Punjab

Fatehgarh Sahib

CC/64/2015

Harwinder Kaur - Complainant(s)

Versus

Md INdia Health Care Service - Opp.Party(s)

Sh GS Maan

11 Jul 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                            Consumer Complaint No.64 of 2015

                                                        Date of institution:  21.07.2015                                       

                         Date of decision   :  11.07.2016

 

Harwinder Kaur, aged about 46 years, wife of Balwinder Singh, resident of village Naulakha, Post Office, Rurki, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

1. MD India Health Care Services, (T.P.A.) Private Limited, Maxpro Info Park, D-38, Phase I, Industrial Area, Mohali through its authorized Signatory.
2. The Naulakha MPCSS Ltd., Village Naulakha, Tehsil & District Fatehgarh Sahib through its authorized signatory.
3. United India Insurance Company Ltd., Divisional Office, SCO 72, Phase IX, Mohali, through its Divisional Manager.

…..Opposite parties

 

Complaint under Sections 12 to 14 of the Consumer Protection Act

Quorum

Sh. Ajit Pal Singh Rajput, President                                       Smt. Veena Chahal, Member                                                   Sh. Amar Bhushan Aggarwal, Member                                                     

Present :      Sh. S.S.Marwa, Adv.Cl. for the complainant.                                                               Sh. Narinder Kumar Sharma, Adv.Cl. for OPs No.1&3.                                               Sh. S.S.Maan, Adv.Cl. for OP No.2.

 

 

 

ORDER

 

By Ajit Pal Singh Rajput, President

                      Complainant, Harwinder Kaur, aged about 46 years, wife of Balwinder Singh, resident of village Naulakha, Post Office, Rurki, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.                   The complainant is a member of the Naulakha MPCSS Ltd. i.e. Co-operative Society, Village Naulakha, Tehsil and District Fatehgarh Sahib, OP No.2. The said society offered insurance scheme to its members through OP No.1, MD India Health Care Service          (under its Bhai Ghanhya Sehat Sewa Scheme). As per said scheme there is a provision that member alongwith his whole family members can be insured and the whole family can take the benefits of said insurance Scheme. Accordingly, the complainant got insured herself as well as whole family with OP No.1. The OPs issued identity card bearing No.MD-15-BGSSS-00214449-SP to the complainant. As per settled terms and conditions of the said insurance policy, the person who joins as member, the medical facilities are being provided totally free of costs.  Due to some medical problem, the complainant started her treatment from Rajindra Hospital, Patiala but the doctors did not conduct the proper treatment of complainant and when she was facing severe pain, she got examined herself from Sohal Hospital, Sirhind      ( one of the listed hospitals in the guide book issued by OP No.1) and was admitted there on 13.06.2014 and where she was operated for NDVH with B/L Salphingectomy and R Oopherectomy. The total amount of treatment and medical expenses were borne by complainant at her own.  During treatment the complainant provided all the relevant documents to the said hospital authority as per the instructions contained in the guide book issued by OP No.3.  The said hospital also sent a request for cashless hospitalization form to OP No.1 under the said scheme and all the facts regarding treatment are mentioned in the said form. When OPs did not give any response to the said hospital regarding the payment of expenses incurred on treatment under the said scheme, then the complainant personally approached the OPs and requested to pay the medical expenses borne by him as per the terms and condition of the policy.  But the OPs put off the matter on one pretext or the other and harassed the complainant by not making the payment of treatment despite the policy of insurance under the said scheme.  The OPs refused to make the payment of medical expenses borne by the complainant by alleging that the said hospital is not covered under the scheme. Earlier the complainant filed a consumer complaint No.CC/148/14 before this Forum and the same was withdrawn by the complainant and the complainant was given liberty to again approach this forum on the same cause of action. Thereafter the complainant filed the claim by submitting relevant documents but the claim of the complainant was not passed. The complainant also served legal notice to the OPs but in vain.  The act and conduct of the OPs shows clear cut deficiency in service and negligence on their part. Hence this complaint for giving directions to the OPs to pay an amount of Rs.40,000/- as medical expenses and further to pay Rs.50,000/- as compensation for mental agony and physical harassment suffered by the complainant.

