FORUM  FEROZEPUR.

QUORUM

                             President             :                                      Member               :         S.

                                                                  C.C. No.232 of 2011                 

                                                                  Date of Institution: 2.5.2011

                                                                  Date of Decision: 28.11.2011

Kala                                                   

....... Complainant

Versus

1.       MD India Healthcare Services (TPA) Private Limited, Regional Office D-38, Max-pro Info Park, Industrial Area, Phase-1, Mohali-160056, through its Authorized Signatory.

2.         TPA (Third Party Administrator), SCO 121-123, 1^st Floor, Sector 34-A, Chandigarh, through its President.

                                                (Opposite party No.2 deleted vide order dated 14.6.2011)

3.       The

4.       ICICI Lombard Health Insurance, Near City, through its Branch Manager.

5.       Hospital, Court Road,

                                                                             ........ Opposite parties

Complaint     Section   12  of

                                                                    *        *        *        *        *

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PRESENT :

For the complainant                   :             

For opposite party No.1 & 4    :        

For opposite party No.2            :         Deleted vide order dated 14.6.2011

For opposite party No.3            :        

For opposite party No.5            :         E x-p

                                            ORDER

SANJAY GARG, :-

Complainant  Kala  Singh   has   filed   the   present  complaint

against M.D. India Healthcare Services Private Limited and others pleading that he, being a member of opposite party No.3 Cooperative society, was insured under

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reimburse the said amount on the ground that the complainant is more than 75 years of age and is not eligible for the claim. Complainant has pleaded that he had duly mentioned his age as 75 years, which has also been mentioned on the insurance card. If the complainant was not eligible for insurance claim, the opposite parties should not have issued him the insurance card. So pleading deficiency in service and unfair trade practice on the part of the opposite parties, the complainant has claimed that the opposite parties be directed to pay him the treatment expenses of Rs.8500/- plus Rs.3000/- spent by the complainant on medicines and tests. Further a sum of Rs.50

2.                Notice of the complaint was issued to the opposite parties. Opposite party No.1 and 4 i.e. MD India Healthcare Services Private Limited (TPA) and ICICI Lombard Health Insurance Company, respectively, appeared and filed their common written reply pleading that under

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the complainant.  Dismissal of the complaint has been prayed for.      

3.                Opposite party No.3 i.e. co-operative society has pleaded in its written reply that the liability, if any, to pay the claim is of the insurance company. Opposite party No.3 is not liable to pay any insurance claim to the complainant. However, it has been pleaded that complainant Kala Singh was the member of the cooperative society and requisite premium for availing the insurance coverage under been denied and dismissal of the complaint has been prayed for.

 4.               Opposite party No.5 hospital, in its written reply, has pleaded that the case of the complainant was sent to opposite party No.1, but opposite party No.1 refused authorization for cashless hospitalization. A sum of Rs.8500/- was charged from the complainant. However, it has been denied for want of knowledge that the complainant spent Rs.3000/- on medicines etc. been denied and dismissal of the complaint has been prayed for.

5.                The name of opposite party No.2 i.e.

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Sewa Scheme was deleted from the array of the parties vide order dated 14.6.2011.

6.               

premium is charged from the member and also for each and every other family member so as to give a health insurance cover   and his family members are covered under the scheme, then they are issued insurance cards and after showing those cards, the persons covered under the scheme are entitled to get cashless hospitalization i.e. all the expenses

7.                The said scheme is being implemented by the Government in collaboration with the insurance company for the last so many years. It is not only known to all the cooperative societies, but also to the members of the cooperative societies that the persons above 75 years of age are not entitled to insurance coverage under the scheme. Not only issued

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literatures to the cooperative societies and general public at large, vide which not only the members of the cooperative societies are got

8.                Though the complainant has not concealed the fact that he was above 75 years of age, but still it was the duty of opposite party No.3 cooperative society to properly scrutinize the papers and forward the papers for insurance only of the eligible persons to the insurance company. If due to some mistake, the complainant was issued the insurance card,

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societies in Punjab and members of the cooperative societies are well aware of the said scheme and its conditions etc. The mistake, if any, has been done by opposite party No.3 cooperative society in sending the name of the complainant to the insurance company. In our view, the complainant is not entitled to any insurance claim under the said scheme. However, a duty was cast upon opposite party No.3 to send the names of the persons, who were eligible under the scheme and due to negligence of the officials of opposite party No.3 cooperative society, not only the complainant, but the opposite parties have been forced into litigation. So we dispose off the present complaint and direct opposite party No.3 to pay a sum of Rs.2000/- as compensation to the complainant for wrongly sending his premium to the insurance company. However, complaint against opposite party No.1, 4 and 5 is hereby dismissed. Orders

Announced

                    28.11.2011

                                                                                      (Sanjay                                                                                         President

                                                                                      (

                                                                                       Member