Punjab

Fatehgarh Sahib

CC/42/2015

Pargat Singh - Complainant(s)

Versus

MD India health care service - Opp.Party(s)

Sh S.S Marwa

13 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

Consumer Complaint  No. 42 of 2015

                                           Date of institution : 17.04.2015                                                 Date of decision    : 13.05.2016

Pargat Singh aged about 34 years son of Dilbag Singh resident of village Marwa, Tehsil Bassi Pathana, District Fatehgarh Sahib.

……..Complainant

Versus

1. MD India Health Care Services (T.P.A.) Private Ltd. Maxpro Info Park, D-38, Phase-1, Industrial Area Mohali through its authorized signatory.
2. ICICI Lombard General Insurance Company, having its Branch Office at 3^rd Floor, Kunal Tower, Mall Road, Ludhiana, Punjab through its concerned signatory.
3. Sandhu Hospital, Chandigarh Bye Pass Road, Shamsher Nagar, Sirhind, Tehsil and District Fatehgarh Sahib through its Managing Director.
4. Assistant Registrar, Co-operative Society, Bassi Pathana, Tehsil Bassi Pathana, Tehsil Bassi Pathana, District Fatehgarh Sahib.

…..Opposite Parties

Complaint Under Section 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. counsel for the complainant.                          Pt. Narinder Kumar, Adv.Cl. for OPs No.1 & 2.                                         None for OPs No.3 & 4.

 ORDER

 

By Ajit Pal Singh Rajput, President

                      Complainant, Pargat Singh aged about 34 years son of Dilbag Singh resident of village Marwa, Tehsil Bassi Pathana, District Fatehgarh Sahib, has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under the Consumer Protection Act. The brief facts of the complaint are as under:

2.                   The complainant is member of Co-operative Society and the said society offered Insurance Scheme to its members through MD India Healthcare Service under Bhai Ghanhiya Sehat Sewa Scheme. As per said scheme there is a provision that member alongwith his whole family members are insured and the whole family can take the benefits of said insurance Scheme. Accordingly, the complainant got insured himself and his whole family with OP No.2. It is further stated that the wife of complainant; namely, Sandeep Kaur, was pregnant and got examined herself from Sandhu Hospital(one of the listed hospitals in the guide book). She was admitted therein on 16.09.2013 and operated upon for the delivery of baby and relieved from hospital on 20.09.2013. The total amount of Rs.80,000/- was incurred on her treatment in the said hospital. It is further stated that doctor of OP No.3 conducted cesarean delivery of his wife just to get huge amount from him and there is no need to conduct cesarean delivery. Therefore, there is deficiency in service on the part of OP No.3. It is further stated that during the treatment of his wife, 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.1, but neither any claim amount nor any response was given by the OPs. The complainant personally approached OPs No.1 & 2 and requested them to pay the said medical expenses as per the terms and condition of the policy but they remained putting off the matter on one pretext or the other and remained harassing the complainant by calling him in the office time and again. The complainant also served a legal notice through his counsel but OPs No. 1 and 2 did not pay claim amount. The act and conduct shows clear cut deficiency and negligence in service on the part of OPs. Hence, this complaint for giving directions to the OPs to pay Rs.80,000/- as claim amount and Rs.50,000/- as damages including punitive damages to the complainant. 

