DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Kavita Sant w/o Sant Parkash, Resident of H.No.80, Phase-3-B-1, Mohali.

                                                                                    ---Complainant

V E R S U S

1]          National Insurance Company Ltd., Regional Office-I, SCO No.332-334, Sector 34-A, Chandigarh.

2]          Medsav Healthcare (TPA) Ltd., Chandigarh, SCO 121-122-123, 2^nd Floor, Sector 34-A, Chandigarh.

3]       Indus Hospital, Opp. D.C. Office, Phase-I, Sector 55, SAS Nagar, Mohali.

---Opposite Parties

BEFORE:            SHRI LAKSHMAN SHARMA                      PRESIDENT

                        SH.JASWINDER SINGH SIDHU            MEMBER

Argued By:            Sh.Puneet Sharma, Advocate for the complainant

Sh.Gaurav Bhardwaj, Advocate for the OPs No.1 & 2.

None for OP-3

PER JASWINDER SINGH SIDHU, MEMBER

1]             Complainant (hereinafter referred to as CC for short) has preferred the present complaint against the Opposite Parties (hereinafter referred to as OPs for short) on the ground that the CC got insured from OP-1 under Bhai Ghanhya Sehat Sewa Scheme Policy vide Policy No.400104/46/08/85/00000096, and was issued Card No.901 1541 99 00013Z, valid for the period 01.10.2008 to 30.09.2009.  The said policy entitled the Members for a cashless Hospitalization from any Hospital mentioned in the List of Hospitals provided by the OP1&2.

                That the CC while suffering from Hepatitis-C infection was treated upon by the OP-3.  The treatment for the ailment began on 04.11.2008 and continued till 17.2.2009.  During this period, the CC remained admitted for two days in every week as per the advice of the Hospital. 

                It is alleged by the CC that while applying for the refund of the expenses incurred by her for the treatment, the OPs refused the same vide letter dated 19.5.2009.  Lastly when the CC was discharged by the Hospital on 18.2.2009, the CC filed the claim before OP-1 along with the details of Bills of Medicines, Laboratory Tests and Discharge Summary but OP-2 denied the same vide letter dated 19.5.2009. 

                However, the CC has disclosed that the claim for the same disease was passed by the Oriental Insurance Co. Ltd. thus claiming her case to be perfect to be entertained by the OPs in the present case.  CC has also admitted that she approached the Insurance Ombudsman, Chandigarh with her complaint with regard to the said denial.  The Ombudsman in its observations clearly mentioned that the CC’s claim was rightly rejected by the OPs.

                The CC has claimed that OP-1 & 2 in connivance with each other have rejected the claim totally in arbitrary and illegal manner.  It is further alleged that this practice of the OPs amounts to deficiency in service and an unfair trade practice.  Aggrieved of the actions of the OPs, CC has claimed direction of the Forum for the payment of her bills amounting to Rs.4,20,205/- along with interest @12% p.a. from the date of the bills paid.  CC has further demanded compensation to the tune of Rs.50,000/- along with Rs.15,000/- as litigation costs.

2]             On notice, OPs filed their respective versions. 

                OP-1 & 2 collectively filed their Written Statement and in preliminary objections has cited the rejection of the claim of the CC by the Insurance Ombudsman, Chandigarh. 

                Whereas on merits, OP-1 & 2 has claimed that the Hospital Admission of the CC was not warranted as mere administering of the injection did not require the Indoor Admission of the CC and the same could be easily administered on OPD Basis. Hence, the claim of the CC was rejected under Day Care Basis. 

                It is further mentioned that the entitlement of the CC’s claim was limited to Rs.2.00 lakh under Bhai Ghanaya Sehat Sewa Scheme and the claim of the CC is beyond the limits of the policy to which the CC has subscribed. 

                OPs have also mentioned that the CC having availed the claim from Oriental Insurance Company Ltd. and its 3^rd Party Administrator, Park Mediclaim Ltd. is not entitled for a simultaneous claim from the OPs. 

                OP-3 in its reply has categorically admitted all the contents of the complaint but has raised objections on the ground that there is no deficiency in service on the part of OP-3 nor the CC has raised any claim against OP-3 for any deficiency in service caused to the CC.  OP-3 has requested that the present complaint is not maintainable and deserves to be dismissed with costs for having been wrongly impleaded.

3]             Parties led their respective evidences.

4]             Having gone through the entire complaint and version of OPs and the evidence of the parties, we came to the following conclusion:-

i)      That the CC at the time of her admission with OP-3 had disclosed her insurance status and her entitlement for cashless treatment.  This fact is clearly reflected from the letter dated 19.5.2009, which is a communication between OP-2 and OP-3.  This letter clearly shows the date of Processing of Claim as 05.11.2008 and Date of Admission as 07.11.2008.

ii)     It is vide this letter that OP-2 rejected the claim of the CC on the ground that the details provided to them regarding the History of the Insurance and Disease of the patient, can be managed on OPD basis.

iii)    The CC had thereafter lodged the claim with OP-1 by submitting duly filled-up claim form (Ann.C-17) along with all the relevant documents to be processed by the OPs but the same was not entertained by the OPs.

iv)    CC has not brought on record any document i.e.  neither the policy document nor the rules or terms & conditions, from where it could be ascertained that the CC had a valid claim. 

v)     The CC has also not cited the grounds which entitled her for the claim that she presently has pressed against the OPs or for which the OPs could be bound to refund her medical claim. 

vi)    CC has also failed to bring on record any document that entitled her for simultaneous claims i.e. while having availed the insurance claim from another insurance company namely Oriental Insurance Co. Ltd. and at the same time also from the OPs for the same treatment. 

                However, Ann.C-17 the Claim Form submitted by the CC to the OPs has clearly mentioned the declaration in printed form which speaks of “…in respect of the above treatment no benefits are admissible to me under any other medical scheme or insurance. I have no objections if my records are verified from the treating hospitals.”

It is surprising that the CC herself having appended her signatures under the above mentioned declaration has lodged two different claims with two different insurance companies for the same treatment.

vii)    The CC has failed to bring any cogent, reliable and trustworthy evidence in support of her contentions as mentioned in her present complaint.

5]             On the above mentioned observations, we find no merit in the present complaint.  The same is dismissed without costs.  Parties to bear their own costs.

                Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

24.08.2011

                                                           (LAKSHMAN SHARMA)

PRESIDENT

 (JASWINDER SINGH SIDHU)

MEMBER