Punjab

Faridkot

CC/14/66

Jaspal Kaur - Complainant(s)

Versus

M.D.Healthcare Services - Opp.Party(s)

N.S. sangha

10 Feb 2015

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      66

Date of Institution: 14.05.2014

Date of Decision :   10.02.2015

 

 

Jaspal Kaur aged 72 years, w/o Sh Harbans Singh r/o VPO Ghaniewala, Tehsil Kotkapura, District Faridkot through her power of attorney Gurshvinder Singh s/o Sh Harbans Singh, r/o VPO Ghaniewala, Tehsil Kotkapura, District Faridkot.

                                                                   ...Complainant

Versus

1.    Managing Director, Healthcare Services (TPA), Pvt Ltd Max Pro    Info Park, D-38, Phase I, Industrial Area, Mohali-160056. Pb.

2.    Bhai Ghanhiya Trust, SCO 16 Sector 7, Chandigarh through its Chief Executive Officer.

3.   ICICI Lombard GIC Ltd presently at SCO No. 501, Sec-70, Mohali, Punjab through its Legal Manager.

....Opposite Parties (OPs)

 

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

 

Quorum: Sh. Ashwani Kumar Mehta, President,

               Smt Parampal Kaur, Member,

               Sh P Singla, Member.

 

Present: Sh N S Sangha, Ld Counsel for complainant,

              Sh Neeraj Maheshwary, Ld Counsel for OP-1 & 3,

              Sh D S Dhaliwal, Ld Counsel for OP-2.

 

(A K Mehta, President)

ORDER

                                            Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against Managing Director, Healthcare Services (TPA) and others/OPs seeking directions to OPs to make payment of remaining claim amount worth Rs 1,33,136/- with interest and for further directing OPs to pay Rs 50,000/- as compensation for harassment and mental tension alongwith Rs 15,000/- as litigation expenses.

2                                    Briefly stated, the case of the complainant is that she is a member of Bhai Khanhya Sehat Sewa Scheme having card no. MD15-BGSSS-00045722-M and is insured under the said scheme and is depositing the requisite amount with Ops every year; that due to slipping from chair, right leg of complainant was fractured and she was admitted in Sandhu Bone & Joint Hospital, Main Bazar, Moga for treatment on 15.11.2013 and she was operated upon by the doctor on 16.11.2013 and during operation, her right knee was replaced; that complainant remained admitted in said hospital and was discharged on 29.11.2013 and complainant had spent Rs 1,48,526/-on her treatment and after completing all formalities, complainant submitted all requisite documents and applied to concerned authority within time for getting her claim worth Rs 1,48,256/-, but she received only amount of Rs 15,390/- for her treatment and remaining amount of Rs 1,33,136/- has not been received so far though complainant has made many requests to Ops to make payment of remaining claim amount, but Ops are lingering on the matter on one pretext or the other; that complainant has also sent registered legal notice dt 13.03.2014 to Ops, wherein requested Ops to make payment of her remaining claim amount, but despite service of said notice, Ops have not made payment of her remaining claim amount, which amounts to deficiency in service and has caused harassment and mental tension and agony to her for which she has prayed for directing the OPs to pay Rs 50,000/- as compensation and Rs 10,000/- as litigation expenses incurred by her besides the main relief. Hence, the complaint.

3                                    The counsel for complainant was heard with regard to admission of the complaint and vide order dated 30.05.2014, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                 On receipt of the notice, the OP-1 and 3 filed written statement taking legal objections that complaint involves intricate questions of law and facts and require voluminous documents and evidence for determination, which is not possible in summary procedure under Consumer Protection Act; that complainant has concealed material facts and documents from Ops as well as from this Forum as complainant did not provide the requisite information for processing of claim regarding her knee treatment/replacement to answering Ops because complainant was bound to supply documents and complete formalities as per terms and conditions of the policy, therefore, claim is premature; that maximum liability under the scheme is Rs 1,50,000/- and there are further sub limits for different diseases/treatment and maximum liability in case of joint replacement is Rs 1,00,000/-; that complainant is not the consumer of Ops and complainant has no locus standi to file the present complaint and it is not maintainable in the present form and is liable to be dismissed and complaint is bad for non joinder of necessary parties as MD India Third Party Administrator in the  scheme is necessary party, which has not been impleaded in this case and this Forum has no territorial jurisdiction to hear and try the present case as no cause of action arises against Ops within the jurisdiction of this Forum. However, on merits, OPs have denied all the allegations levelled by complainant and reiterated that complainant did not submit all the required documents with the claim case and submitted documents qua claim of open reduction of long bones of upper and lower limb and Rs 15,390/- were paid accordingly, but complainant did not send complete record and documents regarding claim of knee replacement and hence, claim is premature. It is further asserted that there is no deficiency in service or unfair trade practice on the part of answering opposite parties. The allegations with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

