BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.327 of 2014

Date of Instt. 17.09.2014

Date of Decision :04.08.2015

Kuldeep Kaur aged about 60 years wife of Surjit Singh R/o House No.88, Chak Shakoor, Tehsil Jalandhar-2, District Jalandhar under A.R.Circle, Jalandhar.

..........Complainant Versus

1. Med India Health Services (TPA) Pvt Ltd, Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali, Punjab-160056 through its Managing Director.

2. Dr.Kangna, District Coordinator, M.D.India, 50 Golden Avenue, near SGL Hospital, Garha Road, Phase-I, Jalandhar-144002.

3. United India Insurance Company Limited, D.O-1, 19 G.T.Road, Jalandhar through its Divisional Manager.

4. Orthonova Hospital, Nakodar Road, Near Nari Niketan, Jalandhar City through its Managing Director.

5. New India Assurance Company Limited, Divisional Office-II, GT Road, Jalandhar.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.Jupinder Singh Adv., counsel for complainant.

Sh.Raman Sharma Adv., counsel for OPs No.3 & 5.

Sh.MK Jain Adv., counsel for OP No.4.

Service of Ops No.1 & 2 dispensed with.

Order

J.S.Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that she is a senior citizen, uneducated, but had learned to write her own name in Punjabi with the help of family members. She is a domestic woman, wife of Surjit Singh R/o Village Chak Shakoor, District Jalanadhar. Surjit Singh is the man member, who is a member of Kharat Kalan, Co-operative Society Limited, Tehsil & District Jalandhar (The Kharat Kalan MPCASS Ltd), having card No.MD-15-BGSSS-002438 17-S. It is further stated by the complainant that her husband did not get any information about the policy and opposite parties No.1 to 3 neither issued terms and conditions of the policy in question nor circulated, communicated to the main member of Surjit Singh or the complainant but the opposite parties No.1 & 2 have issued identify card No.MD-15-BG SSS-002438-17 SP. The complainant being senior citizen, seriously suffered from knee problem and was feeling very severe pain and mental agony. Then the husband of the complainant went to the incharge of Kharat Kalan MPC ASS Ltd, District Jalandhar on 1.7.2014 and requested the incharge to provide the address/detail of the opposite parties No.2 to 4. The incharge has given the address to the main member Surjit Singh on dated 1.7.2014. Then only complainant approached the opposite party No.4 for treatment of her knee on 4.7.2014. The complainant has got Bhai Ghanahya Sehat Scheme (2014-15) Card No.MO15-BG5588-00243817 SP became member which was governed by the terms and conditions of policy of Bhai Ghanahya Sehat Scheme launched by the department of Co-operative, Punjab. This scheme was insured by the opposite party No.3, which has appointed MedSave Health Co.Ltd as third party administrator (TPA). The complainant had knee problem and approached the opposite party No.4, which is the notified hospital at Sr.No.124 at page 28, as per guide book and list of the Network Hospitals, 2014-15. On 4.7.2014, after check-up, the complainant was told that operation is must for replacement of both knee and asked for date and time for operation. The complainant handed over identify card and election identify card showing details and insurance documents for the purpose of free medical treatment. All these documents were kept by the opposite party No.4. On 5.7.2014, the complainant was admitted for the purpose of operation and she was told by hospital authority that they have confirmed her identify card from the Med Save Health Care (TPA) Ltd to the effect that cashless facility can not be extended in this case, but no reason was given by the opposite party No.4 but assured that they will send her claim after treatment. Therefore, under compelling circumstances, the complainant had to spend an amount of Rs.2,94,691/- and she was discharged on 11.7.2014 from Orthonova Hospital of the opposite party No.4. As per the terms and conditions of Bhai Ghanahya Sehat Scheme, the opposite parties No.1 to 4 were liable to reimburse the entire amount of treatment, to the complainant. Inspite of repeated requests and reminders, the opposite parties did not pay any heed to the genuine request made by the complainant in this regard. The complainant had to suffer mental pain, harassment, humiliation at the Orthonova Hospital. The complainant had to spend the amount of Rs.2,96,691/- for the treatment and replacement of knee under the compelling circumstances. On such like averments, complainant has prayed for directing the opposite parties to pay her Rs.2,94,691/- alongwith interest. She has also demanded compensation and litigation expenses.

2. Upon notice, opposite parties No.3 to 5 appeared and filed their written replies. In its written reply the contesting opposite party No.3 pleaded that no claim whatsoever has been lodged by the complainant with the opposite party No.3. Only request for pre-authorization for cashless treatment was received by the MD India Healthcare Services(TPA) Ltd from Orthonova Joint and Trauma Hospital Pvt Ltd, on 8.7.2014, for pre-authorization for cashless treatment of Kuldeep Kaur for Rs.99,607/- whereupon the MD India Healthcare (TPA) PVt Ltd requested for additional documents/information at the earliest to process pre-authorization letter (PAL) i.e MD India Healthcare Services (TPA) Pvt Ltd, requested the hospital on 9.7.2014 to send fresh DOA with 7 days prior intimation, but there was no response from the hospital to the request of the TPA, as such the opposite party No.1 on 25.11.2014 denied pre-authorization request for cashless treatment of complainant of the Orthonova Hospital vide denial of authorization letter dated 25.11.2014. This Forum has no jurisdiction to entertain, try and decide the present complaint as the opposite party No.3 is not a policy issuing office. The policy has been issued by the Mohali Branch of United India Insurance Co.Ltd to the Bhai Ghanhya Trust, Chandigarh, as such the complaint is liable to be dismissed on the ground of lack of jurisdiction only. Moreover, no cause of action has accrued to the complainant against the opposite party No.3, as such the complaint deserves dismissal. Liability of the opposite party No.3, if any is subject to terms and conditions and guidebook and list of network hospitals under the policy which in case of knee replacement is limited to Rs.1 Lac only. It denied other material averments of the complainant.

