BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI

                                  Consumer Complaint No.704 of 2014

                                 Date of institution:          17.12.2014

                                               Date of Decision:            17.07.2015

Manjot Singh son of Gurjeet Singh resident of village Masana, District Bathinda, Punjab, presently residing at H.No.943, First Floor, Phase-4, SAS Nagar, Mohali.

                                                                        ……..Complainant

                                        Versus

1.     M/s. M.D. India Health Care Services (TPA) Ltd., Max Pro Info Park, D-38, Phase-1, Industrial Area, Mohali 160056 through its Managing Director.

2.     United India Insurance Company Limited, SCO 72, Phase-9, SAS Nagar, Mohali through its Branch Manager.

3.     Max Super Specialty Hospital, Near Civil Hospital, Phase-6, SAS Nagar, Mohali through its Managing Director.

………. Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

CORAM

Mrs. Madhu. P. Singh, President.

Shri Amrinder Singh, Member

Mrs. R.K. Aulakh, Member.

Present:    Shri Deep Singh, counsel for the complainant.

OP No.1 Ex-parte.

Ms. Jasleen Kaur, counsel for OP No.2.

Shri Vishal Gupta, counsel for OP No.3

(Mrs. Madhu P. Singh, President)

ORDER

                The complainant has filed the present complaint seeking following direction to the Opposite Parties (for short ‘the OPs’) No1 and 2 to:

(a)    pay him Rs.45,286/- to the complainant.

(b)    pay him Rs.30,000/- with interest @ 12% per annum  for deficiency in service, mental harassment and unfair trade practice.

(c)    pay him Rs.10,000/- as litigation expenses.

                The case of the complainant is that he is insured by OP No.2 under Bhai Ghanya Sehat Sewa Scheme for the year 2014-15 through its society ‘The Pacca Kalan MPCASS Ltd.’.  As per the guide book Ex.C-1 of the scheme, the members of the society and their family members are entitled to cashless treatment upto a sum of Rs.1.50 lacs per member in the empanelled hospitals for medical as well as surgical procedures.  Due to some ailment, the son of the complainant namely Mehtab Singh aged 8 years was taken to OP No.3 for treatment on 26.07.2014, which is the empanelled hospital, its name figuring at Sr.No.203 of booklet Ex.C-1.  The son of the complainant was discharged on 27.07.2014 by OP No.3.  The complainant had to pay the medical bills raised by OP No.3 as the cashless facility was refused.  The complainant submitted the claim to OP No.1 by attaching the relevant documents issued by OP No.3 on 30.07.2014, but the amount of Rs.45,286/- has not been reimbursed to him. The OP No.1 vide letter dated 07.08.2014 repudiated the claim of the complainant on the ground of late submission of claim. Thus, non reimbursement of medical expenses is an act of deficiency in service on the part of the OP Nos.1 and 2.  With these allegations, the complainant has filed the present complaint.

2.             After admission of the complaint, notice was sent to the OPs. OP No.1 was duly served on 06.01.2015 but none appeared for it and was thus proceeded against exparte vide order dated 27.01.2015.

3.             OP No.2 filed reply and has pleaded in the preliminary objections that the complainant had suppressed material facts from this Forum and the complaint is not maintainable as there is an arbitration clause in the MOU signed between the parties. The complaint is bad for non joinder and mis joinder of necessary parties as Bhai Ghanhya Trust has not been impleaded as a party.  The complainant has not followed the procedure mentioned in the guide book.  The complainant has not informed the OP No.1 TPA and OP No.2 about admission of his son in the hospital. The complainant also never contacted at the numbers given in the guidebook to inform that OP No.3 is not giving cashless treatment.  As per the procedure mentioned at Page No.19 of the guidebook, the member was to obtain preauthorization form from the IPD Reception and get it filled from the treating doctor which was to be sent to MD India regional office at Mohali and then TPA has to send authorization within 24 hours. Only on receipt of authorization letter, the network hospital extends the cashless facility to the policy holder.  OP no.3 was not empanelled for treatment of hernia as per MOU. Further as per OP No.2  as per serial No.1.9.4 at Page 6 of Guide Book of BG Scheme Hernia repair  surgery shall be covered only upto the maximum limit of Rs.12,000/- per member and any expenses occurring above Rs.12,000/- shall be borne directly by the member.  OP No.2 is liable to reimburse Rs.12,000/- for treatment to patient in case of Govt. hospital and was liable to pay Rs.12,000/- to the private hospital covered under the scheme.  On merits also OP No.2 has taken the similar stand and denied any deficiency in service on its part.

