DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Complaint Case No.:1067 of 2009

Date of Institution:29.07.2009

Date of Decision  :06.04.2010

Sh. Dharam Singh Son of Sh. Jamadass, resident of Village and Post Office, Machhli Kalan, Tehsil and District Mohali (Punjab).

                                   ---Complainant

V E R S U S

1.              M/s Medsave Healthcare (TPA) Ltd., SCO 121-122-123, Second Floor, Sector –34-A, Chandigarh-160034.

2.              The National Insurance Company Limited, C/o Medsave Healthcare (TPA) Ltd., SCO 121-122-123, Second Floor, Sector –34-A, Chandigarh- 160034.

3.              Dayanand Medical College & Hospital; Unit- Hero DMC Heart Institute, Tagore Nagar, Ludhiana.

4.              Sub-Registrar, Co-operative Societies, Rupnagar (Punjab).

5.              The Machhli Kalan Co-operative Agri Service Society Limited, Village and Post Office Machhli Kalan, Tehsil and District Mohali (Punjab).

---Opposite Parties

QUORUM          SH.LAKSHMAN SHARMA               PRESIDENT

                SH.ASHOK RAJ BHANDARI             MEMBER

                SMT MADHU MUTNEJA              MEMBER

PRESENT:      None for the complainant.

Sh. Gaurav Bhardwaj, Advocate for Ops 1 & 2.

OP-3 already exparte.

None for Ops 4 & 5

                              ---

PER MADHU MUTNEJA, MEMBER 

          The instant complaint has been filed by Sh. Dharam Singh under section 12 of the Consumer Protection Act, 1986 praying therein that OPs 1 & 2 be directed to re-imburse the entire amount spent by him on his medical treatment at DMC, Ludhiana alongwith compensation for mental agony and harassment and cost of the litigation. 

2.        The case made out by the complainant is as follows:-

          The complainant was insured with Medical Insurance Scheme issued under Bhai Ghanhya Sehat Sewa Scheme, by Medsave Healthcare (TPA) Ltd., and National Insurance Co. Ltd., having Policy Number 400104/46/08/85/00000096, Card No.901 1222 45 00020F, Soc Code 2245, with a validity from 01.10.2008 to 30.09.2009. The first premium was deposited by him on 08.09.2008, with Machhli Kalan Co-op Agri. Service Society Limited, Machhli Kalan (Ropar) (OP-4), who were the authorized representatives of Ops 1 & 2. On 02.10.2008  the Complainant suffered acute heart problem and was admitted in DMC Heart Institute, Ludhiana for treatment. He remained in hospital  for his treatment from 02.10.2008 to 10.10.2008. After recovery, he was discharged from the hospital on 10.10.2008. During this period a heart operation was conducted upon him in the hospital. The details of the complete medical record of the hospital have been shown in Annexure C-2 of his complaint. The Complainant incurred an expenditure of Rs.1,73,935/- for his treatment as per bill of DMC at Annexure C-3.

     After his discharge, the Complainant  lodged his claim with the Ops under their Medical Insurance Scheme for medical expenses incurred by him for his treatment. It is pertinent to mention here, that, a Membership Card which should have been in his possession and which could have afforded a cashless medical facility to him by the hospital was not in his possession. This card though issued by the Insurance Company, and valid from 01.10.2008 to 30.09.2009 was received by him only on  14.10.2008. The booklet issued by the Ops “Bhai Kanhaiya Sehat Sewa Scheme Punjab- Guide Book and List of Network Hospital” was given to him at an even later stage.

     He, thus, represented his case to the Ops     1 & 2 for re-imbursement of the amount incurred on his treatment under the Medical Insurance Policy. It is unfortunate that despite various visits by him to the office of the Ops, no constructive action was taken by the Insurers to grant him the claim. On visiting the office of Ops on 07.05.2009, the son of the Complainant was informed by OP-1 that the claim of the Complainant had been rejected. A copy of the rejection letter has been shown as Annexure   C-6. The reason for rejection stated was “Rejected as reimbursement allowed in only Government Hospital”.  It is very pertinent to mention here that in the guidebook issued by the Insurer, the name of the DMC Hospital, has been placed at Serial No.126 in the list of Network Hospitals approved by them for taking treatment under the Medical Insurance Policy.

     Harassed and alleging deficiency in service on the part of Ops, he has filed the present complaint seeking the reliefs mentioned above.

