Punjab

Fatehgarh Sahib

CC/140/2014

Balwinder singh - Complainant(s)

Versus

MD India Heath care service - Opp.Party(s)

Sh SS Maan

15 Jan 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                            Consumer Complaint No.140 of 2014

                                                        Date of institution:  25.11.2014     

                                                           Date of decision   :  15.01.2016

Balwinder Singh aged about 40 years son of Sh. Sucha Singh r/o village Mehmoodpur, Post office Shamashpur, Tehsil Amloh, District Fatehgarh Sahib.

……..Complainant

Versus

1. The M.D.India Health Care Services, (TPA) Pvt. Ltd; Maxpro Info. Park, D-38, Phase-I, Industrial Area Mohali, Punjab(160056), through its authorized signatory/M.D.
2. The United India Insurance Co. Ltd; Registered office, 24, Whites road, Channai 600014 through its authorized signatory/Chairman/MD.
3. The Kaulgarh MPCASS Ltd; Kaulgarh, Tehsil Amloh District, Fatehgarh Sahib, through its Secretary.
4. Satguru Partap Singh Apollo Hospital Ludhiana, near Sherpur Chowk, Ludhiana, through its authorized signatory.

…..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.Maan, Adv.Cl. for the complainant.                                             Opposite Party No.1 exparte.                                                           Sh. Narinder Kumar Sharma, Adv.Cl. for OP No.2.                                   Sh. P.C.Joshi, Adv.Cl. for OP No.3.                                                   Sh. G.S.Sandhu, Adv.Cl. for OP No.4.

 

ORDER

Ajit Pal Singh Rajput, President

                  Complainant, Balwinder Singh aged about 40 years son of Sh. Sucha Singh r/o village Mehmoodpur, Post office Shamashpur, Tehsil Amloh, District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “OPs”) under Sections 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.               The complainant is the member of opposite party No.3 and having account/K.C.C. No.6/110. As per the policy of Government, the complainant become the member of Bhai Ghaniya Sehat Sewa Scheme and paid the requisite membership fee/premium of Rs.967/- on dated 23.01.2014 to OP No.1 and 2 through OP No.3 for the same. Opposite parties No.1 and 2 have issued the valid Health Card No.MD15/BGSSS-00211042-S in the name of complainant. As per the terms and conditions of the above said policy, opposite parties  No.1 and 2 are bound to bear the expenses of health treatment of their members. The complainant suffered pain in the backbone/spine of his body and he remained admitted in Satguru Partap Singh Apollo Hospital Ludhiana from 05.06.2014 to 11.06.2014, the said hospital is in the panel list under the said scheme. The complainant was operated in the said hospital and spent Rs.1,82,733/- on his treatment. At the time of treatment the complainant showed the health card to the said hospital to get his treatment free of cost under the said scheme, but the concerned doctors/hospital authorities had got deposited all the expenditure incurred on treatment with an assurance that after completion of the treatment, the same will be refunded by MD India & Insurance Company to the complainant. Thereafter, complete insurance claim file was sent to OPs No.1 and 2 to get the reimbursement of amount spent on treatment i.e. Rs.1,82,733/- but the OPs No.1 and 2 have refused to pay the same, which amounts to great deficiency in service and unfair trade practice on the part of the OPs. The complainant also got issued a legal notice on 26.09.2014 through registered post but in vain. Hence, this complaint for directing OPs No.1 and 2 to reimburse the treatment amount of Rs.1,82,733/- along with Rs.50,000/- as compensation on account of mental agony and harassment suffered by the complainant.

3.               The complaint is contested by OPs No.2 to 4 but OP No.1 failed to appear to contest this complaint. Hence, he was proceeded against exparte.

