Punjab

Faridkot

CC/21/46

Darshan Singh - Complainant(s)

Versus

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

In Person

30 Nov 2021

ORDER

  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C.C. No. :                  46  of 2021/

                                  306 of 2011

Date of Institution:      22.02.2021/

                                  14.12.2011

Date of Decision:        30.11.2021

 

Darshan Singh aged about 65 years, son of Saudagar Singh, resident of Chand Bhan, Tehsil and District Faridkot.

...Complainant

Versus

1. MD India Healthcare Services Private Limited, Max Pro Info Park, D-38,  Industrial Area, Phase – I,  Mohali  through its Authorized Officer.
2. ICICI Lombard, Health Insurance having its office at F-701, A, Lado Sarai, Behind Golf Course, New Delhi-110030 through its Branch Manager/MD.
3. Amandeep Hospital, Model Town, G T Road, Amritsar through its Authorized Signatory.
4. The Chand Bhan Multipurpose, Co-operative Agriculture Service Society Limited, Village Chand Bhan, Tehsil and District Faridkot.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

(Now, Section 35 of the Consumer Protection Act, 2019)

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Quorum:     Smt Param Pal Kaur, Member.

                     Sh Vishav Kant Garg, Member.

 

Present: Sh Rajneesh Garg, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OP-1,

              Sh Neeraj Maheshwary, Ld Counsel for OP-2,

             Sh Harash Bhasin, Ld Counsel for OP-3,

   OP-4 Ex-parte.

 

ORDER

(Param Pal Kaur, Member)

                                   (Present complaint is remanded back to this Commission by Hon’ble National Consumer Disputes Redressal Commission, New Delhi vide order dated 08.01.2021 passed in Revision Petition No.439/2015 titled as Amandeep Hospital Vs Darshan Singh and others.  It was received on 29.01.2021 vide receipt no.11 dated 29.01.2021 and as per instructions of Hon’ble National Commission, New Delhi was ordered to be put up before the Bench on 22.02.2021 the date already fixed by Hon’ble National Commission.

2                                               Complaint No.306 of 2011 was allowed by this Forum on 25.04.2012 wherein OP-3 Amandeep Hospital was

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ordered to refund the amount of Rs.1,500,000/-to complainant on account of medical expenses incurred by him on his treatment and Rs.30,000/-as compensation for harassment and mental agony suffered by him and for litigation expenses.

2                         As per directions given by Hon’ble National Commission, OP-1 and OP-2 were directed to file written version, but they did not file their written version, therefore, complainant is decided accordingly)

3                                     Briefly stated, the case of the complainant is that complainant being member of The Chand Bhan Multipurpose Cooperative Agriculture Service Society Ltd. /OP-4, was insured with ICICI Lombard, Health Insurance Company under Bhai Ghanya Sehat Sewa Scheme against Policy No.4016/00004117 and said Scheme was valid for the period from 01.02.2010 to 31.01.2011 and as per said scheme, beneficiary was entitled for free treatment in empanelled hospitals. During subsistence of policy in question, complainant suffered from some spinal cord problem and was admitted in the

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hospital of OP-3 from 30.05.2010 to 11.06.2010 as indoor patient and spent Rs.3,50,000/-on his treatment. Complainant has alleged that at the time of admission in the hospital of OP-3, OP-3 assured him that their hospital is empanelled hospital and benefits available under Sehat Sewa Scheme would be provided to him, but later on OP-3 refused to give those benefits. Grievance of the complainant is that despite repeated requests, OPs failed to reimburse the amount paid by him on his treatment.

4                                    OP-1 and OP-2 were exparte in original complaint, but vide order of Hon’ble National Commission, New Delhi they were given oppertunity to file their written version. But this time again, despite availing sufficient opportunities, Insurance Company failed to furnish written statement.

