DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT
Complaint No. : 129 of 2018
Date of Institution: 31.07.2018
Date of Decision : 16.07.2019
Jaspreet Singh aged about 20 years, son of Swaran Singh r/o Dogar Basti, Street No.22 (R), District Faridkot.
...Complainant
Versus
- M D India, Health Insurance, TPA Pvt Ltd, Maxpro Info Park D -38, Industrial Area, Phase-I, Mohali, Punjab160055.
- United India Insurance Company Ltd, SCO-72, Phase-9 Mohali, Punjab160062.
- Managing Director PHSC and Secretary Health (Chairman) State Level Disputes Redressal Committee, Bhagat Puran Singh Health Insurance Scheme, SAS Nagar, Mohali, Punjab 160056.
- Deputy Medical Commissioner, Faridkot District Level Disputes Redressal Committee, Bhagat Puran Singh Health Insurance Scheme, Tehsil and District Faridkot.
.....Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Quorum: Sh. Ajit Aggarwal, President,
Smt. Param Pal Kaur, Member.
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Present: Sh Lalwinder Singh Chauhan, Ld Counsel for complainant,
Sh Ashok Monga, Ld Counsel for OP-2,
Sh Atul Gupta, Ld Counsel for OP-3 and 4,
OP-1 Exparte.
ORDER
(Ajit Aggarwal, President)
Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs for deficiency in service in not making payment of Rs. 40,000/-of insurance claim on account of his treatment and for further directing OPs to pay Rs.10,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses.
2 Briefly stated, the case of the complainant is that complainant was insured under Bhagat Puran Singh Scheme vide card no 93045010354800219 and policy bearing no 11210048161800000091 was issued to him for the period from 1.11.2016 to 31.03.2018. It is submitted that during the subsistence of said policy, complainant fell from his motorcycle and he got injuries on his right knee and nose. Right Patella /right knee cap of complainant was operated and he remained admitted in Guru Gobind Singh Medical College and Hospital, Faridkot for his treatment and paid Rs.40,000/-to hospital authorities. Thereafter, complainant lodged claim with OPs, but despite investigation conducted by Investigator of OPs and submission of all documents and completion of requisite formalities, Ops have not cleared the claim. Action of Ops in not making payment of claim amount of Rs.40,000/ amounts to deficiency in service and it has caused
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harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.
3 The counsel for complainant was heard with regard to admission of the complaint and vide order dated 1.08.2018, complaint was admitted and notice was ordered to be issued to the opposite parties.
4 On receipt of the notice, OP-2 filed written statement wherein they have denied all the allegations of complainant being wrong and incorrect and asserted that complainant is not their consumer and there is no relationship of consumer and service provider between them. It is averred that complainant did not give them requisite immediate intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and conditions of the policy in question. Complaint involves complicated questions of law and facts requiring lengthy evidence, which is not possible in summary procedure of this Forum. No cause of action arises against answering Ops and present complaint is vague and is based on wrong facts and complainant has no locus standi to file the present complaint. It is further averred that complainant was not insured with them at the relevant time and neither complainant nor other respondents provided them proper insurance particulars and therefore, they are not liable to make payment of any insurance claim. There are several
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regional offices, divisional offices and branch and micro offices and it is not possible to locate the insurance particulars without supply of the same by complainant or by other OPs i.e OP-1, OP-3 and OP-4. All the other allegations are denied being wrong and incorrect and asserted that there is no deficiency in service on the part of answering Ops and prayed for dismissal of complaint with costs.
5 OP-3 and OP-4 also filed reply through counsel and have denied all the allegations of complainant being wrong and incorrect and asserted that complaint is not maintainable as complainant is not their consumer and as per terms and conditions of the policy, there is no provision for reimbursement of amount spent on treatment as it is a cashless policy. Complainant did not insure himself under Bhagat Puran Singh Sehat Bima Yojna and no card was issued to him. moreover, if he availed the health insurance scheme, then he would have been issued card. This is a cashless scheme and he could have produced the card at the time of getting treatment from the concerned doctor. It is altogether denied that complainant fell from his motorcycle on 20.10.2017 and sustained alleged injuries. It is also denied that he availed any treatment from said hospital and spent Rs.40,000/-for his treatment. All the other allegations are totally denied being wrong and incorrect and it is reiterated that there is no deficiency in service on the part of answering Ops. Prayer for dismissal of complaint is made.
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6 Registered cover containing summons and copy of complaint alongwith relevant documents was sent to OP-1, but it did not receive back undelivered and it was presumed to be served. No body appeared in the Forum either in person or through counsel on date fixed on behalf of OP-1 and therefore, after long waiting till 4 O’ Clock, OP-1 was proceeded against exparte vide order dated 23.10.2018.
