BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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                                        Complt. Case No.:1247 of 2009

Date of Institution:   01.09.2009

Date of  Decision :   21.12.2009 

Jasveer Singh son of Gurdeep Singh, resident of Village Kotla Bajwara, P.O.Manopur, Fatehgarh Sahib

….…Complainant

                                V E R S U S

1]     Medsave Health Care (TPA) Ltd., SCO No.121-122-123, 2^nd Floor, Sector 34-A, Chandigarh 160034, through their Administrator.

2]     National Insurance Company Ltd., SCO No.121-122-123, 2^nd Floor, Sector 34-A, Chandigarh 160034.

3]     Fortis Hospital, Phase-VIII, Mohali, through Medical Superintendent.

                                        ..…Opposite Parties

CORAM:    SH.JAGROOP SINGH MAHAL       PRESIDENT

                SH.SIDDHESHWAR SHARMA         MEMBER

DR.(MRS) MADHU BEHL              MEMBER

Argued by:        Sh.Saurabh Kaushik, Adv. for Sh.Arvind Kashyap, Adv. for complainant.

Sh.Gaurav Bhardwaj, Adv. for OPs No.1 & 2

Sh.Munish Kapila, Adv. for OP No.3.

PER SHRI JAGROOP SINGH MAHAL, PRESIDENT

                Briefly put, the complainant took the Membership of “Bhai Ghanhya Sehat Sewa Scheme” launched by OP No.1 whereby he was issued policy (Annexure C-1) effective from 1.10.2008 to 30.8.2009 and the insurer was OP No.2 Insurance Company.  It is averred that under the said policy, the insured can avail the cashless treatment in any of the empanelled hospital and in case a patient/insured chose to go to a Govt. Hospital, the expenditure shall be reimbursed.  It is also averred that the complainant being insured under the said policy, was admitted in Fortis Hospital, Mohali from 4.2.2009 to 13.2.2009 and incurred the expenditure of Rs.2 lacs on his treatment and when he was discharged from the said hospital, he was asked to clear the said bill & medical expenses instead of giving cashless treatment.  Moreover, the OP No.1 rejected his claim on the ground that the policy has been cancelled without any reason.  Therefore, this complaint has been instituted alleging the above act of OPs as gross deficiency in service and unfair trade practice, due  to which he had to suffer mental tension, physical harassment and financial loss.

2]             OP No.2 filed reply, which was also adopted by OP No.1, wherein the issuance of policy in question has been admitted. It is stated that OP No.1 was Third Party Administrator.  The treatment so taken by the complainant at Fortis Hospital is also admitted.  It is denied that the policy of the complainant was cancelled.  However, it is submitted that the complainant knew how to avail cashless and reimbursement benefits.  It is also submitted that the claim was rightly rejected on the ground that reimbursement was not allowed from the empanelled hospitals as per the terms & conditions and the complainant could have availed cashless facility from the said empanelled hospital i.e. Fortis Hospital, Mohali and no reimbursement was allowed thereafter.  Only cashless treatment was available at Fortis Hospital, Mohali from where the complainant took treatment.  Denying all other allegations, it is prayed that the complaint qua answering OPs be dismissed.

3]             In their reply OP No.3-Fortis Hospital also admitted the treatment so given to the complainant as well as receipt of treatment charges.  However, it is stated that the process of Cashless Facility commenced with mandatory tendering of I-Card issued by the beneficiary of Bhai Ghanhya Sehat Sewa Scheme (BGSSS) to the IPD reception of the Network Hospital/Nursing Home.   It is also stated that  the I-Card issued by OP No.1 as a TPA of National Insurance Company-OP No.2 was never tendered by the complainant or his attendant either at the time of initial admission to the emergency or within 24 hours of Hospitalization and even thereafter till the time of his final discharge on 13.2.2009 and in the absence of tendering the I-Card, as prescribed, the OP Hospital collected its charges from the complainant, which he deposited without disclosing the fact that he was beneficiary of the said scheme and therefore, there was no deficiency on the part of answering OP in charging the complainant.  It is further stated that the complainant after his discharge and making all necessary payment brought to the notice of answering OP on 13.3.2009 at the time of follow up that he was a beneficiary of said Scheme and stated that he would like to claim reimbursement of his expenses from OPs No.1 & 2 and on that stage, the answering OP rendered all possible assistance to the complainant and also signed & attested the Claim Form for Bhai Ghaniya Sehat Sewa Scheme in Punjab issued by OP No.2 Insurance Company. Denying any type of deficiency on the part of OP No.3, it is prayed that the complaint qua answering OP be dismissed.

4]             Parties led evidence in support of their contentions.

5]             We have heard the ld.Counsel for the parties and have perused the record.  

6]             The Learned Counsel for the OP has argued that there is no provision under the Insurance Policy to reimburse the expenses if the treatment is obtained from the empanelled hospital.  It was admitted that the Fortis hospital is on their panel and the treatment otherwise was perfectly legal and valid.  The Learned Counsel further argued that reimbursement can be allowed only if the treatment is obtained from the government hospital.  The Learned Counsel however could not point out any provision in the policy under which the reimbursement is to be refused if the treatment is taken from the empanelled hospital.  There is nothing wrong on the part of the complainant because he had gone to the empanelled hospital and obtained the treatment therefrom.  Whether the payment is made by the OP directly to the hospital or the complainant pays the money and the OPs reimburses the same, there is no loss to the OP.  If this facility was not to be provided then there should have been a specific assertion in the negative under the terms and conditions of the policy but the same is missing.  We are therefore of the opinion that the reimbursement could not be refused by the OP on any such ground.

7]             In view of the above discussion, we are of the opinion that the present complaint must succeed. The same is accordingly allowed.  The OPs are directed to pay the reimbursement claim of Rs. 1,92,917/- to the complainant within 30 days from the receipt of the copy of this order failing which the OPs would be liable to pay the same alongwith interest @8% p.a. since the filing of the present complaint i.e.01.09.09, till the amount is actually paid to the complainant and litigation costs of Rs.5,000/-.

                Certified copies of this order be sent to the parties free of charge.  The file be consigned.