BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.324 of 2015

Date of Instt. 04.08.2015

Date of Decision : 02.03.2016

Jasbir Kaur Anand wife of Davinder Pal Singh Anand R/o 63, Vasant Avenue, Jalandhar.

..........Complainant Versus

1. MD India Health Care Services (TPA) Private Limited, Max Pro Info Park, D-38, Industrial Area, Phase-I, Mohali.

2. Bhai Ghanayya Sehat Sewa, D-38, Industrial Areal Phase-I, Mohali, Punjab.

3. United India Insurance, Lajpat Nagar Market, Jalandhar.

4. Deputy Registrar, Cooperative Societies, Jalandhar.

5. Imperial Urban Co-operative Bank, Lajpat Nagar, Jalandhar.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: Sh.Ashwani Kumar Mehta (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Sandeep Singh Adv., counsel for complainant.

Sh.AK Arora Adv., counsel for OP No.3.

Opposite parties No.4 & 5 in person.

Opposite parties No.1 & 2 exparte.

Order

Ashwani Kumar Mehta (President)

1. Complainant Jasbir Kaur have filed the present complaint against MD India Health Care Services (TPA) Private Limited etc opposite parties (OP) under section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as 'Act') on the allegations of deficiency in service, unfair trade practice and negligence with a further prayer to direct the OPs to finalize and reimburse the full claim of the complainant and to pay amount of Rs.43381/- with interest alongwith Rs.1 Lac as compensation on account of mental tension, harassment etc and Rs.11,000/- as litigation expenses.

2. The case of the complainant in brief is that her son Ishminder Singh Anand is shareholder in the Imperial Urban Co-operative Bank, Lajpat Nagar, Jalandhar and a scheme named Bhai Ghanhya Sehat Sewa Scheme was floated vide which shareholder in cooperative society registered under Punjab Co-operative Societies Act, 1961 and shareholders of Imperial Urban Co-operative Bank alongwith their family members were entitled to get treatment from any private hospital or nursing home approved by Bhai Ghanya Sehat Sewa and also from all government hospitals for any medial or surgical treatment where patient remained in the hospital for at least 24 hours alongwith other terms and conditions of the scheme and as such complainant being mother of Ishminder Singh Anand was entitled to be member of the said scheme under the policy and a identity card was also issued to the complainant; that complainant fell ill on 20.1.2015 and had breathing problem and she was immediately taken to Punjab Institute of Medical Sciences, Jalandhar where the doctor advised her to take to some cardiac centre and then complainant was taken to Shri Ram Cardiac Centre, Jalandhar for treatment and as the family member of the complainant were not carrying medical card with them, so they were asked to deposit the amount in order to start the treatment; that complainant was discharged from hospital on 26.1.2015 and after discharge from the hospital, claim form alongwith medical bills, discharge report and other relevant documents were submitted to the OPs on 30.1.2015 by Ishminder Singh Anand through Imperial Urban Co-operative Bank, Jalandhar and the total bill of the hospital was Rs.63,661/-; that the claim was further sent to OPs on 10.2.2015 for final settlement and complainant was told that the claim would be finalized within period of 10 to 15 days but the claim was not settled as promised and then repeated phone calls were made to the OP on different occasion and every time, it was told that the claim is under process and would be settled shortly; that even membership card of the complainant was submitted to the OPs on their demand but even then the claim was not settled; that on 24.3.2015, an amount of Rs.20,280/- was credited in the bank account of the complainant through online payment and when complainant enquired with regard to remaining amount of the claim then she was told that the company has passed the claim only for Rs20,280/- and when complainant enquired about the reason for partial payment of claim then she was bluntly told that they do not know the reason and nothing more can be done in the matter; that even thereafter, complainant approached the OPs many times for reimbursement of remaining amount spent by her but with no effect though at the time of floating of the policy, the OPs claimed that in case of medical need of the member, he would be given treatment free of cost under the terms and conditions of the policy from approved hospitals and if any amount is spent then that would be reimbursed to the concerned member but complainant was not reimbursed the full cost of treatment inspite of repeated request and this act and conduct of the OPs amounts to deficiency in service and unfair trade practice and is unethical and negligence on the part of the OPs which caused harassment, mental tension and agony to the complainant and deficiency in service on the part of the OPs. Hence, present complaint was filed.

3. After formal admission of the complaint, notice was issued to the OPs and OPs No.1 & 2 were duly served through registered letters but none appeared on their behalf in the Forum and vide detailed order dated 15.9.2015, OPs No.1 & 2 were proceeded against exparte.

