Punjab

Fatehgarh Sahib

RBT/CC/327/2018

Shiam Singh - Complainant(s)

Versus

MD India Healthcare Services, Pvt, Ltd - Opp.Party(s)

Samir Rathaur

22 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

COMMISSION, FATEHGARH SAHIB

                                                             

RBT No.	:	CC/327/2018
Consumer  Complaint No.	:	RBT/CC/327/2018
Date of Institution	:	19.03.2018
Date of Decision	:	22.6.2023

 

Shiam Singh son of Late Sh. Abhimanyu Singh, aged about 60 years, resident of V.P.O Sotal Baba, Tehsil Chamkaur Sahib, District Ropar, Punjab.                                                                   

…………....Complainant

                                        Versus

1. MD India Healthcare Services (TPA) Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-1. Mohali, Punjab-160 056.
2. ICICI Lombard, Registered address: ICICI Lombard House 414, P. Balu Marg, Off: Veer Sawarkar Marg, near Sidhivinayak Temple, Prabhadevi, Mumbai-400025.
3. Bhai Ghaniya Trust, C/o The Punjab Institute of Co-operative Training Limited, SCO-2945-46, near Patrol Pump, Sector-22/C, Chandigarh.
4. Mayo Healthcare, Super Specialty Hospital, Sector 69, Near Gurudwara Singh Shaheedan, SAS Nagar Mohali, Punjab (Complaint not admitted against it, vide order dated 5.4.2018).
5. The Paprali MPCASS Limited, through its Secretary, Village & Post office Paprali, Tehsil Chamkaur Sahib, District Ropar, Punjab.

                                                        …….......Opposite Parties

Complaint under Section 12 of Consumer Protection Act 1986 (Old)

Quorum

Sh. S.K. Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

 

Present:  None for complainant.

              None for OPs No.1, 2 and 3.

              Complaint against OP No.4 not admitted.

                 

PER MS. SHIVANI BHARGAVA, MEMBER:

This complaint has been filed against the OPs (opposite parties) under Section 12 of Consumer Protection Act, 1986 alleging deficiency in service with the prayer for giving direction to the OPs to reimburse the amount incurred by the complainant on his treatment in the Mayo Healthcare, Super Speciality Hospital, Mohali along with interest @ 24% on the said amount from 23.9.2016 and to pay compensation for harassment and litigation expenses to the complainant.

2.     Brief facts of the case are that the complainant is a member of OP No.5 being registered Member of the said Society.  The complainant deposited the premium amount for availing the benefit of medical insurance scheme; namely, ‘Bhai Ghanihya Sehat Sewa Scheme” by Punjab Government.  OP No.2 i.e. ICICI Lombard Insurance Company issued Card MD15-BGSSS-00516692-S under Bhai Ghanihya Sehat Sewa Scheme to the complainant. It was cashless medical policy.  On 22.9.2016 the complainant suffered difficulty while passing urine and the complainant was admitted in Mayo Hospital i.e. OP No.4 from 23.9.2016 to 24.9.2016. The complainant was medically operated upon and a surgery of right URSL+PNLT+DJ stenting was done under SA on 23.9.2016. He was advised PUC removal on 27.9.2016 and stent removal after two weeks in his discharge summary besides other medicines. Although the complainant as per medical insurance cover provided to him was to be provided with Cashless Medical Facility in the Hospital but the Hospital charged various amounts from the complainant on different pretexts inter-alia on account of medicines. The invoices of medicines issued to the complainant amounting to Rs.1,680/- & Rs.270/- were dated 24.9.2016 and 27.9.2016. The Hospital also charged Rs.2,500/- on account of OPD DJ stent removal; a sum of Rs.600/- on account of consultation charges and another sum of Rs.450/- for medicines on 4.10.2016. The complainant was charged another sum of Rs.15,000/- by the Hospital. The complainant after his discharge from the Hospital duly represented his case with the Third Party Administrator “MDINDIA (TPA)” i.e. OP No.1. The complainant was being told in the office of TPA that the matter at their end was being taken up with the hospital but since it required detailed documentation at the end of the hospital, therefore, these normally takes time ranging from 5 to 6 months. The complainant till date of filing of the complaint was not refunded the amount despite his entitlement to the cashless medical facility.  Hence, this complaint.

3.     Notice of the complaint was given to OP Nos.1, 2, 3 and 5 through registered post. The complaint against OP No.4 was not admitted, vide order dated 5.4.2018. OPs Nos.1, 2 and 3 appeared through their counsel.  OP No.5 appeared through its Representative and filed written version.

4.     The complaint has been contested by OPs No.1 and 2 and they jointly filed written version by raising various legal objections.  The complainant had already received Rs.10,495/- on 20.10.2016 in lieu of his claim from OPs.  In the present case it is admitted case of the complainant and other OPs that the required premium was never reached to Insurance Company and accordingly there was no commencement/ retention of risk by the Insurance Company. Hence denying any deficiency in service on their part, OPs Nos.1 and 2 have prayed for dismissal of complaint.

