Complainant Jasbir Singh through the present complaint filed U/s 12
of the Consumer Protection Act, 1986 (hereinafter called the Act) has prayed for
issuance of the necessary directions to the titled opposite parties to reimburse
Rs.90,000/- to the complainant along with interest @ 18% P.A. being the
expenses incurred on his wife's medical treatment besides Rs.5,000/- as
damages for causing harassment to him.
2. The case of the complainant in brief is that he alongwith his wife Kanwaljit Kaur being the members of the Sujanpur Co-Operative Agriculture Society became members of the ICICI Lombard General Insurance Company vide Bhai Ghanhya Sehat Sewa Scheme policy. Opposite party no.2 insurer had also issued them Health Cards for getting medical treatment in the listed network of different hospitals, in case of need. Somehow his wife Kanwaljit Kaur felt ill in June, 2013 suffering from Asthma and heart situation. He took her ailing wife Kanwaljit Kaur to one of the listed hospitals namely opposite party no.4 Babbar Heart Care Center and General Hospital. However, his wife could not survive inspite of medical treatment and demised on 6.7.2013. The complainant has further stated that he has to spent more than Rs.2,00,000/- on the medical treatment of his ailing wife and he had to pay the medical expenses to the opposite party no.4 hospital who did not accept the health card issued by the opposite party no.2 insurer. Since that time the complainant has been approaching the various offices of the opposite parties but his grievance of denial of medical expenses has not been redressed and thus he preferred to file the present complaint with the prayed relief as mentioned herein above.
3. Upon summons/notice the opposite parties no.1 and 2 appeared and filed their joint written reply through the counsel admitting therein the membership of the complainant and his demised wife. However, it has been stated that the insurance claim of the complainant including the cashless pre-authorization was never received at their end from the opposite party no.4 hospital or even by the complainant himself. Thus, there arose no cause of action against them hence the present complaint need to be dismissed with costs.
4. Similarly, the opposite party no.3 Co-Operative Society also filed their written reply admitting the membership and the entitlement of the complainant and his wife to receive medical reimbursement at the ends of opposite party no.1 insurers. Likewise opposite party no.4 hospital also appeared and filed its written reply stating therein that the complainant and his wife throughout their stay in the hospital while undergoing the medical treatment never disclosed the fact of their membership with the opposite party no.1 insurer or showed their health cards to them and thus there was no occasion for the opposite party no.4 hospital to file the medical reimbursement claim/cashless pre-authorization etc. Lastly, the complaint has been prayed to be dismissed with costs.
5. Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 alongwith other documents Ex.C2 to Ex.C59 and closed the evidence.
6. Counsel for the opposite parties no.1 and 2 tendered into evidence affidavit of Meenu Sharma Ex.OP1,2/1 alongwith other documents Ex.OP1,2/2 and Ex.OP1,2/3 and closed the evidence.
7. Counsel for the opposite party no.4 tendered into evidence affidavit of Dr.Kartar Singh Babbar Ex.OP4/1 and closed the evidence.
8. Evidence of the opposite party no.3 was closed by order vide order dated 12.1.2015.
9. We have duly considered the pleadings of both the parties; heard the arguments advanced by their counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purpose of adjudication of the present complaint.
10. We find that the opposite party no.1 Third Party Administrators & the opposite party no.2 insurers have straightaway refused having ever received any insurance claim pertaining to the Policy in question and have thus put forth their collective innocence (as a coincidental sequence to ‘ignorance’) of the matter under dispute. The Policy has been a ‘cash-less’ Policy but no cash-less pre-authorization was ever received from the opposite party no.4 Hospital where the complainant’s wife (the Deceased Life Assured) received her medical treatment and thus the opposite party no.1 TPA & the opposite party no.2 insurers are absolved of any and/or all liability under the Act. The opposite party no.4 Hospital in turn have turned down/straightaway refuted the complainant’s allegation/assertion that the ‘insurance ID Health Card’ was duly handed over to them right at the time of admission of the DLA patient to get the cash-less pre-authorization; whereas the complainant has stood fast by his assertion although the same does not find its right place in the complaint’s pleadings. Both the complainant and the opposite party no.4 Hospital could neither produce some direct primary evidence in support of their respective but diagonally opposite claims nor some cogent secondary evidence in their respective favor. Thus, the handing over of the insurance ID Health card has turned into a one ‘complex’ question of fact to be resolved first to adjudicate the complaint in hand.
11. In the light of the above, we are of the considered opinion that the present question of fact being complex/complicated in nature, it shall not be feasible to resolve/adjudicate the same under the available prescribed summary procedure under the Act and is thus disposed of with liberty to the complainant to approach the competent civil court to get the relief of his choice, if he so desires or so advised. However, the litigating parties shall themselves bear their own costs, here.
12. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to records.
(Naveen Puri)
President.
ANNOUNCED: (G.B.S.Bhullar) (Jagdeep Kaur)
FEB. 5, 2015. Member. Member.
*YP*