4.               In reply to the complaint OP No.2 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 the facts of the complaint, OP No.1 stated that the complainant was member of Bhai Ghaniya Sehat Sewa Scheme and it is specifically mentioned in the policy of insurance/agreement/guide book that the person under BGSSS may take treatment in Government hospitals of Punjab and Chandigarh as detailed in the list of Network Hospitals and Nursing homes. It has been clearly written/mentioned under the name of SPS Apollo hospital, Ludhiana at Sr. No.175 that this hospital is eligible to treat the patients under the scheme for Cardiac Patients and patients under treatment of joint replacement only. The complainant has not taken any medical treatment from SPS Apollo Hospital Ludhiana, which can be covered under the scheme. Therefore, the claim of the claimant is not payable as per terms and conditions of the policy. The OPs are not bound to bear the expenses of health treatment of their members. It is specifically stated that every policy/contract of insurance is to be based on settled terms and conditions to which the insured has to follow the same. But the complainant did not fulfill the terms and conditions of policy of insurance, as such, OPs were not bound to make the payment of his treatment to the concerned hospital. After denying the other averments made in the complaint, it prayed for dismissal of the complaint.

4.               In reply to the complaint OP No.3 raised certain preliminary objections, inter alia, that the complaint is not maintainable; the complainant is stopped by his own act and conduct to file the present complaint; the complaint is false, frivolous and vexatious; the complainant has no locus standi or cause of action to file the present complaint and this Forum has got no jurisdiction to try and decide the present complaint. As regards the facts of the complaint, OP No.3 denied the other averments made in the complaint and prayed for dismissal of the complaint.

5.               In reply to the complaint OP No.4 stated that the complainant got treatment from it and in lieu of treatment provided to complainant, it charged the expenses of treatment from the complainant. At that time, the complainant did not disclose any fact about the alleged policy. There is no deficiency in service or unfair trade practice on its part and even the complainant himself does not claim any relief against it. After denying the other averments made in the complaint, OP No.4 prayed for dismissal of complaint qua it.

6.               In order to prove the case, the complainant tendered in evidence attested copy of Kissan Co-operative Credit Card Ex. C-1, attested copy of receipt No.861297 Ex. C-2, attested copy of guide book and network of hospitals Ex.C-4, original discharge summary Ex. C-5, original retail invoice/bills(colly) Ex. C-6, claim form Ex. C-7, copy of legal notice Ex. C-8, postal receipts Ex. C-9 and C-10, affidavit of complainant Ex. C-11 and closed the evidence. In rebuttal OP No.2 tendered in evidence affidavit of Harmail Singh, AM Ex. OP2/12 along with true copies of documents Ex.OP2/1 to OP2/11/A and closed the evidence.  No evidence has been led by  OP No.3 and 4. Therefore, their evidence was closed by order.

7.               The ld. counsel for the complainant has submitted that the main controversy involved in the present case is that the claim of the complainant was repudiated i.e Ex.OP2/11/A, as the complainant had got himself treated from the network hospital which was not authorized to treat the diseases being suffered by the complainant. The ld. counsel stated that even if OP No.4 was not authorized to provide the treatment, OP No.1 was bound to  reimburse the amount for which the complainant would be entitled to if he had got himself treated from the empanelled Hospital, authorized to treat the nature of the disease complainant was suffering from. The ld. counsel pleaded that it is a admitted fact that the complainant was insured and was also entitled for reimbursement of the total expenses of Rs.1,50,000/- lakh per year, per family on floaters basis and the same has been stated by the Asst. Manager in his statement in para no.2 i.e Ex.OP2/12.The ld. counsel argued that the complainant was entitled to receive Rs.1,50,000/- and the claim of the complainant was rejected without application of mind and in a technical manner. The ld. counsel further argued that  OP No.1 & 2 committed deficiency of service while repudiating the claim of the complainant in arbitrary manner.

