Punjab

Ludhiana

CC/14/497

Gopaljee Prasad - Complainant(s)

Versus

MD India Health Care Services (TPA) Pvt.Ltd - Opp.Party(s)

26 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

                                                                 C.C.No: 497 of 16.07.2014

                                                                     Date of Decision: 26.02.2015

Gopaljee Prasad s/o Ram Ayodhya Prasad r/o House No.25, Gali No.4, Near Guru Nanak Nagar, 33ft Road, Mundian Kalan, Ludhiana now at 149, Sector-1, SFS Colony, near Agarwal Farm, Mansarovar, Jaipur, Rajasthan.

                                                                                          … Complainant

                                      Versus

1.MD India Health Care Services(TPA) Pvt. Ltd. Regd Office & H.O.Building A-2, 3^rd Floor, E Space, Vadgaon Sheri, Nagar Road, Pune-411014, through authorized signatory.

2. MD India Health Care Services(TPA) Pvt. Ltd. Cabin No.2, First Floor, Madhok Complex, Ferozepur Road, Ludhiana-141001 through authorized signatory.

3.United India Insurance Company Limited, Regd & Head Office 24, Whites Road, Chennai-600014 through authorized signatory.

4.United India Insurance Company Limited, D.O.XI, New Delhi-through authorized signatory.

                                                                             … Opposite parties

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986. 

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

                   Ms.Babita, Member.

                  

Present:       Sh.M.S.Sethi, Advocate for complainant.

                   Sh.D.R.Rampal, Advocate for Ops.

 

                        ORDER

 

(R.L.AHUJA, PRESIDENT)

 

1.       Present complaint under section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Gopaljee Prasad(herein-after in short to be referred as ‘Complainant’) against MD India Health Care Services(TPA) Pvt. Ltd and others(herein-after in short to be referred as ‘OPs’)- directing them to set-aside the repudiation letter dated 25.3.2013 and to pay the claimed amount of Rs.37,685/- alongwith interest @12% p.e. from the date of repudiation of the claim till realization besides Rs.25,000/- as compensation for causing mental agony and harassment and Rs.7500/- as legal expenses to the complainant.

2.                Brief facts of the complaint are that the complainant is member of Sail Group Medi Claim Scheme of United India Insurance Co.Ltd and under the said scheme, the OP3 and OP4 have authorized OP1 and OP2 to provide the cashless facility to the members of Sail Group(Steel Authority of India) & in this respect, the Ops provided the Health Card bearing MIN No.4715826 which was valid from 1/2012 to 12/2012 to the complainant to avail medical facilities in India at anywhere with authorized hospital during its life time. The complainant preferred its following medical bills against the treatment got from CMC Hospital, Ludhiana:-

Sr.No.         Treatment Period   Cashless amount denied                  Claim No.

1.       17.8.2012 to 7.9.2012             Rs.25,643.69P       CCN MD11374469

2.       12.9.2012 to 15.9.2012           Rs.6072/-               CCN MD11402557

3.       26.9.2012 to 27.9.2012           Rs.5970/-               CCN MD11414974

The complainant had submitted the mediclaim for the treatment period 17.8.2012 to 7.9.2012 and filed claim form dated 20.9.2012 and submitted the discharge certificate and medical expenses bills etc., for the remaining amount of Rs.25,643.69P. However, OP1 and OP2 had paid certain amounts directly to the hospital while refusing to pay the remaining amount without disclosing any cause/reason. The Ops, however, refused to provide complete cashless facilities against the treatment period from 17.8.2012 to 7.9.2012, 12.9.2012 to 15.9.2012 and 26.9.2012 to 27.9.2012. However, against the claim for the period 12.9.2012 to 15.9.2012, the Ops denied providing cashless facility vide its denial authorization letter dated 14.9.2012 sent to CMC Hospital, Ludhiana on the ground that the Cashless Hospitalization is denied as eligibility of claim under the policy cannot be ascertained. The complainant however, thereafter submitted the medi claim for the treatment period 12.9.2012 to 15.9.2012 and filed claim form dated 28.9.2012 and submitted the discharge certificate and medical expenses bills etc., for Rs.6072/-. The OP1 and OP2 however paid the certain amount directly to the hospital while refusing to pay the remaining amount. The complainant also submitted the medi claim for the treatment period 26.9.2012 to 27.9.2012 and filed claim form dated 29.9.2012 alongwith discharge certificate and medical expenses bills etc. for Rs.5950/-. The OP1 and OP2 paid certain amount directly to the hospital while refusing to pay the remaining amount of Rs.5970/- without disclosing any cause/reason. Op1 and OP2 vide email dated 25.3.2013, however, had given clarification against claim of RS.25,643/- that they are co-coordinating with their concerned team and they will update at the earliest but despite of various communication in writing by the complainant, there is still no response. In reply dated 25.3.2013, the OP1 and OP2 had repudiated the claim of Rs.6072/- against the clause 6.7 of the policy on the allegations that the treatment given to the patient does not support the need for hospitalization. In the reply dated 25.9.2013, the Op1 and OP2 had repudiated the claim of Rs.5970/- on the ground that the insured person had exhausted his sum insured for the year. Such act and conduct of Ops for repudiating the claim of the complainant is claimed to be deficiency in service on their part. Hence, this complaint.

