DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 58/2015
Date of Institution : 08.04.2015
Date of Decision : 11.09.2015
1. Harjinder Singh aged about 51 years son of Mal Singh.
2. Swaranjit Kaur aged about 47 years wife of Harjinder Singh residents of Mangewal, Tehsil and District Barnala.
…Complainants
Versus
1. The MD India Health Care Services (TPA) Pvt. Limited, through its Manager, Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali, Punjab.
2. United India Insurance Company Limited, registered Head Office 24, Whites Road, Chennai-600014 through its Manager.
3. United India Insurance Company Limited, Customer Care 136, Firoz Gandhi Market, Ludhiana-141001 through its Divisional Manager.
4. The Mangewal MPCASS Limited, Village Mangewal through its Secretary.
5. Deep Hospital, 481, Model Town, Ludhiana, through its Authorized Signatory Dr. BPS Brar.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. VS Sandhu counsel for the complainant
Opposite party No. 1 exparte
Sh. NK Singla counsel for opposite parties No. 2 and 3
Sh. PS Kaushal counsel for the opposite party No. 4
Sh. Pankaj Bansal counsel for opposite party No. 5
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(SHRI S.K. GOEL PRESIDENT):
The complainants namely Harjinder Singh alongwith his wife Swaranjit Kaur (hereinafter referred as complainants) has filed the present complaint against The MD India Health Care Services (TPA) Pvt. Limited and others (hereinafter referred as opposite parties) under Consumer Protection Act, 1986 (in short the Act).
2. The facts emerging from the present complaint are that the complainant No. 1 Harjinder Singh being the member of The Mangewal MPCASS Limited Village Mangewal opposite party No. 4 had obtained the services of opposite parties by getting insurance vide policy No. 112100/48/14/41/00000029 valid from 16.5.2014 to 15.5.2015 having cards No. MDIS-BGSSS-00106675-S and MDI5-BGSSS-00301466-SP under Bhai Ghanhya Sehat Sewa Scheme policy. The complainant No. 1 got insured himself as well as his family members through the above said policy.
3. It is alleged that the complainant No. 2 was having some problem in spine and for the treatment she went to Deep Hospital of opposite party No. 5 alongwith her husband. After check up of complainant No. 2, the opposite party No. 5 advised for the operation. The complainant told the opposite party No. 5 that they were having medical insurance under Bhai Ghanhya Scheme and they showed their policy insurance cards and identity cards for pre-authorization. The opposite party No. 5 told that they need not to be worried as their treatment will be done free of costs as per the policy. Therefore, the complainant No. 2 was admitted in their hospital on 27.5.2014. The opposite party No. 5 operated her for fixation of lumber spine and she was discharged on 3.6.2014. Then the opposite party No. 5 insisted for the payment of Rs. 70,874/- i.e. the treatment amount and medicines etc. On this the complainant told that they were covered under the policy but the opposite party No. 5 told that they can take reimbursement of the same from the opposite parties No. 1 to 3. It is further alleged that the said amount was spent on pre and post operation medicines including accommodation and other miscellaneous expenses at the hospital of opposite party No. 5. After the discharge from the hospital the complainant No. 2 alongwith her husband approached the opposite parties No. 1 to 3 and 5 a number of times for reimbursement of Rs. 70,874/- but the opposite parties No. 1 to 3 and 5 flatly refused the claim of the complainants. Thus it is alleged that the opposite parties No. 1 to 3 and 5 are deficient in rendering the services to the complainant and intentionally induced complainants to pay the bill knowingly and therefore they are guilty of mal practice. Hence the present complaint is filed seeking the following reliefs directing the opposite parties.-
1) To pay the medical expenses amounting to Rs. 70,874/- alongwith interest @ 18% per annum from the date of operation till realization.
2) To pay Rs. 25,000/- on account of mental agony and harassment.
3) To pay Rs. 11,000/- on account of litigation expenses.