5                                                    OP-2 also filed reply taking preliminary objections that present complaint is not maintainable against answering OP as  neither complainant is consumer of OP-2 nor there is any deficiency on the part of answering OP; that complaint filed by complainant is false, frivolous and vexatious and the same is liable to be dismissed; that no cause of action accrues to complainant for filing the complaint and complaint is not maintainable before this Forum at Faridkot as it has no territorial jurisdiction to entertain and decide the complaint against OP-2 as registered office of OP-2 is at Chandigarh and members/beneficiaries have been clearly informed that complete financial and legal liabilities, if any, arising consequent to operation of Scheme or the Policy, shall rest exclusively and unconditionally with MD India Health Care Services (TPA) Ltd/OP-1 and ICICI Lombard GIC Pvt Ltd, insurer during the period 20.11.2012 to 19.11.2013; that ICICI Lombard was the insurer, but complainant has failed to implead the same as necessary party and complaint is therefore, bad in nature; that the member has given her undertaking on the enrolment form that she has understood all the terms and conditions of the Scheme and declaration made by her is final, irrevocable and wholly binding on her and complaint is liable to be dismissed qua answering OP. However, on merits, ld counsel for OP-2 asserted that OP-2 is a registered Trust and Bhai Kanhaiya Sehat Sewa Scheme is meant for providing Health Care Services to the members and employees of the Cooperative Societies and Cooperative Department, Punjab and ICICI Lombard General Insurance Company, which is not impleaded as party,  was the insurer during 20.11.2012 to 19.11.2013, which had appointed MD India Health Care Services/OP-1 as Third Party Administrator (TPA) and according to provisions of Bhai Ghanhiya Sehat Sewa Scheme, the TPA had to issue Identity Cards to members of the Scheme, to inspect hospitals and recommend to the Trust for their empanelment, to grant authorization and to settle the claim of hospital/beneficiaries under the scheme; that OP-2 is neither the Service Provider nor the complainant is consumer of answering OP; that it is the insurer and the TPA, who were the Service Providers and claim settling authorities under the scheme, therefore, complaint is not maintainable and answering OP cannot be held liable for any payment to complainant and complainant has no cause of action against OP-2; that all the allegations levelled by complainant are denied being false and frivolous and request for dismissal of complaint with costs is made.

6                            Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1, and documents Ex C-2 to C-7 and then, closed his evidence.

7                                                  In order to rebut the evidence of the complainant, the ld Counsel for OP-1 and 3 tendered in evidence documents Ex OP-1,3/1 to OP-1,3/3 and closed the evidence. Ld Counsel for OP-2 tendered in evidence affidavit Ex OP-2/1 and closed the evidence on behalf of OP-2.

8                                                           We have heard the learned counsel for the parties and have very carefully gone through the evidence and documents on the file.

9                                   The Ld Counsel for complainant contended that complainant is a member of Bhai Kanahiya Sehat Sewa Scheme and was insured under the said scheme with the Ops/Insurance Company. He contended that OP-1 is Third Party Administrator (TPA) of the Ops who was to investigate and decide insurance claims of the Members. He contended that complainant slipped on 15.11.2013 and got fractured her right knee and she was operated on 16.11.2013 and her right knee was replaced and was discharged from the hospital on 29.11.2013 and spent Rs 1,48,526/- for the treatment. He contended that complainant prepared the claim case under the said insurance policy and filed the same with Ops but Ops allowed the claim of the complainant only up to 15,390/- and remaining amount of Rs 1,33,136/-was withheld without any reason and justification. He contended that complainant requested and visited the office of Ops many times but with no effect and later on complainant served a legal notice dated 13.03.2014 upon Ops but inspite of that, the balance payment was not made and complainant had to file the complaint in hand. He contended that act and conduct of the Ops/Insurance Company was illegal and it caused harassment and mental agony to the complainant and she was to file complaint in hand and as such, complaint is required to be allowed and Ops are required to be directed to pay the balance amount of Rs 1,33,136/-alongwith compensation and litigation expenses as mentioned in the complaint.

