Before the District Consumer Disputes Redressal Forum, Room No. 208 2nd Floor, District Administrative Complex, Tarn Taran
Consumer Complaint No : 05 of 2017
Date of Institution :08.02.2017
Date of Decision : 14.03.2019
Kabal Singh son of Raghbir Singh resident of VPO Dhand, District Tarn Taran. ...Complainant
Versus
- 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,
- ICICI Lambard 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 Parties Sh. Dinesh Sharma Advocate
ORDERS:
Charanjit Singh, President;
1 The complainant Kabal 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 160056and others (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to release the insurance claim/ reimbursement of Rs. 1,50,000/- to the complainant. The complainant has also prayed Rs. 20,000/- as compensation and Rs. 30,000/- as litigation expenses.
2 The case of the complainants in brief is that he is a farmer and he is a member of Farmer Cooperative Society, The Dhand, 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 left knee and for that he approached Guru Ramdass Charitable Hospital, Wallah Amritsar on 07.09.2016 and was diagnosed for damaged knee and was referred by this hospital for knee replacement surgery of this knee. 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 the “Bhai Ghanhya Sehat Sewa Scheme” and gave the approval for the treatment. On the approval of the treatment/ surgery by the representative of the Opposite parties No.1 & 2, the complainant’s left knee was replaced by the hospital on 12.9.2016 and at the time of purchasing of the artificial knee the Hospital authorities told the complainant that his attendance is required to purchase the artificial knee, so the complainant immediately informed the representatives of the Opposite Parties No..1 & 2 to pay for the artificial knee and for the surgery and other expenses of the complainant’s treatment but the Opposite Parties No.1 & 2 told the complainant that the complainant has to pay from his own pocket for the time being and reimbursement of the expenses on the treatment will be made by them to the complainant after the treatment and after supplying of the documents relating to the treatment i.e. the bills and treatment record to them so inspite of being assured by the Opposite Parties No.1 & 2 that whole of the treatment will be cashless and will be directly paid by them to the hospital, the complainant had to pay from his own pocket for the purchase of total artificial knee replacement and for hospital and other expenses from his own pocket amounting to Rs.1,50,000/-. The hospital authorities told the complainant on 26.9.2016 about his discharging from the hospital, so the complainant immediately called the representatives of the Opposite parties No. 1 & 2 to reimburse the expenses paid by the complainant from his own pocket inspite of being policy holder of the Opposite parties but the opposite parties told the complainant that same will be reimbursed in the couple of day and all the bills and payment receipts were supplied by the complainant to the Opposite Parties No.1 & 2 alongwith the treatment record as required by these opposite parties. The complainant approached the secretary of the society and informed whole of the incident to him and he immediately approach the Opposite Parties No .1 & 2 to reimburse Rs.1,50,000/- 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.1,50,000/- to him but all in vain. Feeling dissatisfied by the act and conduct of the opposite party, the complainant perforce has filed this complaint against the opposite party.
3 After formal admission of the complaint, notice was issued to Opposite Parties and appeared through counsel and filed written version contesting the complaint on the preliminary objections that the present complaint is not legally maintainable and the same is an abuse of Process of law. The complainant has not come to the Forum with clean hands and had suppressed the material facts from the notice of this Forum. The complainant has concealed and has suppressed the material and relevant fact of the case. The complaint has been filed with malafide and dishonest intention and has not only concealed the material facts from this Forum but has also twisted and distorted the same to the suit their own convenience and to mislead the Forum. The complainant has acted in bad faith with respect to subject of this complaint and has approached this Forum with unclean hands, hence in view of doctrine of clean hands “one who comes unto equity must come with clean hands” the complaint deserves no fate other than out right dismissal. The contract of the insurance between the respondent and complainant is governed by its policy terms and conditions. The complainant has made up a false and concocted story and is trying to mislead this Forum, therefore, the complainant is not entitled to any relief from this Forum. From the bare perusal of the complaint itself and from the above said facts and circumstances it becomes quite evident that the complainant has failed to establish any negligence in service, deficiency in service and unfair trade practice on the part of opposite parties and as such the complaints is liable to be dismissed on this ground also. The present complainant had never lodged any claim to the opposite parties and even no claim has ever been processed by the opposite parties, as such, the present complaint is premature. The present complaint is bad for mis-joinder and non-joinder of the necessary parties as all the legal heirs of the late Smt. Mohinder Kaur have not been impleaded as party in the present complaint. As per the averments in the complaint and the documents placed on the record, it is crystal clear that no claim has ever been lodged by the complainant. On merits, the opposite parties have reiterated the stand as taken in the preliminary objection 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.
4 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 complainant Ex. C-1 alongwith documents Ex. C-2 to Ex. C-53 and closed the evidence. To rebut the evidence of the complainant, Ld. counsel for the opposite parties No. 1, 2 tendered in evidence affidavit of Sh. Apurva Legal Manager Ex. OPs/1 and closed the evidence.
5 We have heard the Ld. Counsel for the complainant and opposite parties and have gone through the evidence and documents placed on the file by the parties.