5                                  OP-3 admitted before the Commission that complainant was admitted in their hospital and undertook treatment therefrom. It is also admitted that it was partner hospital with Bhai Ghanhya Sehat Sewa Scheme upto 30.09.2009. Stand taken by OP-3 is

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that their hospital was empanelled with Bhai Ghanyha Sehat Sewa Scheme only upto 30.09.2009. New Scheme commenced from 1.02.2010 till 31.01.2011 and during this term no fresh MOU was signed by them with concerned authorities of scheme and Insurance Company, rather OP-3 was wrongly mentioned in the list of partner hospitals. OP-3 treated the patient as an independent patient and not as a member of Bhai Ghanyha Sehat Sewa Scheme and as a private hospital, OP-3 was well within its right to charge the patient for treatment provided by them. Vide notice dated 08.06.2010, OP-3 Hospital called upon concerned authorities to remove their name from the list of partner hospitals and in reply thereto, ICICI Lombard /Op-1 and 2 informed OP-3 that name of Amandeep Hospital has been removed from the list of empanelled hospitals for cashless hospitalization and apprised that a  public notice to this effect was already given by them in Daily Punjabi Tribune on 06.05.2010. Even Bhai Ghanaya Trust vide its letter dated 21.06.2010 wrote to OP-2 ICICI Lombard that they had received notice from OP-3 regarding wrong publication of name of OP-3 in the list of network hospitals. It

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is further averred that the day on which complainant was admitted in their hospital, on that day, answering OP was not a partner hospital under the said scheme. There is no deficiency in service on the part of OP-3 as being not the partner hospital, it was unable to provide cashless treatment to complainant.

6                              As per OP-4 there is no deficiency in service on their part. Said Scheme is successfully running and people are taking treatment under said scheme and services are being provided to beneficiaries.

7                              Ld Counsel for complainant tendered in evidence affidavit Ex C-1 and documents Ex C-2 to Ex C- 59, affidavit of complainant Ex C-60, supplementary affidavit of complainant Ex C-61 and then, closed the evidence.

8                               To rebut the evidence of complainant, OP-3 tendered in evidence affidavit of Dr Amandeep Kaur Ex R-1, copy of legal notice Ex R-2, copy of letter of ICICI Lombard Ex R-3 and then,

 

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closed the same on behalf of OP-3. There is no reply or  evidence from OP-1 and OP-2.

9                                         We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents available on record.

10                                              The case of the complainant is that he was insured under Bhai Ghanaya Sehat Sewa Scheme for the period from 01.02.2010 to 31.01.2011 and as per scheme, being member of it, he was entitled for cashless treatment.  During subsistence of policy in question, he fell ill and remained admitted in the hospital of OP-3 from 30.05.2010 to 11.06.2010 and spent Rs.3,50,000/-from his own pocket though as per scheme, he was entitled for cashless hospitalization, but grievance of the complainant is that at the time of admission in OP-3 hospital, he informed hospital authorities that he was duly insured under said scheme and was entitled to get benefit thereof. Initially OP-3 assured to give all the benefits under said scheme, but later on

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refused to provide those benefits. On the contrary, stand taken by OP-3 is that it is no longer partner hospital with said scheme since 30.09.2009. Claim sought by complainant pertains to period 30.05.2010 to 11.06.2010 under Bhai Ghanaya Sehat Sewa Scheme valid from 01.02.2010 to 31.01.2011, but during this disputed period Amandeep Hospital was not under any contract with Insurance Companies for providing cashless treatment. I was partner hospital with Bhai Ghanhya Sehat Sewa Scheme upto 30.09.2009. During period in dispute, complainant was treated as an independent patient and not as a member of Bhai Ghanyha Sehat Sewa Scheme and as a private hospital, OP-3 was well within its right to charge the patient for treatment provided by them. Vide legal notice dated 08.06.2010, OP-3 Hospital asked OP-1, 2 and 4 to remove their name from the list of partner hospitals and in reply thereto, ICICI Lombard /Op-1 and 2 informed OP-3 that name of Amandeep Hospital has been removed from the list of empanelled hospitals for cashless hospitalization and

 

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apprised that a  public notice to this effect was already given by them in Daily Punjabi Tribune on 06.05.2010. It is reiterated that the day on which complainant was admitted in their hospital, on that day, OP-3 was not a partner hospital under the said scheme.