3.                   The complaint is contested by OPs and OP No.1 and 2, filed joint written reply in which they raised certain preliminary objections, inter alia, that the present complaint is not maintainable; the present complaint is false, frivolous, vague and vexatious in nature and is liable to be dismissed under Section 26 of the Consumer Protection Act and the complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the OPs. As regards to the facts of the complaint they stated that under the scheme every insured person was covered upto an amount of Rs.1,50,000/- on floater basis subject to terms and conditions of the policy as mentioned in the guidebook, which was duly supplied to the insured and was placed on record by the complainant. It is further stated that after passing of one month on 23.10.2013 OP No.1 received a claim form along with bills from the complainant for claiming the amount of Rs.28,390/-. After pursing the bills and treatment record, they sanctioned an amount of Rs.9500/- as per terms and conditions of the policy and the said amount was immediately send to the complainant, vide cheque No.000716 dated 21.11.2013. The claim of the complainant was not payable as per terms and conditions of the policy as no intimation regarding the treatment was given to OP No.2 and the reimbursement amount is allowed only for the treatment taken in Government Hospital. As per the documents, the complainant paid Rs.21,400/- to the Hospital and Rs.6990/- were spent on medicines. To get undue benefits the complainant placed on record advance payment receipt No.297 dated 16.09.2013 of Rs.5,000/- and receipt No.304 dated 20.09.2013 of Rs.16,000/- in order to show the double payment. 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.3 stated that there were some problems in pregnancy of Sandeep Kaur, hence, she was operated. The patient was suffering from Gestational Diabetes, Pregnancy induced Hypertension with Rh Neg Pregnancy.  For this Sandeep Kaur was admitted for control of the GDM and PIH on 03.09.2013 to 05.09.2013 in Sandhu Hospital. As Sandeep Kaur having complicated pregnancy because of Gestational Diabetes with PIH with Rh-Neg Pregnancy, she was admitted on 16.09.2013. The foetus developed foetal distress for which cesarean  section was conducted on 16.09.2013. It is further stated that meconium stained liquor was noticed by the Pediatrician attending the baby on delivery for which IV Fluids, Oxygen inhalation and IV antibiotics were given to the baby on delivery. Thus, cesarean section was necessitated to protect the lives of both the mother and child.  It is further stated that as per guidance of OP No.1 the patient or his/her family member must disclose regarding his/her membership within 24 hours to the concerned Hospital/Doctor after admission and  thereafter the concerned Hospital/Doctor will intimate OP No.1 and then treatment/operation will be conducted, but neither the complainant nor his wife informed OP No.3 regarding their membership. The complainant spent total expenditure of Rs.28,390/- on the treatment of his wife. There is no deficiency in service on the part of OP No.3. After denying the other averment made in the complaint, OP No.3 prayed for dismissal of the complaint.

5.                   In reply to the complaint OP No.4 stated that it has not committed any fraud with the complainant nor obtained any amount from him.  If the complainant has any grouse or grudge, the same is because of nonpayment of medical expenses to him by the concerned authorities and it has nothing to do with the said matter. There is no deficiency and negligence in service on the part of OP No.4. After denying the other averments made in the complaint, it prayed for dismissal of the complaint qua it. 

6.                   In order to prove the case the complainant tendered in evidence copy of identity card of complainant Ex. C-1, copy of identity card of Sandeep Kaur Ex. C-2, copy of guidebook Ex. C-3, copies of bills Ex. C-4 to Ex. C-7, copy of receipts Ex. C-8 to Ex. C-11, copy of notice Ex. C-12, copy of postal receipt Ex. C-13, his affidavit Ex. C-14 and closed the evidence. In rebuttal OPs No. 1 and 2 tendered in evidence affidavit of Meenu Sharma, Ex. OP1/1, payment detail Ex. OP1/2, copy of policy Ex. OP1/3, term and conditions Ex. OP1/4 and closed the evidence.  OP No.3 tendered in evidence affidavit of Dr. Manpreet Singh Ex. OP3/1 along with true copies of documents Ex. OP3/2 to OP3/8 and closed the evidence. OP No.4 tendered in evidence affidavit of Satnam Singh Ex. OP4/1, true copy of resolution Ex. OP4/2 and closed the evidence.

