Punjab

StateCommission

A/11/908

Jasbir Singh - Complainant(s)

Versus

Medsave Health - Opp.Party(s)

K.S Chahal

02 Mar 2015

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, DAKSHIN MARG, SECTOR-37A, CHANDIGARH

 

FIRST APPEAL No.908 of 2011

 

                                                 Date of Institution: 09.06.2011

 Date of Decision  : 02.03.2015

Jasbir Singh aged about 53 years, son of Sh. Sarwan Singh r/o Village Majara, P.O. Sahnewal, District Ludhiana.

…..Appellant/Complainant

 

VERSUS

 

1.      Medsave Health Care (T.P.A.) Ltd. SCO 121-122-123, IInd Floor,    Sector 34-A, Chandigarh.

 

2.      Medsave Health Care (T.P.A.) Ltd. Cabin No.5, Lower Ground         Floor, Madho Complex, Near Aarti Chowk, Ludhiana.

 

3.      The National Insurance Company Ltd. Div. Office No.1, Link   Road, Atam Park, Ludhiana.

 

4.      Joint Registrar, Co-operative Societies, Patiala c/o Central Co-         operative Bank Ltd. Patiala.

 

 

…..Respondents/Opposite Parties

 

First Appeal against the order dated 07.03.2011 passed by the District Consumer Disputes Redressal Forum, Ludhiana.

Quorum:

 

Hon’ble Mr.Justice Gurdev Singh, President

          Sh. Baldev Singh Sekhon, Member

                   Smt. Surinder Pal Kaur, Member

 

Present:

 

          For the appellant                  :   None

          For respondent Nos.1,2&4          :   Ex-parte

          For respondent No.3           :   Sh. Pavinder S.Bedi, Advocate

BALDEV SINGH SEKHON, MEMBER

          This appeal has been filed by the appellant/complainant against the order dated 07.03.2011 passed by the District Consumer Disputes Redressal Forum, Ludhiana (in short “District Forum”), vide which his complaint against the respondents/opposite parties ( in short 'OPs') was dismissed.

2.      Briefly stated, the facts of the case are that the complainant got himself, alongwith his dependents, insured with OP No.3 under Bhai Ghanaiya Sehat Sewa Scheme, through the Majara Janta Co-operative Agriculture Service Society Ltd., on payment of total premium of Rs.1822/- and  policy, bearing  No.400104/46/08/85/00000096 valid from 01.10.2008 to 30.09.2009 having ID Card No.90105027500027Z, was issued to him. It was pleaded that on the night of 27.6.2009, he met with an accident near Ludhiana, in which he was seriously injured.  Thereafter, he was admitted in Satguru Partap Singh Apollo Hospital, Sherpur Chowk, Ludhiana, where he remained admitted upto 11.7.2009 and he spent Rs.3,12,421/-  as medical expenses. It was further pleaded that at the time of admission in the said hospital, the complainant was unconscious and could not inform the insurance authorities regarding his illness. His relatives telephoned the Ludhiana Office of Medsave Health Care Ltd. but there was no positive response from them. Thereafter, his relatives informed the officials of the Majara Janta Co-operative Agriculture Service Society Ltd. regarding the accident and his admission in the said hospital but still he did not get any positive response. Even after the discharge from the hospital, the complainant remained bed ridden due to injury on his mouth and therefore, he could not eat or talk properly due to which he could not personally visit and communicate with the insurance authorities. On 9.9.2009, he contacted the OP No.2 personally as well as  telephonically, but the person present there flatly refused to entertain his application for the settlement of insurance claim. It was a clear case of deficiency in service and unfair trade practice on the part of the OPs, who declined the just and reasonable claim of the complainant. Complainant also served  legal notice dated 10.9.2010 upon the OPs through his counsel Sh. Bhalinder Singh Gill, Advocate. The said notice was received by the OPs as neither the registered envelop nor the acknowledgement was received back by him or his counsel. But nothing was heard from them. In the complaint filed before the District Forum, the complainant sought directions to the OPs to settle his claim immediately and to pay a compensation of Rs.25,000/- on account of harassment and deficiency in service, alongwith interest @ 24% per annum from the date of service of the notice upon OPs.

3.      The complaint was contested by the OPs. OP No.1 and 2, in their joint written reply, pleaded that the complaint was not maintainable as the complainant had not come to the District Forum with clean hands and that he had concealed the material facts. As per the terms and conditions of the policy, the insurance company was liable to provide only cashless facility and reimbursement of the claim amount was admitted  only in case the treatment was taken from the Govt. Hospital. The complainant could have got treatment from an empanelled hospital for that particular disease for which the hospital was empanelled. In the present case, the complainant got treatment from Apollo Hospital, Ludhiana which was empanelled for availing treatment for heart diseases only whereas the complainant had taken the treatment for alleged injuries suffered in a Motor Vehicle Accident, for which the said hospital was not empanelled. In this regard public notices were duly published in the Daily Ajit newspaper on 17.1.2009 and in the Daily Tribune on 02.01.2009. Hence, the claim of the complainant could not be accepted. It was further pleaded that the complainant was well aware of this fact as he was supplied with a copy of the terms and conditions of the policy at the time of supplying the ID card to him. Despite that, he paid the amount for treatment to the Hospital. As such, the reimbursement could not be made. Moreover, they did not receive any request for cash less treatment from the treating hospital. Infact, the hospital was required to disclose to the complainant that it was empanelled only for heart diseases. It was further pleaded that a toll free number was given in the 'guide book' and the insured was advised to obtain confirmation from OP No.1 before getting admitted to any hospital but, in the present case, he did not contact the OPs on the toll free number. As such, he was guilty of his own conduct. It was further pleaded that in order to save the patients from the harassment of making payment to the hospital and to stop the hospitals from making mis-use of their empanelment, it was specifically provided that no cash would be paid by the patient to the hospitals and that re-imbursement of amount so paid would be made only in case patient avails the treatment from a Govt. hospital. Denying all other allegations, dismissal of the complaint was prayed.