4. OP No.3 appeared through counsel and filed written statement contesting the complaint on the preliminary objections that there was no deficiency in service and unfair trade practice on the part of the answering OP and the claim of the complainant has already been settled as per terms and conditions of the insurance policy and insurance policy was issued by answering OP in the name of Bhai Ghanaya Trust based on agreement between answering OP and Bhai Ghanaya Trust and the claim are settled and paid on the basis of package rates and claim in the case in hand has also been settled as per Bhai Ghanaya schedule of rates prescribed under the said scheme and amount of Rs.20,280/- has been paid to the complainant which was due and payable under the insurance policy and bifurcation of the amount under different rates as per settlement was also attached with the reply. As such, the complaint is without any cause of action and is liable to be dismissed with special cost. On merit, the issuance of the insurance policy in dispute under the said scheme and treatment taken by the complainant under the said policy was not denied being matter of record. It was also admitted that complainant filed claim with OP and same was processed and amount of Rs.20,280/- was credited to the account of the complainant. All other allegations mentioned in the complaint were denied with a prayer to dismiss the complaint with cost.

5. OP No.4 appeared through authorized official and filed written statement contesting the complaint on the preliminary objections that there is no privity of contract between the answering OP with the complainant or her son Ishminder Singh Anand and complaint has been filed against the answering OP without any cause of action and the complaint is also bad for mis-joinder of OP No.4 as any claim under Bhai Ghanaya Sehat Sewa Scheme is to be settled by OPs No.1 to 3 and amount due under the claim is to be paid by OP No.3 and OP No.4 have no role in the settlement of any claim nor amount found due under the policy is to be paid by OP No.4. On merit, it was not denied if Ishminder Singh Anand was shareholder of OP No.5 and floating of the scheme was also admitted. It was also not denied if complainant lodged any claim with OP No.5 which was sent to OPs No.1 to 3. It was asserted that OPs No.1 to 3 were to verify the claim under the policy and to make payment and answering OP have no concern with the claim. All other allegations mentioned in the complaint were also denied for want of knowledge or being not concern with the answering OP and prayer was made for dismissal of the complaint against answering OP.

6. OP No.5 also appeared through authorized representative and filed written statement contesting the complaint. It was admitted that Ishminder Singh Anand is shareholder of OP No.5 bank and scheme namely Bhai Ghanaya Sehat Sewa Scheme was floated and Ishminder Singh was main member and his dependents are also member of the scheme and insurance premium was paid by him. It was admitted that complainant is mother of Ishminder Singh Anand and was dependent member of the policy holder and her admission in the hospital being ill was also not denied. It was also admitted that complainant filed claim alongwith medical bills which was sent by answering OP to D.R.Office, Jalandhar for reimbursement. It was asserted that the answering bank is not bound to reimburse the claim as the bank acted only as a agent and reimbursement is to be made by the company itself as per their rules and answering bank have no role in the reimbursement of the claim. All the other allegations of the complaint were denied with prayer to dismiss the complaint.

7. Both the parties were given sufficient opportunities to lead evidence in order to prove their respective cases.

8. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C10 and closed evidence.

9. On the other hand, learned counsel for the OP No.3 has tendered affidavit Ex.OP3/A alongwith copies of documents Ex.OP3/1 to Ex.OP3/3 and closed evidence. Authorized official of OP NO.4 tendered affidavit Ex.OP4/A alongwith copy of document Ex.OP4/1 and closed evidence. Authorized representative of OP No.5 tendered affidavit Ex.OP5/A and closed evidence.

10. We have carefully gone through the record and also heard the learned counsels for the parties.

11. The learned counsel for the complainant contended that Ishminder Singh Anand son of the complainant was member of the insurance scheme floated by Bhai Ghanaya Sehat Sewa Scheme and being member of the said scheme was entitled to reimbursement of medical treatment bill. He further contended that complainant fell ill and admitted in the hospital and took treatment and spent an amount of Rs.63,661/- but the OPs paid only Rs.20,280/- out of the total medical bill and remaining amount of Rs.43,381/- was not paid inspite of repeated request and phone calls. He further contended that complainant was not sent even the policy nor the terms and conditions of the policy and as such the terms and conditions of the policy are not applicable to the complainant. It was also contended that complainant was not told about the rates fixed between the society and insurer nor any document containing the rates fixed between the insurer and society were conveyed to the complainant and as such those rates are not applicable to the complainant. He further contended that at the time of taking insurance policy, the complainant was told that the policyholder would be entitled for treatment free of cost and if any amount is spent by policyholder then that would be reimbursed fully but complainant was reimbursed only partial amount of Rs.20,280/- out of the total medical claim of Rs.63,661/- which amounts to deficiency in service and unfair trade practice and this conduct of the OPs have caused harassment and mental agony to the complainant and as such complainant is entitled to remaining amount of the claim alongwith compensation and litigation expenses as mentioned in the complaint.