7.                   The Ld.counsel for the complainant has stated that OP No.3 has decided the claim of the complainant in an arbitrary manner. He submitted that due to cesarean delivery of the wife of complainant, the total expenses amounting to Rs.80,000/- was paid by the complainant to OP No.3 for Hospitalization, Operation and Medicines. The ld. counsel also submitted that OP No.2 had alleged that it, reimbursed an amount of Rs.9500/- but the complainant never received the cheque and nor OP No.2 has placed on record any document to establish that the said cheque was sent or the payment of Rs.9,500/- was received by the complainant. The ld. counsel pleaded that the clause 1.9.7 of terms and conditions i.e Ex.OP1/4 relied upon by OP No.2 is with regard to normal delivery and in the case of the complainant, it was a cesarean delivery. He also pleaded that as per the booklet OP No.3 is on the list of network Hospitals and keeping in view the bills submitted by the complainant, OP No.2 was bound to reimburse an amount of Rs.80,000/-. The ld. counsel further pleaded that OP No.3 had intentionally conducted cesarean, as at the time of admission in Hospital the Doctor had informed the complainant, that it was a case of normal delivery and thereafter  conducted cesarean delivery in order to raise the Hospital expenses. He argued that OP No.3 has sworn an affidavit i.e Ex.OP-3/1 and stated in  para no.2, that OP No.3 had received a sum of Rs.21,000/-,Rs.5000/- on 16.09.2013 and Rs.16000/- on 20.09.2013 and also stated that complainant spent total expenditure of Rs.28,390/- i.e medicines worth Rs.7390/- + Rs.21000/-. The ld. counsel also argued that it is well established from the act and conduct of the OPs that they have committed deficiency of service and complainant deserves to be compensated for the same.

8.                   On the other hand, the ld. counsel for OPs No.1 & 2 has submitted that under the scheme every insured person was covered upto an amount of Rs.1,50,000/- on floater basis subject to terms and conditions of the policy i.e Ex.OP-1/4. The ld. counsel further submitted that as per clause 1.9.7 of the terms and conditions, the complainant was covered to maximum sum of Rs.10,000/- per Maternity and OP No.2, reimbursed an amount of Rs.9,500/- vide cheque dated 21.11.2013. The ld.counsel pleaded that it has been admitted by the complainant and OP No.3 that the complainant spent total amount of Rs.28,390/- on the treatment of his wife for cesarean delivery. He also pleaded that rest of the bills placed on the record are forged and fabricated ones, the complainant intended to commit fraud with the OPs and is now misleading this  Forum. The ld. counsel argued that reimbursement payment is made according to the fee and treatment taken from Government Hospital. He also argued that receipt dated 16.09.2013 amounting to Rs.5000/- Ex.C-9 and receipt dated 20.09.2013 amounting to Rs.16,000/- i.e Ex.C-10 are advance payment receipts and are placed on record, in order to double the payment. The ld. counsel made a submission that the present complaint be dismissed being case of fraud and non maintainable as a sum of Rs.9500/- had been paid towards the maternity claim of the complainant.

9.                   OP No.3 has stated that no deficiency in service has been committed by the OP. He submitted in his pleadings that cesarean operation was conducted keeping in view the medical condition of the mother and the foetus and the complainant was charged a sum of Rs.28,390/- for the treatment i.e Hospitalization, Operation and Medicines of his wife for cesarean delivery. OP No.3 has stated that it has no dispute with the complainant. It has been pleaded that the present complainant is filed because of non- payment of medical expenses to complainant by the concerned OPs and it has nothing to do with the said matter. 

10.                 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 are of the opinion, that it is well established from material placed on record i.e Ex.C-1 to C-12 and the affidavit sworn by Dr.Manpreet Singh i.e Ex.OP-3/1 alongwith the material documents i.e Ex.OP-3/2 to Ex.OP-3/8, that the complainant had taken the treatment from OP No.3,who is on the list of network Hospitals at Sr.No.52 as mentioned in the Guidebook i.e Ex.OP-1/4. It is also established from bills and receipts i.e Ex.C-4 to Ex.C-10 and  from the affidavit sworn by Dr.Manpreet Singh i.e Ex.OP-3/1, whereby it has been stated in para no.2 “that complainant spent total expenditure of Rs.28,390/- i.e medicines worth Rs.7390/- + Rs.21000/-". It is also established from the copy of claim submission check list i.e Ex.OP-3/6 that OP No.3 forwarded the claim form to OP No.1. In our opinion complainant paid a sum of Rs.56,780 for treatment as stated by OP No.3. The ld. counsel also made a statement dated 18.03.2016 before this Forum that the complainant never received any payment from OP No.2.