4. Upon notice, the opposite party No. 1 did not appear despite service so the opposite party No. 1 was proceeded against exparte.
5. The opposite parties No. 2 and 3 filed a joint written version taking legal objections interalia on the grounds of maintainability, non joinder and mis joinder of necessary parties, concealing of material facts, no cause of action, estoppal, no jurisdiction and the complaint is frivolous one. On merits, it is pleaded that Bhai Ghanyha Trust Chandigarh purchased insurance policy No. 112100/48/14/41/00000029 valid from 16.5.2014 to 15.5.2015 from the opposite parties. However, they submitted that the opposite party No. 5 is empaneled only for cataract and joint replacement and as per letter written by opposite party No. 5 to opposite party No. 1 it has been specifically stated that opposite party No. 5 cannot be able to give services to BGSSS cardholders due to rates being on very lower side. It is further submitted that complainant No. 2 obtained treatment from opposite party No. 5 in general medical management for which opposite party No. 5 is not empaneled and the complainants are not covered under the insurance policy for getting the treatment. Thus the claim of the complainant No. 3 has rightly being repudiated by the opposite party No. 1 as per the terms and conditions of the insurance policy. However, they have denied the other allegations of the complainants and finally prayed for the dismissal of the complaint.
6. The opposite party No. 4 has also filed a separate written version stating therein that Harjinder Singh son of Mal Singh resident of Mangewal being a member of the opposite party No. 4 had obtained the services of the opposite parties by getting the said policy valid from 16.5.2014 to 15.5.2015 having cards No. MDIS-BGSSS-00106675-S and MDI5-BGSSS-00301466-SP under Bhai Ghanhya Sehat Sewa Scheme policy for himself as well as for his family members and they have not specifically denied the allegations of the complainants. They have finally prayed that justice should be done to the complainants.
7. The opposite party No. 5 has also filed separate written version taking legal objections interalia on the ground of jurisdiction, locus standi, suppression of material facts, misuse of process of law, mis joinder of parties and no privity of contract between them. On merits, it is submitted that the answering opposite party had agreed to provide services for eye and ortho department only. No other services were covered under the agreement executed between opposite party No. 1 and the answer opposite party. No patient of any other department except eye and ortho has ever been treated by the answering opposite party under the said scheme. The opposite party No. 5 has further admitted to the extent that the complainant No. 2 approached them for neuro problem in spine and was treated by neuro surgeon to the best of his professional ability and complainant No. 2 remained under the treatment with them from 27.5.2014 to 3.6.2014. It is further averred that the complainants were made clear that the services of neuro department were not covered under the alleged insurance cover. Complainants made inquiries from opposite parties No. 1 to 4 and after satisfying themselves the complainants had willingly and voluntarily opted for treatment from the opposite party on payment of charges and they had paid the entire amount at the time of discharge of complainant No. 2. It is further submitted that even otherwise when the patients of ortho and eye department covered under the said policy present themselves for treatment from opposite party No. 5 then an intimation is sent to opposite parties No. 1 to 3. After verifying the validity of the policy an authorization letter is issued by them which enables the opposite party No. 5 to get the reimbursement from them. No such procedure was followed at the time of admission of complainant No. 2. No objection or protest has been made by the complainants either at the time of admission or at the time of discharge. They have denied any promise or representation was ever made by the opposite party No. 5. They have denied the other allegations of the complainants and finally prayed for the dismissal of the complaint with costs.
8. In order to prove their case, the complainants have tendered into evidence affidavit of Harjinder Singh Ex.C-1, discharge card Ex.C-2, copy of identity card of Harjinder Singh Ex.C-3, copy of identity card of Swaranjit Kaur Ex.C-4, bills Ex.C-5 to Ex.C-34 and closed their evidence.
