Punjab

Nawanshahr

CC/115/2015

Jarnail Singh - Complainant(s)

Versus

M.D. India Health Care Service(TPA) Pvt Ltd - Opp.Party(s)

Eshan Bhardwaj

04 Mar 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No.         :     115 of 01.10.2015

Date of Decision:                    :     04.03.2016

Jarnail Singh aged about 54 years S/o Raja Singh @ Raju Resident of Village Chhokran, Tehsil Nawanshahr, District Shaheed Bhagat Singh Nagar.

                                                                             …Complainant

Versus

1. M.D. India Health Care Service (T.P.A.) Pvt. Ltd. Regional Office, Max Pro Info Park, D-38, Phase-1, Industrial Area, Mohali through Regional Officer.
2. M.D. India Health Care Service (T.P.A.) Pvt. Ltd., Branch Office, 50, Golden Avenue, Near S.G.L. Hospital, Garha Road, Phase-1, Jalandhar through Branch Manager.
3. M.D. India Health Care Service (T.P.A.) Pvt. Ltd., District Office through Sethi Ram District Coordinator Resident of Village Kultham, Tehsil Nawanshahr, District SBS Nagar.
4. United India Insurance Company Limited, Branch Office Nawanshahr, Tehsil Nawanshahr, District SBS Nagar.
5. United India Insurance Company Limited, Head Office 24, Whites Road, Chennai – 600014.

          …Opposite Parties

                             Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:

SH.G.K. DHIR, PRESIDENT

MS.SUSHMA HANDOO, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant                      :         Sh.G.S. Kahlon., Advocate

For OPs                                   :         Sh.Santokh Singh, advocate

 

 

ORDER

PER SH.G.K. Dhir, PRESIDENT

 

1.       Complainant filed present complaint under Section 12 of Consumer Protection Act, 1986, by alleging that Ops No.1 to 3 have different branches for looking after weaker sections of the society, so as to provide medical facilities to them.  Bhai Ghanaiya Sehat Sewa Scheme is a policy issued by the OP trust.  That policy is meant for the members of the cooperative societies/Institutions registered under the Punjab Cooperative Societies Act, 1961.  The members of the said policy can avail benefit under the said scheme from various hospitals mentioned in the list of the guide attached with the policy.  OPs No. 4&5 are the concerned insurers.  Complainant, being member of the Rahon M.P. CASS Limited, deposited Rs.684/- as premium of the said policy on 04.01.2014 with National Central Cooperative Bank Limited, through cheque favouring Bhai Ghanaiya Sehat Sewa Scheme.  Said amount was debited from account of complainant on 16.01.2014.  An identity card bearing No.MD15-BGSSS-00220000-S was issued in name of complainant under that policy.

