Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  :    69 of 2019

Date of Institution                      :   02.09.2019

Date of Decision               :   23.12.2019

Kulwinder Kaur wife of Tega Singh, resident of village Usma Tehsil & District Tarn Taran.

                                                                             …..Complainant

Versus

1. M.D. India Health Insurance TPA Pvt. Ltd. Mohali Towers, 1^st Floor, Plot No. F-539, Phase 8-B, Industrial area, Airport Road, Mohali through its MD 160071.
2. United India Insurance Company Ltd. having its Head Office at 24, Whites Road, Cheenai through its MD 600014.

                                                                             …Opposite Parties

Complaint Under section 12 & 13 of Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

For Complainant                     Sh. H.S. Sandhu Advocate

For Opposite Parties               Ms Keerti Mahajan Advocate.

ORDERS:

Charanjit Singh, President;

1        The complainant Kulwinder Kaur has filed the present complaint under Consumer Protection Act (herein after called   as 'the Act') against M.D. India Health Insurance TPA Pvt. Ltd. Mohali Towers, 1^st Floor, Plot No. F-539, Phase 8-B, Industrial area, Airport Road, Mohali through its MD 160071 (opposite party No. 1) and United India Insurance Company Ltd. having its Head Office at 24, Whites Road, Cheenai through its MD 600014 (opposite party No. 2) on the allegations of deficiency in service and negligence in service on the part of the opposite parties with the allegations that the complainant is insured by the Bhai Ghaniya Sehat Sewa Scheme i.e. the insurance scheme of Punjab Govt. for Members of the Farmers and the complainant had paid insurance premium to the opposite parties through the secretary of this co-operative society.  As per the terms and conditions of the insurance scheme, the insured can avail cashless treatment in case of need up to the extent permitted. The complainant fell ill on 22.12.2018 with severe pain in her chest and also felt difficulty in breathing and as such was in serious condition and was taken to Guru Nanak Dev Super-specialty Hospital, Tarn Taran for treatment, where she was admitted on 22.12.2018 till 24.12.2018 where she was provided treatment and was operated upon. The authorities of Guru Nanak Dev Super specialty Hospital demanded Rs. 34,527/- from the complainant but the complainant told that she is insured by the opposite parties and as such, the expenses will be borne by them but due to adamant behavior of the hospital authorities the complainant had to pay this amount from her own pocket to them, although the hospital authorities gave DHS-47 form signed by them to the complainant describing the seriousness of illness of the complainant and also mentioning the amount of bill paid by her to them and was also provided with the copies of bills in detail. The complainant immediately approached the opposite parties and lodged reimbursement with them and also supplied them with the documents i.e. bills etc. and the opposite parties issued the file/ claim number to her and assured her that her reimbursement claim will be released to her in a fortnight, so the complainant waited for this much time and after the lapse of this time again called the opposite parties for reimbursement claim, the opposite parties again asked for some time to do so.  The cause of action has arisen in favor of complainant against the opposite parties on 14.8.2019 when the opposite parties flatly refused to release the reimbursement claim of the complainant.  The complainant has prayed as follows:-

1. The opposite parties may be directed to pay immediately release Rs. 34,527/- to the complainant being the reimbursement of the expenses made by her from her own pocket.
2. The opposite parties may kindly be directed to compensation of Rs. 30,000/- & Rs. 20,000/- as litigation expenses on account of mental & physical harassment
3. Any other relief to which the complainant is found entitled to that may also be granted in his favour.

Alongwith the complaint, the complainant has placed on record his affidavit Ex. C-1, self attested copy of insurance card Ex. C-2, Self attested copy of discharge summery Ex. C-3, Self attested copy of DHS-47 Form Ex. C-4, Self attested copy of Bills Ex. C-5.

2        After formal admission of the complaint, notice of this complaint was sent to the opposite Parties and opposite parties appeared through counsel but have not filed written version within stipulated period of the Consumer Protection Act. Therefore, the opposite parties have failed their right to file written version vide order of this Forum on 4.11.2019.

