Punjab

Firozpur

CC/15/63

Jamuna Devi alias Yamna Devi - Complainant(s)

Versus

M.D India Healthcare & Others - Opp.Party(s)

R.K Dua

26 Aug 2015

ORDER

Consumer Disputes Redressal Forum
Room No. B-122, 1st Floor, B-Block, District Administrative Complex
Ferozepur Cantt (Punjab)
 
Complaint Case No. CC/15/63
 
1. Jamuna Devi alias Yamna Devi
Wife of Sukhdial, R/o Village Shaheed Udham Singh Wala (Jiwan Arian), Tehsil Guruharshai, District Ferozepur
Ferozepur
Punjab
...........Complainant(s)
Versus
1. M.D India Healthcare & Others
Opp. Udham Singh Market, Near International Hotel, Ferozepur City through its Branch Manager
Ferozepur
Punjab
2. United India Insurance Co. Ltd.
The Mall, Ferozepur City through its Branch Manager
Ferozepur
Punjab
3. Bhai Ghaniya Sehat Sewa Scheme Policy
SCO No.121-122 and 123, First Floor, Sec-34 A, Chandigarh through its President
Chandigarh
Punjab
4. The Jiwan Arain Multipurpose Co-operative Agriculture Societies
Village Jiwan Arain, Tehsil Guruharhshai, District Ferozepur
Ferozepur
Punjab
5. Bikram Joint & Trauma Centre
Opp. Guru Gobind Singh Hospital, Giani Jail Singh Market, Sadaq Road, Faridkot
Faridkot
Punjab
............Opp.Party(s)
 
BEFORE: 
  Gurpartap Singh Brar PRESIDENT
  Inderjeet Kaur MEMBER
 
For the Complainant:R.K Dua, Advocate
For the Opp. Party: Vishal Arora, Advocate
ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FEROZEPUR.

                                                                   C.C. No. 63 of 2015                                                                                            Date of Institution: 9.2.2015          

                                                                   Date of Decision: 26.8.2015

Jamuna Devi @ Yamna Devi, wife of Sukhdaial, resident of village Shaheed Udham Singh Wala(Jiwan Arain), Tehsil Guruharsahai, District Ferozepur, Mobile No.98550-69038.

                                                                                       ....... Complainant

Versus       

  1.    MD India Health Care Services (TPA)  Pvt. Ltd. Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali, Punjab-160055 through its Managing Director.

2.   United India Insurance Company Ltd. The Mall, Ferozepur City through its Branch Manager.

 

3.   Bhai Ghaniya Trust through Registrar-Cooperative Societies, Government of Punjab, 17, Bays Building, Sector 17, Chandigarh-160017 through its President.

 

4.   The Jiwan Arain Mulitpurpose Co-operative Agriculture Societies, Village Jiwan Arain, Tehsil Guruharsahai, District Ferozepur.

 

5.   Bikram Joint & Trauma Centre, opposite Guru Gobind Singh Hospital, Giani Jail Singh Market, Sadaq Road, Faridkot.

 

                                                                             ........ Opposite parties

Complaint   under Section  12 of the Consumer Protection Act, 1986.

                                                          *        *        *        *        *        *

C.C. No. 63 of 2015                         //2//

PRESENT :

For the complainant                        :  Sh. Rajesh Kumar Dua, Advocate.

For opposite parties Nos.1&2                    : Sh. Vishal Arora, Advocate.

For opposite parties Nos.3&4                    : Sh. Shallinder Bhalla, Advocate.