2.       Complainant faced problem of Bilateral iliac occlusion in month of May 2014, due to which he was admitted in Fortis Hospital Mohali, on 28.05.2014.  Name of that hospital figures in the list of empanelled hospitals, from where treatment can be got under said scheme.  Complainant was discharged from that hospital on 30.05.2014 after treatment.  Complainant did show the card issued by OPs to staff of Fortis Hospital by making them clear that he is to avail benefit of policy/scheme referred above.  However, the hospital staff claimed that they will issue bills of whole treatment to the complainant and thereafter complainant can claim the amount as per policy terms.  Complainant after discharge from Fortis Hospital tried to find office of OP No.3 at Nawanshahr and got knowledge as if no such particular office is there at Nawanshahr.  Complainant even got knowledge that he can meet OP No.3 in the government offices or at his Village or while roaming.  Complainant met Op No.3 in June 2014 and submitted the claim form alongwith hospital receipts of amount of Rs.1,50,000/-.  Complainant was disclosed by OP No.3 that his claim will be satisfied within three months, but despite visits by complainant to office of Op No.3, his claim remained unsatisfied.  Complainant then served legal notice dated 21.01.2015 through post, but to no effect. Earlier, complaint filed was allowed by this Forum vide orders dated 02.07.2015 by directing complainant to submit the bills, claim form and other requisite documents within 30 days either with OP No.1 or OP No.2, who after receipt of the same will transmit them to concerned OP within 7 days.  Further directions issued through above said orders was to the effect that concerned OPs will decide the claim of complainant within 30 days and then disburse the adjudged amount (if any) within 30 days.  Even liberty was given to complainant to approach this Forum again by filing fresh complaint, in case decision given by OPs against him.  In pursuance of those orders, complainant submitted the claim form and other requisite documents with OP-1 within the time stipulated by the earlier orders of this Forum, but despite that the claim was rejected on grounds that application for claim submitted after long gap of 417 days and that complainant had undergone non-cardiac treatment from Fortis Hospital, despite the fact that liability of OPs is to pay for cardiac treatment.  OPs have not bothered about the earlier orders of this Forum, but they transferred an amount of Rs.1190/- in account of complainant.  This transfer of the partial amount alleged to be illegal and that is why legal notice dated 11.08.2015 was served and thereafter complainant visited office of OPs again.  It is claimed that OPs have not paid litigation expenses of Rs.3000/- awarded by the earlier order of this Forum.  So by pleading deficiency in service on part of OPs, directions sought to OPs to refund Rs.1,50,000/- with interest @18% per annum.  Compensation of amount of Rs.1,00,000/- on account of mental and physical harassment also sought.   

3.       On notice being issued to OPs, they appeared.  Joint written statement by all the Ops filed through counsel by claiming that they have not issued any such insurance policy as claimed by complainant.  Even they claimed to have not received any cashless/non cashless claim under BGSSS card #MD15-00220000 till date.  Complainant also alleged to be barred by his act and conduct from filing the complaint.  Complainant has no cause of action and even complaint alleged to be bad for non joinder of necessary parties.  These OPs claims to be not aware of the treatment, if any, got by complainant from any hospital. It is claimed that OPs have not issued any documents to complainant and nor any claim has been received from the complainant till date. Each and every other averment of the complaint denied.           

4.       Affidavit Ex.CW1/A of complainant and photocopies of documents Ex.C-1 to Ex.C-15 were tendered and then counsel for complainant closed the evidence.

5.       On the other hand, affidavit Ex.OPA of Sh.Joga Singh, Senior Branch Manager, United India Insurance Company, Nawanshahr is tendered in evidence and thereafter counsel for OPs closed the evidence.

6.       Oral arguments of counsel for the parties were heard because no written arguments submitted.  File also carefully perused.

