Punjab

Ludhiana

CC/14/797

Darshan Singh - Complainant(s)

Versus

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

SPS Puri

27 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

Consumer Complaint No. 797 of 21.11.2014

Date of Decision          :   27.12.2016

 

Darshan Singh aged about 58 years s/o Malkit Singh r/o village Lakha, Tehsil Jagraon, District Ludhiana.

….. Complainant

Versus 

 

1.MDIndia Healthcare Services (TPA) Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali, Punjab. Third Party Administrator of respondent no.2.

2.United India Insurance Company Limited, through regional office: Feroze Gandhi Market, Ludhiana.

3.Regional Coordinator of MDIndia Healthcare Services (TPA) Pvt. Ltd., Cabin No.2, First Floor, Madhok Complex, Ferozepur Road, Ludhiana.

4.The Lakha Multipurpose Cooperative Agricultural Service Society Limited, VPO Lakha, Tehsil Jagraon, District Ludhiana.

5.Global Heart and Super Speciality Hospital, Ferozepur Road, Near Octroi Post, Ludhiana.

6.Bhai Ghanhya Trust (2014-15), Punjab through its CEO, S.C.O.2945-46, Punjab, Sector 22-C, Chandigarh.

..…Opposite parties

 

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant                     :         Sh.S.P.S.Suri, Advocate

For Op1 and OP3          :         Ex-parte

For OP2                         :         Sh.M.R.Saluja, Advocate 

For OP4                         :         None

For OP5                         :         Sh.Narotam Ghai, Advocate

For OP6                         :         Sh.Ravinder Sharma, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Shorn off unnecessary details, the case of the complainant is that he is an agriculturist and is member of Bhai Ghaniya Sehat Sewa Scheme(2014-15)(hereinafter in short referred to as ‘BGSS scheme’) floated by Government of Punjab. Complaint is filed under Section 12 and 14 of the Consumer Protection Act, 1986(hereinafter in short referred to as ‘Act’) for release of Rs.1.50 lac, the insured amount along with compensation amount of Rs.2 lac for mental harassment,torture and inconvenience.Complaint filed by claiming that complainant is member of OP4, due to which, he is entitled to the benefit of the above referred BGSS scheme meant for the benefits of members of the Agriculture Service Societies. Complainant was enrolled for medical health insurance through OP4 with OP6, due to which, he is entitled for the cashless treatment to be provided through empanelled hospitals of OP6. Complainant was issued Card No.MD15-BGSSS-00342602-S along with guide book. Premium was paid by the complainant through OP4. OP2 is the insurer, who is to pay the claim to the hospital for availed medical  facility. OP1(hereinafter in short referred to as ‘TPA’) is the third party administrator of OP2. Complainant on 4.9.2014 suffered from heart problem and was taken to hospital of OP5 for treatment because the same was in the list of empanelled hospitals of OP1(TPA) as per the terms contained in guide book issued by OP6. Complainant after medical checkup was admitted in the hospital of OP5 on 4.9.2014. Complainant did show the card issued by OP6 to OP5 and called upon to provide the cashless treatment, but OP5 flatly refused and demanded cash payment of Rs.1,50,000/-. Complainant insisted that he is entitled for cashless treatment for the heart disease to the extent of Rs.1,50,000/- and OP5 being empanelled hospital has to provide the same, but OP5 did not accede to the request and that is why, complainant had to express readiness to pay any amount above Rs.1,50,000/-. Despite this offer, OP5 refused to provide the cashless treatment to the extent of Rs.1,50,000/- even. So, complainant has to pay Rs.1,50,000/- as demanded by doctors in OP5, hospital. Complainant was operated for bye-pass heart surgery by  doctor Sh.Brajesh Kumar Badhan. For this treatment, the complainant had to remain admitted in OP5 hospital for the period from 4.9.2014 to 16.9.2014. After getting discharge from the said hospital, complainant contacted Sh.Bobby Kumar, Coordinator of OP1 at Ludhiana on his mobile No.93160-08381, but this person refused to oblige the complainant. Thereafter, the complainant sent a registered complaint/claim to OP1 vide registered letter dated 30.09.2014, but no reply was received and that is why this complaint filed by pleading deficient service and adoption of unfair trade practice.