3.  In the reply tendered by Ops 1 & 2 they have stated that the Complainant is not entitled to any reimbursement since all procedures with regard to his medical treatment were carried out in Hero DMC Heart Institute, Ludhiana. They have rejected the claim on the ground that for the treatment of Acute Myocardial Infection the reimbursement was allowed only in government hospitals and not in other hospitals where cashless facility was to be given by the empanelled hospitals. Hospital expenditure is allowed to the insured only if treatment is taken in Government Hospital. A Membership card had been issued to the Complainant, which he has not presented at the time of treatment. This is a lapse on his part. They have further stated that though Hero DMC Heart Institute, Ludhiana is on the panel of the OP No.1, but it was required to give cashless facility to the beneficiaries only if the card was shown to them. The reimbursement is allowed only in government hospitals as per the Scheme. They have further alleged that there was no delay in delivery of Membership Card by them to the beneficiary. In case the beneficiary had not received the Membership Card from the concerned Society, he should have contacted the OP-1 at their Toll Free number. The Complainant could also collect the Policy / Booklet from the Co-operative Society at any time. 

     Pleading that there was no deficiency in service on the part of the OPs 1 & 2 they have prayed for dismissal of the complaint.

4.  Notice was issued to the OP-3, which was duly served. Despite service, nobody has appeared on its behalf, therefore, the OP-3 was proceeded exparte on 06.10.2009.

5. In the reply furnished by Ops 4 & 5 they have submitted that the Complainant had deposited the premium amount as prescribed by Ops 1 & 2 with  OP-5. They have further submitted that the insurance cards were received by the them, after the date of commencement of the insurance policy. The said membership cards were received and distributed by OP No.5 and distributed among its members on 06.10.2008. However, since the Complainant was not available in the village on the said date his card could not be delivered to him. It is furthermore important to mention that the Guide Books mentioned herein were not supplied by the Ops 1 & 2 to them alongwith the Insurance Cards. Thus the Cards alone were distributed. However, the Complainant alongwith other members of the Society were duly made aware about all the terms and conditions of the Policy.

     Pleading that there was no deficiency in service on the part of the OPs 4 & 5, they have prayed for dismissal of the complaint against them.

6.   None appeared on behalf of the complainant and OPs No.4 & 5 at the time of hearing of arguments. As the case was already fixed for arguments, therefore, we decided to dispose of the present complaint on merits under Rule 4(8) of the Chandigarh Consumer Protection Rules, 1987 read with section 13(2) (c) of the Consumer Protection Act, 1986 as amended upto date even in the absence of the learned counsel for the Complainant and OPs No.4 and 5.

     We have read the complaint and the replies including annexures, affidavits etc. tendered by Ops 1,2,4 & 5  (OP-3 already exparte) and heard the learned counsel for the Ops 1 & 2.  

7.        The Complainant after getting his life insured from OP fell sick and was treated at DMC, Ludhiana for acute heart problem. Unfortunately, since the Membership Card of the insurers was not in his possession at that time, he could not avail of a cashless entry for his treatment. This card was delivered to him only after his discharge from the hospital. The Ops 1 & 2 submit that his complaint could not be entertained since he had not availed the cashless use of the card since they had already issued the card in his name. However Ops 4 & 5 who are their agents, submit that the Complainant was not available at his residence on 06.10.2008, when the card was sent to his address. The card was handed over to him only after he came back from hospital. Further they have stated that the Complainant should not have gone to DMC, but to a Government Hospital for his treatment. This plea seems absurd since the name of DMC figures in their list of approved hospitals at Sr. No.126.

8.   In view of the above arguments, it is clear that the Complainant has not misused or gone beyond the facility available to him as per the Medical Insurance Policy issued to him by Ops     1 & 2. The Membership Card could have been used by him but only if was in possession of it.

9.   In view of these findings, we allow this complaint and direct the Ops 1 & 2 to do the following:-

i)              To reimburse the entire amount of Rs.1,73,935/- incurred by the Complainant on his treatment at DMC Hospital, Ludhiana as per treatment chart (Annexure C-3).

ii)         To pay a sum of Rs.50,000/- as compensation for mental agony and harassment.

iii)    To pay a sum of Rs.5000/- as litigation expenses.

10.  Ops 1 & 2 are directed to comply with the above order within a period of six weeks from the date of the receipt of the order, failing which the Ops 1 & 2 shall be liable to pay interest on 2,23,935/- @18% p.a. from the date of this order till the actual date of realization.

11.  As there is no deficiency in service on the part of the Ops 3,4 and 5, the complaint qua them is dismissed.

12.     Certified copies of the order be supplied to the parties free of any charge. The file be consigned to the record room after compliance.    

Announced

06.04.2010                  

          sd/-

                                     (LAKSHMAN SHAMRA)

PRESIDENT

Sd/-

  (ASHOK RAJ BHANDARI)

MEMBER

Sd/-

  (MADHU MUTNEJA)

MEMBER

JS

C.C.No. 1067 /2009

PRESENT:       None

                    ……

As per separate detailed order of even date, this complaint is allowed. After compliance, file be consigned to record room.

Announced.

06.04.2010     Member        President          Member