3.                Upon notice of the complaint, OP3 and OP4 were duly served and appeared through their counsel Sh.D.R.Rampal, Advocate and filed their written reply, whereas, OP2 refused to receive the summon and as such, OP3 was proceeded against ex-parte vide order dated 5.9.2014 by this Forum, whereas, notice of the complaint was sent to OP1 through registered post on 24.09.2014, but the same was not received back and as such, after expiry of 30 days of period, Op1 was proceeded ex-parte vide order dt.27.10.2014 by this Forum. 

4.                Op3 and OP4 filed their written reply, in which, it has been submitted in the certain preliminary objections that the present complaint is not maintainable in the present form as the same is false and frivolous one. The complaint is bad for non-joinder and mis-joinder of necessary parties as the OP1 and OP2 are not the necessary parties. This Hon’ble Forum has got no jurisdiction to entertain and try the present complaint. The policy was issued by answering OP4, who has its Divisional office at New Delhi and claim file of the complainant was processed by OP1 at Pune and nothing was done by the answering Ops at Ludhiana. The complainant has not come to this Hon’ble Forum with clean hands and he has suppressed the material facts. The claim of the complainant was minutely scrutinized by the Op1 and payable amount was paid to the complainant. The complainant has failed to submit the required documents for settlement of amount of Rs.25,643/- as alleged by him and his claim to this amount was treated as ‘No Claim’. The claim of the complainant had been repudiated by the competent authority of the answering Ops and repudiation letter dated 12.3.2013 was duly posted to the complainant. The complainant is estopped by his act and conduct from filing the present complaint. Due services have been rendered by the answering Ops and there is no deficiency in service on the part of the answering Ops. On merits, it is submitted that the parties are governed by terms and conditions of the insurance policy. The amount is to be paid as per the terms and conditions of the insurance policy and manual/guidelines laid down by the answering OP3 the head office of the answering Ops for settling such type of claims. The claim was lodged by the complainant and the amount claimed at serial no.2 and 3 in the complaint are non-payable one as explained in email dated 4.11.2014 and complainant has failed to provide the relevant documents for the settlement of the alleged amount as mentioned at serial no.1 despite request letter dated 1.11.2012 and 21.11.2012 of OP1 and said claim was treated as ‘No Claim’, due to non supply of the required supporting documents. It is not denied being matter of record that the complainant lodged the claim for the period of 17.8.2012 to 7.9.2012 with OP1. However, it is submitted that the payable amount was worked out and paid to the complainant. The complainant was called upon vide request letters dated 1.11.2012 and 21.11.2012 by Op1 with regard to the additional claim of RS.25,643/- of complainant with the request to provide all the prescriptions for medical bills purchase in cash, explanatory certificates from treating physician stating reason of purchasing cash bills during hospitalization but complainant has failed to provide those documents and due to non-supply of the required documents, the claim pertaining to the alleged additional claim of Rs.25,643/- was treated as ‘No Claim’ and claim file was closed. The complainant cannot take advantage of his own wrong. The payable amount was paid with regard to the treatment of the complainant and this fact has also been mentioned by the complainant in the complaint itself. Further, it is submitted that the claim for the treatment of the period 12.9.2012 to 15.9.2012 is matter of record. The payable amount was paid. The claim of Rs.6072/- was not paid as treatment given to the complainant does not support the need for hospitalization and said claim is not admissible and was rightly repudiated as per the terms and conditions of the insurance policy. Further, it is submitted that the claim of Rs.5970/- was found not payable one and was repudiated on 12.3.2013 as balance sum insured had exhausted. Otherwise, similar pleas were taken as taken in the preliminary objections and at the end, denying any deficiency in service and all other allegations of the complaint levelled in the complaint being wrong and incorrect, answering Ops prayed for the dismissal of the complaint.