2.                OP1 and OP3 are ex-parte in this case.  

3.                OP2 filed written statement by pleading interalia as if this Forum has no jurisdiction; complaint filed without supporting any documents of claim and that owing to involvement of complicated questions requiring elaborate evidence, the matter can be decided by Civil Court of competent jurisdiction only.    Insurance policy was not issued by OP2 because the same is an administrative office. No agreement was executed at Ludhiana between Op2 and complainant and nor any claim filed with OP2 at Ludhiana and as such, keeping in view the facts that the policy was issued by Mohali Office, it is claimed that this Forum has no territorial jurisdiction. OP1, the TPA demanded documents from the complainant vide letter dated 16.9.2014, but the complainant has not supplied the same and that is why, claim of the complainant was made as ‘no claim’ vide letter dated 5.12.2014. Action of making the claim of the complainant as ‘no claim’ due to non supply of the documents defended as legal and justified by claiming that there is no deficiency in service on the part of OP2. It is denied for want of knowledge that complainant suffered from any heart problem because comments in that respect cannot be submitted without going through the treatment record of the hospital. It is denied that the complainant is entitled to the amount of Rs.1,50,000/-. No cause of action has accrued to the complainant and as such, by denying the other averment of the complaint, prayer made for dismissal of the complaint.

4.                In separate written statement filed by OP4, each and every averment of the complaint admitted by claiming that complainant owing to suffering of heart problem on 4.9.2014 was entitled for cashless treatment to the extent of Rs.1,50,000/-. Besides, it is claimed that the complainant got treatment from the empanelled hospital of OP6 i.e. from OP5 and as such, complainant being member of OP4 society, entitled for the amount of Rs.1,50,000/-  because he remained admitted in the hospital of OP5 for the period from 4.9.2014 to 16.9.2014. It is claimed that this Forum has jurisdiction to entertain the complaint and complaint is within limitation. It is also admitted that the complainant is a consumer. However, it is denied that Ops provided services for consideration, or that there is breach of conditions or negligence in providing services under the scheme. OP2 is liable to pay the amount claimed in the complaint. The scheme is provided for    the welfare of the rural and poor people especially the members of OP4 society and      as such, OPs are liable to pay the amount.

5.                In separate written statement filed by OP5, it is pleaded interalia as if no relief available to the complainant under the provisions of Consumer Protection Act against OP5 because OP5 has been dragged unnecessarily in litigation with ulterior motive. It is admitted that the complainant suffered from heart disease on 4.9.2014, due to which, he was admitted as indoor patient in Op5 hospital for medical treatment. Allegations regarding OP5 being entered in the list of empanelled hospitals prepared by OP1, denied by claiming that after 14.7.2014, OP5 is not in the empanelled hospitals list. Vide letter dated 14.7.2014, OP5 withdrew itself from the empanelment and as such, it is no more to a service provider of any of Ops. Copy of letter dated 14.7.2014 was sent to OP1 and annexed with the written statement. After such withdrawal, OP5 is independent    to run its hospital and to provide the medical treatment on charges. OP5 is not bound by the conditions of other Ops. At the time of payment by the complainant in OP5 hospital for medical treatment, it was made clear to the complainant that as OP5 is not empanelled hospital and as such, complainant is not entitled for cashless treatment. Complainant was disclosed that he is free to get cashless treatment from any empanelled hospital and there is no compulsion for him to get treatment from OP5 hospital. After knowing this fact and understanding the whole situation, complainant himself opted for admission on payment of medical expenses and hospitalization charges in hospital of OP5. So, refusal by OP5 to provide the cashless treatment defended as justified. It is denied that the complainant has to pay Rs.1,50,000/- against the provisions of the scheme. Rather, it was the choice of the complainant to get his treatment from the hospital of OP5 voluntarily and as such, there is no deficiency in service on the part of OP5 in providing the     treatment after acceptance of the medical treatment.Complainant liable to pay hospitalization charges. No cause of action accrued to the complainant against OP5. No contract alleged to be existing between the complainant and OP5 or between the other Ops and OP5 and as such, by denying other averments of the complaint, prayer made for dismissal of the complaint.