3.                   The complaint is contested by the OPs and OPs No. 1 and 3 filed joint written reply, in which they raised certain preliminary objections, inter alia, that the present complaint is not maintainable in the present form and the complainant has suppressed the true and material facts from this Forum. As regards to the facts of the complaint they stated that OP No.1 issued Group Mediclaim Policy in favour of Bhati Ghanhiya Trust. The policy of insurance/agreement bearing BGSSS card No. MD15-BGSSS-0214449, CCN MD10039977 was executed under the said scheme, covering the members and employees and their family members of the eligible cooperative societies covering the risk of treatment of medical diseases requiring minimum 24 hours hospitalization up to an expenditure of Rs.1,50,000/- per year per family on floaters basis subject to the terms and conditions of the scheme as detailed in the Guide Book issued by MD India Health Care Services(TPA) Pvt. Ltd., through the network hospital/nursing homes listed in the Guide book. It is further stated that after thorough investigation, the claim of the complainant was repudiated by OPs No. 1 and 3 as the same does not cover the terms and conditions of policy of insurance issued by OP No.1.  After considering the claim of the complainant under the terms and condition of the policy, it was found that the claim is not payable as the claim documents were received late. The complainant was discharged on 13.06.2014 and thereafter she submitted the claim file to TPA office on 25.04.2015 i.e. after 316 days from the date of discharge from the hospital. As per the terms and conditions of the policy, the claim is not payable if the claim documents are received after 60 days from the date of discharge of the treated patient. Moreover, the complainant took treatment from Private Hospital namely; Sohal Hospital, Sirhind, District Fatehgarh Sahib, which is not a Government Hospital. Therefore, the claim of the complainant was rightly repudiated by the OPs. Hence, there is no deficiency in service on their part. After denying the other averments made in the complaint, they prayed for dismissal of the complaint.

4.                   In reply to the complaint, OP No.2 stated that the Government gave instructions to it through DRCS, Fatehgarh Sahib to make the members under the Bhai Ghanhiya Sehat Sewa Scheme and to suggest the members to the society regarding the said scheme. Accordingly, the society suggested the said scheme to its members and the complainant was made member of the said scheme through it.  The complainant deposited the premium and it sent the same to Bhai Ghanhiya Sehat Sewa Trust Chandigarh through demand draft.  The matter is between complainant and OPs No.1 & 3 and OP No.2 has no fault and it is not liable to pay any claim or compensation to the complainant in any manner. After denying the other averment made in the complaint, OP No.2 prayed for dismissal of the complaint qua it.

5.                   In order to prove the case the complainant tendered in evidence his affidavit Ex. C-1, legal notices dated 16.06.2015 Ex. C-2 & C-3, postal receipts Ex. C-4- to C-7, copy of previous complaint filed in this Forum Ex. C-8,  copy of affidavit Ex. C-9, copy of order dated 08.04.2015 Ex. C-10, copy of Identity card Ex. C-11, copy of guide book Ex. C-12, treatment record Ex. C-13 to C-28 and closed the evidence. In rebuttal OPs No. 1 & 3 tendered in evidence affidavit of Sh. Harmel Singh, Assitant Manager, Ex. OP3/1, along with true copies of documents, i.e. letter dated 27.08.2015 Ex. OP3/2, letter dated 22.04.2015 Ex. OP3/4, card Ex. OP3/5, discharge card reports Ex. OP3/6, certificate Ex. OP3/7, the OPD slips are Ex. OP3/7A and OP3/8, microscopic examination Ex. OP3/9, medical slips Ex. OP3/10 to OP3/14, USG P/o Ex. OP3/15, HIV report Ex. OP3/16, lab reports Ex. OP3/17 and Ex. OP3/18, receipts are Ex. OP3/19 to OP3/24, diagnosis slip Ex. OP3/25, guide book Ex. OP3/26, order passed by this Forum Mark-A and closed the evidence.