For opposite party No.5                             : None

QUORUM

S. Gurpartap Singh Brar, President

Mrs. Inderjeet Kaur, Member 

 ORDER

GURPARTAP SINGH BRAR, PRESIDENT:-

As per averments, Jamuna Devi complainant is the member of opposite party No.4 i.e. The Jiwan Arain Multipurpose Co-operative Agriculture Societies, Village Jiwan Arain, Tehsil Guruharsahai, District Ferozepur and as per scheme of Punjab Government, complainant along with his other family members was covered under the Bhai Ghaniya, Health Care Schemes of cashless hospitalization. Opposite party No.2 United India

C.C. No. 63 of 2015                         //3//

Insurance Company Ltd., is the insurance company, who has to pay the claim passed by TPA on account of cashless hospitalization for the members of the Society during the continuation of the policy. The complainant was suffered from knee pain and the complainant got checked from Baghi Hospital, Ferozepur on 16.9.2014 and the Doctor of Baghi Hospital was advised complainant for knee transplant. After that the complainant was got checked at Bikram Joint & Trauma Centre, Faridkot, there complainant was also advised for knee transplant immediately. The complainant admitted in the hospital of opposite party No.5 on 1.10.20174 and was discharged on 8.10.2014, where the knee of the both legs of the complainant was transplanted. The son of the complainant namely Harmesh Chand has intimated to opposite parties Nos.1and 2 regarding knee transplant of both legs of the complainant vide letter dated 23.9.2014 through registered cover dated 25.9.2014. The complainant had to spent Rs.2,35,600/- on her treatment from her own pocket. The claim of the complainant under the cashless hospitalization was rejected by opposite parties. Opposite party No.5 Bikram Joint & Trauma Centre, Faridkot is newly added in the list of network hospitals. Till today opposite parties Nos.1and 2 have not settled the claim of the complainant due to which the complainant had suffered a lot on

C.C. No. 63 of 2015                         //4//

account of mental pain, agony tension, harassment and financial loss. Pleading deficiency in service and unfair trade practice on the part of the opposite parties, the complainant has prayed that the opposite parties be directed to pay  the amount spent by the complaint on her treatment i.e.Rs.2,35,600/- and to pay Rs.1,00,000/- for mental pain, harassment  as compensation and to pay Rs.11,000/- as litigation expenses.

2.                  Upon notice, the opposite parties appeared and filed its separate written replies to the complaint. In its written reply, the opposite parties Nos.1 and 2 took some preliminary objection interalia that opposite party No.5 Bikram Joint & Trauma Centre, Faridkot, was not empanelled under the scheme and that no pre-authorization request was received by opposite party No.1 TPA at Mohali from any empanelled hospital. On merits, it has been pleaded in the written reply that no pre- authorization request was received by opposite party No.1 TPA at Mohali from any empanelled hospital. Receiving of any pre-authorization request from opposite party No.5 hospital regarding the alleged hospitalization was out of question as the said hospital is not in the list of network/empanelled hospitals. Moving a general application by the son of the complainant with respect to non empanelled/non network hospital is of no consequence until

C.C. No. 63 of 2015                         //5//

and unless, the procedure is not followed through the empanelled hospital and treatment is taken in the empanelled hospital. The maximum insurance cover in respect of joint replacement surgeries was Rs.1,00,000/- only as per clause 1.9 of the booklet containing terms and conditions of the scheme. Other allegations of the complaint have been denied and dismissal of the complaint has been prayed for.

3.                Opposite party No.3 filed its written reply to the complaint. In which, opposite party No.3 took some preliminary objection interalia that the present complaint is not maintainable; that the complainant is not a consumer of opposite party No.3; that the complainant is false and the same is liable to be dismissed; that no cause of action whatsoever accrued to the complainant for filing the complaint and that this Hon’ble Forum has got no territorial jurisdiction to entertain and decide this complaint against opposite party No.3. On merits, it has been pleaded in the written reply that the complainant is not consumer of the opposite party. Opposite party is nor the service provider or claim settled authority. Opposite parties Nos.1 and 2 who are service providers as the opposite party has paid the requisite premium to the Insurer and they are claim settling authorities. Opposite party can not be held liable for any payment to the complainant. Other allegations of the

C.C. No. 63 of 2015                         //6//

complaint have been denied and dismissal of the complaint has been prayed for.