5.     The complaint has been contested by OP No.3 and filed written version by raising various legal objections that Bhai Ghanihya Trust is a registered Nodal Agency for the monitoring and implementation of the Bhai Ghanihya Sehat Sewa Scheme, which is meant for providing Healthcare Service to the members and employees of the Cooperative Societies and Cooperative Department. For implementation of “Bhai Ghanihya Sehat Sewa Scheme” OP No.3 appointed the ICICI Lombard General Insurance Company Ltd. i.e. OP No.2 as “Insurer” for the period from 1.1.2016 to 31.12.2016 which further appointed OP No.1 i.e. the MD India Healthcare Service Pvt. Ltd., as Third Party Administrator.  According to the provisions of the Bhai Ghanihya Sehat Sewa Scheme, the Third Party Administrator was responsible for issuing of Identity cards to the beneficiaries, for inspection of hospitals and thereafter to recommend them to be taken on panel of hospitals, to grant authorizations, to settle the claims of hospitals and beneficiaries, to make the payments to the empanelled hospital for providing cashless services to the beneficiaries of the scheme on receipt of money from the Insurer or to reimburse the payment to the concerned beneficiaries.  The claim, if any, is to be settled by TPA.  As the complainant is a ‘consumer’ of OPs Nos.1 and 2, as they were the service providers and claim settling authorities under the scheme.  Therefore, if they have failed to comply with the provisions of the Scheme, they may be held liable for the same. Denying any deficiency in service on its part a prayer for dismissal of the complaint was made against OP No.3.

6.     The complaint has been contested by OP No.5 and filed written version by raising various legal objections that Shiam Singh was a Member of the Paprali MPCASS Ltd., Paprali and cardholder of Bhai Ghanihya Scheme. OP No.5 is not aware about the fact that Shiam Singh, complainant, was admitted in any Hospital. OP No.5 has no knowledge about the fact that he had received the payment from any authority for his medical bills.  Denying any deficiency in service on its part a prayer for dismissal of the complaint against it has been made.

7.     In support of his complaint, the complainant has filed his own affidavit dated 29.1.2018 and copies of documents along with complaint i.e. copy of Insurance Membership Card, Annexure C-1, copy of Discharge Clearance/Medical Record as Annexure C-2, copies of sale invoices as Annexure C-3 (colly), copies of OPD Procedure Receipt dated 4.10.2016 as Annexure C-4 (Colly) and copy of receipt dated 23.9.2016 for Rs.15,000/- issued by May Hospital as Annexure C-5.   In rebuttal, OP No.3 along with written version annexed documents i.e. copy of orders of Hon’ble State Commission, as Annexure OP-3/1 and copy of certain regulations as Annexure OP-3/2.

8.     The case had been called several times during the day. Neither the complainant nor the OPs nor any of their Representatives appeared on their behalf. Since the complaint pertains to year 2018, therefore, we have proceeded to decide the complaint on merits on the grounds advanced before us by both the parties. We have also gone through the written arguments submitted by opposite parties Nos.1 and 2.

9.     Admittedly. the complainant is beneficiary of Bhai Ghanihya Sehat Sewa Scheme being run by the Punjab Government for the members of Cooperative Societies to provide cashless medical insurance for which he was issued Identity Card, Annexure C-1, by OPs Nos.1 and 2-Insurance Company.  The complainant spent Rs.20,500/- on his treatment in Mayo Hospital, Mohali, which is proved from sale invoices/receipts, Annexure C-2 to Annexure C-5. OPs Nos.1 and 2 did not reimburse his insurance claim. OPs Nos.1 and 2 averred that they paid an amount of Rs.10,495/- to the complainant but there is no evidence on record to prove that said amount was paid to the complainant. It’s an evasive reply on behalf of the OPs that Annexure C-5 is not a bill/receipt. 

10.   We are of the considered opinion that the real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had duly taken the treatment and factum of treatment is supported by records duly certified by Doctors/hospital concerned.  The relevant authorities are required to be more responsive and cannot act in a mechanical manner to deprive an employee of his legitimate reimbursement.  Therefore, OP No.2-ICICI Lombard Insurance Company is held liable for deficiency in service for not reimbursing the genuine insurance claim of the complainant. 

11.   OP No.2 has not furnished any list showing the payment after deduction as per policy rules.  Thus the amount submitted by the complainant is to be taken  as correct .The cashless mediclaim is to be reimbursed by OP No.2-Insurance Company. OP No.1 is claim processing agency, which is just to process the claim. OPs Nos.3 to 5 are proforma OPs.

12.   Keeping in view the facts and circumstances of the present case, the present complaint is partly allowed against OP No.2 and is dismissed against other OPs. OP No.2 is directed as under:-

[a]      To pay Rs.20,500/- to the complainant along with interest @ 9% per annum from the date of filing of compliant within a period of 30 days from the date of receipt of certified copy of this order, failing which rate of interest shall be @ 12%;

[b]     To pay Rs.15,000/-, as compensation, for  harassment and mental tension suffered by him including  litigation expenses.

Copies of this judgment be sent to the parties as per rules.  The complaint could not be decided within the statutory period due to pandemic of Covid-19 and paucity of staff.  File be sent back to District Consumer Disputes Redressal Commission, Mohali, for consignment.

 

 

(S.K. AGGARWAL)

     PRESIDENT

 

 

(MS. SHIVANI BHARGAVA)

                MEMBER

 

 

 (MANJIT SINGH BHINDER)

                MEMBER

Pronounced on : 22.06.2023