6 Ld. counsel for the complainant contended that the complainant is a member of Farmer Cooperative Society, The Dhand, 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” and a card has been issued in favour of complainant which is Ex. C-41. He further contended that the complainant suffered severe pain in his left knee and for that he approached Guru Ramdass Charitable Hospital, Wallah Amritsar on 07.09.2016 and was diagnosed for damaged knee and was referred by this hospital for knee replacement surgery. He further contended that 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 the “Bhai Ghanhya Sehat Sewa Scheme” and gave the approval for the treatment. He further contended that on the approval of the treatment/ surgery by the representative of the Opposite Parties No.1 & 2, the complainant’s left knee was replaced by the hospital on 12.9.2016 and at the time of purchasing of the artificial knee the Hospital authorities told the complainant that his attendance required to purchase the artificial knee, so the complainant immediately informed the representatives of the Opposite Parties No..1 & 2 to pay for the artificial knee and for the surgery and other expenses of the complainant’s treatment but the Opposite Parties No.1 & 2 told the complainant that the complainant has to pay from his own pocket for the time being and reimbursement of the expenses on the treatment will be made by them to the complainant after the treatment and after supplying of the documents relating to the treatment i.e. the bills and treatment record to them. He further contended that the hospital authorities told the complainant on 26.9.2016 about his discharging from the hospital, so the complainant immediately called the representatives of the Opposite parties No. 1 & 2 to reimburse the expenses paid by the complainant from his own pocket inspite of being policy holder of the Opposite parties but the opposite parties told the complainant that same will be reimbursed in the couple of day and all the bills and payment receipts were supplied by the complainant to the Opposite Parties No.1 & 2 alongwith the treatment record as required by these parties. The complainant has placed on record discharge card Ex. C-42 which shows that the complainant was admitted in the hospital on 7.9.2016 and discharge on 26.9.2016 and the complainant has also placed on record retail invoice Ex. C-2, medical record of the hospital Ex. C-3 to Ex. C-39, C-43 to Ex. C-50. He further contended that complainant approached the secretary of the society and informed whole of the incident to him and he immediately approach the Opposite Parties No .1 & 2 to reimburse Rs.1,50,000/- 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 vide Ex. C-53. He further contended that the complainant also approached the Opposite Parties No. 1 & 2 through correspondence and on phone to reimburse Rs.1,50,000/- to him but all in vain.
7 On the other hands, Ld. counsel for the opposite party contended that the present complaint is not legally maintainable and the same is an abuse of Process of law. The complainant has not come to the Forum with clean hands and had suppressed the material facts from the notice of this Forum. The complainant has concealed and has suppressed the material and relevant fact of the case. The complaint has been filed with malafide and dishonest intention and has not only concealed the material facts from this Forum but has also twisted and distorted the same to suit their own convenience and to mislead the Forum. The complainant has acted in bad faith with respect to subject of this complaint and has approached this Forum with unclean hands, hence in view of doctrine of clean hands “one who comes unto equity must come with clean hands” the complaint deserves no fate other than out right dismissal. The contract of the insurance between the respondent and complainant is governed by its policy terms and conditions. The complainant has made up a false and concocted story and is trying to mislead this Forum, therefore, the complainant is not entitled to any relief from this Forum. He further contended that from the bare perusal of the complaint itself and from the above said facts and circumstances it becomes quite evident that the complainant has failed to establish any negligence in service, deficiency in service and unfair trade practice on the part of opposite parties and as such, the complaints is liable to be dismissed on this ground also. He further contended that the present complaint had never lodged any claim to the opposite parties and even no claim has ever been processed by the opposite parties, as such, the present complaint is premature. He further contended that the present complaint is bad for mis-joinder and non-joinder of the necessary parties as all the legal heirs of the late Smt. Mohinder Kaur have not been impleaded as party in the present complaint. He further contended that as per the averments in the complaint and the documents placed on the record, it is crystal clear that no claim has ever been lodged by the complainant and prayed for dismissal of the complaint.
8 In the present case, the complainant has proved on record that the complainant has replaced his knee from the hospital vide treatment record Ex. C-3 to Ex. C-39, C-43 to Ex. C-50 and the complainant has also brought on record Ex. C-41 which is card issued by Bhai Ghanhya Sehat Sewa Scheme, which also proved that the complainant is insured. But the main objection of the opposite party is that the complaint had never lodged any claim to the opposite parties and even no claim has ever been processed by the opposite parties, as such, the present complaint is premature. From the perusal of the file, it reveals that the claim of the complainant has not been decided so far. On the other hand, the Ld. counsel for the complainant alleged that the complainant has supplied all the bills and payment receipts to the opposite parties. In case Balu Waman Kadam vs. ICICI Lombard General Insurance Co. IV (2013) CPJ 16A (CN) (Mah.), the matter was similar, wherein the Insurance Company was asking the complainant to submit the documents and the complainant was alleging that he had already submitted the requisite documents to the Insurance Company. In such circumstances, the Hon’ble State Consumer Disputes Redressal Commission Maharashtra disposed of the matter, by directing the Insurance Company to reconsider the claim of the complainant within one month on receipt of the required documents from the complainant. 9 While relying upon the above said authority, the Hon’ble State Commission, Punjab, Chandigarh passed the similar orders in case M/s Trends, through its Proprietor vs The Oriental Insurance Company Limited & Anr. Consumer Complaint No.245 of 2015 decided on 04.08.2017; and M/s Gurbir Rice Mills v. United India Insurance Company Ltd. & Ors. Consumer Complaint No.404 of 2016, decided on 09.10.2017, directing the Insurance Company to reconsider the claim of the complainant after submission of requisite documents by the complainant to it. 10 In view of our above discussion as well as keeping in view the ratio of above said judgments, we are of the opinion that the ends of justice would be met, if the Insurance Company be directed to decide the claim of the complainant, after the complainant submit all the requisite documents. 11 In view of the above discussion, the present complaint is disposed of with the direction to the complainant to submit the requisite documents for deciding the claim within a period of 15 days from the date of receipt of copy of order and on approaching the complaint for supplying the requisite documents, the opposite parties will issue proper receipt acknowledging the same. The opposite parties shall decide the claim of the complainant within a further period of two months therefrom and in case of failure on the part of the opposite parties, the claim case of the complainant deemed to have been accepted. Copies of the orders be furnished to the parties free of costs as per rules. File is ordered to be consigned to the record room. Announced in Open Forum Dated: 14.3.2019 |
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