6.                In separate written statement filed by OP6, it is pleaded interalia as if the complaint against this OP is not maintainable because the complainant is not its consumer and there is no deficiency in providing services on the part of this OP. It is claimed that the complaint being false, vexatious and frivolous, merits dismissal, particularly when the complainant has no cause of action against OP6. Territorial jurisdiction of this Forum also denied by claiming that Bhai Ghanhya Trust has its office at Chandigarh and Courts at Chandigarh alone has jurisdiction to entertain any petition or any claim under the scheme. Every members including complainant was enrolled under the scheme after supplying the terms and conditions and after making him to read and understand the contents. So, the complainant is bound by the terms and conditions contained in the agreement executed between OP6 and the insurer. Members/beneficiaries were clearly informed with the financial and legal liabilities, if any, arising consequent to the operation of the scheme and the liability under the policy will rest exclusively with OP1 and OP2 during scheme period of 16.5.2014 to 15.5.2015. OP1 was appointed as TPA of the insurer i.e. OP2. Liability of OP1 as TPA was to issue identity card in respect of hospitals and submit recommendations to OP6 for the empanelment of the hospitals. Even responsibility of  OP1 was to grant authorization, to settle the claims, make payments to the empanelled hospitals for providing cashless services to the beneficiaries of the scheme etc. Complainant had already declared through enrollment form that declaration submitted by him is irrevocable, final and binding on him. OP6 is not a necessary or proper party to the complaint. Admittedly, OP6 is a registered Trust constituted for providing health care services to the members and employees of Cooperative Societies and Cooperative Departments of Punjab. OP2 is the insurer, for implementing the scheme during the period of 16.5.2014 to 15.5.2015. OP6 is neither the service provider and nor the complainant is a consumer of OP6. Rather, OP2 is the insurer and OP1 TPA, who are the service providers and claim settling authorities under the scheme and as such, by denying each and every other averment of the complaint, prayer made for dismissal of the complaint with costs.

7.                Complainant to prove his case tendered in evidence his affidavit Ex.CX along with documents Ex.C1 to Ex.C8 and thereafter, his counsel closed the evidence.

8.                On the other hand, counsel for OP2 tendered in evidence affidavit Ex.RW2/A of Sh. Baljit Singh, Manager of OP2 along with documents Ex.R1 to Ex.R3 and then closed the evidence.

9.                Counsel for OP5 tendered in evidence affidavit Ex.R5/A of Dr.Brajesh K.Badhan, Chief Cardiologist of OP5 hospital along with documents Ex.R1/5 and Ex.R2/5 and then closed the evidence.

10.              Counsel for OP6 tendered in evidence affidavit Ex.R6/A of Sh.H.S.Sidhu, Chief Executive Officer of Bhai Ghanhya Trust along with documents Ex.R6/1 and Ex.R6/2 and then closed the evidence.

11.              No evidence has been adduced by OP4 and nor anyone appeared on behalf of OP4 since from long time and as such, OP4 also treated as ex-parte through separate order of today.

12.              Written arguments not submitted by any of the parties, but oral arguments alone addressed and those were heard. Records gone through minutely. 

13.              Ex.C2 is the Guide Book of BGSS scheme floated by the Punjab Government.As per Ex.C2, for Cardiac Operation treatment, insurance amount of Rs.1,50,000/-      is payable under this scheme for the benefit of enrolled members is a fact borne from the page no.3 and page no.5 (clause no.1.9) as well as page no.6 (clause no.1.9.5) of this booklet. After going through page no.12 of this booklet Ex.C2, it is made out that OP2 is the insurer, but OP1 is the appointed administrator. After going through page no.12 of Ex.C2, it is made out that OP1 as administrator is to provide necessary directions for the benefit of the employees and beneficiaries, so that they may get treatment under the scheme from the network hospitals. Further, OP1 made liable in supervisory role to get treatment provided to the beneficiaries under cashless scheme. So, virtually responsibility was put on OP1 to act for the benefit of the members of the scheme,in supervisory role,so that treatment from the empanelled hospitals may be got by them.In view of this duty caste on OP1 as an administrator, it was obligatory on the part of OP1 to see that the complainant and other members gets cashless treatment from the empanelled hospitals. To strengthen the supervisory role of OP1, it was obligatory on the part of OP1 to appoint coordinator or other employees at District Level, so that settlement of the claims under the scheme may take place and scheme may be implemented. As per page no.12 of Ex.C2, it is the duty of OP1 to empanel the hospitals for the benefit of the beneficiaries. It was also the duty of OP1 to give information about the details of the scheme to the beneficiaries and for that purpose wide publicity to be given by OP1. Even OP1 to dispose of the complaints submitted by the beneficiaries as per conditions on page no.13 of Ex.C2. In view of these duties caste on OP1, it was obligatory for OP1 to ensure that the beneficiaries under the scheme get cashless treatment. For that purpose, appointment of District Coordinator was done by OP1, so that the lodged claims may be settled at earliest. List of the coordinators for each districts given on the end page of the booklet Ex.C2. Sh.Bobby Kumar, District Coordinator for