4.                Opposite party No.4 filed its written reply to the complaint. In which, opposite party No.4 took some preliminary objection interalia that the present complaint is not maintainable; that the complainant has not come to the Forum with clean hands; that this Forum has got no jurisdiction to try, decide the present complaint and the same is liable to be dismissed. That the complainant has got no locus-standi to file the present complaint. On merits, it has been pleaded in the written reply that the complainant has not taken treatment in a Network approved hospital. Opposite party had no intimation qua the alleged treatment allegedly taken by the complainant. Other allegations of the complaint have been denied and dismissal of the complaint has been prayed for.

5.                Opposite party No.5 filed its written reply to the complaint. In which opposite party No.5 have denied all the allegation of the complainant for want of knowledge. Other allegations of the complaint have been denied and dismissal of the complaint has been prayed for.

 

C.C. No. 63 of 2015                         //7//

6.                          Ld. Counsel for the complainant tendered into evidence Ex. C-1 to Ex. C-19 and closed evidence on behalf of the complainant. On the other hand, learned counsel for the opposite parties Nos.1 and 2 tendered into evidence Ex. OP-1&2/1 to Ex. OP-1&2/4 and closed evidence on behalf of opposite parties Nos.1 and 2. On the other hand, learned counsel for the opposite parties Nos.3 and 4 tendered into evidence Ex. OP-3&4/1 to Ex. OP-3&4/3 and closed evidence on behalf of opposite parties Nos.3 and 4. On the order hand, the evidence of opposite party No.5 was closed by order on dated 13/8/2015.

7.                We have heard the learned counsel for parties and have also gone through the file.

8.                The version of the complainant is that he is member of the opposite party No.4 and as per scheme of Punjab Government, complainant along with his other family members was covered under the Bhai Ghaniya, Health Care Schemes of cashless hospitalization is admitted by the opposite parties. The grievances of the complainant is that the claim of the complainant is repudiated by opposite party Nos.1 and 2 on the ground that the claim of the complainant is not covered under the policy because the

C.C. No. 63 of 2015                         //8//

complainant took the treatment from hospital which is not on the empanelled hospital and as per policy treatment taken at non empanelled hospital is not covered under the policy. The complainant has not entitled to get any claim. Opposite parties Nos.1 and 2 has placed on file guide book and list of network hospitals Ex. OP-1&2/2 to prove that opposite party No.5 i.e. Bikram Joint & Trauma Centre, Faridkot from where the complainant transplanted their knee is not empanelled hospital and does not cover under the scheme. From the documents Ex.OP-1&2/2 it is proved that opposite party No.5 Bikram Joint & Trauma Centre, Faridkot is not empanelled hospital as per scheme of the policy. As per clause 1.9 that treatment taken in non network hospital except Government Hospital is not covered under the scheme, which is clearly mentioned in the documents is Ex. OP-1&2/2. In the present complaint, the complainant took the treatment from Bikram Joint & Trauma Centre, Faridkot which is not empanelled hospital. As such, the complainant is not entitled to get any claim. In the guide book Ex. OP-1&2/2 in which it is mentioned on the page No.10 that as per clause 1.9 of the booklet that the treatment taken in non networking hospital except Government Hospital is not covered. From the guide book it is proved that the treatment taken a non network hospital was not covered under the policy.

C.C. No. 63 of 2015                         //9//

The complainant is not complied all the terms and condition of the policy. So, the complainant is not entitled to any claim under the policy. The complainant is failed to prove any deficiency in service.

9.                In view of what has been discussed above, the present  complaint fails and the same is hereby dismissed without any order as to cost. File be consigned to record room.

 

Announced                                                           (Gurpartap Singh Brar)

26.08.2015                                                   President  

 

 

 

                                                                   (Inderjeet Kaur)                                                                                           Member

 

 

 

 

 

 

 
 
[ Gurpartap Singh Brar]
PRESIDENT
 
[ Inderjeet Kaur]
MEMBER

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