6.                   The ld. counsel for the complainant has submitted that the main controversy involved in the present case is, that OP no.1 & 2 had repudiated the claim of the claimant vide letter dated 27/08/2015 by stating “We wish to submit that Non-Cashless Claim file of said case was rejected because: 1) Claim documents received after 60 days of date of discharge of the treated patient. From DOA – 13.06.2014 to 13.06.2014 and submitted claim file to TPA office on date 25.04.2015 ( Which is after lapse of 316 days). Accordingly to policy terms & conditions claim documents received after 60 days of date of discharge of the treated patient is not payable. Hence, claim is not payable under the scheme; 2) Patient took treatment for Hysterectomy, hysterectomy is not payable from private hospital, according to policy terms & conditions hysterectomy is only payable from government hospital. Hence Claim is not payable under the scheme ”,in an arbitrary manner. The ld. counsel pleaded that as per the booklet i.e Ex.C-12, Sohal Hospital is on the list of network Hospitals and keeping in view the bills submitted by the complainant, OP No.1 & 3 were bound to reimburse the claim of the complainant. The ld. counsel also pleaded that it is proved from the medical treatment documents i.e Ex.C-13 to Ex.C-28 placed on record that complainant had taken treatment from Sohal Hospital and Rajindra Hospital, Patiala. He further pleaded that Sohal Hospital had also forwarded the claim case of the complainant to the OPs. The ld. counsel also argued that it is well established from the act and conduct of the OPs that they have committed deficiency in service and complainant deserves to be compensated for the same.

7.                   On the other hand, the ld. counsel for  OP No. 1 & 3 has submitted that the cashless claim of the complainant was rightly repudiated vide letter dated 27/08/2015 i.e Ex.OP3/2, keeping in view the terms and conditions mentioned in the guidebook i.e Ex.OP3/4. He stated that as per the miscellaneous clause mentioned in the guidebook at Sr.No.2, that “no claim from the beneficiary shall be entertained for processing and settlement by TPA, if received after 45 days from the date of discharge from the Government Hospital”. He further submitted that in the case of the complainant the claim was received after 60 days from the date of discharge and claim file was submitted to the TPA, office after a period of 316 days i.e on 25/04/2015. The ld. counsel also stated that as per the clause 1.9.11 treatment taken in non network hospitals except in Government Hospitals are only covered. He pleaded that the complainant has failed to place on record any material evidence to establish that Sohal Hospital had forwarded the claim of the complainant on her behalf. The ld.counsel argued that complainant is not entitled to reimbursement as she got her self treated for Hysteretomy from private hospital, as per clause 1.9.3 Hysteretomy treatment is only permissible at Government Hospital.

8.                   On the other hand, the ld. counsel for OP No.2 submitted that the OP society suggested the said scheme to its members and the complainant was made member of the said scheme through it. He pleaded that OP No.2 has no involvement in decisions made by OP No.1 & 3. The ld. counsel further pleaded that the present complaint be dismissed qua OP no.2, as no deficiency in service had been  committed by the OP.

9.                    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, we find force in the contentions of the ld. counsel for OPs No.1 & 3. In our opinion OPs No.1 & 3 repudiated the cashless claim of the complainant, keeping in view the terms and conditions of the guidebook i.e Ex.OP3/4. Firstly, as per the miscellaneous clause of guidebook at Sr.No.2, “No claim from the beneficiary shall be entertained for processing and settlement by TPA, if received after 45 days from the date of discharge from the Government Hospital”. Whereas in case of complainant; claim was filed after 60 days from the date of discharge and claim file was submitted to the TPA, office after a period of 316 days i.e on 25/04/2015. In our opinion, complainant has miserably failed to give reasonable explanation with regard to the delay. Secondly, it is evident from the medical treatment record i.e Ex.C-13 to Ex.C-28 that the complainant had got treatment for Hysteretomy from Sohal Hospital. As per clause 1.9.3 “Hysteretomy shall be permissible in Govt. Hospital only at Govt.rates.”  In our opinion the complainant has failed to prove her case from the evidence produced on record. With regard to OP No.2,we are of the opinion that OP No.2 does not have any kind of involvement with regard to decision making of the claim. Thirdly, the complainant has failed to produce any evidence on record, that can establish that Sohal Hospital had timely forwarded her claim to the OPs No.1 & 3.

10.                 Accordingly in view of our aforesaid discussion, we find that the OPs had not committed any deficiency in service by repudiating the claim of the complainant, the same had be rejected in view of the terms and conditions. Hence the present compliant is hereby dismissed being devoid of any merit.  

11.                 The arguments on the complaint were heard on 08.07.2016 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:11.07.2016

(A.P.S.Rajput)                          President

 

(Veena Chahal)                        Member

 

      (A.B.Aggarwal)                       Member