11.                 OP No.2 filed an affidavit of Meenu Sharma, authorized signatory of OP No.2 and has stated in para No.1 that as per clause 1.9.7 nothing is due against the complainant. The same is reproduced; “Maternity is to be covered upto the maximum limit of Rs.10,000/- per pregnancy per year not exceeding Rs.10,000/- per beneficiary/family on floater basis per year. However the overall upper ceiling of Rs.1.5 lacs would remain applicable”. On perusal of the guidebook, we have observed that the clauses, starts from clause 1.1, on page no.2 and ends on clause 1.9.6 at page no.8 of the guidebook. There is no clause 1.9.7 mentioned in the guidebook or the policy i.e Ex.OP-1/3 nor OP No.2 has placed on record any such terms and conditions. OPs No.1 & 2 have failed to place on record any claim documents whereby the complainant had claimed a sum of Rs.28,390/- as alleged by OP No.2 in its pleadings. OP No.2 has also failed to place on record any document or postal receipt proving that the alleged cheque amounting to Rs.9500/- was sent to the complainant. It is no where mentioned in any documents placed on record that the reimbursement shall be as per Government Hospital charges.

12                  We find it pertinent to reproduce the clause (vi) & (vii) of the policy i.e Ex.OP-1/3; (vi) “The financial extent of the coverate under the Policy shall be an amount of Rupees 1.5 lacs per family on Floater basis per year, subject to the terms and conditions of the scheme. The insurance coverate of rupees 1.5 lacs can be utilized by any of the Beneficiaries individually or collectively along with other Beneficiaries from his family”,

Clause (vii)    “Only cash less hospitalization benefit will be allowed in private hospitals and reimbursement claims from Govt. Hospital only”. As per the guidebook i.e Ex.OP-1/4, under the heading Reimbursement of claims of hospitalization in Govt. Hospitals, on page No.21 of the guidebook, it has been mentioned that if the insurer takes treatment from any Government Hospital, the insurer shall be reimbursed on submission of the bills. On page 17 of the guidebook, under the heading Cashless service it has been mentioned; “Members will be provided a cashless facility in the hospitals/nursing home, as per the list attached. This would mean that a patient can avail of treatment in any one of the Network Hospitals without actually having to pay the bills. In case a patient prefers a government hospital, the expenditure shall be reimbursed, provided the beneficiary submit the claim to TPA within 45 days of discharge”.

13.                 Accordingly, in view of our aforesaid discussion, we find that OPs No.1 and 2 had acted negligently, while settling the claim of the complainant, hence committed deficiency in service. We direct OPs No.1 and 2 to reimburse/pay a sum of Rs.28,390/- for treatment taken from OP No.3. The complainant is also held entitled for compensation on account of mental agony amounting to Rs.10,000/- alongwith litigation cost of Rs. 5000/-. OP No.1 & 2 are directed to comply with the order of this Forum within 45 days from the date of receipt of copy of this Order. In case OPs No. 1 & 2 fails to comply with the same, within the stipulated period, they shall be liable to pay 9 % interest per annum on the aforesaid awarded amount from the date of institution of the present complaint i.e. 17.04.2015 till its realization. With regard to OPs No.3 and 4, we are of the opinion that OP No.3 acted in the interest of the child and mother, keeping in view the medical conditions and OP No.4 had no concern with regard to the reimbursement of the claim by OPs No.1 & 2. Therefore we find that OPs No.3 & 4 have not committed any deficiency in service. The present complaint stands  accepted.

14.                 The arguments on the complaint were heard on 06.05.2016 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:13.05.2016

(A.P.S.Rajput)                          President

 

(Veena Chahal)                        Member

 

      (A.B.Aggarwal)                       Member