list of the hospital of opposite parties No.1 & 2 as per the Punjab Government Scheme and told the hospital authorities that whole of the expenses of the treatment will be borne by the opposite parties No. 1 & 2 so the Hospital Authorities immediately called the representatives of opposite parties No. 1 & 2 and they visited the Hospital and met the complainant and filled a form for cashless treatment under "Bhai Ghanhya Sehat Sewa Scheme" and gave the approval for the treatment, so the hospital authorities provided treatment to the complainant but after the operation, the hospital authorities demanded an amount of Rs.23,000/- from the complainant i.e. including the operation expenses, medicines, rent of the room and other miscellaneous expenses that also includes of bill, but the complainant told them that he is not to pay the bills from his pocket, rather the opposite parties No. 1 & 2 who had given the approval to the treatment, the complainant being medically insured with them but the hospital authorities did not hear the request of the complainant, so the complainant had to pay Rs.23,000/- from his own pocket vide a number of receipts and was discharge from the hospital on 21.06.2016. The complainant approached the secretary of the society and informed whole of the incident to him and he immediately approached the opposite parties No .1 & 2 to reimburse Rs.23,000/- to the complainant spent by him from his own pocket inspite of being insured with them by paying Rs.1,305/- through his society as premium. The complainant also approached the opposite parties No .1 & 2 through correspondence and on phone to reimburse Rs.23,000/- to him but all in vain. This act of the opposite parties constitutes deficiency in services, unfair trade practice. Feeling dissatisfied by the act and conduct of the opposite parties, the complainant perforce has filed this complaint against the opposite parties.

3        After formal admission of the complaint, notice was issued to Opposite Parties and Opposite Party No. 1 was proceeded against exparte vide order dated 20.12.2016 of this Forum.

4        Opposite Party No. 2 appeared through counsel and filed written version contesting the complaint on the preliminary objections that the present complaint is not legally maintainable. The complainant has not come to the Forum with clean hands and has suppressed material facts. The present complaint is baseless and abuse of process of law just to harass the opposite party. The claim of the complainant is excessive and exaggerated. The contract of the insurance between the respondent and complainant is governed by its policy terms and conditions The words in an insurance contract must be given paramount importance and interpreted as express without any addition, deletion or substitute" and as such the complaint is liable to be dismissed. For processing and deciding the claim of the complainant, the opposite party has to adopt a particular procedure laid down by I.R.D.A. and has to complete the necessary formalities, so that the company may assess the admissibility of the claim as per the policy terms and conditions. It is submitted that the replying opposite party received a pre-request for authorization of letter received on 27.07.2016 and that request was denied under exclusion clause 8.0 as the hospitalization is primarily for investigative purpose and charges incurred at hospital or nursing home primarily for diagnostic, X-Ray of laboratory examination not leading to indoor treatment. So the claim of the complainant was denied as stated above as per the letter. Therefore, the present complaint is liable to be dismissed on this simple score only.  The opposite party has never received any reimbursement claim from the complainant after the above said letter nor any document has ever been supplied by the complainant to reimburse the alleged amount of the complainant. It is submitted that the present complaint is pre-mature as the complainant has never lodged any claim to the replying opposite party for reimbursement of the alleged amount. The final claim of the complainant has never been processed by the opposite party, so the present complaint is pre-mature. The policy issued is subject to certain terms and conditions as contained in the policy documents and terms settled between the parties.  The alleged problem which has been pleaded in the complaint does not required any indoor treatment, so as per the policy terms and condition if the problem does not require any indoor treatment, the opposite party does not liable to pay any amount to the complainant and all the other allegations in the complaint have been denied by the opposite parties and prayer was made for dismissal of the complaint with costs. 

5        Sufficient opportunities were granted to the parties to lead evidence in order to prove their respective case. Ld. counsel for the complainant tendered in evidence affidavit of Buta Singh complainant Ex. C-1, alongwith documents Ex. C-2 to Ex. C-10 and mark A and closed the evidence. To rebut the evidence of the complainant, Ld. counsel for the opposite party No. 2 tendered in evidence affidavit of Amandeep Singh Legal Manager Ex. OP2/1 and closed the evidence.

6        We have heard the Ld. Counsel for the complainant and opposite party No. 2 and have gone through the evidence and documents placed on the file by the parties.