            

8.               On the other hand, the ld. counsel for OP No.2 has stated that the claim of the complainant had been rightly repudiated as the SPS Apollo Hospital was empanelled to treat the patients under the scheme for Cardiac Patients and patients under treatment of joint replacement only as mentioned in the repudiation letter i.e Ex.OP2/11/A. The ld. counsel also stated that it is clearly mentioned in the guide booklet i.e Ex.OP2/3 at Sr.No.175 that the OP no.4/hospital was empanelled but not authorized to provide treatment for Neuro Surgery related patients. The ld. counsel argued that since the claim of the complainant was not covered under the terms and conditions of the policy, therefore the same had to be repudiated.

9.               The ld. counsel for OP 3 stated that the OP has been impleaded as party for the purpose of jurisdiction only. He submitted that the OPs role was only to enroll the persons under the scheme and the liability to reimburse the claim amount was that of OP no.1 and 2. The ld. counsel further submitted that the present complaint deserves to be dismissed qua the OP.

10.             The ld.counsel for OP no.4 submitted that the complainant was admitted in emergency state and the moral duty of OP no.4 was to save the life first. The ld. counsel also submitted that at the time of the admission the ID card issued by OP no.1 & 2 was never shown to the OP and therefore they were unable to take pre-authorization before giving the treatment. The ld. counsel argued in case the relative/guardian would have produced the ID card issued by OP No.1 & 2 the OP would have mentioned the name of OP No.1 & 2 in the column of sponsor. He further argued that it is well established from Ex.C-6 (colly) that in Column of  sponsor it is stated “Cash” that proves that the complainant nor his relatives  produced the ID card issued by OP No.1 & 2 before treatment and it was only after the payment the complainant showed the said ID card and the claim of the complainant was processed .   

11.             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 that there is merit in the submissions made by the Ld. Counsel for the complainant. In our opinion as per the guide booklet clause 1.1 to 1.9.10  i.e Ex.OP2/3 and the statement of the Assistant Manager i.e Ex.OP2/12 the complainant was entitled for reimbursement of the total expenses of Rs.1,50,000/- lakh per year, per family on floaters basis. OP no.1 & 2 simply cannot escape from their liability by stating the network hospital was not authorized to give treatment therefore the said claim of the complainant be rejected. In our view, OP no.1 & 2 were suppose to get the estimate from the empanelled/network hospital authorized to provide treatment for neuro surgery cases i.e Sobti Neuro & Super Specialty  Hospital,Ludhiana mentioned at Sr.No.174 in the guide booklet i.e Ex.OP2/3 issued by OP No.1 or as per the clause 1.1 to 1.9.10  mentioned in the booklet.

12.             Accordingly in view of the aforementioned discussion, we find that OP no.1 & 2 had repudiated the claim of the complainant merely on the technical ground and thus had committed deficiency of service. In our opinion OP no.3 & 4 had not committed any act of negligence. Hence we direct OP no. 1 & 2 to reimburse the claim of the complainant after getting the estimate/costs from the empanelled/network Hospital authorized to provide treatment for Neuro Surgery cases i.e Sobti Neuro & Super Specialty Hospital mentioned at Sr.No.174 in the guide booklet i.e Ex.OP2/3 issued by OP No.1 or as per the clause 1.1 to 1.9.10 i.e Rs.1,50,000/- lakh per year, per family on floaters basis, as per the booklet being relied upon by the OPs. OP No.1 & 2 are further directed to pay  compensation on account of mental as well as physical harassment suffered by complainant amounting to Rs.15000/- alongwith litigation cost of Rs.5000/-. OP No. 1 & 2 are directed to comply with the order of this Forum within 45 days from the date of receipt of the same. In case the OPs are unable to comply with this order they shall be liable to pay 9 % interest per Month till its realization. The present complaint stands accepted against OP No.1 & 2.  

 

    

10.                          The arguments on the complaint were heard on 11.01.2016 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: 15.01.2016

(A.P.S.Rajput)      

 President

 

                                                                               (Veena Chahal)

                                                                                    Member

 

(A.B.Aggarwal) 

  Member