Ludhiana District appointed  is a fact borne from the penultimate page                  of booklet Ex.C2. So, certainly plea taken by the complainant is correct that he contacted Sh.Bobby Kumar, the District Coordinator at Ludhiana on 16.9.2014, after discharge from the hospital of OP5,for settlement of the claim. Guidelines for getting the benefit of the scheme through claim even provided in this booklet Ex.C2 itself. Treatment by the complainant was got from the empanelled hospital at Ludhiana and he contacted District Coordinator Sh.Bobby Kumar at Ludhiana and even the enrollment card Ex.C1 mentions address of Jagraon Circle in Ludhiana District of complainant and as such, virtually the complainant was enrolled under the BGSS Scheme in Ludhiana District. OP1 and OP2 both have its branch offices or office at Ludhiana and as such, in view of the fact that the complainant got treatment from Ludhiana hospital and above facts, it is obvious that the cause of action accrued to the complainant for availing benefit under the scheme within the territorial limit of Ludhiana. Being so, this Forum certainly has territorial jurisdiction to entertain the complaint because of accrual of cause of action in the territorial jurisdiction of this Forum and because of availability of branch offices and office of OP1 and OP2 within the territorial jurisdiction of this Forum.

14.            Though, provisions of Civil Procedure Code are not strictly applicable to the consumer complaints, but for ascertaining the territorial jurisdiction of this Forum, guidance can be had from the provisions of CPC. Analogous to provisions of Section 20 of CPC are provison of section 11 of the Consumer Protection Act,1986. After going through Section 11(2) of the Act, it is made out that the complaint can be filed in a District Forum,within the local limits of whose jurisdiction, the cause of action, wholly or in part arises or the opposite party or any of the Opposite parties, where there are more than one, at the time of institution of the complaint, actually and voluntarily resides or carries on business or has a branch office etc. As the branch office of both OP1 and OP2 is at Ludhiana and the cause of action wholly arose to the complainant within the territorial jurisdiction of this forum, due to his enrollment as a member at Jagraon and getting of treatment at Ludhiana and submission of claim through District Coordinator at Ludhiana and as such, certainly this Forum has territorial jurisdiction. Submissions advanced by counsel for Ops to the contrary has no force at all.

15.              It is contended by Sh.Narotam Ghai, Advocate representing OP5 that due treatment was provided to the complainant by OP5 hospital when it ceased to be on the empanelled list after withdrawal notices Ex.R1/5 and Ex.R2/5 addressed to OP1. Even if OP5 may have withdrawn from the empanelled list of hospitals, despite that procedure for delisting of empanelled hospital envisaged in Ex.R6/2. The Empanelment Form duly filled in all respect by the networking team has to be forwarded by OP1(TPA) to OP2(insurer) as per clause 6.1.8 of Ex.R6/2. However, approval of OP6(Trust) required before such empanelment as per clause 6.1.9 of Ex.R6/2. Complaints against the Network Hospitals received from the beneficiaries or from the officers of the Department of Cooperation to be looked into by OP1 is provided by clause 6.1.12 of Ex.R6/2. OP1 to submit his recommendations along with supporting evidence/material to OP6, the Trust who is to take disciplinary action including depanelment of any Network Hospital is provided    by clause 6.1.13 of Ex.R6/2. As per clause 6.1.15, OP1 to ensure that the    Network Hospital mandatorily sends the e-preauthorization, along with the softcopy of all the reports, radiological images of all radiological investigations/modalities and besides photo of  the patient, for obtaining authorization from the TPA within the timeframe. It is the duty of TPA to ensure that the process of e-preauthorization is completely functional, including operational online TPA web portal as per clause 6.1.16 of Ex.R6/2. OP1 as well as OP2 to review the categorization of the hospitals on a quarterly basis and to submit the review reports with recommendations, if any, for change in categorization of status of the hospitals to OP6 on quarterly basis for its approval as per clause 6.1.18 of Ex.R6/2. As per clause 6.1.20 of Ex.R6/2, both OP1 and OP2 to ensure that all the Network Hospitals are intimated and well informed that no payment shall be made in respect of any expenditure at rates, which are higher than the rates contained in the Bhai Ghanhya Schedule of Rates. It is obligatory on OP1 and OP2 to make arrangement before the start of the scheme to ensure that the regular and uninterrupted supply of Claim Form, Preauthorization Form and Claims Check List to all the Network Hospitals in sufficient quantity takes place as per clause 6.1.21 of Ex.R6/2. Functioning of the Network Hospitals to be monitored by both OP1 and OP2 as per clause 6.1.22 of Ex.R6/2. Categorization status of any hospital cannot be changed by the insurer/TPA without obtaining written approval of Bhai Ghanhya Trust as per clause 6.1.18 of Ex.R6/2. Latest updated list of Network Hospitals shall be sent by the insurer/TPA to OP6 on a quarterly basis for information is also provided by clause 6.1.18 of Ex.R6/2. So, from all these pointed out clauses, it is made out that the functioning of the empanelled hospitals to be monitored by OP1 and OP2 and in case, categorization of status of an empanelled hospital to be changed, then same can be changed after written approval from OP6. Neither letter Ex.R1/5 and nor Ex.R2/5 addressed to OP6, the trust and as such, it is obvious that status of OP5 hospital has not been changed by OP6 as required by the above quoted clauses of Ex.R6/2. If this categorization status of OP5 as empanelled hospital under the scheme not changed by OP6, the authorized authority as per clauses of Ex.R6/2, then certainly unilateral withdrawal from the empanelment through letters Ex.R1/5 and Ex.R2/5 will not affect the rights of the complainant to claim the benefits under the scheme.

