PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34,35 and 36 against the opposite parties on the allegations that the complainant is a farmer and he is member of farmer Cooperative society, Chautala, multipurpose Society Ltd. and this society got medically insured him with the OP Nos. 1 and 2 being the member and as per the scheme of Punjab Government commonly known as “Bhai Ghanya Sehat Sewa Scheme”. The complainant suffered severe Chest Pain, difficulty in breathing, Urine output and vomiting, for that he approached Guru Nanak Dev Superspecialty Hospital, Tarn Taran on 29.1.2021 and was diagnosed with CORONARY ARTERY DISEASE (CAD) (TVD) P.PTCA to LAD/LCX Heart Disease/ Kidney Patient and was got admitted by this Hospital on the same day. The complainant told the hospital authorities that he is medically insured with the OPs Nos. 1 and 2 and as per the information provided to him this Hospital is on the penal/ list of the hospital of the OP Nos. 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 OPs No. 1 & 2 so the Hospital Authorities immediately called the representatives of OP Nos. 1 and 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, so the hospital authorities provided treatment for heart blockage PTCA stent to LAD/LCX (two stents) on 31.1.2021 to the complainant but after the operation/ treatment, the hospital authorities demanded amount of Rs. 1,63,790/- 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 hospital authorities did not hear to the request of the complainant, so the complainant had to pay Rs. 1,63,790/- on various dates to the hospital authorities from his own pocket vide a number of receipts and was discharged from the hospital on 4.2.2021. The complainant approached the secretary of the society and informed whole of the incident to him and he immediately approached the OP Nos. 1 and 2 to reimburse Rs. 1,63,790/- to the complainant spent by him from his own pocket inspite of being insured with them by paying through his society as premium. The complainant approached the opposite parties No. 1 and 2 through correspondence and on phone to reimburse Rs. 1,63,790/- to him but all in vain. The complainant prayed the following relieves.
- The opposite parties No. 1 and 2 may kindly be directed to release the insurance claim/ reimbursement of Rs. 1,63,790/- to the complainant.
- It is further prayed that an amount of Rs. 10,000/- as compensation and Rs. 20,000/- as litigation expenses on account of mental & physical harassment caused to the complainant at the hands of the opposite parties, in the interest of justice, equity and fair play.
Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, Self attested copy of Bill dated 4.2.2021 Ex. C-2, Self attested copy of Insurance Claim dated 6.2.2021 Ex. C-3, Self attested copies of receipts Ex. C-4 to Ex. C-8, Self attested copies of Pharmacy receipts Ex. C-9 to Ex. C-11, Self attested copy of discharge summary Ex. C-12, Self attested copies of Diagnosis report Ex. C-13 and C-14, Self attested copies of Insurance Card Ex. C-15, C-16, self attested coy of Aadhar Card of complainant Ex. C-17, Self attested copy of Ration Card of complainant Ex. C-18.
2 Notice of this complaint was sent to the opposite parties and opposite party No. 2 appeared through counsel and filed written version by interalia pleadings that complicated questions of facts and law are involved in the present case and the matter can only be decided on the basis of the evidence to be led by both the parties. The complainant has to prove the nature of his illness and treatment by leading cogent medical evidence through examining the attending and treating doctor and to be cross examined by the opposite party assurance company. Similarly, the evidence on behalf of the opposite party has also to be produced to rebut the contention of the complainant and if proved by leading evidence on his behalf. Moreover, the issuing of insurance policy, payment of premium and nature of illness, if any covered under the policy have also to be proved by producing witnesses. The complainant as per his own version was admitted in Guru Nanak Super Speciality Hospital, Tarn Taran with severe chest pain, difficulty in breathing, urine output and vomiting and was treated for heart disease/ kidney patient on 29.1.2021 and was treated by doctors for heart blockage and was inserted stent on 31.1.2021. No detail by way of date of alleged visit and name of the visiting official have been given in the complaint and this allegation is only by way of allegation and liable to be rejected summarily. The complainant has applied for release of Rs. 1,63,790/- by way of insurance claim and it can only be claimed by filing a civil suit and affixing necessary court fees thereon. Therefore, this commission has got no jurisdiction to entertain, try and decide the present complaint. It is alleged by the complainant in the complaint that he was the member of farmer cooperative multipurpose society, Chutala, and through whom the premium is alleged to have been paid, is a necessary and proper party and in the absence of the same the present complaint is liable to be dismissed. Only the said society who is alleged to have received the premium form the complainant and got him insured is solely liable if at all there was any alleged insurance. The payment of premium and effecting of insurance can also be proved only be said society by way of evidence cross examination of witnesses of society. No details by way of policy number, date of insurance and the insuring office have been mentioned in the petition. Even the insurance policy has not been attached with the complaint nor it has been supplied inspite of repeated demands by filing a specific application in this regard. In the absence of the insurance policy the particulars of insuring office and the nature of insurance and sum assured, neither any specific reply can be given nor any relief can be granted to the complainant and against the opposite party. The complainant lacks material particulars. Due to non-supplying of insurance policy dispute of