12. The learned counsel for the OP No.3 contended that complainant is not insured under the policy and the contract of insurance took place only between OP No.3 and Bhai Ghanaya Sehat Sewa Scheme. He further contended that complainant is entitled to reimbursement of treatment only under the Bhai Ghanaya Sehat Sewa Scheme and terms and conditions mentioned in the policy and agreed between Bhai Ghanaya Sehat Sewa Society and insurance company. He further contended that claim of the complainant was processed as per terms and conditions of the insurance policy and as per terms and conditions and rate of treatment fixed under the insurance policy and correct amount was paid to the complainant out of the claim amount which was admissible under the policy and as such complaint is false and is liable to be dismissed.

13. The authorized representative of OPs NO.4 and 5 contended that they are simply performa parties in the complaint as they have no role in the settlement of the medical claim under the policy because the claim is to be settled and paid by OP No.3 insurance company as the contract of insurance took place between insurance company and Bhai Ghanaya Sehat Sewa Society and as such complaint against OPs No.4 and 5 is also liable to be dismissed.

14. After going through the record of the case, evidence and documents produced by the parties on the file, this Forum does not find any force in the contention of learned counsel for the complainant. It is admitted fact in this case that Ishminder Singh Anand son of the complainant was shareholder in the OP No.5 bank which is a co-operative society under the Punjab Co-operative Society Act and by virtue of being shareholder of the society, he became member of Bhai Ghanaya Sehat Sewa Society. It is also admitted fact in this case that complainant fell ill and got treatment and thereafter she filed claim to OP No.5 bank which was sent to OP No.4 Deputy Registrar Office and in turn was sent to OPs No.1 & 3 insurance company. It is also admitted fact in this case that OP No.3 insurance company scrutinized claim documents and found the complainant entitled to reimbursement of Rs.20280/- out of the claim filed by the complainant which has been challenged by the complainant in the present complaint.

15. The contention of the complainant is that she filed claim for Rs.63,661/- but the OP No.3 insurance company paid Rs.20,280/- and as such she is entitled for remaining claim amount alongwith compensation, damages and interest. Whereas contention of OP No.3 insurance company is that the claim has been processed by the insurance company through TPA OP No.1 in accordance with terms and conditions of the insurance policy and Bhai Ghanaya Sehat Sewa Scheme and the rate approved by it. Definitely, complainant is not insured directly by OP No.3 insurance company and OP No.3 insurance company insured Bhai Ghanaya Sehat Sewa Society and complainant is covered under the said insurance policy being member of said society. Otherwise also, complainant have stated in para 1 of the complaint that a member of the society is to get treatment from the hospital mentioned in the scheme and the treatment is also governed by other terms and conditions of the scheme. OP have proved the terms and conditions of the scheme mentioned in the document Ex.C10 which has also been proved by OP No.3 as Ex.OP3/2. Ex.OP3/2 is insurance policy issued by OP No.3 in the name of Bhai Ghanaya Trust and it is clearly mentioned in the insurance policy that the policy is governed as per agreement took place between the trust with the company and this policy is governed by the agreement took place between the parties. The terms and conditions of the agreement are mentioned in guide book which is proved by the complainant as Ex.C10. The rate list is also proved by OP as Ex.OP3/3. The contention of the OP No.3 is that the claim of the complainant was processed and finalized as per rate list Ex.OP3/3. The learned counsel for the complainant only contended that this rate list was not conveyed to the complainant nor the terms and conditions of the scheme were conveyed to the complainant by the insurance company and as such complainant is not governed by this rate list or terms and conditions. However, there is no force in the contention of the complainant as OP No.3 insurance company was not required to serve the rate list and other terms and conditions of the scheme to the complainant as the insurance contract is only between Bhai Ghanaya Trust and insurance company. Moreover, these terms and conditions and other documents seems to have been in the notice of shareholder because the complainant have mentioned in the complaint that the treatment is to be taken from the hospital mentioned in the list and as per other terms and conditions of the scheme which means that terms and conditions of the scheme were brought in the notice of the shareholder. The learned counsel for the complainant could not point out that the claim of the complainant was not processed in accordance with rate list Ex.OP3/3. Otherwise, the learned counsel for the OP No.3 contended that the claim of the complainant was settled strictly as per rate list Ex.OP3/3 and its detail have been mentioned in the finalization letter Ex.OP3/1. The learned counsel for the complainant could not rebut this argument of the OP No.3. Otherwise, the claim of the complainant has been processed and finalized as per terms and conditions of the policy and rate list proved on the file by OP No.3 and as such complainant could not prove any deficiency in service on the part of the OP and in this eventuality, complainant is not entitled to remaining amount of his claim except the amount already paid by OP No.3 insurance company and complainant is not entitled to any relied under complaint.

16. In the light of above discussion, the complaint fails and same is hereby dismissed. However, in the peculiar circumstances of the case, the parties are left to bear their own cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Ashwani Kumar Mehta

02.03.2016 Member Member President