16.     OP5 hospital is an empanelled Hospital is disclosed by entry No.168 at page no.31 of booklet Ex.C2. No notification of delisting of OP5 issued after 14.7.2014 and nor any change of status of OP5 divulged by OP1 and OP2 to Op6 as per requirement of Ex.R6/2 till getting of treatment by the complainant during period from 4.9.2014 to 16.9.2014 and as such, certainly complainant got the treatment from the approved hospital. If at all OP5 has withdrawn unilaterally from the list of empanelled hospitals, then it is for OP1 and OP2 to see as to what action against

OP5 can be taken. For the non taking of any action by OP1, OP2 and OP6 against OP5 as per mandatory provisions or agreement arrived at between them, complainant cannot be made to suffer because primary responsibility                   for providing of cashless treatment facilities for medical treatment is of OP1 and OP2, being TPA and insurer as per various clauses of Ex.R6/2 and of contents of Ex.C2 as referred above.

17.              After going through judgment Ex.R6/1 decided on 19.8.2010 in First Appeal No.77 of 2007 by the Hon’ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh in a case titled as Sanjvni Trust(Regd.) vs. Surinder Singla and others, it is made out that claimant is not entitled for medical reimbursement from the Trust or the cooperative societies because claim maintainable against the insurer as per terms and conditions of insurance policy. The same is the position in the case before us because here on completion of certain formalities by the TPA, the insurance claim in respect of the medical treatment as per condition of Ex.C2 to be granted by OP2 as insurer. If OP5 has charged Rs.2,15,000/- from the complainant through bill Ex.C3, then it is because of unilaterally withdrawal from the empanelled hospitals by it. However, as the primary responsibility of reimbursement is of the insurer or for deficiency in providing services is of TPA because of not taking action against the empanelled hospital and as such, OP1, OP2 and OP6 may sue OP5. However, the complainant cannot be made to suffer because complainant is consumer of OP2, being insurer.

18.              Privity of contract for getting services provided through empanelled hospitals was between the OP1, OP2 and OP6 on one side, but OP5 on other side, to which, the complainant is not a party and as such, complainant cannot hold OP5 liable for the lapses on the part of OP1, OP2 or OP6 in not taking action against OP5.

19.              Deficiency in service on the part of OP5 cannot be inferred because no allegations of deficiency in service in providing treatment levelled against OP5. Main function of OP5 was to provide treatment after acceptance of charges either from OP2 or from the complainant and same function was performed by OP5 and as such, certainly submissions advanced by Sh.Narotam Ghai, Advocate has force that the complaint against OP5 is not maintainable. Similar submissions of Sh.Ravinder Sharma, Advocate representing OP6 has force because claim has      to be paid by the insurance company and liability of collecting the premium was of OP4. OP4 after collecting the premium forwarded the same to the insurer and as such, deficiency in service on the part of OP4 and OP6 even is not there, particularly when the claim against Trust is not maintainable as per judgment Ex.R6/1 as referred above. So, complaint against OP4 to Op6 merits dismissal because the complainant is not a consumer of anyone of them, but of OP1 and OP2 only.

