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

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Surinder Kaur wife of Sh. Ajit Singh resident of Village Manupur, Tehsil and Distt. Fatehgarh Sahib.

….…Complainant

                           V E R S U S

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

2.  National Insurance Co. Ltd., SCO No.121-122-123, 2^nd Floor, Sec.34-A, Chandigarh-160034.

3.  Gian Sagar Hospital, Ram Nagar, Banur, Tehsil Rajpura and Distt. Patiala 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 complainant.

Sh. Gaurav Bhardwaj, Adv. for OPs 1 & 2

Sh. D.D. Sharma, Adv. for OP-3.

PER SHRI JAGROOP SINGH MAHAL, PRESIDENT

             Succinctly put, the complainant took membership under ‘Bhai Ghanhya Sehat Sewa Scheme’ valid from 1.10.2008 to 30.9.2009 issued by OP-1.  As per the policy the complainant was to be provided a cashless treatment in the empanelled hospital, nursing home and in case the patient chose to go to a Govt. hospital, the expenditure was to be reimbursed.  She was admitted in Gian Sagar Medical College, Patiala from 20.5.2009 to 16.6.2009 and incurred expenses of about Rs.30,000/- on her medical treatment.  However, she was made to clear the bills before discharge by OP-3.  She requested the OP-1 to reimburse the expenses but they rejected the claim on the ground that the policy has been cancelled without any prior notice to her.  When the OP-1 did not reimburse the claim despite requests she gave a legal notice dated 11.7.2009, but to no avail. Hence this complaint alleging that the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.

2.             In their written reply OPs 1 & 2 submitted that the card issued in view of the policy was cancelled as it was found that the complainant had enrolled herself by stating her age to be 54 years whereas her age was 57 years and information regarding this was given to the quarters concerned vide letter dated 14.5.2009 and 14.7.2009 respectively and despite that the complainant got herself admitted in the OP-3 hospital.  It has been denied that the answering OPs cancelled the policy of the complainant without any prior notice to her.   Denying all the material allegations of the complainant and pleading that there has been no deficiency in service or unfair trade practice on their part prayer for dismissal of the complaint has been made. 

3.             OP-3 in their separate written reply admitted that the complainant was admitted in their hospital and was asked to clear the bill as she was not insured under the scheme.  Pleading that neither any relief has been sought against them nor any deficiency in service alleged, this OP also prayed for dismissal of the complaint. 

4.             Parties led evidence in support of their contentions.

5.             We have heard the Learned Counsel for the parties and have also perused the record. 

6.             The contention of the Learned Counsel for the OP is that the complainant has mentioned her age in annexure C-1 as 54 years whereas in the photo identity card copy of which is annexure R-4, her age has been mentioned as 57 years. Before cancelling the policy the OPs did not give any opportunity of being heard to the complainant.  The rules of natural justice therefore require that an opportunity of being heard should have been given to the complainant before cancelling the policy. The OPs are therefore directed to hold an enquiry and to ascertain the date of birth of the complainant and take further action only, thereafter.

7.             Whether the age of the complainant was 54 or 57 years, the complainant was entitled to the reimbursement of medical expenses.  Annexure C-2 contains the terms and conditions of the policy. According to para 1.1 a member is entitled to the facility till he/she reaches the age of 75 years.  Admittedly the complainant was below 75 years and was entitled to the claim.  The claim therefore could not be denied by the OPs on this ground.

8.             It is also argued by the Learned Counsel for the OPs that the treatment was obtained from an empanelled hospital where cashless treatment was available. It is argued that the reimbursement of medical expenses could be allowed only if the treatment is obtained from the Government Hospital, as mentioned in annexure C-2 under the heading “third party administrator MedSave HealthCare (TPA) Limited cashless facility”. However there is no mention in this chapter if the cashless policy would not be available to a member getting treatment from empanelled hospital and making the payment of the bills to the said hospital.  Otherwise also there is no loss to the OP-2, whether they pay the amount of the hospital, or the complainant pay to OP-3 and OP-2 reimburses the said claim to the complainant.  This ground has been unnecessary introduced by the OPs for denying the claim of the complainant.

9.             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 therefore directed to pay a sum of Rs.30,000/- alongwith costs of litigation of Rs.2,000/- within 30 days of the receipt of the copy of this order failing which they would be liable to pay the entire amount alongwith interest @12% p.a. since the filing of the present complaint i.e. 01.09.09, till the amount is actually paid to the complainant. They would be however free to ascertain the age of the complainant after giving her an opportunity of being heard.

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