BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.443 of 2015
Date of institution: 03.09.2015
Date of Decision: 04.05.2016
1. Surinder Pal resident of House No.151, Desu Majra Colony, Kharar, Mohali.
2. Gurmeet Kaur w/o Surinder Pal, resident of House No.151, Desu Majra Colony, Kharar, Mohali.
……..Complainants
Versus
1. National Insurance Company Ltd. through its Manager, SCF 40-41, Sector 59, Phase-5, Mohali, Punjab (160055).
IInd Address:
4, Peareylal Building, 42, Janpath New Delhi 110001.
2. Sun Pharmaceutical Industries Ltd. through its Manager c/o Ranbaxy Lab. Ltd., Village Toansa, PO Ralmajra, Tehsil Balachaur, SBS Nagar, Nawanshahar, Punjab.
IInd Address:
A-41, Industrial Area, Phase-VIII-A, SAS Nagar, Mohali.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
CORAM
Mrs. Madhu. P. Singh, President.
Mrs. R.K. Aulakh, Member.
Present: Complainant in person.
Shri Punit Jain, counsel for OP No.1.
Shri Abhivadya Sood, counsel for OP No.2.
(Mrs. Madhu P. Singh, President)
ORDER
The complainant has filed the present complaint seeking following direction to the Opposite Parties (for short ‘the OPs’) to:
- refund them amount of Rs.63,641/- with interest @ 18% per annum from the date of payment.
- Pay them compensation of Rs.50,000/- for deficiency in service and unfair trade practice and towards mental torture, pain, agony and harassment.
(c) to pay to the complainants Rs.20,000/- towards litigation cost.
The complainant No.1 is an employee of OP No.2. OP No.2 has taken group medi claim policy for the welfare of its employees and their spouses and dependants and the premium is deducted from the salaries of the employees. Complainant was earlier also getting reimbursement of medical bills and expenditure incurred in the hospital from OP No.1. On 07.02.2015 complainant No.2 was admitted in Kaushal Hospital and information in this regard was given to OP No.1. Complainant No.2 was discharged from the hospital on 14.02.2015. Complainant No.1 paid the expenses of the treatment from his pocket. Complainant No.1 completed all the formalities and submitted documents to the OPs. OP No.2 asked from the complainant No.1 some other documents for reimbursement of the claim which the complainant No.1 submitted. But the OPs had not reimbursed the amount of bills of Rs.63,641/- and rejected the claim on flimsy grounds. The complainants served legal notice dated 27.07.2015 upon the OPs but the OPs have not replied to the same. Non reimbursement of bill amount is an act of deficiency in service on the part of the OPs. Thus, with these allegations the complainants have filed the present complaint.
2. OP No.1 in the preliminary objections of written statement has pleaded that the allegations made in the complaint against it are false and the complaint is not maintainable. This Forum has no jurisdiction to try the same on the ground of mis joinder and non joinder of necessary parties. The complainants do not fall within the definition of ‘consumer’. After receiving intimation of claim, OP No.1 forwarded the claim documents to its panel doctor to give assessment report and as per the opinion dated 26.04.2015 the claim can be settled only after submission of complete in patient record with post hospitalization follow up treatment record. The complainants failed to provide complete requisitioned record and as per opinion dated 28.05.2015 given by panel doctor the submitted in patient record was incomplete and did not establish the cause of hospitalization and as such the claim was not payable. As per terms and conditions of the insurance policy, the complainants were bound to provide complete medical record as demanded by OP No.1 for processing the claim. The liability of OP No.1 strictly lies within the terms of the policy and it cannot be held liable for the claims falling outside the scope of such policy subject to confirmation of policy under Section 64 (v) (b) of the Insurance Act. On merits, OP No.1 has pleaded that in case OP No.1 has earlier reimbursed the medical bills that does not entitle the complainants as a matter of right to get reimbursement for every claim made thereafter as each claim has to be processed depending upon its peculiar facts and circumstances. Denying any deficiency in service on its part, OP No.1 has sought dismissal of the complaint against it.
3. OP No.2 in the preliminary objections of written statement has pleaded that the complainants do not fall within the definition of consumer as per the Consumer Protection Act. OP No.2 has got its employees insured under the Group Medicals Tailor Made with Floater Scheme. OP No.2 made regular payments towards the premiums with OP No.1 and there has never been any default in the payment of premium by OP No.2. OP No.2 has communicated the claim of the complainants to OP No.1 without any delay which shows bonafide of OP No.2. OP No.2 has not caused any loss to the complainants. On merits, OP No.2 has admitted that OP No.2 had reimbursed the medical claim of the complainants earlier. Rejection of the claim of the complainants has been done by OP No.1 and OP No.2 is not in the knowledge of the same. OP No.2 has admitted receipt of legal notice from the complainants. OP No.2 is not bound to reimburse the claim of the complainants. There is no deficiency in service on the part of OP No.2. Lastly OP No.2 has prayed for dismissal of complaint against it.