11                                         Document Ex R-2 is copy of legal notice issued by advocate of OP-3 to OP-1 and 2 Insurance Company for deleting the name of Amandeep Hospital from the list of partner hospitals of Bhai Ghanaya Sehat Sewa Scheme. It is clearly mentioned in this notice that OP-3 was partner hospital with Bhai Ghanaya Sehat Sewa Scheme till 30.09.2009. New scheme commenced from 1.02.2010 and was valid uptil 31.01.2011 and for this term OP-3 Amandeep Hospital never signed any MOU with Insurance Company under said Bhai Ghanaya Sehat Sewa Scheme. This legal notice is dated 08.06.2010 and in reply thereto OP-3 received letter dated 17.08.2010 Ex R-3 from ICICI Lombard Insurance Company wherein they have informed OP-3 that name of their hospital has been removed

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from the list of network hospitals for cashless hospitalization. In second para of this letter Insurance Company has again assured OP-3 Amandeep Hospital that Public Notice regarding removal of name of Amandeep Hospital from the list of empanelled hospital has already been given in  “Punjabi Tribune” dated 06.05.2010.

12                                  It is transpired that Insurance Company has been intentionally playing hide and seek with the Commission. Despite availing several opportunities, they did not file reply and did not come forward to clear the allegations of complainant and to defend the position of OP-3 during period in dispute.

13                               Ex R-3 is substantial and cogent evidence in favour of OP-3 that itself speaks out that Amandeep Hospital/OP-3 was not on the panel of Insurance Company for providing cashless treatment to complainant during disputed period. It is only Insurance Company that can clear the picture that during the period of 30.05.2010 to 11.06.2010 when complainant underwent treatment,

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Amandeep Hospital was on their list of empanelled hospitals or not. Had OP-3 on the list of empanelled hospital of Insurance Company for providing cashless treatment, it would not have issued legal notice Ex R-2 to Insurance Company for deleting its name from the list of partner hospitals meant for providing cashless treatment. Moreover, if OP-3 was on the list of empanelled hospitals, then, there was no need for Insurance Company to write letter to Amandeep Hospital informing the same that its name has been removed from their list of network of hospitals for cashless hospitalization. ICICI Lombard has specified in their letter Ex R-3 that they have issued Public Notice in Punjabi Tribune on 06.05.2010, regarding removal of name of Amandeep Hospital from the list of their empanelled hospitals. Had OP-3 on the list of their empanelled hospitals, it would have no need to refuse the provision to facilitate cashless treatment to complainant.

14                              From the above discussion and keeping in view document Ex R-2 that is  legal notice dated  08 June, 2010 issued by

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Amandeep Hospital to Bhai Ghanaya Scheme and to Insurance Company and Ex R-3 letter written by Insurance Company to OP-3 Hospital that name of Op-3 has been removed from the list of partner hospitals, it is observed that claim sought by complainant pertains to period 30.05.2010 to 11.06.2010 under Bhai Ghanaya Sehat Sewa Scheme valid from 01.02.2010 to 31.01.2011, but during this disputed period Amandeep Hospital was not on the panel of Insurance Companies to facilitate cashless treatment, therefore, complainant is not entitled to get cashless treatment from OP-3, rather he should claim reimbursement for expenditure incurred by him on his treatment from Insurance Company under which he was insured. Therefore, complaint in hand is hereby allowed against OP-1 and OP-2 and complaint against OP-3 and 4 stands hereby dismissed. OP-1 and 2 are directed to make payment of Rs.1,50,000/-to complainant alongwith compensation at the rate of 9% per anum from the day he made payment to Amandeeep Hospital and are further directed to pay Rs.25,000/-to complainant as compensation for harassment and mental agony

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suffered by him and Rs.15,000/-as litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which complainant shall be liable to proceed under Section 71 and 72 of the Consumer Protection Act. Copy of the order be supplied to parties free of costs. File be consigned to record room.

Announced  on

Dated : 30.11.2021               (Vishav Kant Garg)             (Param Pal Kaur)           

        Member                                Member