9. To rebut the evidence of the complainant the opposite parties No. 2 and 3 have tendered into evidence affidavit of Balwinder Singh Ex.OP-2.3/1, copy of letter regarding empanelment of hospital Ex.OP-2.3/2, copy of letter dated 26.5.2015 Ex.OP-2.3/3, copy of insurance policy Ex.OP-2.3/4 and closed the evidence. The opposite party No. 4 also tendered in evidence affidavit of Jagmeet Singh Secretary of opposite party No. 4 Ex.OP-4/1, copy of dispatch list Ex.OP-4/2, copy of Member Enrollment form Ex.OP-4/3 and closed the evidence. The opposite party No. 5 also tendered in evidence affidavit of Dr. Baldeep Singh Ex.OP-5/1, copy of letter regarding empanelment of hospital Ex.OP-5/2, copy of memorandum of understanding Ex.OP-5/3 and closed the evidence.
10. We have heard the learned counsel for the parties and have gone through the record on the file carefully.
11. It is not disputed that complainant Harjinder Singh son of Mal Singh, resident of Mangewal being a Member of the Mangewal MPCASS Limited Village Mangewal opposite party No. 4 had obtained the services of the opposite parties by getting medical insurance vide policy No. 112100/48/14/41/00000029 valid from 16.5.2014 to 15.5.2015. It is also not disputed that the said Harjinder Singh as well as his family members were insured through the said policy. Ex.OP-4/2 is the dispatch list issued by the opposite party No. 1 showing the name of the complainant Harjinder Singh and his wife Swarnjeet Kaur under the head of insured persons. Ex.OP-4/3 is the copy of the Member Enrollment Form which shows the name of the society as the Mangewal M.P. CASS Limited and complainants were members of Bhai Ghanhya Sehat Sewa Scheme. This further shows that the total premium paid by the main member on behalf of the family was Rs. 1,088/-. Ex.OP-2.3/4 is the policy issued by the United India Insurance Company Limited opposite parties No. 2 and 3 which shows the insurer's name as The Bhai Ghanhya Trust and policy No. 112100/48/14/41/00000029 and it is valid from 16.5.2014 to midnight of 15.5.2015. It also shows the net premium paid was Rs. 3,49,21,036/- and the sum assured was Rs. 27,14,49,000/-.
12. Thus it is an admitted fact that the complainants were insured with the insurance company/opposite parties No. 2 and 3 for medical treatment from the period 16.5.2014 to 15.5.2015.
13. Now the next question arises whether there was a privity of contract between the opposite parties for implementation of Bhai Ghanhya Sehat Sewa Scheme. It is relevant to refer the Memorandum of Understanding Ex.OP-5/3. The opening words reads as under.-
“Memorandum of Understanding (MOU) between United India Insurance Company Limited, MD India Healthcare Services (TPA) Pvt. Ltd. and Deep Nursing Home and Children Hospital for implementation of Bhai Ghanhya Sehat Sewa Scheme.
This agreement made at 17 Day of Feb 2014
Between
United India Insurance Co. Ltd.
And
MD India Healthcare Services (TPA) Pvt. Ltd.
And
Deep Nursing Home and Children Hospital
14. The above said Memorandum of Understanding further shows the various terms and conditions. Some relevant provisions of this Memorandum of Understanding reads as under.-
Article 1: Effective Date
1.1 This agreement will be valid from 17 Feb 2014 to 17.2.2015
Article 2: General Provisions
2.1 The hospital shall treat BGSS Policy beneficiaries in a courteous manner and as per good business practices and Standard treatment protocols expected from them.
2.2 The hospital will offer treatment under cashless service and will bill United India Insurance Co. Ltd. as per annexed Rate list subject to the terms and conditions of this MOU.
2.10 The hospital shall not exercise its own and absolute discretion under any circumstances whatsoever to decide upon the coverage/non coverage of the disease/ailment of treatment of the beneficiary. Hospital shall unconditionally abide by the decision of TPA regarding admissibility of any PAL/claim at all times.
The hospital shall not deny cashless treatment to any of the beneficiary until and unless it receives written denial letter from the TPA in response to the PAL sent to the TPA via E-Preauthorization.
