Punjab

Fatehgarh Sahib

CC/63/2015

inderjit Singh - Complainant(s)

Versus

Md India health Care - Opp.Party(s)

G.S Marwa

11 Jul 2016

ORDER

  DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                            Consumer Complaint No.63 of 2015

                                                        Date of institution:  21.07.2015                                   

                        Date of decision   :  11.07.2016

Inderjit Singh, aged about 23 years, son of Balwinder Singh, resident of village Naulakha, Post Office, Rurki, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

1. The M.D.India Health Care Services, (T.P.A.) Private Limited, Maxpro Info Park, D-38, Phase I, Industrial Area, Mohali through its authorized Signatory.
2. The Naulakha MPCSS Ltd., Village Naulakha, Tehsil & District Fatehgarh Sahib through its authorized signatory.
3. United India Insurance Company Ltd., Divisional Office, SCO 72, Phase IX, Mohali, through its Divisional Manager.

 

…..Opposite parties

Complaint under Sections 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.Cl. for the complainant.                                                                   Sh. Narinder Kumar Sharma, Adv.Cl. for OPs No.1&3.                                          Sh. S.S.Maan, Adv.Cl. for OP No.2.

ORDER

 

By Ajit Pal Singh Rajput, President

                      Complainant, Inderjit Singh, aged about 23 years, son of Balwinder Singh, resident of village Naulakha, Post Office, Rurki, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite Parties (hereinafter referred to as “the OPs”) under Sections 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.                   The complainant is a member of the Naulakha MPCSS Ltd. i.e. Co-operative Society, Village Naulakha, Tehsil and District Fatehgarh Sahib, OP No.2. The said society offered insurance scheme to its members through OP No.1, MD India Health Care Service( under its Bhai Ghanhya Sehat Sewa Scheme). As per said scheme there is a provision that member alongwith his whole family members can be 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.1. The OPs issued identity card bearing No. MD15-BGSSS-00214449-SN1 to the complainant and identity card bearing No.MD-15-BGSSS-00214449-SP to his mother, namely; Smt. Harwinder Kaur. As per settled terms and conditions of the said insurance policy, the person who joins as member, the medical facilities are being provided totally free of costs. The complainant was admitted in Amar Hospital( one of the listed hospital as shown in the guide book), vide admission No.2014005303, for the treatment of Gastroenterology and he was operated for the said disease. The total expenditure incurred on the treatment and medical expenses were borne by the complainant at his own.  During treatment 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.3.  The said hospital also sent a request for cashless hospitalization form to OP No.1 under the said scheme and all the facts regarding treatment are mentioned in the said form. When OPs did not give any response to the said hospital regarding the payment of expenses incurred on treatment under the said scheme, then the complainant personally approached the OPs and requested to pay the medical expenses borne by him as per the terms and condition of the policy.  But the OPs put off the matter on one pretext or the other and harassed the complainant by not making the payment of treatment despite the policy of insurance under the said scheme.  The OPs refused to make the payment of medical expenses borne by the complainant by alleging that the said hospital is not covered under the scheme. Earlier the complainant filed a consumer complaint No.CC/149/14 before this Forum and the same was withdrawn by the complainant and the complainant was given liberty to again approach this forum on the same cause of action. Thereafter the complainant filed the claim by submitting relevant documents but the claim of the complainant was not passed. The complainant also served legal notice to the OPs but in vain.  The act and conduct of the OPs shows clear cut deficiency in service and negligence on their part. Hence this complaint for giving directions to the OPs to pay an amount of Rs.45,000/- as medical expenses and further to pay Rs.35,000/- as compensation for mental agony and physical harassment suffered by the complainant.

