Complainant Jagir Kaur through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the necessary directions may kindly be issued to the opposite parties to pay Rs.75,000/- incurred on her treatment alongwith interest @ 12% per annum from the date of treatment till its realization alongwith costs and damages of Rs.10,000/- for unnecessary harassment to her.
2. The case of the complainant in brief is that her husband namely Tarlok Singh is member of Shankarpura Co-Operative Agriculture Service Society for the last more than 10 years. Her husband alongwith other members of the said Society insured with the ICICI Lombard General Insurance Company opposite party no.2 vide Bhai Ghanhya Sehat Sewa Scheme Policy through the said Secretary. Premium of Rs.1405 is being paid to the opposite party no.3 for every year by her husband. She is dependent on her husband as such she is also beneficiary of the Scheme and her risk is covered under the Scheme. Health Card of the said ICICI Lombard Company bearing its no.MD15-BGSSS-00466713-SP and MD15-BGSSS-00466713-S respectively has been issued in her favour and her husband, which was valid at the relevant time. She was insured upto the expenditure of Rs.1,50,000/- for her medical treatment. She has further pleaded that in the month of January 2016 she suffered problem in the movement of her Hip Joint. Complainant got herself medically check up whereby she was advised for operation of her Hip Joint. After going through the booklet regarding prescribed Hospital authorized for treatment under Bhai Ghanhya Sehat Sewa Scheme Policy, complainant alongwith her husband went to Sri Guru Ram Dass Charitable Hospital Mehta Road Wala Amritsar, opposite party no.4. She as well as her husband shown her abovesaid Health Card to the concerned Doctor cum Manager of the Sri Guru Ram Dass Chartable Hospital, where she was given proper treatment with effect from 22.2.2016 to 3.3.2016 and was discharged on 3.3.2016 by the said Hospital after conducting the operation of her right Hip. She spent about Rs.75,000/- on her medical treatment. The account has been maintained by her regarding expenditure of medical treatment. Out of the total expenses some expenditure receipts have been maintained by her. She met to coordinator appointed by opposite party no.1 regarding reimbursement of the amount spent on her medical treatment, but he put the matter on one pretext or the other and refused to do any help. She also requested to Sri Guru Ram Dass Charitable Hospital Mehta Road Walla, Tehsil and Distt.Amritsar, Authorities to recommend his case for reimbursement of the amount spent on her medical treatment. The card was shown prior to admission and at the time of entire medical treatment to the Hospital Authority opposite party no.4 but the opposite party has shown its inability by saying that computer is not attending the card. Complainant also requested many times to opposite party orally, by face and as well as by way of telephone, to reimburse the said amount but opposite party has neither reimbursed the amount nor given any reply to her request. A legal notice dated 29.3.2016 was also issued through registered letter to the opposite parties but of no avail. Hence this complaint.
3. Notice of the complaint was served upon the opposite parties. Opposite party no.1 and 2 appeared through their counsel and filed their joint written reply taking the preliminary objections that the complainant has no cause of action to file the present complaint; the complaint is premature and no claim has ever been filed by any person or complainant; as no claim has been filed and as such it was wrong and denied that complainant was insured with opposite party and even otherwise as per terms and conditions of the policy, only cashless facility is available and provision of reimbursement is not available and as such now the complainant is not entitled for any claim from the opposite party and the complaint is bad for non joinder of necessary parties. On merits, it was submitted that no claim has ever been filed by the complainant and as such the opposite party is having no knowledge regarding the facts. The complainant may put strict proof of it. There is only facility of cashless and that too only in empanelled hospital. There is no provision of reimbursement. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
4. Opposite party no.3 appeared through its counsel and filed its written statement stating therein that Tarlok is member of the C-Operative Society. Tarlok Singh himself insured with the ICICI Lombard General Insurance Company as per the Bhai Ghanhya Sehat Sewa Scheme Policy. It was also correct that premium of Rs.1405 was being paid by the husband of the complainant every year. It was admitted that Health Card of ICICI Lombard Company bearing No.MD15-BGSSS-00466713-SP and MD15-BGSSS-00466713-S has been issued to complainant and her husband Tarlok Singh. Husband of the complainant was insured upto the expenditure of Rs.1,50,000/- for medical treatment for himself as well as for his dependants. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
5. Opposite party no.4 appeared through its counsel and filed its written reply taking the preliminary objections that the present complaint is not maintainable and opposite party no.4 had not received any amount from the complainant during the treatment and had only received Rs.200/-. As regards the charges/expenses of operation or room charges, the opposite party no.4 had not received any payment. Moreover, the complainant had not given the correct documents i.e. membership of Bhai Ghanhya Sehat Sewa Scheme Policy and the opposite party no.4 is not a necessary party to the complaint. On merits, it was submitted that complainant had not furnished the material documents i.e. regarding membership of Bhai Ghanhya Sehat Sewa Scheme Policy. Hence, the claim is vague, false and frivolous. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
6. Jagir Kaur, complainant tendered into evidence her own affidavit Ex.C1, of Tarok Singh Ex.C2 along with other documents Ex.C3 to Ex.C37 and closed the evidence.
7. Counsel for the opposite parties no.1 and 2 tendered into evidence affidavit of Sh.Karan Nagala Ex.OP-1, 2/1 and closed the evidence.
8. We have examined all the documents/evidence produced on record and have also duly considered and perused the arguments duly put forth by the learned counsels for both the sides, while adjudicating the present complaint. From the pleadings and evidence on record we find that the present complaint is premature since the opposite party has not yet decided the insurance claim as no claim has been filed by the complainant with them. Thus we dispose of the complaint and direct the complainant to approach the opposite party and submit the requisite relevant documents/information desired by them for settling the insurance claim within 30 days of the receipt of these orders and further direct the opposite party insurance providers to decide the claim as per the terms and conditions of the policy within 30 days of the receipt of documents from the complainant. The opposite party is further directed to decide insurance claim duly filed by the complainants duly verified as per the settled procedure laid down by their regulating Agency IRDA.
9. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.
(Naveen Puri)
President
Announced: (Jagdeep Kaur)
October,25 2016 Member
*MK*
