Punjab

Fatehgarh Sahib

CC/69/2016

Harkaran Singh - Complainant(s)

Versus

MD India Health Care Service - Opp.Party(s)

Sh Surinder Singh Mann

22 Sep 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                            Consumer Complaint No.69 of 2016

                                                        Date of institution:  22.07.2016                               

                                                      Date of decision   :  22.09.2017

Harkaran Singh aged about 46 years son of Sh. Jagjit Singh, resident of village Mustfabad, Tehsil Bassi Pathana, District Fatehgarh Sahib.

……..Complainant

Versus

1. The M.D.India Health Care Services, (TPA) Pvt. Ltd; Maxpro Info. Park, D-38, Phase-I, Industrial Area Mohali, Punjab(160056), through its authorized signatory/M.D.
2. The ICICI Lombard General Insurance Co. Ltd; 4^th Floor, Plot No.#149, Industrial Area, Phase-1, Next to Hometel Hotel, Chandigarh (U.T.) through its Manager/Chairman.
3. Cheema Medical Complex, Phase IV, near Telephone Exchange, S.A.S.Nagar, Mohali, District S.A.S.Nagar Mohali through its authorized signatory.
4. The Kotla Masood, Cooperative Agriculture Service Society, Ltd; Kotla Masood, Post office Dhunda, Tehsil Bassi Pathana, District Fatehgarh Sahib through its Secretary.

…..Opposite parties

Complaint under Sections 12 to 14 of the Consumer Protection Act

 

Quorum

Sh. Ajit Pal Singh Rajput, President                          

 Sh. Inder Jit, Member                                                     

Present :   Sh. S.S.Maan, Adv.Cl. for the complainant.                      

                 Opposite Parties No.1 & 3 exparte.                             

                  Sh. Sumit Gupta, Adv.Cl. for Opposite Party No.2.          

                    None for Opposite party No.4.

ORDER

Ajit Pal Singh Rajput, President

                  Complainant, Harkaran Singh aged about 46 years son of Sh. Jagjit Singh, resident of village Mustfabad, Tehsil Bassi Pathana, District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “OPs”) under Sections 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.               The complainant is the member of opposite party No.4 and having account/K.C.C. No.258. As per the policy of Government, the complainant become the member of Bhai Ghaniya Sehat Sewa Scheme and paid the requisite membership fee/premium of Rs.1854/- on dated 16.12.2015, vide cheque No.734970, to OP No.1 and 2 through OP No.4 for the same. Opposite parties No.1 and 2 have issued the valid Health Card No.MD15/BGSSS-00506940-S in the name of complainant. As per the terms and conditions of the above said policy, opposite parties  No.1 and 2 are bound to bear the expenses of health treatment of their members. The complainant met with a road side accident on 17.04.2016 and suffered multiple injuries and his leg was broken in the said accident. He remained admitted from 19.04.2016 to 22.04.2016 in Cheema Medical Complex, OP No.3, which is on the panel of the said scheme. The complainant was operated upon in the said hospital and spent Rs.1,21,559/- on his treatment including the transportation and other miscellaneous charges to the tune of Rs.50,000/-.The complainant is still under treatment.  At the time of treatment, the complainant showed the health card to the said hospital and requested to get his treatment free of cost under the said scheme, but the concerned doctors/hospital authorities had got deposited all the expenditure incurred on treatment with an assurance that after completion of the treatment, the same will be refunded by MD India & Insurance Company to the complainant. Thereafter, complete insurance claim file was sent to OPs No.1 & 2 to get the reimbursement of amount spent on treatment i.e. Rs.1,21,559/- and also many times visited the concerned OPs to pay the said amount along with other expenses but the OPs No.1 and 2 have failed to pay the same, which amounts to great deficiency in service and unfair trade practice on the part of the OPs. The complainant also served a legal notice dated 13.06.2016 on OPs No.1 & 2 through registered post but in vain. Hence, this complaint for directing OPs No.1 and 2 to pay the amount of Rs.1,21,559/- as expenditure incurred on the treatment of the complainant plus Rs.50,000/- spent as transportation charges and other expenses along with Rs.50,000/- as compensation on account of mental agony and harassment suffered by the complainant.

3.               Notice of the complaint was issued to the OPs but OPs No.1 & 3 chose not to appear to contest this complaint despite service. Hence, OPs No. 1 & 2 were proceeded against exparte.  OP No.4 appeared through representative Sh. Kuljinder Singh, Salesman, who marked his presence on two hearing only and thereafter failed to turn up for filing written reply. Hence, the right to file the written version of OP No.4 was struck off.