3. In its separate written reply opposite party No.4, inter-alia, pleaded that the complainant was admitted in hospital on 5.7.2014 at about 2.30 PM and she was successfully operated upon on 6.7.2014 and she was discharged on 11.7.2014. The relatives of the complainant have submitted the paper alongwith Card under Bhai Khanhiya Trust on 8.7.2014. The same were submitted on the same day to Med India Health Services. So there is no question for making any request by the complainant to avail cashless facility. So question of assuring the complainant for sending her claim after treatment does not arise at all. The opposite party No.4 never took any responsibility in respect of the complainant or opposite parties No.1 to 3. The only part which was to be performed by the opposite party No.4 was to operate the knee joints which were successfully done and the complainant duly made payment before operation. The complainant is putting forth a false story by involving the opposite party No.4 to make out a false case.

4. In its separate written reply, opposite party No.5 pleaded that there is no privity of contract between the complainant and the opposite parties No.5. The opposite party No.5 is not necessary party in the present complaint. The complaint is bad for mis-joinder of necessary party as there is no allegation by the complainant against the opposite party No.4 qua the treatment given to her by opposite party No.4 or any error or omission or negligence in professional service rendered. Without admitting any liability it is submitted that the opposite party No.5 has insured the opposite party No.4 vide policy No.36100036140400000017 for the period 6.6.2014 to 5.6.2015 under the Professional Indemnity Policy for doctors for indemnifying the insured in the claims arising out of bodily injury and/or death of any patient caused by or alleged to have been caused by error, omission, or negligence in professional service rendered or which should had been rendered by the insured. In the present case, there is neither any error nor any omission or negligence on the part of opposite party No.4, as such there is no liability of the opposite party No.5 and the complaint is liable to be dismissed. It denied other material averments of the complainant.

5. Notice to opposite parties No.1 & 2 was dispensed with.

6. In support of her complaint, learned counsel for the complainant has tendered into evidence affidavit Ex.CW/1 alongwith copies of documents Ex.C1 to Ex.C20 and closed evidence.

7. On the other hand, learned counsel for the opposite parties No.3 and 5 have tendered affidavits Ex.OP3/A and Ex.OP5/A alongwith copies of documents Ex.OP3/1 to Ex.OP3/5, Ex.OP5/1 and Ex.OP5/2 and evidence of opposite parties No.3 and 5 was closed by order. Further learned counsel for opposite party No.4 has tendered affidavit Ex.OP/4/A and closed evidence.

8. We have carefully gone through the record and also heard the learned counsel for the parties and further gone through the written arguments submitted on behalf of complainant.

9. The husband of the complainant was insured with opposite party No.3 insurance company under Bhai Ghanahya Sehat Scheme. ExC3 is card in the name of husband of the complainant and Ex.C4 is card in the name of present complainant. According to opposite party No.3, the complainant has never lodged any claim with the insurance company or opposite party No.1 and as such the question of deciding the claim does not arise. Counsel for the opposite party No.3 insurance company contended that complainant had merely applied for pre-authorization for cashless treatment and same was declined as it was submitted after the operation has been performed. Discharge card of the complainant is on record and as per discharge card, she was admitted on 5.7.2014 and discharged on 11.7.2014. According to opposite party No.4 hospital, the operation was performed on 6.7.2014 and the relatives of the complainant have submitted the paper alongwith card under Bhai Ghanahya Sehat Scheme Trust on 8.7.2014 and same were submitted on the same day to Med India Health Service. At the time of arguments, learned counsel for the complainant could not show if the complainant has ever lodged claim with the opposite party No.3 insurance company or opposite party No.1. Even if request for pre-authorization or sending of legal notice or filing of the present complaint is treated as lodging of claim with the concerned opposite party, the fact remains that the opposite party insurance company has not decided the claim of the complainant so far. So we feel that opposite party No.3 insurance company should be given an opportunity to decide the claim of the complainant one way or another i.e either to accept it or reject it, on the basis of documents, if any already submitted by the complainant and further on the basis of documents which she has produced during the trial of the present complaint and further on the basis of documents which the complainant may further submit to the insurance company.

10. In view of above discussion, the present complaint is disposed off with the directions to the opposite party No.3 to decide the claim of the complainant one way or another i.e either to accept it or reject it, on the basis of documents, if any already submitted by the complainant and further on the basis of documents produced by her during the trial of the present complaint and the documents which she may further submit to the insurance company within 15 days from the date of receipt of copy of this order. The complainant is directed to submit any further document to the opposite party No.3 insurance company which she may desire in support of her claim within 15 days and after expiry of said period of 15 days, the insurance company shall positively decide the claim of the complainant one way or another i.e either accept it or reject it within two months positively, on the basis of documents, if any already submitted by the complainant or produced by her during the trial of the present complaint and further on the basis of documents which she may further submit to the insurance company within the said period of 15 days failing which the claim of the complainant to the extent of maximum liability as per guidelines of the claim i.e Rs.1 Lac shall be deemed to have been accepted by the insurance company. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

04.08.2015 Member Member President