4.             OP No.3 in its reply has pleaded that the complaint is being devoid of merits and is baseless. No cause of action has arisen against OP No.3. On merits, it is pleaded that the complainant never requested for cashless facility and produced the requisite documents pertaining to the scheme. The complainant himself signed the Inpatient Face Sheet and Admission Request Form on 26.07.2014 wherein he had undertaken that he will pay all medical and service charges for the treatment to be provided to his son.  Denying any deficiency in service on its part, OP No.3 too has sought dismissal of the complaint against it.

5.             To succeed in the complaint, the complainant proved on record affidavit Ex.CW-1/1 and tendered in evidence documents Ex.C-1 to C-8.

6.             Evidence of OP No.2 consists of affidavit of Ms. Hemali Batra, its Dy. Manager Ex.OP-1/1 and copies of documents Ex.OP-1 to OP-6.

7.             After filing of reply, none appeared for OP No.3 and even no evidence was tendered by it. Thus, its evidence was closed by order on 08.06.2015.

8.             We have heard learned counsel for the parties and have also gone through written arguments filed by complainant and OP No.2.

9.             The factum of issuance of the policy and the currency of the policy is not disputed. The complainant has availed the services of the hospital OP No.3 as per the information booklet Ex.OP-1 issued by OP Nos.1 and 2 when the complainant had become member of the scheme. The son of the complainant being the beneficiary of the scheme from OP No.3 as an indoor patient from 26.07.2014 and 27.07.2014 for the treatment of hernia. OP NO.3 has though given him the treatment but has not provided him the benefit of cashless treatment available to the complainant under the policy.  Therefore, the complainant has paid the treatment expenses from his own pocket and submitted the claim with the TPA i.e. OP No.1.  The claim of the complainant has been repudiated by the OP No.1 vide repudiation letter dated 07.08.2014 Ex.C-8 on two grounds i.e.  the claim documents received after 30 days of date of discharge of the treatment and secondly as per terms and conditions of the policy the treatment taken only from Govt. hospital is reimbursable.

10.           After going through the pleadings and evidence the issue in the present complaint emerges whether the OP No.1 has repudiated the claim of the complainant contrary to the  terms of the insurance policy and if so has indulged into the act of deficiency in rendering the  service and unfair trade practice as alleged by the complainant.

11.           In order to appreciate the first ground of repudiation i.e. submission of documents after 30 days of date of discharge as per documents of record or not, we proceed further on this issue. It is admitted that the complainant’s son being the beneficiary of the policy has undergone treatment for hernia in the empanelled hospital OP No.3. As per OP No.3 the patient was given indoor treatment from 26 to 27.07.2014 and during the stay in the hospital he has undergone two surgeries. As per OP No.3 in its reply Para No.3 the complainant never requested for cashless facility and rather signed the Inpatient Face Sheet and admission request form on 26.07.2014 wherein he has undertaken that he will pay all medical and service charges for the treatment to be provided to the patient i.e. son of the complainant. Therefore, the hospital after giving treatment has charged a total sum of Rs. 45,286/- and the same has been paid by the complainant himself as per his own undertaking.  After discharge from the hospital on 27.07.2014, the complainant submitted the claim for reimbursement of treatment charges to OP No.1 on 30.07.2014 Ex.C-7 and the claim documents are having been received in the office of OP No.1 on 30.07.2014 as is evident from office stamp of OP No.1 on the body of Ex.C-7. Thus by no stretch of imagination it can be termed that the documents have been submitted after expiry of 30 days from the date of discharge. The patient was discharged on 27.07.2014 and the claim was lodged on 30.07.2014. Thus, repudiation of the claim of the complainant on the ground of late submission of document is quite contrary to the facts and documents on record and the complainant has clearly proved the submission of documents within the time frame as per terms of the policy.  The act of the OP No.1 in declining the claim on false ground of late submission of document is an act of deficiency in service and unfair trade practice on the part of OP No.1.

