DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 114
Instituted on: 08.03.2018
Decided on: 16.08.2018
Rameshwar Singh aged 68 years son of Shri Jora Singh, resident of Village Ghanauri Khurd, VPO Ghanauri Kalan, Tehsil Dhuri, District Sangrur.
…Complainant
Versus
1. M.D. India Insurance TPA Pvt. Ltd. through its Manager, Mohali Tower, First Floor, Plot No.F-539, Phase-8-B, Industrial Area, Airport Road, Mohali, Punjab 160071.
2. Reliance General Insurance company Ltd. through its Manager, 19, Reliance Centre, Walchand Hirachand Marg, Ballard Estate, Mumbai 400 001.
3. The Ghanauri Khurd MPCASS Ltd. (Society) Village Ghanauri Khurd, Block Sherpur, Tehsil Dhuri, District Sangrur through its Secretary.
4. Hero DMC Heart Institute, Tagore Nagar, Civil Lines, Ludhiana through its Manager.
5. Gharchaz Orthopaedic and Dental Care, 494/5, Lane 2, Dashmesh Avenue, Haripura Road, Sangrur through its Manager.
6. Comrade Jagdish Chander Freedom Fighter Civil Hospital, Sangrur through C.M.O.
..Opposite parties.
For the complainant : Shri Nem Kumar, Adv.
For Opp.Party No.1&2: Shri Amit Goyal, Adv.
For Opp.Party No.3 : Shri B.S.Sohi, Adv.
For OP NO.6 : Ms.Anmol Sharma.
For OP No.4&5 : Exparte.
Quorum: Sarita Garg, Presiding Member
Vinod Kumar Gulati, Member
Order by : Sarita Garg, Presiding Member.
1. Shri Rameshwar Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant being the member of OP number 3 availed medical insurance services under Bhai Ghanhya Sehat Sewa Scheme under policy number 200431728440000001 and was entitled for cashless medical treatment from the empanelled hospital and for this he paid an amount of Rs.1387/- as premium on 5.4.2017. Further case of the complainant is that he maintains account card number 68 with the Sangrur Central Cooperative Bank Branch Katron through secretary of OP number 3. The grievance of the complainant is that he was suffering from serious pain giving ailment of right knee due to which the complainant was having great difficulty in doing the routine activities and as such the complainant approached OP number 5 during May 2018 for availing cashless treatment under the said scheme, and the hospital authorities applied for cashless treatment of the complainant, but the Ops denied the same on the ground that seven days prior intimation required for planned surgery and thereafter the complainant approached the Ops so many times, but nothing happened. Further case of the complainant is that he visited OP number 4 during the second week of December, 2017 which further asked to the complainant to undergo examination by the concerned doctor of DMC Ludhiana, but again the case of the complainant is that thereafter he visited OPs number 5 & 6 to get the treatment, but of no avail. The complainant was entitled treatment under the cash less policy, but no treatment was provided by the insurance company. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to provide cashless medical treatment of total arthroplasty of right knee of the complainant and further claimed compensation and litigation expenses.
2. In reply filed by the OPs number 1 and 2, legal objections are taken up on the grounds that the complaint is not maintainable on the ground that 7 days prior intimation was not provided by the hospital authorities to the insurer, which was mandatory as per the agreement done with the hospital, the coverage of the insurance policy has already expired on 14.3.2018, that the complainant has no cause of action, and that the complainant has not come to the Forum with clean hands. On merits, it is admitted that the complainant approached OP number 4 in the month of May, 2017 for treatment of knee replacement and OP number 4 applied for authorisation for cashless treatment, but the same was denied as requirement of prior notice of seven days before planned surgery was not given. It is further stated that the complainant or the hospital authorities never approached the Ops thereafter. Had the complainant actually was ready to comply with the formalities, then he should have got sent pre authorisation request to the OPs through hospital authorities by giving seven days prior notice for planned surgery. Any deficiency in service on the part of the OPs has been denied.
3. In reply filed by OP number 3, the allegations levelled in the complaint have been denied qua OP number 3.
4. Record shows that the OPs number 4 and 5 were proceeded against exparte.
5. In reply filed by OP number 6, the allegations levelled in the complaint have been denied and issuance of the card to the complainant is admitted.
6. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-15 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 & 2 has produced Ex.OP1&2/1 to Ex.OP1&2/5 copies of documents and affidavits and closed evidence. The learned counsel for OP number 3 has produced Ex.OP3/1 to Ex.OP3/4 copies of documents and affidavit and closed evidence. The learned counsel for OP number 6 has produced Ex.OP6/1 affidavit and closed evidence.
7. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.
8. It is an admitted fact between the parties that the complainant being a member of the OP number 3 was insured with the OPs number 1 and 2 under the cashless policy by paying the insurance premium to the tune of Rs.1387/- on 5.4.2017. In the present case, the grievance of the complainant is that he suffered the problem of pain in the right knee, as such, he approached the OP number 4 for treatment during the May, 2017 for availing cashless treatment, who sent pre authorisation request to the Ops number 1 and 2, but the Ops number 1 and 2 denied the request on the ground that 7 days prior intimation was not provided by the hospital authorities to the insurance company for getting pre authorisation consent for the treatment. We have very carefully perused the whole case file and found that after the denial of pre authorisation request in May, 2017 thereafter the complainant never approached to get the treatment to any of the hospital authorities nor the complainant took treatment from his own pocket, if it was necessary one. Though the complainant has produced on record Ex.C-4 a certificate issued by Dr. Pankaj Mahindra of DMC Ludhiana on 19.5.2017, but there is nothing on record that the complainant ever took any treatment of his knee. Now, the fact remains that the complainant has not got any treatment for his right knee. Had there been the urgency, then the complainant would have taken the treatment and then could claim the amount from the insurance company, if the prior cashless approval was denied by the insurance company as per the terms and conditions of the policy. In the circumstances, we feel that there is no deficiency in service on the part of the Ops number 1 and 2. It is further made clear had the complainant thereafter applied for 7 days prior intimation required for planned surgery, then the position would be another one, which the complainant failed to do so.
9. Accordingly, in view of our above discussion, we find no merit in the complaint and the same is, therefore, dismissed. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
August 16, 2018.
(Sarita Garg)
Presiding Member
(Vinod Kumar Gulati)
Member