7        Ld. counsel for the complainant contended that he is a member of Farmer Cooperative Society, The Kot Jaspat, multi- purpose Society Ltd. and this society got medically insured him with the opposite parties No. 1 & 2 being the member and as per the scheme of the Punjab Government commonly known as "Bhai Ghanhya Sehat Sewa Scheme". The complainant has made the payment of Rs. 1,305/-  vide Ex. C-3  and a Card Ex. C-4 has been issued to the complainant. He further contended that the complainant suffered severe pain in his abdomen and for that he approached Guru Nanak Dev Super specialty Hospital, Tarn Taran on 13.06.2016 and was diagnosed with Stone in his Gall Bladder i.e. [Pita] and was admitted in the hospital on the same day and remain admitted in the hospital from 13.6.2016 to 21.6.2016 vide Ex. C-5. The complainant told the hospital authorities that he is medically insured with opposite parties No.1 & 2 and as per the information provided to him this Hospital is on the penal/list of the hospital of opposite parties No.1 & 2 as per the Punjab Government Scheme and told the hospital authorities that whole of the expenses of the treatment will be borne by the opposite parties No. 1 & 2 so the Hospital Authorities immediately called the representatives of opposite parties No. 1 & 2 who visited the Hospital and met the complainant and filled a form for cashless treatment under "Bhai Ghanhya Sehat Sewa Scheme" and gave the approval for the treatment, so the hospital authorities provided treatment to the complainant but after the operation, the hospital authorities demanded an amount of Rs.23,000/- which the complainant has made the payment vide receipts Ex. C-6 to Ex. C-9, as the opposite parties No. 1 and 2 refused to make the payment to the hospital. The complainant also approached the opposite parties No. 1 & 2 through correspondence and on phone to reimburse Rs.23,000/- to him but all in vain. This act of the opposite parties constitutes deficiency in services, unfair trade practice and the complainant prayed that the present complaint may be allowed with costs.

8        Ld. counsel for the opposite party No. 2 contended that the contract of the insurance between the respondent and complainant is governed by its policy terms and conditions. He further contended that opposite party No. 2 received a pre-request for authorization of letter received on 27.07.2016 and that request was denied under exclusion clause 8.0 as the hospitalization is primarily for investigative purpose and charges incurred at hospital or nursing home primarily for diagnostic, X-Ray of laboratory examination not leading to indoor treatment. So the claim of the complainant was denied as stated above as per the letter. He further contended that the present complaint is liable to be dismissed on this simple score only.  The opposite party has never received any reimbursement claim from the complainant after the above said letter nor any document has ever been supplied by the complainant to reimburse the alleged amount of the complainant. He further contended that the present complaint is pre-mature as the complainant has never lodged any claim to the opposite party No. 2 for reimbursement of the alleged amount. He further contended that the final claim of the complainant has never been processed by the opposite party, so the present complaint is pre-mature. He further contended that the policy issued is subject to certain terms and conditions as contained in the policy documents and terms settled between the parties.  He further pleaded that the alleged problem which has been pleaded in the complaint does not required any indoor treatment, so as per the policy terms and condition if the problem does not require any indoor treatment, the opposite party does not liable to pay any amount to the complainant and prayed for dismissal of the complaint.

9        In the present case, insurance of the complainant with the opposite parties is not disputed.  The complainant has proved on record that he was diagnosed with the stone in his Gall Bladder i.e. Pita and was got admitted by this Hospital on the same day. To prove his contention, the complainant has placed on record discharge card Ex. C-5 which shows the name of patient as Buta Singh, Date of Admission as 13.6.2016, date of discharge as 21.6.2016. The said document also shows that the complainant was operated there. It is also proved on record that the complainant has spent Rs. 23,000/- for his treatment in the hospital vide receipts Ex. C-6 to Ex. C-9.  It all shows that the complainant has got his operation from Guru Nanak Dev Super Specialty Hospital Tarn Taran and has made the payment of his treatment to the said hospital of Rs. 23,000/- and the complainant requested that inspite of insurance policy, the opposite party has not made the above said payment to the complainant. On the other hand, the opposite party No. 2 has submitted that a pre-request for authorization of letter received on 27.07.2016 and that request was denied under exclusion clause 8.0. But the opposite party No. 2 has not proved on record any policy document containing the exclusion clause 8.0 and mere taking objection in the written version has not given any help to the opposite party No.2.

10      The opposite party No. 2 in para No. 6 of the preliminary objection of the written version has pleaded that that the claim of the complainant was denied. However, on the other hands, in Para No. 7 of the complaint, the opposite party No. 2 has pleaded that the complaint is pre mature. The opposite party No. 2 cannot take duel stand at one time. Moreover the complainant has intimated the opposite party No. 2 regarding his treatment, which is very much clear from Ex. C-10 i.e. denial of authorization letter  by the opposite party No. 2 on the ground of Exclusion ground 8.0. It shows that the opposite party No. 2 was due intimation. But in the present case, the opposite party No. 2 has alleged that the complaint is pre matured. But even taking the plea that the present complaint is pre mature is also not tenable as It is usual with the insurance companies to show green  pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of  excuses to deny the claim. Reliance in this connection can be had on the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.”

Therefore, repudiation of the claim of the complainant in such an event is not justified at all.  The complainant has prayed in his complaint that he incurred Rs.23,000/- on his treatment.

11      In view of the above discussion, the present complaint is allowed and the opposite parties are directed to release a sum of Rs.23,000 /-  (Rs. Twenty three thousand only) to the complainant. Complainant is also entitled to Rs. 5,000/- ( Rs. Five thousand only) as compensation on account of harassment and mental agony and Rs 3,000/- (Rupees Three Thousand only) as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.