4. Evidence of the complainants consists of affidavit of complainant No.1 Ex.CW-1/1 and copies of documents Ex.C-1 to C-7.
5. Evidence of OP No.1 consists of affidavit of R.K. Sidana, its Dy. Manager Ex.OP-1/1; affidavit of Dr. Jitendra Nagpal Ex.OP-1/2 and copies of documents Ex.OP-1 to Ex.OP-4.
6. Evidence of OP No.2 consists of affidavit of Surinder Kumar Bhandari its authorised representative Ex.OP-2/1
7. We have heard the complainant in person, counsel for the OPs and have gone through the written arguments filed by the OPs.
8. The complainant No.1 is admittedly beneficiary of the insurance scheme purchased by OP No.2 from OP No.1 for the benefits of its employees and their dependants. The fact that during the currency of the policy, claimant Surinder Pal being employee of OP No.2 has got his wife Smt. Gurmeet Kaur admitted in Kaushal Hospital and took indoor treatment and paid a total sum of Rs.63,641/-. She was suffering from fever, vertigo tinnitus with nausea since two days, swelling and redness and hyper sensitivity reaction on face and whole body with sore throat as per certificate issued by the treating hospital Ex.C-1. The treating doctor submitted the hospital bills alongwith complete treatment and medical record of the patient to OP No.2. OP No.2 further submitted the claim to OP No.1 vide Ex.C-3, total amount of medical expenses as per claim was Rs.63,641/-. OP No.1 after receipt of claim, raised certain queries with OP No.1 because as per OP No.1 the documents were not complete. The complainant No.1 through OP No.2 submitted the requisite documents to OP No.1 as is evident from exchange of e-mails between OP No.1 and OP No.2 Ex.C-4. Despite receiving the complete documents, OP No.1 has repudiated the claim on the basis of their own panel doctor’s report vide letter dated 28.05.2015 Ex.OP-3. As per their own panel doctor’s report, the IP has not submitted the complete record and does not establish the cause of hospitalization, hence the claim is not payable.
9. The report of the panel doctor of the OP No.1 Ex.OP-2, when perused, does not disclose the basis of his findings. The record submitted by the complainants with the OPs as well as on the record of this Forum clearly shows that the treatment has been undertaken by the complainant from a hospital which falls within the parameters of the hospital prescribed as per terms of the policy. The hospital being an authorised hospital is fully equipped to give the treatment to the patient as it has specialized doctors of medicine and ENT and the treating doctor as per Ex.C-1 has admitted the patient on 07.02.2015 on the advice of medicine and ENT specialist after going through and analyzing the symptoms the patient has shown at the time of investigation. Therefore, the report of the panel doctor of the OP No.1 without analysis of Ex.C-1 is not a reliable piece of evidence to decline the claim of the complainants. Further for the same beneficiary of the insured, the medical treatment under taken by the daughter of complainant No.1 from the same hospital and the claim so submitted, has been partially accepted by OP No.1. Therefore, the OP No.1 cannot have double standards. The act of OP No.1 in declining the genuine claim of the complainants an very safely be termed as an act of deficiency in service and unfair trade practice. Hence, the complaint against OP No.1 deserves to be allowed and the complainant deserves to be compensated.
10. Since OP No.2 being employer of the complainant No.1 has immediately forwarded the claim of the complainants to OP No.1 for further action as the claim amount was to be reimbursed by OP No.1. Hence, there is no deficiency in service on the part of OP No.2. Thus, complaint against OP No.2 is liable to be dismissed.
11. In view of above discussions, the complaint is allowed against OP No.1 and dismissed against OP No.2. OP No.1 is directed:
(a) to entertain the claim of the complainants and pay them the due sum as per the policy against the submitted bills of Rs.63,641/- (Rs. Sixty three thousand six hundred forty one only) with interest thereon @ 9% per annum from date of repudiation of the claim i.e. 28.05.2015.
(b) to pay to the complainants a lump sum compensation of Rs.20,000/- (Rs. Twenty thousand only) for mental agony, harassment and costs of litigation.
Compliance of the above directions 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.
May 04 2016.
(Mrs. Madhu P. Singh)
President
(Mrs. R.K. Aulakh)
Member