7.       Earlier with same allegations a complaint was filed by complainant against OPs which was decided on 02.07.2015 by this Forum by holding that complainant will submit the bills, claim form and other requisite documents within 30 days from date of those orders either with OP-1 or with OP-2, who after receipt of the same, will transmit them to concerned OP within 7 days of receipt thereof and then the concerned OP will decide the claim of complainant within 30 days.  It was also held through orders dated 02.07.2015 passed in Consumer Complaint No.12 of 09.02.2015 titled as Jarnail Singh Vs MD India Health Care and others (copy of which is produced as Ex.C-11) that in case complainant not satisfied with the decision of the claim, then he can approach this Forum by filing fresh complaint.  The claim of complainant after submission of the claim form and other documents in pursuance of orders Ex.C-11 was rejected by OPs vide letter Ex.C-15 of date 11.08.2015.  In this letter Ex.C-15 itself it has been mentioned that in pursuance of the order dated 09.07.2015 of this Forum, the documents were submitted by complainant in Mohali Office of OP No.1 on 21.07.2015, but the claim rejected because of submission of documents after 417 days from date of discharge of complainant on 30.05.2014 from hospital concerned.  That rejection of the claim is illegal and erroneous because when orders contained in Ex.C-11 has become final due to not being shown to be challenged in appeal/revision, then both the parties bound by its terms.  As through Ex.C-11 itself complainant was required to submit the documents including claim form, bill etc within 30 days w.e.f. 02.07.2015 and as such in view of acknowledgment of OPs through Ex.C-15 qua receipt of these documents on 21.07.2015, it is obvious that the claim documents were submitted by complainant within time, particularly when in Para No.10 of Ex.C-11, itself it has been held that complainant earlier submitted the claim documents with OP-3 in June 2014.  As despite the submission of the earlier documents within 60 days of discharge, the claim of the complainant was repudiated by OPs and the said action has been found illegal and as such in view of the compliance qua submission of the documents within period stipulated through Ex.C-11, OPs cannot claim that the claim documents not submitted within time.  Ground taken in Ex.C-15 qua submission of documents after 417 days is absolutely incorrect, particularly when through Ex.C-11, it has been held that complainant had earlier submitted the claim form and other documents with OP-3 in June 2014.  Discharge of the complainant after treatment from hospital took place on 30.05.2014 is a fact mentioned in Ex.C-15 itself.  So the earlier documents submitted in June 2014 were submitted by complainant within alleged period of 60 days fixed by the terms and conditions of the policy.  So the ground taken qua receipt of the documents after 417 days of discharge in Ex.C-15 is only taken for rejection of the claim for harassment of complainant, particularly when the same ground is violative of terms of the earlier orders passed by this Forum through Ex.C-11.  OPs cannot wriggle out from the terms of Ex.C-11, particularly when they have not challenged this order at all.

8.       Second ground for rejection of claim of complainant through Ex.C-15 is that as complainant got treatment from Fortis Hospital Mohali for bilaterial iliac stenting and as such in view of the said treatment being for non-cardiac ailment, the claim is not entertainable. That ground of rejection again is improper and illegal because stenting treatment got done on 29.05.2014 for cardiac corrections.  In Ex.C-7, the discharge summary of complainant, it is mentioned that complainant admitted in Fortis Hospital due to complaint of numbness of both feet for the last 4-5 years due to which he was taken up for bilaterial iliac stenting.  In the operative notes contained in Ex.C-7, it is mentioned that bilaterial common femoral artery retrograde was punctured.  Further, it is mentioned that stenting done of bilaterial iliac arteries.  So these operative notes alongwith the courses in hospital mentioned in Ex.C-7 enough to establish that complainant got treatment for cardiac ailment.  In view of that rejection of the claim is illegal on ground that non cardiac treatment was got by complainant from an hospital empanelled for cardiac treatment.  As both grounds of rejection contained in Ex.C-15 are improper, illegal and whimsical as well as arbitrary and as such complaint deserves to be allowed with directions to OPs to pay the insured amount of Rs.1,50,000/- stipulated through clause 1.9 of Ex.C-4 (the policy), particularly when record of the bills Ex.C-5/A to Ex.C5/H enough to establish that more than Rs.1,83,949/- was spent by complainant for cardiac treatment.  Mention of figure of Rs.1,83,949/- made in Ex.C5/A itself.  As the claim has been repudiated illegally for harassing complainant and by taking false plea of non-submission of the claim documents within time and as such compensation of Rs.5,000/- at least should be allowed for such harassment.       

9.       As a sequel of the above discussion, this complaint is allowed and OPs are directed to pay to the complainant Rs.1,50,000/- as insured amount within 40 days from date of receipt of copy of this order, failing which to pay interest on this amount @9% per annum from the date of filing of this complaint namely 01.10.2015 till payment.   Compensation of Rs.5,000/- for harassment and litigation expenses of Rs.5,000/- is also payable to complainant by OPs within 30 days from the date of receipt of copy of this order.

10.     The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed and consigned to the Record Room.

Dated:  04.03.2016

 

  

(Sushma Handoo)                                                        (G.K. Dhir)

Member                                                                         President