3.                   The complaint is contested by the OPs and OPs No. 1 and 3 filed joint written reply, in which they raised certain preliminary objections, inter alia, that the present complaint is not maintainable in the present form and the complainant has suppressed the true and material facts from this Forum. As regards to the facts of the complaint they stated that OP No.1 issued Group Mediclaim Policy in favour of Bhati Ghanhiya Turst. The policy of insurance/agreement bearing BGSSS card No. MD15-BGSSS-0214449, CCN MD10039974 was executed under the said scheme, covering the members and employees and their family members of the eligible cooperative societies covering the risk of treatment of medical diseases requiring minimum 24 hours hospitalization up to an expenditure of Rs.1,50,000/- per year per family on floaters basis subject to the terms and conditions of the scheme as detailed in the Guide Book issued by MD India Health Care Services(TPA) Pvt. Ltd., through the network hospital/nursing homes listed in the Guide book. It is further stated that after thorough investigation, the claim of the complainant was repudiated by OPs No. 1 and 3 as the same does not cover the terms and conditions of policy of insurance issued by OP No.1.  After considering the claim of the complainant under the terms and condition of the policy, it was found that the claim is not payable as the claim documents were received late. The complainant was discharged on 06.09.2014 and thereafter he submitted the claim file to TPA office on 25.04.2015 i.e. after 231 days from the date of discharge from the hospital. As per the terms and conditions of the policy, the claim is not payable if the claim documents are received after 60 days from the date of discharge of the treated patient. Moreover, the complainant took treatment from Amar Hospital, Patiala, which had been withdrawn from BGSSS provider network on 15.07.2014. Therefore, the claim of the complainant was rightly repudiated by the OPs. Hence, 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.2 stated that the Government gave instructions to it through DRCS, Fatehgarh Sahib to make the members under the Bhai Ghanhiya Sehat Sewa Scheme and to suggest the members to the society regarding the said scheme. Accordingly, the society suggested the said scheme to its members and the complainant was made member of the said scheme through it.  The complainant deposited the premium and it sent the same to Bhai Ghanhiya Sehat Sewa Trust Chandigarh through demand draft.  The matter is between complainant and OPs No.1 & 3 and OP No.2 has no fault and it is not liable to pay any claim or compensation to the complainant in any manner. After denying the other averment made in the complaint, OP No.2 prayed for dismissal of the complaint qua it.

5.                   In order to prove the case the complainant tendered in evidence his affidavit Ex. C-1, legal notices dated 16.06.2015 Ex. C-2 & C-3, postal receipts Ex. C-4 & C-5, copy of previous complaint filed in this Forum Ex. C-6, copy of order dated 08.04.2015 Ex. C-7, copy of Identity card Ex. C-8, copy of guide book Ex. C-9, treatment record Ex. C-10 to C-28 and closed the evidence. In rebuttal OPs No. 1 & 3 tendered in evidence affidavit of Sh. Harmel Singh, Assitant Manager, Ex. OP3/1, along with true copies of documents, i.e. guide book Ex. OP3/1/A, letter dated 27.08.2015 Ex. OP3/2, receipt Ex. OP3/3, reports Ex. OP3/4 to OP3/7, final break up bills Ex. OP3/8 to OP3/16, case summary card Ex. OP3/17, letter dated 22.04.2015 Ex. OP3/8, card issued by OP Ex. OP3/19, order of this Forum Mark-A and also tendered in additional evidence attested copy of detailed guide book Ex.OP3/20( containing 1 to 50 pages),  attested copy of insurance premium details Ex. OP3/21 and  closed the evidence. No evidence has been lead by OP No.2.

6.                   The ld. counsel for the complainant has submitted that the main controversy involved in the present case is, that OPs No.1 & 3 had repudiated the claim of the claimant vide letter dated 27/08/2015 by stating “We wish to submit that Non-Cashless Claim file of said case was rejected because: 1) Claim documents received after 60 days of date of discharge of the treated patient. From DOA – 05.09.2014 to 06.09.2014 and submitted claim file to TPA office on date 25.04.2015 (Which is after lapse of 231 days). Accordingly to policy terms & conditions claim documents received after 60 days of date of discharge of the treated patient is not payable; 2) Patient took treatment in Amar Hospital Patiala from 05.09.2014 to 06.09.2014, but the said hospital has withdrawn from BGSSS provider network dated 15.07.2014. Hence claim is not payable under the scheme.", in an arbitrary manner. The ld. counsel pleaded that as per the booklet i.e Ex.C-9, Amar Hospital was on the list of network Hospitals and keeping in view the bills i.e Ex.C-18 to Ex.C-27 submitted by the complainant, OPs No.1 & 3 were bound to reimburse the claim of the complainant. The ld. counsel also pleaded that it is proved from the medical treatment documents placed on record that complainant had taken treatment from Amar Hospital, Patiala. He further pleaded that Amar Hospital had also forwarded the claim case of the complainant to the OPs. The ld. counsel argued that as and when the Amar Hospital was removed from the list of network hospitals, it was the duty of the OPs to intimate the same to the complainant. He also argued that in case the said fact was within the knowledge of the complainant, he would not have taken treatment from Amar hospital. The ld. counsel further argued that it is well established from the act and conduct of OPs No.1 & 3 that they had committed deficiency in service and complainant deserves to be compensated for the same.

