DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH [Complaint Case No:170 of 2010] Date of Institution : 22.03.2010 Date of Decision : 07.07.2011 ---------------------------------------------- Sh. Bharpur Singh son of Sh. Hari Singh, resident of Village Chhajli, Tehsil Sunam, District Sangrur. ---Complainant. V E R S U S 1. Medsave Health Care (TPA) Ltd., SCO No.121-122-123, 2nd Floor, Sector 34-A, Chandigarh through its G.M./M.D. 2. The Chhajli Cooperative Agriculture Service Sabha Ltd., Branch Chhajli, Tehsil Sunam, District Sangrur through its Secretary. 3. National Insurance Company Limited through its Manager (Full Address as disclosed by OPs No.1 & 2.). ---Opposite Parties. BEFORE: SHRI LAKSHMAN SHARMA PRESIDENT SMT. MADHU MUTNEJA MEMBER Argued By:Sh. Ajay Singh Parmar, Advocate for the complainant. Sh. Gaurav Bhardwaj, Advocate for OPs No.1 & 3. OP No.2 exparte. PER LAKSHMAN SHARMA, PRESIDENT Sh. Bharpur Singh has filed this complaint under section 12 of the Consumer Protection Act, 1986 praying therein for the following reliefs:- i) To pay a sum of Rs.1,03,000/- to indemnify the expenditure incurred by the complainant on his treatment. ii) To pay a sum of Rs.10,000/- as compensation for mental agony, harassment and inconvenience. iii) To pay litigation expenses. 2. In brief, the case of the complainant is that he is a Member of The Bhai Ghanhya Trust. The said trust took a Group Insurance Policy from OP No.3 known as “Group Mediclaim-Tailor Made with Floater”. As per the terms of the said policy, every member of the said trust was entitled for indemnification of the expenditure incurred on the treatment taken by the member. According to the complainant, he suffered fracture neck (femer Rt.) and for the treatment of hernioplasty, was admitted in Bassi Nursing Home, Rajpura Road, Near Dhobi Ghat, Civil Lines, Ludhiana, where he was operated upon. The complainant spent a sum of Rs.1,03,200/- on his treatment. According to the complainant, even prior to the operation (at the time of admission), the concerned doctor had intimated the Insurance Company about the nature of ailment and about the expenditure to be incurred on such ailment. However, according to the complainant, OP approved only a sum of Rs.14,621/-. Later on the complainant approached the OP and requested that as he has spent a sum of Rs.1,03,200/- on his treatment, the said amount be paid to him and he be indemnified for the expenditure incurred on his treatment. However, the officials of OP refused to do so. Ultimately, the complainant filed a consumer complaint before the District Consumer Disputes Redressal Forum, Sangrur. Finding that the said Forum has no jurisdiction over the matter, the complainant withdrew the complaint and filed a fresh complaint before this Forum praying for the reliefs mentioned above. 3. In the written statement filed by OPs No.1 and 3, it has been admitted that that the complainant being a Member of the Bhai Ghanhya Trust, was insured vide Group Mediclaim Policy No.2008/400104/46/08/8500000096 valid for the period 01.10.2008 to 20.9.2009 under the Scheme known as “Group Mediclaim-Tailor Made with Floater”. It has also been admitted that the complainant took treatment from Bassi Nursing Home, Ludhiana and he was operated upon for fracture neck (femer Rt.). It has also been admitted that a request for indemnification of the expenditure was received. According to OPs, as per the negotiated package rates, a sum of Rs.14,621/- was approved by the OPs as the complainant had taken treatment in a ‘C’ category hospital. However, later on it was found that the hospital in which the complainant had taken treatment was of ‘B’ category, so, a sum of Rs.15,390/- was approved as per the negotiated package rates for ‘B’ category hospital. Thus, according to the OPs, the complainant is entitled to an amount more than Rs.15,390/- as per the terms and conditions of the policy. It is pleaded that OPs No.1 and 3 are still ready and willing to pay this amount of Rs.15,390. However, according to these OPs, the complainant is not entitled to a sum of Rs.1,03,200/- as demanded by him, so, the complaint deserves dismissal. 4. OP No.2 was duly served but none appeared on its behalf to contest the case. Therefore, OP No.2 was ordered to be proceeded against vide order dated 15.02.2011. 5. We have heard the learned counsel for the parties and have gone through the documents on record. 6. It is admitted case of the parties that the complainant being a member of the Bhai Ghanhya Trust was insured for the period 01.10.2008 to 20.9.2009 vide Group Mediclaim Policy No.2008/400104/46/08/8500000096 under the Scheme known as “Group Mediclaim-Tailor Made with Floater”. It is also the admitted case of the parties that the complainant took treatment from Bassi Nursing Home, Ludhiana where he was operated upon for fracture neck (femer Rt.) i.e. hernioplastry. The learned counsel for the OPs Insurance Company has drawn our attention to Annexure R-2, which is a copy of schedule attached with the policy. As per this document, a person who has undergone Bipolar Hip Arthroplasty. THR (P) in ‘B’ category hospital is entitled to Rs.15,390/- only. As per the written statement filed by OPs No.1 and 3, they are willing and ready to pay the said amount to the complainant. The learned counsel for the complainant was asked to point out any clause in the policy entitling the complainant to claim amount more than Rs.15,390/-. However, the learned counsel failed to point out any such clause in the policy. 7. In these circumstances, in view of the terms and conditions of the policy, the complainant is entitled to a sum of Rs.15,390/- only and the OPs No.1 and 3 are willing to pay the said amount. 8. In view of the above findings, this complaint is allowed and the OPs No.1 and 3 are jointly and severally directed to pay a sum of Rs.15,390/- to the complainant for indemnification of the expenditure incurred by him on his treatment. However, the complaint qua OP No.2 is dismissed as the complainant was insured by OPs No.1 nd 3 only and they are liable to indemnify the complainant. 9. OPs No.1 and 3 had offered to pay a sum of Rs.15,390/- on the first available opportunity to the complainant, so, the complainant is not entitled to any compensation or litigation expenses. 10. This order be complied with by the OPs No.1 and 3 jointly and severally within 45 days from the date of receipt of its certified copy, failing which OPs No.1 and 3 shall be liable to pay Rs.15,390/- to the complainant along with penal interest @18% p.a. from the date of order till its realization. 11. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced 7th July, 2011 Sd/- (LAKSHMAN SHARMA) PRESIDENT Sd/- (MADHU MUTNEJA) MEMBER Ad/-
C.C.No.170 of 2010 Present: None. --- The case was reserved on 06.07.2011. As per the detailed order of even date recorded separately, this complaint has been allowed qua OPs No.1 and 3 only and dismissed against OP No.2. After compliance file be consigned. Announced. 07.07.2011 President Member
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | , | | 