4.               The complaint is contested by OP No.2, who filed written reply. In reply to the complaint OP No.2 raised certain preliminary objections, inter alia, that the present complaint is false, frivolous and vague in nature; the present complaint is not maintainable in the present form and the same is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified money from the OPs. As regards the fact of the complaint, OP No.2 stated that the Bhai Ghanhya Sehat Sewa Scheme, had been started by Government of Punjab for the members of various eligible rural Co-operative Societies of Punjab to provide the medical health insurance.  As per the said scheme registered members of the society who obtained the insurance policy and paid the requisite premium are entitled to get the benefit under the policy. The total insurance cover of the said policy is Rs.1,50,000/- per family on floater basis.  The guide book containing all the terms and conditions of the policy, details of network hospital along with health card were duly supplied to every insured member by M.D. India Health Care Service Ltd. In the present case, the complainant and OP No.3 did not lodge any claim with OP No.1 regarding treatment allegedly taken by the complainant. As per the terms and conditions of the policy, in case of emergency admission, before getting treatment at the network hospital, a pre-authorization is required from OP No.1 within 24 hours and for that, the complainant has to fill the pre-authorization form available with the hospital and also to submit the health card and ID proof and thereafter the hospital sends the pre-authorization letter alongwith health card of the patient and ID proof to OP No.1 for cashless facility. But in the present case no pre-authorization request was received by OP No.1. As the complainant and the hospital did not lodge any claim with OPs, there is no occasion for OPs to verify the treatment/expenses incurred by the complainant at the hospital. There is clear cut violation of the terms and conditions of the policy. There is no deficiency in service and unfair trade practice on the part of the answering  OP. After denying the other averments made in the complaint, OP No.2 prayed for dismissal of the complaint.

5.               In order to prove his case, the complainant tendered in evidence attested copies of documents Ex. C-1 to Ex. C-17, original postal receipt Ex. C-18, affidavit of complainant Ex. C-19 and closed the evidence.  In rebuttal OP No.2 tendered in evidence affidavit of Karan Nangla, Manager Legal, as Ex. OP2/1. No other evidence has been tendered by OPs No. 2 & 4 despite several opportunities. Hence, their evidence was closed by order.

6.                Learned counsel for the complainant has submitted that the main controversy involved in the present case is, that the claim of the complainant was not reimbursed, despite the fact that complainant had got himself treated from the network hospital which was authorized to treat the  the complainant. He pleaded that it is a admitted fact that the complainant was insured and was also entitled for reimbursement of the total expenses of Rs.1,50,000/- per year, per family on floaters basis and the same has been stated by the Asst. Manager in his statement in para No.10  Ex.OP2/1. Learned counsel argued that the complainant was entitled to receive Rs.1,50,000/- but the claim of the complainant has not been reimbursed.

7.               On the other hand, the ld. counsel for OP No.2 has stated that the claim of the complainant could not be reimbursed, as the complainant and the hospital/OP No.3 did not lodge any claim with OP No.1, thus there was no occasion for OP No. 1 to verify the treatment/expenses incurred by the complainant at the hospital. He pleaded that till the filing of the present complaint, no pre-authorization request was received by OP No.1 nor any claim was filed for reimbursement. Learned counsel argued that it is a clear cut violation of the terms and conditions of the policy and the present complaint deserves to be dismissed.

8.               After hearing the Ld. Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions, it is established from the affidavit sworn by Karan Nangla, Manager, in para no.10 that complainant was insured and was also entitled for reimbursement of the total expenses of Rs.1,50,000/- per year, per family on floaters basis Ex.OP2/1. It is also established from the medical treatment record Ex.C-4 to Ex.C-16 that the complainant after an accident on 17/04/2016, had undergone treatment at the empanelled/network Hospital/OP no.3 and had paid a total sum of Rs.1,21,559/- for his treatment. In our opinion, it has been proved on record that OP no.3 violated the terms and conditions of the Policy by not taking pre-authorization from OP No.1 and thereafter did not even forward the cashless claim of the complainant being on the panel of OP no.1 & 2.

9.               Accordingly, in view of the aforementioned discussion, we find that OP No.2 had not reimbursed the claim of the complainant due to unfair trade practice being adopted by OP No.3/empanelled/network Hospital, who was supposed to take pre-authorization and thereafter submit the claim of the complainant with OP No. 1, as per the terms and conditions of the policy. We further find OP No.3 empanelled/network Hospital, misled the complainant and gave false assurance to the complainant, that after completion of treatment, the same shall be got released from OP no.1 as it is evident from affidavit by way of statement Ex.C-19 of the complainant. Hence, we direct the OP No.3 empanelled Hospital to pay a sum of Rs. Rs.1,21,559/-(Rs.One Lakh twenty one thousands five hundred fifty nine only) for total expenses incurred on the treatment of the complainant because due to the act and conduct of OP No.3, the complainant was unable to get the same reimbursed. OP No.3 is further directed to pay compensation on account of mental as well as physical harassment suffered by complainant amounting to Rs.15000/- alongwith litigation cost of Rs.5000/-.

10.             OP No.3 is directed to comply with the order of this Forum within 45 days from the date of receipt of certified copy of this order. In case OP No.3 is unable to comply with this order, OP No.3 shall be liable to pay 9 % interest PA till its realization. The present complaint stands accepted against OP No.3.  

11.             The arguments on the complaint were heard on 08.09.2017 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.      

Pronounced                                                                                              

    Dated: 22.09.2017

(A.P.S.Rajput)              

President

 

                                                                               (Inder Jit)                                       

                                                                                Member