5.                After filing the written reply on behalf of OP3 and OP4, Sh.D.R.Rampal, Advocate had also filed an application for setting aside the ex-parte proceedings orders dated 5.9.2014 and 27.10.2014 against OP1 and OP2 which was allowed vide order dated 14.11.2014 and thereafter, on 5.12.2014, Sh.D.R.Rampal, Advocate had suffered statement that written statement on behalf of OP3 and OP4 be also considered as written statement on behalf of OP1 and OP2 as they had adopted the written reply filed by the written statement by OP3 and OP4.

6.                In order to prove the case of the complainant, learned counsel for the complainant has placed on record affidavit of complainant Ex.CA, in which, he has reiterated all the contents of the complaint. Further, learned counsel for the complainant has placed on record documents Ex.C1 to Ex.C20.

7.                On the other hand, in order to rebut the case of the complainant, learned counsel for the OPs tendered into evidence affidavit Ex.RA of Sh.Baljit Singh, Branch Manager of OP2, in which, he has reiterated all the contents of the written reply filed by the Ops and rebutted the case of the complainant. Further, learned counsel for the OPs has proved on record documents Ex.R1 to Ex.R9.

8.                We have heard the learned counsel for the learned counsel for the parties and have also gone through the documents on record very carefully.

9.                Perusal of the record reveals that it is an undisputed fact between the parties that the complainant is member of Sail Group Medi Claim Scheme of OP3 and OP4 and they authorized to OP1 and OP2 provide the cashless facility to the members of Sail Group and the complainant was provided the Health Card bearing MIN No.4715826 which was valid from 1/2012 to 12/2012 to the complainant. Further, it is an admitted fact that the complainant had taken the medical treatment from the CMC Hospital, Ludhiana and lodged the claims with the Ops of the treatment period from 17.8.2012 to 7.9.2012 for an amount of Rs.25,643.69P, 12.9.2012 to 15.9.2012 for an amount of Rs.6072/- and 26.9.2012 to 27.9.2012 for an amount of Rs.5970/-. As per the contention of the learned counsel for the complainant that the Ops have not paid the entire amount qua the claim lodged by the complainant and have illegally and arbitrarily repudiated the same without disclosing any reason.

10.              During the course of arguments, learned counsel for the Ops has stated at bar that the complainant has not submitted all the required documents which are necessary for the settlement of the claim of the complainant. On the other hand, learned counsel for the complainant has stated at bar that the complainant had already submitted all the relevant documents and in case, if any, documents are required by the Ops from the complainant, then the complainant is ready to submit the same with the Ops.

11.              Since, perusal of the file reveals that the OPs have not repudiated the claim of the complainant so far and have only closed the claim file of the complainant as ‘No Claim’ on account of non-submission of the documents from the complainant for settlement of the claim. So, it will be in the fitness of things that if the present complaint is partly allowed by giving necessary direction to the complainant to furnish the necessary documents for the settlement of all the claims as per the requirements of the OPs and thereafter, directions are given to the Ops to reconsider all the claims of the complainant as per the terms and conditions of the insurance policy in accordance with law. 

12.              Hence, in view of the above discussion, the present complaint is partly allowed with the direction to the complainant to furnish the necessary documents for the settlement of all the claims, within 15 days with the Ops as per their requirements and thereafter, directions are given to the Ops to reconsider all the claims of the complainant and to settle and pay the same to the complainant as per the terms and conditions of the insurance policy in accordance with law, within 45 days after receipt of the documents from the complainant, failing which, Ops are liable to pay interest @9% p.a. from the date of lodging of claims till its realization. Keeping in view the facts and circumstances of the present case, no order as to compensation and litigation costs is passed. Copy of the order be made available to the parties free of costs. File be completed and consigned to record room.

 

(Babita)                (Sat Paul Garg)              (R.L.Ahuja)

            Member                Member                       President.  

Announced in Open Forum

Dated:26.02.2015

Gurpreet Sharma.