7.         On the other hand, the ld. counsel for OPs No. 1 & 3 objected to the contentions made by the ld. counsel for the complainant. He stated that it was not possible for Amar hospital to forward the cashless claim of the complainant as on 15/07/2014 the said hospital had withdrawn from BGSSS provider network and complainant took treatment from 05/09/2014 to 06/09/2014. The ld. counsel pleaded that in fact, the complainant should have grievance against Amar hospital as due to negligence act of Amar hospital, complainant had to suffered as alleged. The ld. counsel also pleaded that the claim was repudiated purely on the basis of the terms and conditions stated in the booklet i.e Ex.OP3/20, miscellaneous clause mentioned in the guidebook at Sr.No.2, that “no claim from the beneficiary shall be entertained for processing and settlement by TPA, if received after 45 days from the date of discharge from the Govt. Hospital”. He further pleaded that complainant was discharged on 06.09.2014 and thereafter the claim file was submitted to TPA office on 25.04.2015 i.e. after 231 days from the date of discharge from the hospital and the complainant has also failed to give any justification for the delay. The ld. counsel argued that the complainant has failed to prove his case from the evidence produced on record and the present complaint deserves to be dismissed with special cost.

8.                   On the other hand, the ld. counsel for OP No.2 submitted that the OP society suggested the said scheme to its members and the complainant was made member of the said scheme through it. He pleaded that OP No.2 has no involvement in decisions made by OPs No.1 & 3. The ld. counsel further pleaded that the present complaint be dismissed qua OP No.2, as no deficiency of service had been  committed by the OP.

9.                   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 find force in the submissions made by the ld. counsel for the OPs. In our opinion the claim of the complainant had been repudiated mainly on two grounds; unexplained delay of 231 day in submission of cashless claim. Treatment taken from non-network hospital. In our opinion OPs No.1 & 3 repudiated the cashless claim of the complainant, keeping in view the terms and conditions of the guidebook i.e Ex.OP3/20. As per the miscellaneous clause of guidebook at Sr.No.2, “no claim from the beneficiary shall be entertained for processing and settlement by TPA,if received after 45 days from the date of discharge from the Government Hospital”. Whereas in case of complainant; claim was filed after 231 days i.e 25/04/2015. In our opinion, complainant has miserably failed to give a reasonable explanation with regard to the delay. It is also evident from the medical treatment record i.e Ex.C-5 to Ex.C-22 that the complainant had got treatment from Amar Hospital,Patiala. In our opinion the complainant has failed to prove his case from the evidence produced on record. With regard to OP No.2,we are of the opinion that OP No.2 does not have any kind of involvement with regard to decision making of the claim. The complainant has failed to produce any evidence on record, that can establish that the Amar Hospital,Patiala was on the list of network of hospitals at the time of availing the treatment and it had timely forwarded his claim to the OP no.1 & 3.

10.                 Accordingly in view of our aforesaid discussion, we find that the OPs had not committed any deficiency of service by repudiating the claim of the complainant, the same had be rejected in view of the terms and conditions. Hence the present compliant is hereby dismissed being devoid of any merit.

11.                 The arguments on the complaint were heard on 08.07.2016 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:11.07.2016

(A.P.S.Rajput)                           President

 

(Veena Chahal)                         Member

 

      (A.B.Aggarwal)                        Member