4.      OP No.3 also filed a separate reply but identical to the written reply, as filed  by OPs No.1 and 2.

5.      OP No.4, in its written reply, admitted that the complainant had met with an accident and was admitted  in Apollo Hospital, Ludhiana,  but denied for want of knowledge that the complainant spent Rs.3,12,421/- on his treatment. It was also admitted that the said society was informed by Gurmit Singh, son of the complainant, regarding the accident. It was prayed that the complaint against it be dismissed as no cause of action has arisen against it.

6.      Parties led their evidence by way of affidavits and documents before the District Forum, which after going through the same, allowed the complaint, in the aforesaid terms.

7.      Aggrieved by this order, the complainant has come up in appeal on the ground that in the 'guide book' issued  at the time of issuance of policy,  list of network hospitals was also included in which   at Sr. No.127, name of SPS Apollo Hospital is mentioned.  But there is no mention about the fact that said Hospital was empanelled only for heart diseases. The complainant got himself insured with effect from 01.10.2008 while OPs have alleged that, vide publication in Daily Ajit dated 17.01.2009  and in Daily Tribune dated 24.01.2009, it was notified that the SPS Apollo Hospital was empanelled only for heart disease. Since the policy commenced from 1.10.2008, subsequent publication in the newspaper could not have affected the rights of the complainant because on the day, when he got the insurance policy, the said hospital was on list of empanelled hospital for all diseases as specified in the Guide book. It was further submitted that publication of any such notice can only affect the policies issued after 17.01.2009 only. The fact about complainant having obtained the treatment from SPS  Apollo Hospital, Ludhiana has not been denied by OPs.  Therefore, he is entitled to the reimbursement of the claim. Once the policy is issued, its terms and conditions cannot be changed. Moreover, there is no such condition under which such a change can be affected subsequently. Acceptance of the appeal as well as the complaint and setting aside of the impugned order was prayed.  

8.    We have thoroughly gone through the pleadings of the parties, have carefully perused the evidence on record and heard the learned counsel of the parties.

9.      Admittedly, the complainant met with an accident during the subsistence of the insurance policy purchased by him from OP No.3 under Bhai Ghanaiya Sehat Sewa Scheme, Punjab. It is not denied by the OPs that the complainant remained admitted in SPS, Apollo Hospital, Ludhiana from 27.6.2009 till 11.7.2009 after he met with an accident on 27.06.2009, during which he reportedly spent Rs.3,12,421/- as medical expenses. However, his insurance claim for reimbursement of said amount was not entertained on the ground that SPS Apollo Hospital was empanelled only for heart related diseases   and not for injuries suffered during any accident.  The complainant has proved on record the 'guide book' issued by OP No.1 containing the list of the hospitals empanelled under the insurance policy as Ex.C-6, in which at Sr. No.127, the name of SPS Apollo Hospital, G.T.Road, Ludhiana has been included. But it is not  mentioned therein that the said hospital was only meant for treatment of heart diseases. It is the specific case of the complainant that he became unconscious after he met with the road accident and therefore, he could not inform the OPs regarding his admission in the said hospital nor he could produce his identity card to the said hospital. OPs have contended that vide subsequent public notices published in the Daily Ajit dated 17.1.2009 (Ex.R-2) and in the Daily Tribune dated 24.01.2009 (Ex.R-3), SPS, Apollo Hospital, Ludhiana was restricted to give treatment for the heart diseases only. Admittedly, the policy was issued on 01.10.2008 and at that time the said hospital was duly empanelled for taking treatment in respect of all the diseases. The OPs have not placed on record any policy condition under which any change can be affected in the list of empanelled hospitals after the issuance of the policy. Otherwise also, mere publication of the notice in the newspaper was not sufficient to intimate the beneficiaries about any such change having been affected. No direct intimation was given to complainant.

10.    Though OPs have  contended that they were only liable to provide cashless treatment from the empanelled hospitals but since the complainant was unconscious at the time of admission to the said hospital, therefore, he  was not in a position to present his identity card or to convey to the TPA (OP No.1). His  claim could not have been  declined merely on the ground that he, instead of availing the cashless treatment, directly paid the amount to the hospital  from his pocket. No specific procedure is laid down in the 'Guide book' which is to be followed in case beneficiary  is not in a position to intimate the TPA or to the treating hospital about the insurance policy purchased by him. Under these peculiar circumstances, which were not disputed by OPs and were beyond the control of the complainant. We are of the considered view that the claim of the complainant, as detailed in Ex.C-3, needs to be considered and settled as per the terms and conditions of the policy.

11.    Accordingly, the appeal filed by the complainant is partly allowed and OPs No.1 to 3 are directed to settle the claim of the complainant for reimbursement of amount spent by him on his treatment as per the rates admissible in Government hospitals within 30 days from the receipt of the copy of this order,  considering the complainant to have taken the treatment from a duly empanelled hospital.

12.    The arguments in the case were heard on 18.02.2015 and the order was reserved.  Now, the order be communicated to the parties.

13.    The appeal could not be decided within the statutory period because of the heavy pendency of the court cases.

 

 

 (JUSTICE GURDEV SINGH)

PRESIDENT

 

(BALDEV SINGH SEKHON)

MEMBER

 

(SURINDER PAL KAUR)

MEMBER

March 02 , 2015