20.              As per clause 6.3.2 of Ex.R6/2, the TPA to issue ID Card to each beneficiary, which is the sole requirement to be produced by the beneficiary to the Network Hospital. So,production of Identity Card Ex.C1 by the complainant before empanelled hospital of OP5   was the only requirement, which was to be performed by the complainant for getting cashless treatment under scheme Ex.C2. Complainant through affidavit Ex.CA able to establish that he presented his Identity Card Ex.C1 before OP5, but OP5 refused to provide the services without charging for medical treatment. That claim of the complainant is acceptable, particularly when in the written statement filed by OP5 as well as in the affidavit Ex.R5/A of Dr.Brajesh K.Badhan(who treated the complainant), it is mentioned that as OP5 has withdrawn from the empanelment and as such, it did not remain as service provider. That withdrawal through Ex.R1/5 and Ex.R2/5 took place on 14.7.2014, but without issue of notification of depanelment or delisting by OP6 and      as such, claim of the complainant is believable that he was not provided the cashless treatment facility, despite his enrollment under the scheme after issue of identity card Ex.C1. Even OP4 in their written statement admitted that the complainant being member of Agriculture Service Societies in question was issued Identity Card Ex.C1, due to which, he is entitled for the benefits of the scheme contained in Ex.C2.

21.              It is vehemently contended by Sh.M.R.Saluja, Advocate representing OP2 that insurance policy number not mentioned anywhere in the complaint and nor name of the complainant mentioned in Ex.R1 and as such, complainant is not a consumer of OP2. Even if the name of the complainant not mentioned in Ex.R1, but clause 6.3.2 of Ex.R6/2 establishes that production of issued identity           card enough to establish the identity of the complainant as beneficiary of the scheme and as such, the above pointed omissions are not fatal to the case of the complainant at all.

22.              As per clause 6.5.1 of Ex.R6/2, OP1 as TPA to act as a frontline for the satisfactory redressal of grievances of the beneficiaries. As per clause 6.5.2 of Ex.R6/2, all the grievances to be responded by the OP1(TPA) immediately. It is the responsibility of OP1 to ensure that grievances pertaining to getting cashless access in the Network Hospitals are resolved within two hours of receipt of such grievances in emergency cases, but within 6 hours in planned admission cases. The grievances related to delayed response in obtaining authorization from the TPA shall be acted upon immediately. All other grievances should be appropriately addressed within 24 hours of the grievances being brought to the notice of the TPA. If any grievance remains unresolved beyond a period of 24 hours of the grievance being brought to the notice of the TPA, the same shall be brought to the notice of the insurer and the Trust on an immediate basis along with reasons for not resolving the same is provided by clause 6.5.3 of Ex.R6/2.

23.              Complainant sent application Ex.C5 through post on 30.9.2014 as revealed by copy of postal receipts Ex.C6 and Ex.C7 and as such, virtually the complainant brought the grievance of non providing of cashless facilities to him to the notice of OP1 and as such, it was for OP1 to act on this grievance. By acting on this grievance, OP1 through letter Ex.R3 disclosed the complainant that he should provide the original documents along with claim form within the stipulated period and only thereafter, the claim will be repudiated or accepted. It is the case of the Op2 that requisite documents were not submitted by the complainant and that is why, his claim was repudiated. Non submission of the original documents by the complainant is not a fault of the complainant because complainant after giving intimation through Ex.C5 to OP1 was left with no liability because verification of submitted photostat copies of bills and identity card was the responsibility of OP1. OP1 shirked in its responsibility of verifying such documents and as such, deficiency in service on the part of OP1 is there in this respect. As per clause 6.1.14 of Ex.R6/2, in the event of depanelment/complete or partial suspension/temporary suspension or depanelment of any Network Hospital by the insurer, for which, the prior approval has not been accorded by the Trust, the insurer shall unconditionally and without any demur make the reimbursement of the hospitalization expenses of such period, at the actual rates charged by the hospital, irrespective of the Bhai Ghanhya Schedule of Rates, not exceeding the maximum limit of Rs.1.5 lac of sum insured, along with 10% interest on the claimed amount, directly to the member, for any hospitalization taking place in such Network Hospital, which has been depanelled/completely or partially suspended/temporarily suspended or depanelled by the TPA/Insurer, at its own absolute discretion. In view of this clause 6.1.14 of Ex.R6/2, the insurer to remain liable to pay for the reimbursement of the hospital expenses incurred on treatment from the Network Hospital, even if the suspension of the same may not have  taken place. That suspension of the hospital of OP5 temporarily or partially not shown to have taken place by the dates, complainant got treatment from 4.9.2014 to 16.9.2014 and as such, insurer to remain liable to pay for the reimbursement as per clause 6.1.14 of Ex.R6/2.  