demand and payment receipts of premium if any no liability can be fastened on the opposite party. The opposite party has got no knowledge about the alleged ailment and admission in the hospital of the complainant. No intimation of any kind was given either to the opposite party or any other insuring office. If at all the complainant was insured by any of the opposite parties. The opposite party has got no knowledge about the complainant telling the hospital authorities about his being insured with opposite parties No. 1 and 2 and that the hospital authorities had told him that treatment expenses will be borne by opposite parties No. 1 and 2. No date has been mentioned about the alleged visit and if any alleged approval was given then why the same has not been placed on the file and it all goes to show that these are false and baseless allegations. The opposite parties have got no knowledge about any treatment of the complainant or of any payment by the complainant to the hospital authorities Unless and until it is proved by documentary evidence that the complainant was insured for cashless treatment in the hospital by the opposite parties No. 1 and 2 and that any alleged approval was given for his treatment. The complainant is not entitled for any kind of relief against the opposite parties. The complainant or the society through which the premium is alleged to have been paid but no document by way of receipt for payment of alleged premium has been placed on file and it clearly goes to show that the complainant is making false claims about his having been insured with opposite parties No. 1 and 2. No copies of the alleged letter dated 10.6.2021 has been placed on the file. The opposite party No. 2 has denied the other contents of the complaint and prayed for dismissal of the same. The opposite party No. 2 has placed on record affidavit of SK Sharma Divisional Manager New India Insurance Company Ex. OP R/1.
3 Notice of this complaint was sent to the opposite party No. 1 no one appeared on behalf of opposite party No. 1 and consequently, the opposite party No. 1 was proceeded against exparte.
4 We have heard the Ld. counsel for the complainant and opposite party No. 2 and have carefully gone through the record placed on the file.
5 In the present case the complainant has placed on record insurance Card Ex. C-15 and C-16 and other documents alongwith filing the present complaint.
6 The case of the complainant is that he is a farmer and is member of farmer Cooperative society, Chautala, multipurpose Society Ltd. and this society got medically insured him with the OP Nos. 1 and 2 being the member and as per the scheme of Punjab Government commonly known as “Bhai Ghanya Sehat Sewa Scheme”. The complainant suffered severe Chest Pain, difficulty in breathing, Urine output and vomiting, for that he approached Guru Nanak Dev Superspecialty Hospital, Tarn Taran on 29.1.2021 and was diagnosed with CORONARY ARTERY DISEASE (CAD) (TVD) P.PTCA to LAD/LCX Heart Disease/ Kidney Patient and was got admitted by this Hospital on the same day. The complainant told the hospital authorities that he is medically insured with the OPs Nos. 1 and 2 and as per the information provided to him this Hospital is on the penal/ list of the hospital of the OP Nos. 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 OPs No. 1 & 2 so the Hospital Authorities immediately called the representatives of OP Nos. 1 and 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, so the hospital authorities provided treatment for heart blockage PTCA stent to LAD/LCX (two stents) on 31.1.2021 to the complainant but after the operation/ treatment, the hospital authorities demanded amount of Rs. 1,63,790/- 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 hospital authorities did not hear to the request of the complainant, so the complainant had to pay Rs. 1,63,790/- on various dates to the hospital authorities from his own pocket vide a number of receipts and was discharged from the hospital on 4.2.2021. The complainant approached the secretary of the society and informed whole of the incident to him and he immediately approached the OP Nos. 1 and 2 to reimburse Rs. 1,63,790/- to the complainant spent by him from his own pocket inspite of being insured with them by paying through his society as premium. The complainant approached the opposite parties No. 1 and 2 through correspondence and on phone to reimburse Rs. 1,63,790/- to him but all in vain. But on the other hands, case of the opposite party No. 2 is that no intimation of any kind was given either to the opposite party or any other insuring office.
7 From the perusal of the file, neither the complainant nor the opposite party No. 2 has placed on record any document i.e. repudiation letter which reveals that the claim of the complainant has been decided. Infact the claim has not been decided so far and the same is still pending. Moreover, the pleadings of the opposite party No. 2 are that no intimation of any kind was given either to the opposite party No. 2 or any other insuring office.
8 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 again and again 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 following directions
(a) The opposite party No. 2 will submit the list of requisite documents to the complainant within 15 days from the date of receipt of copy of this order.
(b) The complainant will submit the claim with requisite documents to the opposite party No. 2 -Insurance Company for deciding the claim within a period of further one month and on approaching the complaint for supplying the requisite documents, the opposite party No. 2 will issue proper receipt acknowledging the same.
(c) The opposite party no. 2 shall decide the claim of the complainant within a further period of two months therefrom
In case of failure on the part of the opposite party No. 2, the claim case of the complainant deemed to have been accepted. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission and due to COVID -19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission
25.06.2024