Article 11: Termination
11.1 Either party can terminate this MOU by giving 30 days prior notice.
11.2 United India Insurance Co. Ltd. can terminate the MOU without any notice subject to prior approval of the Trust in the following cases:
11.2.1 The hospital violates any of the terms and conditions of this MOU; or
11.2.2. The hospital allows mis-representation in regards to the identity of the beneficiary taking treatment under the scheme.
15. Apart from the above MOU, reference is also made to the guidebook in Punjabi for the period 2014-15 of Bhai Ghanhya Sehat Sewa Scheme. At page No. 30 name of Deep Nursing Home and Children Hospital, Model Town, Ludhiana is mentioned as one of the hospital where the members can get their medical treatment. It is also not disputed that the complainants got the treatment from Deep Medical Hospital, Ludhiana opposite party No. 5 from 27.5.2014 to 3.6.2014 which falls within the policy period. The reason for repudiating the claim of the complainants by the insurance company is mentioned that the opposite party No. 5 Deep Nursing Home was empaneled only for cataract and joint replacement and not for any spinal problem for which the complainants got the treatment from the opposite party No. 5. They have relied upon letter Ex.OP-2.3/4 dated 26.5.2015 written by the opposite party No. 1 to insurance company wherein it is mentioned that Deep Hospital Ludhiana is empaneled only for cataract and joint replacement and therefore the claim was repudiated. In fact this letter was written on the basis of the letter written by Deep Nursing Home opposite party No. 5 to the MD India Healthcare Services (TPA) Pvt. Limited wherein the said Deep Hospital, Ludhiana has mentioned that they want to empaneled only for eye and ortho and for others, they do not agree as the rates were very low. But this letter does not show any date. Moreover, no evidence has been produced by the insurance company or Deep Hospital to show that the said Deep Nursing Home has terminated its agreement prior to the medical treatment of the complainant No. 2. The letter Ex.OP-2.3/4 is written after about one year of the treatment by the opposite party No. 1 to the insurance company. There is no document on record to show that Deep Nursing Home was empaneled only for cataract and ortho. Therefore, the termination of contract by opposite party No. 5 prior to the treatment of the complainant is not proved on the record.
16. Therefore we are the opinion that there is a deficiency in service on the part of the opposite parties by repudiating the claim of the complainants. This view also finds support from the judgment titled National Insurance Company Limited Versus Dharam Singh and others reported in 2011 (1) CPJ-48.
17. Now the question arises as to what amount was spent by the complainants in getting the medical facility from the opposite party No. 5. The complainants have placed on record various bills issued by Deep Drug Store Ludhiana Ex.C-5 to Ex.C-26 and other Indoor bills Ex.C-27 to Ex.C-32 of Deep Nursing Home and one bill of Deep Biodiagnostics Ex.C-34 and another bill of Punjab Pharmacy of Rs. 16,032/- Ex.C-33. The total amount was shown to be spent Rs. 70,874/-. However, it is relevant to refer that the bill of Punjab Pharmacy dated 27.5.2014 does not have any reference by the Deep Hospital nor it is issued by any sister concern of opposite party No. 5 and thus it cannot be taken into consideration. After deducting the amount of Rs. 16,032/- the amount remains to be paid Rs. 54,842/-.
18. As a result of above discussion we are of the opinion that the complaint filed by the complainants is partly allowed and opposite parties No. 2 and 3 are directed to pay Rs. 54,842/- to the complainants alongwith interest at the rate of 9% per annum from the due date till realization. The opposite parties No. 2 and 3 are also directed to pay Rs. 5,000/- as compensation and Rs. 2,100/- as litigation expenses to the complainants. This order shall be complied with within 30 days from the date of receipt of this order. Copy of this order be supplied to parties free of costs. File be consigned to records.
ANNOUNCED IN THE OPEN FORUM:
11th Day of September 2015
(S.K. Goel)
President
(Karnail Singh)
Member
(Vandana Sidhu)
Member