24.              As responsibility of appointing District Coordinator or making available of claim form, preauthorization form and of monitoring the function of the Network Hospital is of TPA as per clauses 6.1.15; 6.1.16; 6.1.18; 6.1.21 and 6.1.22 of Ex.R6/2 and as such, in view of the fact that the name of OP5 hospital was existing in the list of empanelled hospitals in Ex.C2, complainant could have availed the treatment under the scheme from this hospital. Responsibility of intimating from time to time, about any changes in the number of Network Hospitals is of OP1 as per clause 6.1.28 of Ex.R6/2, but that responsibility is not performed by OP1 by getting the name of OP5 excluded from the list of empanelled hospitals contained in Ex.C2, despite  receipt of letters Ex.R1/5 and Ex.R2/5 dated 14.7.2014 each and as such, inaction on the part of OP1 led the complainant to believe as if he got treatment from the empanelled hospital. Being so, insurer cannot be exonerated from liability.

25.              As per incorporation at page no.14 of Ex.C2, the beneficiary for getting the treatment facilities to show his identity card issued by the TPA only and the same was done by the complainant and as such, no fault attributable to the complainant, particularly when as per clause No.1 at page 15 of Ex.C2, the beneficiary can go to any of the Network Hospital/Nursing Home mentioned in the guidebook for treatment and that was done by the complainant because the name of OP5 was existing at the serial No.168 of Page no.31 of Ex.C2.

26.              As per incorporation at page No.15 of Ex.C2, list of Network Hospitals to be sent by OP1 to its District Coordinator and even Toll-free service can be availed by the beneficiary for ascertaining the name of the hospital under empanelment. Complainant contacted Sh.Bobby Kumar, District Coordinator as per his case and as such, in view of non supply of the information qua delisting of OP5 by the said Bobby Kumar or anybody else, complainant was free to avail the treatment facility from empanelled hospital i.e. OP5.

27.              As per clause 4 incorporated at page no.15 of Ex.C2, beneficiary is to get the preauthorization form filled from the doctor treating him and thereafter, he will submit the same in that hospital. Those hospital authorities to send those forms/cases to TPA for approval. As per clause no.5 existing at page no.16 of Ex.C2, the beneficiary after treatment to left the bills with his signatures in the empanelled hospital. Besides, as per this clause 5 at page no.16 of Ex.C2, beneficiary to leave all the original documents, investigator report and discharge summary etc., in the hospital, from where he got treatment. As per clause 4 existing at page no.17 of Ex.C2, beneficiary to submit the claim within 45 days after discharge from the hospital with nearest office of TPA. That was done by the complainant by sending intimation Ex.C5 on 30.9.2014 after discharge from the hospital on 16.9.2014 and as such, fault cannot be attributed to the complainant. Moreover, as referred above, the original documents consisting of discharge summary and investigator report to be left in the hospital is provided under the scheme and as such, action of calling the original documents from the complainant through letter Ex.R3 is quite improper.

28.              As per clause 6.6.14 of Ex.R6/2, beneficiary may approach either the insurer or the Trust for submission of the representation and thereafter, the said representation to be forwarded to TPA. On receipt of this representation, the TPA to reopen the claim file, verify the facts and gave its decision on the representation in writing and release the payment within 7 days of receipt of such representation, if the representation is allowed. In case, the representation is disallowed, then TPA shall give its decision along with elaborate and justifiable reasons within 7 days of receipt of such representation. So, rejection of claim for want of production of original documents by the TPA is quite improper because the original record of the treatment to remain in the hospital from where treatment got by the beneficiary and verification of that record to be done by the TPA. Such verification by the TPA can be done from submitted photostat copies of record through Ex.C5, but same not shown to be done and as such, TPA did not act as per clause 6.6.14 of Ex.R6/2.

29.              As per law laid down in case of Avneet G.Singh vs. ICICI Lombard General Insurance Company Limited and others-2014(2)CLT-374(Chandigarh State Consumer Disputes Redressal Commission), in case of cashless health insurance policy, complainant provides the available medical record with her, then beyond that the insurance company could collect the medical record from the concerned hospital.  In view of this legal proposition and in view of the above pointed clauses of Ex.R6/2, it is obvious that the responsibility of verification of the treatment record of the complainant from the hospital of OP5 was of OP1, but that responsibility not shown to be performed and as such, deficiency in service on the part of OP1 is there, resulting in repudiation of claim, due to non submission of the documents alone.