3        Ld. counsel for the complainant contended that the complainant is insured by the Bhai Ghaniya Sehat Sewa Scheme i.e. the insurance scheme of Punjab Govt. for Members of the Farmers and the complainant had paid insurance premium to the opposite parties through the secretary of this co-operative society.  As per the terms and conditions of the insurance scheme, the insured can avail cashless treatment in case of need up to the extent permitted. He further contended that the complainant fell ill on 22.12.2018 with severe pain in her chest and also felt difficulty in breathing and as such was in serious condition and was taken to Guru Nanak Dev Super-specialty Hospital, Tarn Taran for treatment, where she was admitted on 22.12.2018 till 24.12.2018 where she was provided treatment and was operated upon. The authorities of Guru Nanak Dev Super specialty Hospital demanded Rs. 34,527/- from the complainant but the complainant told that she is insured by the opposite parties and as such, the expenses will be borne by them but due to adamant behavior of the hospital authorities the complainant had to pay this amount from her own pocket to them, although the hospital authorities gave DHS-47 form signed by them to the complainant describing the seriousness of illness of the complainant and also mentioning the amount of bill paid by her to them and was also provided with the copies of bills in detail. He further contended that the complainant immediately approached the opposite parties and lodged reimbursement with them and also supplied them with the documents i.e. bills etc. and the opposite parties issued the file/ claim number to her and assured her that her reimbursement claim will be released to her in a fortnight, so the complainant waited for this much time and after the lapse of this time again called the opposite parties for reimbursement claim, the opposite parties again asked for some time to do so and prayed that the present complaint may be allowed.

4        The opposite parties placed ion record written arguments and contended that the complainant never visited the opposite parties nor lodged any claim with the opposite parties and never submitted any claim form and documents. The opposite parties made efforts to search the documents and during this time, defence of the opposite parties was struck off as they could not file the within time due to want of documents as the same were not found in record despite best efforts. The complainant has failed to place on record any document showing that she ever lodged claim with the opposite parties and whether the hospital authorities ever intimated the claim to the opposite parties and as per official records, the complainant never lodged claim nor intimated the opposite party regarding her disease or hospitalization and there is no question to consider or refuse the claim. The complainant was under obligation to immediate lodge the claim on her disease to the opposite parties upon which the opposite parties have to consider the documents regarding disease and hospitalization as per policy terms and conditions but the complainant failed to lodge the claim with the opposite party in time and after lapse of considerable period, she filed the complaint directly before this Forum which is not legally sustainable and liable to be rejected forthwith and the opposite parties are not liable for any claim of hospitalization or compensation etc. as claimed for as the hospitlaition or compensation etc. as claimed for, as the complainant is guilty of her own lapse and her complaint is not legally maintainable and on account of the reasons detailed above, the complainant has not come to the Forum with clean hands and suppressed the true and material facts from this Forum as such, she is not entitled to any relief as claimed for and she is estopped by her own act and conduct from filing the present complaint and complainant has got no cause of action to file the present complaint and prayed that the present complaint may be dismissed.

5        We have heard the Ld. counsel for the parties and have also carefully gone through the evidence and documents on the file.

6        In the present case, the complainant has placed ion record insurance card which is Ex. C-2 issued by Bhai Ghanhya Sehat Sewa Scheme in favour of complainant, which shows that the complainant is insured with the opposite parties.  The complainant has also placed on record discharge summery   Ex. C-3 which shows that the complainant remained admitted in Guru Nanak Dev Supper specialty Hospital Goindwal Sahib Road, Tarn Taran on 22.12.2018 and discharged on 24.12.2018 and the complainant has also placed on record document i.e. D.H.S. 47 Ex. C-4 showing the amount of bill of Rs. 34,527.05 Paise,  and the complainant has also placed on record consolidated report  of Guru Nanak Dev Super Specialty Hospital Tarn Taran which shows that the complainant has made the payment of Rs.34,527/- to the said hospital for her treatment. In the present case, insurance is not disputed and the documents placed on record shows that the complainant remained admitted in the hospital for her treatment and the complainant has paid an amount of Rs. 34,527.05 Paise from her own pocket. The claim of the complainant has not been decided so far and the same is still pending for want of required documents.  On the other hand, the Ld. counsel for the complainant contended that the complainant has supplied all the requisite documents to the opposite parties in time and the opposite parties with malafide intention are not deciding the claim of the complainant but the complainant has not placed on record any document which shows that the complainant has supplied documents 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 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. 

7        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. 

8        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.

9        In view of the above discussion, the present complaint is disposed of with the direction to the complainant to submit the requisite documents to opposite parties 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.