12.           The next ground of repudiation is that the hospital from where the son of the complainant has undertaken treatment is not empanelled for the treatment of hernia disease and for the treatment of hernia disease and that too with the medical reimbursement upto Rs.12,000/- from a Govt. Hospital.  The counsel for the complainant has referred to the guidebook and list of hospitals network issued by OP No.1. The name of treating hospital OP No.3 figures at Sr.No.203 in the list of network hospitals and there is no mention of exclusion of any disease or treatment which the complainant is not entitled to undertake from the listed network hospitals i.e. OP No.3. Therefore, believing the information given in the booklet he has approached OP No.3 for treatment of hernia disease and the hospital has also not disclosed him while giving the treatment that their hospital is not emplaned with the OP No.2 for giving treatment of hernia.  Therefore, plea of OP No.2 that the complainant has undergone the hernia treatment from a private hospital OP No.3 is against the terms of the policy and he is not entitled to get the treatment and reimbursement. The OPs in order to rebut the plea of the complainant has relied upon Ex.OP-4 i.e. Memorandum of Understanding signed between OP Nos.1 and 3 where the OP No.3 has agreed to provide treatment for certain diseases excluding hernia. The perusal of the document clearly shows that this is an internal document between OP No.1 and 3 and the complainant is not privity to such MOU. Therefore, the information regarding the network hospitals provided to the complainant in the guidebook Ex.OP-1 is sacrosanct and believing the same that the hernia treatment is not excluded from the purview of hospital OP No.3 he has undergone the treatment for the disease from OP No.3. Therefore, the complainant has not violated any terms of the policy. Even the guidebook does not disclose that the complainant is entitled to hernia treatment only from Govt. hospital and that too with a cap of Rs.12,000/-.

13.           Another plea raised by the OPs that before going to the hospital as per the guidebook the complainant was required to enquire from the TPA before availing the facility from the hospital.  We have gone through the contents of guidebook and identity card issued by OP No.2, there is no such pre condition mentioned and in case the OPs have failed to update the complainant about the latest status of hospital whether they are still empanelled or de-empanelled or entitled to give treatment for a particular disease or general disease etc. the OPs cannot take the benefit of its own wrong while declining the claim of the complainant. Therefore, the repudiation of the claim on the ground that reimbursement of the hernia treatment from Govt. hospital is reimbursable is contrary to the facts on record. Thus, the repudiation of the claim on the ground that son of the complainant has undergone the treatment in a private hospital and the amount is not reimbursable as he has not gone treatment in Govt. hospital, is an act of deficiency in service and unfair trade practice writ  large on the part of OP No.1. Thus, the repudiation of the claim on both the counts is contrary to the facts and evidence on record and we hold OP No.1 i.e. TPA being the administrator of scheme is an act of deficiency in service and unfair trade practice.

14.           The next question arises whether the complainant is entitled to reimbursement of actual spent i.e. Rs. 45,286/- or as per the maximum limit under the policy. Since the terms and conditions of the policy are sacrosanct and binding on the parties, therefore, the complainant is entitled to reimbursement of Rs.12,000/-  besides compensation for mental agony, harassment which he has suffered due to acts of omission and commission on the part of OP No.1. So far OP No.2 is concerned, it has admitted having received the insurance premium and issued the insurance policy but denied having received any claim from the TPA, the claim against OP No.2 is not maintainable. Hence complaint against OP No.2 is dismissed.  So far OP No.3 is concerned; the treating hospital has not provided the cashless benefit to the complainant as the complainant himself has signed the Inpatient Face Sheet and Admission Request Form where he has undertaken to pay the whole treatment charges. Therefore, OP No.3 has not been deficient in rendering the services to the complainant. Therefore, there is order against OP No.3 and complaint against it is also dismissed.

15.           In view of above discussion the complaint is allowed against OP No.1 with the following directions:

(a)    to reimburse to the complainant Rs.12,000/- (Rs. Twelve thousand only) with interest thereon @ 9% per annum w.e.f. 07.08.2014 till payment.

(b)    to pay a lump sum compensation of Rs.10,000/- (Rs. Ten thousand only)  for mental agony, harassment and costs of litigation.

                Compliance of this order be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.

Pronounced.                           

July 17, 2015.     

                            (Mrs. Madhu P. Singh)

                                                                        President

(Amrinder Singh)

Member

(Mrs. R.K. Aulakh)

Member