30.              As per law laid down in case of Sunil Sharma vs. National Insurance Co.Ltd-II(2015)Consumer Protection Judgments-46(Delhi State Commission), an otherwise genuine claim should not be rejected on flimsy and technical grounds. In case, it is so done, then the confidence of the people in the insurance companies will stand deeply eroded. Further, as per ratio of this case, Consumer Forums are not expected to go in technicalities of the Civil or Criminal jurisprudence because consumer disputes are to be decided on yardsticks of reasonableness,probability and by applying with full force the principles of natural justice. But as the reasonableness and probability discussed in detail above lean in favor of holding that deficiency in service committed by OP1 in not performing its duties of verifying the treatment record of the complainant from hospital of OP5 and OP1 even failed to get notified the delistment and depanelment of OP5 before or after the time of treatment by the complainant from OP5 and as such, in view of this, Op1 cannot escape from liability along with that of OP2 because     repudiation of claim is unjustified. OP3 is the branch office of OP1 at Ludhiana and as such, for the deficiency in service on the part of OP1 to OP3 each, they are held liable. However, amount of Rs.1,50,000/- cannot be ordered to be paid by OP2 to the complainant straightway because verification of the hospital record regarding treatment of the complainant to be done by OP1 or OP3 yet and thereafter, recommendations to be submitted by them qua the acceptance of repudiation of the claim. However, for deficiency in service on the part of         OP1 to OP3 each, complainant stood mentally harassed and as such, he is entitled for some of the hefty amount of compensation, otherwise, the authorities like OP1 to OP3 will reject the claim on flimsy grounds, despite the fact that                 cashless insurance facility schemes flawed by the Government for the   beneficiaries after acceptance of premium from the beneficiaries. Repudiation of the claim in this case is against the spirit of scheme contained in Ex.C2 and also due to shirking of responsibility by OP1 to perform its due function and as such, some hefty compensation for mental harassment allowed. However, complaint against OP4 to OP6 not maintainable because complainant is not a consumer of any of them as discussed above and as such, complaint against OP4 to OP6 is dismissed.

31.              Even as per incorporation at page no.21 of Guide Book Ex.C2, it is mentioned that responsibility for enforcing the scheme, whether financial or legal, will be of TPA and of the insurance company. Further, it is specifically mentioned at page no.21 of this booklet Ex.C2 itself that after coming into force of the scheme, Trust i.e.OP6 or the cooperative society i.e. OP4 in no way can be held liable. Liability of the Trust and of the cooperative society is only to transmit the received amount to the insurance company as per this incorporation at page no.21. When these clauses specifically incorporated in the guide book Ex.C2 and the terms and conditions of the contract binding upon the parties and nothing can be added or subtracted thereto, then in view of this specific incorporation at page no.21 of Ex.C2, certainly liability of paying the amount will be of insurer or of TPA and not of remaining Ops.Duty of OP4 is to collect the premium and transmit the same, but that of OP6 is to empanel or delist the hospitals only. In view of this also as the claim put forth for seeking the claim amount and as such exclusive liability will remain of OP1 to OP3 and not of remaining Ops at all.

32.              Therefore, as a sequel of the above discussion, complaint allowed against OP1 to OP3 only, but the same is dismissed against OP4 to OP6 each. OP1 or OP3 after verifying the treatment records of the complainant from the hospital of OP5 will submit their recommendations qua acceptance or repudiation of claim within 30 days from the date of receipt of copy of this order. After receipt of these recommendations by OP2, necessary decision of paying the insurance claim or of intimating the complainant qua repudiation will be taken within 30 days.  Compensation for mental harassment and agony of Rs.20,000/-(Rupees Twenty thousand only), but litigation expenses of Rs.5000/-(Rupees Five thousand only) more allowed in favour of the complainant and against OP1 to OP3, whose liability held as joint and several. Compliance of directions of paying awarded compensation and litigation expenses be made by OP1 to OP3 within 30 days from the date of receipt of copy of this order. In case, on recommendations of OP1 or OP3, any claim amount is found due to the complainant, then payment of the same will be made by OP2 to the complainant within 30 days from the date of recommendations of OP1 or OP3, failing which, complainant will be entitled to interest @8% per annum from today onwards till receipt of adjudged amount. Copies of order be supplied to the parties free of costs as per rules.

33.                        File be indexed and consigned to record room.

 

                              (Param Jit Singh Bewli)           (G.K.Dhir)

                                     Member                               President

Announced in Open Forum

Dated:27.12.2016

Gurpreet Sharma.