7 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 31 and then, closed his evidence.
8 In order to rebut the evidence given by complainant, the ld Counsel for OP-2 tendered in evidence, document Ex OP-2/2 and closed the evidence on behalf of OP-2. Ld counsel for OP-3 and 4 tendered in evidence affidavit of Jagraj Singh Ex R-1 and document Ex R-2 and closed the same on behalf of OP-3 and 4.
9 We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents placed on the file.
9 After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that he was insured under
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Bhagat Puran Singh Scheme for the period from 1.11.2016 to 31.03.2018 and during the subsistence of said policy, he met with an accident and sustained injuries on his right knee and nose. He remained admitted in Guru Gobind Singh Medical College and Hospital, Faridkot where Right Patella /right knee cap of complainant was operated and he incurred Rs.40,000/- for his treatment. After that, complainant lodged the claim, duly submitted requisite documents to the OPs and completed all formalities, but despite all this Ops have not made payment of insurance claim. Repeated requests made by complainant for passing his genuine insurance claim, served no purpose. It amounts to deficiency in service on the part of OPs. In reply, OP-2 to OP-4 have denied all the allegations of complainant being wrong and incorrect and asserted that there is no deficiency in service. Ld counsel for OP-2 took plea that all the allegations of complainant are incorrect and complainant is not their consumer. As per OP-2, complainant did not give them timely intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and conditions of the policy and even he was not insured with them at the relevant time and neither complainant nor OP - 3 and 4 supplied insurance particulars to them and therefore, they are not liable to pay any insurance claim and there is no deficiency in service on their part. On the other hand, stand taken by OP-3 and OP-4
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complainant is not their consumer and as per terms and conditions of the policy, there is no provision for reimbursement of amount spent on treatment as it is a cashless policy. Complainant was not insured under Bhagat Puran Singh Sehat Bima Yojna and no card was issued to him. All the allegations regarding admission of complainant in Guru Gobind Singh Medical College and Hospital, Faridkot and treatment taken by him. There is no deficiency in service on their part.
10 In order to prove his pleadings, complainant has stressed on document Ex C-10 copy of Bhagat Puran Singh Health Insurance Scheme that clearly depicts that policy in question was issued in the name of complainant and he was insured under said scheme. Thus, allegation of Ops that complainant was not insured under said scheme has no legs to stand upon and this document is self explanatory and proves that complainant was insured under said scheme and he sustained injuries and undertook treatment during the subsistence of said policy. It also reveals the card number against policy no 11210048161800000091 valid for the period from 1.11.2016 to 31.03.2018. Documents Ex C-2 to ExC-9 are copies of legal notices issued by complainant to OPs through his counsel whereby made requests to OPs to clear the insurance claim of complainant. Documents Ex C-12 is copy of discharge follow up card of complainant that leaves no doubt to the pleadings of complainant that he got admitted in Guru Gobind Singh Medical College and Hospital, Faridkot on 20.10.2017 during the subsistence of policy in question and there, operation of right patella was conducted on 23.10.2017 and he was
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also given treatment for nasal bleedings and he was discharged therefrom on 27.10.2017. Further copies of bills and prescription slips are Ex C-13 to Ex C-31 that prove that complainant spent expenditure on his treatment and paid this amount to hospital authorities. Document Ex C-10 showing membership and card number issued to complainant Jaspreet Singh under Bhagat Puran Singh Sehat Bima Yojna is beyond any doubt. Complainant has placed on record sufficient and cogent evidence to prove his pleadings. There is no reason to doubt that complainant has suffered huge harassment and mental agony by action of OPs in not making payment of insurance claim on account of expenses incurred by him on his treatment.
11 From the above discussion and in the light of evidence produced by the respective parties, we are of considered opinion that complainant has succeeded in proving his case. However, from the careful perusal of bills and other hospital record placed on file, it is made out that he has paid Rs.22,995/-to hospital authorities for his treatment. Complaint filed by complainant is hereby accepted against OP-1 and 2 with direction to them (OP-1 and OP-2) to pay Rs.22,955/- alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization to complainant who was insured with OPs against policy in question. OP-1 and 2 are further directed to pay Rs.4,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him as well as for litigation expenses. Compliance of this order be made within one month of the
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receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Complaint against OP-3 and OP-4 stands hereby dismissed as they have no role in making payment of insurance claim. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.
Announced in Open Forum
Dated : 16.07.2019
(Param Pal Kaur) (Ajit Aggarwal)
Member President
