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

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Complt.  Case No :  32  of  2010

Date of Institution:    18.01.2010

Date of Decision  :    10.08.2010

Soma Devi W/o Late Sh.Ravinder Dass, resident of VPO Akoi Sahib, Tehsil and District Sangrur.

……Complainant

V E R S U S

1]          Medseva Health Care (TPA Limited), through its Manager, SCO No.121-122-123, 2^nd Floor, Sector 34-A, Chandigarh.

2]          National Insurance Company Limited, through its Manager, SCF 40-41, Phase-V, Mohali.

.…..Opposite Parties

CORAM:          SH.LAKSHMAN SHARMA                         PRESIDENT

                    SH.ASHOK RAJ BHANDARI            MEMBER

                    MRS.MADHU MUTNEJA                        MEMBER

PRESENT:     Sh.Rajbir Singh, Adv. for complainant.

Sh.Gaurav Bhardwaj, Adv. for OPs.

PER MADHU MUTNEJA, MEMBER

                The instant complaint has been filed by Sh.Soma Devi wife of Late Sh.Ravinder Dass, against the OPs for non-payment of medical claim amount as well as causing her mental & physical harassment.

1]             The facts in brief are as under:-

                The husband of the complainant i.e. Late Sh.Ravinder Dass had taken an insurance policy from the OPs under Bhai Ghanhya Sewat Sewa Scheme Policy Group Mediclaim Policy  valid from 1.10.2008 to 30.9.2009 (Ann.C-1).  Her husband fell ill and was admitted in Hero DMC Heart Institute, Tagore Nagar, Ludhiana as an indoor patient.  He ultimately died on 12.4.2009. A sum of Rs.150,000/- were spent on his treatment while he remained as an indoor patient in the said hospital.

                Thereafter, the complainant lodged the claim with OP No.2 demanding payment, as per insurance policy.  She also submitted all medical bills of her husband. Inspite of many reminders from her side, the OPs failed to pay the claim amount.  The complainant has thus filed the present complaint against the OPs seeking reimbursement of medical expenses of Rs.1,50,000/- spent on the treatment of her husband (insured) as well as  compensation for harassment along with cost of litigation.

2]             After admission of the complaint, notices were sent to the OPs.

3]             OPs No.1 & 2 in their reply have admitted the issuance of mediclaim policy to the deceased.  It is submitted that under the Bhai Ghanhya Sehat Sewa Scheme Policy there are notified Nursing Homes/Private Hospitals from where the insured can take treatment on cashless basis on showing his card.  Also the insured can take treatment from any Govt. Hospital and then claim reimbursement. It is also submitted that since the husband of the complainant, late Sh.Ravinder Dass, took treatment from Dayanand Medical Hospital, Ludhiana, which is not on the Panel of the Scheme, hence reimbursement was not allowed as per the Policy Terms & Conditions and the claim was therefore, rightly not paid.  It is prayed that as there was no deficiency on the part of OPs, the complaint should be dismissed.   

4]             We have heard the ld.Counsel for the parties and have also perused the evidence and documents placed on record by the parties.

5]             The husband of the complainant after getting his life insured from the OPs fell sick and was treated at DMC Hospital, Ludhiana. He ultimately died on 12.4.2009.  A sum of Rs.1,50,000/- was spent on his treatment at the said hospital.  The claim filed by the complainant, who is the wife of the deceased, was declined by the OP’s. 

6]             The ground taken by the OPs for non-reimbursement of treatment expenses is that Dayanand Medical College & Hospital was not on the panel of Medsave Health Care Ltd., hence no reimbursement was allowed and therefore, the claim was not paid.

7]             This plea of OP’s seems absurd.  Hero DMC Heart Institute, Ludhiana is a unit of Dayanand Medical College & Hospital, Ludhiana. It is being run by the Management & Ownership of Hero DMC Heart Institute, Ludhiana.  The name of Hero DMC Heart Institute, Ludhiana appears in their list of approved hospitals at Sr. No.126.  Therefore, Dayana Medical College & Hospital, Loudhiana where the deceased took treatment should also be considered as an approved hospital as per the list issued by the OP for medical treatment to cover the insurance. 

8]             In view of the above, it is clear that the insured (deceased) had not misused or gone beyond the facility available to him for his treatment as per the Medical Insurance Policy issued to him by OPs No.1 & 2.

9]             In view of these findings, this complaint is allowed.  The OPs will jointly and severally pay the following to the complainant:-

i)         The entire amount of Rs.1,50,000/-, which was incurred on the treatment of insured (since deceased) at DMC Hospital, Ludhiana.

ii)        To pay a sum of Rs.20,000/- to the complainant as compensation for mental agony and harassment.

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

10]            The aforesaid amounts shall be paid by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy of this order, failing which they shall pay the aforesaid amounts, except litigation cost, along with interest @12% per annum from the date of order till the date of actual payment, besides paying the litigation cost of Rs.5,000/- to the complainant.

11]            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

10^th Aug., 2010                                                            Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

                                                                   Sd/-

                                       (ASHOK RAJ BHANDARI)

MEMBER

                                                                                                Sd/-

                                                    (MADHU MUTNEJA)

MEMBER

‘Om’