    10                                             The ld counsel for OP-1 and OP-3 contended that complainant being Member of Bhai Kanahiya Sehat Sewa Scheme was insured with Ops/Insurance Company and Health Card was issued to her. He contended that complainant was hospitalized and she filed the claim for reimbursement and after going through the record of the case and in accordance with the terms and conditions of the Policy, which are fully detailed in the guide book of Bhai Kanahiya Sehat Sewa Scheme issued by OP-1/MD India Health Care Services Ex OP-1, 3/3, an amount of Rs 15,390/-was sanctioned and paid to the complainant. He contended that under the Policy in dispute the maximum limit for payment under the Insurance Policy each family is Rs 1.5 lac as mentioned in the guide book Ex OP-1,3/3 and maximum limit for replacement of joint is Rs 1 lac as mentioned in regulation 1.9 of the said guide book. He contended that even for the sake of arguments if the claim of the complainant is maintainable, then the same cannot be sanctioned for more than Rs 1 lac as mentioned in the guide book. He contended that complaint is totally false and has been filed in order to gain illegal benefit and extract money from the Ops and is liable to be dismissed.

   11                              It is admitted fact in this case that complainant is a Member of Bhai Kanahiya Sehat Sewa Scheme and being Member of said scheme, was insured with the Ops/Insurance Company for health services. It is the case of the complainant that she suffered knee injury and was hospitalized and later on she filed claim for Rs 1,48,526/-. It is  admitted fact that OP paid Rs 15,390/- out of claim and did not pay the balance amount. However, the Ops/Insurance Company has not explained as to why the remaining amount of the claim was rejected and not paid to the complainant. The OP/Insurance Company has only proved affidavit of Meenu Sharma, Manager Legal Ex OP-1, 3/1, Insurance Policy Ex Op-1,3/2 and guide book Ex Op-1,3/3 and no other document has been proved on the file by the OP/Insurance Company nor any detail has been filed as to why the remaining amount of the claim was rejected. Otherwise, the OP/Insurance Company have proved the guide book Ex Op-1,3/3 which contains terms and conditions of the Insurance Policy. It is correct that Insurance Policy is a contract and parties are bound by terms and conditions and terms and conditions of the said insurance contract are mentioned in the guide book Ex Op-1,3/3 and parties are bound by the same. As per guide book, the maximum limit per family under the policy is Rs 1.5 lac and maximum limit for replacement of joint/surgery is Rs 1 lac. As scuh, complainant is not entitled to more than Rs 1 lac under the Policy for the treatment availed by her. It is admitted fact that she has received Rs 15,390/-and as such, complainant is only entitled to Rs 84,610/- under the Insurance Policy out of claim filed by her. Otherwise the act and conduct of the Ops in illegally rejecting the claim must have caused harassment and mental agony to the complainant as she had to request and visit the Ops many times and ultimately, she was compelled to file the complaint and had undergone the ordeal of trial and as such, complainant is also entitled to compensation on account of harassment and mental agony and on account of litigation expenses.

   12                               In the light of above discussion, the complaint is hereby partly allowed with costs in favour of complainant and against OP-1 and 3 as OP-2/Trust is not liable to pay the claim amount as the complainant was insured with only OP-3/Insurance Company and OP-1 is the third party administrator(TPA) of the OP-3. The complainant is held entitled to recover Rs 84,610/-as claim amount and is also held entitled to Rs 10,000/-as compensation for harassment and mental agony and Rs 2000/-as litigation expenses. Compliance of the order be made within one month from the date of receipt of the copy of the order, failing which complainant shall be entitled to initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of order be given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 10.02.2015

                                      Member            Member                  President

 (P Singla)          (Parampal Kaur)     (A K Mehta)