DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Consumer Complaint No : 257/2014.
Date of Institution : 25.11.2014.
Date of Decision : 11.5.2015.
In the matter of:
Yadbinder Kumar S/o Sh. Balaki Ram, H.No. B-III/56, Pakho Wala Bagh, Sahoria Street, Pharwahi Bazaar, Barnala-148101.
...Complainant
Versus
New India Assurance Company Ltd., K.C. Road, Near St. No. 6, Barnala, through its Branch Manager. ...Opposite Party
Complaint Under Section 12 of Consumer Protection Act, 1986.
Before:-
1. Sh. Sukhpal Singh Gill : President.
Sh. Karnail Singh : Member.
Ms. Vandna Sidhu : Member.
For the complainant : Sh. R.K. Jain, Advocate
For the opposite party : Sh. Varinder Goel, Advocate
ORDER: BY SUKHPAL SINGH GILL, PRESIDENT:
Yadbinder Kumar complainant (herein referred as to CC for short), has preferred the present complaint against the Opposite Party (herein referred as to O.P for short), on the ground that, CC had earlier filed a complaint bearing No. 85/14, wherein, inadvertently some typing mistakes cropped up in the complaint and the same was withdrawn with permission to file a fresh complaint on the same cause of action.
It is alleged that, CC is a regular subscriber of the mediclaim policy of the O.P from 2007 and had obtained mediclaim insurance from the O.P vide cover note No. 544692 for the period 10.5.2013 to 10.5.2014 and paid a premium of Rs. 7,214/-.
It is further alleged that, on 4.7.2013, CC suddenly fell ill and was rushed to Sat Guru Apollo Hospital, Ludhiana, where the CC underwent various diagnostic procedures and was discharged after administering on intraviterial injection as a day care procedure. CC had to spend Rs. 7,290/- for the same.
It is further alleged that, on 12.7.2013, CC again had some problem in the eyes, so he went to the S.D. Mahabir Dal Hospital, Bathinda, for checkup and remained under consultation of the same hospital till 31.7.2013, for right eye and intimation was given to the O.P.
It is further alleged that, on 18.7.2013, CC again had some problem in the eyes and went to the Grewal Hospital, for checkup and was operated upon in the same hospital for the left eye and was discharged from hospital on the same day. It is alleged that, O.P directly collected the bill from the Hospital and paid the same to the Grewal Hospital directly. CC submitted the original documents of treatment alongwith bills to the O.P, for payment of claim on 30.8.2013.
It is further alleged that, O.P has not paid the claim of the CC despite the lapse of long time and putting of the matter on the one pretext or the other on the ground that, they have sent the claim to their TPA for approval, whereas the CC has no relation with the TPA and it is an inter se arrangement of the O.P.
It is further alleged that, during the pendency of the previous complaint, O.P informed that, the TPA has rejected the claim of the CC there being violation of the Clause 1 & 3.2 of New India Policy, however no repudiation letter has been received by the CC till today. It is alleged that, no policy was supplied to the CC.
Thus, alleging deficiency in service on the part of the OP, CC has sought the following reliefs.-
a) OP be directed to pay the treatment cost of Rs. 40,367/- as per bills submitted.
b) Further, OP be directed to pay Rs. 1,00,000/- as compensation and Rs. 5,500/- as litigation expenses.
The complaint of the CC is signed and is also verified. Further, the complaint is supported by an affidavit of the CC.
2. In reply, OP has raised a number of legal objections on the ground that, CC already filed complaint No. 85/14 with malafide intention. The complaint was fixed by the Forum for arguments on 13.10.2014, 14.10.2014 and 15.10.2014, but during arguments on 15.10.2014, when the Counsel for O.P brought the facts before the Forum that, in Para No. C of the complaint, CC stated that, on 12.7.2013 CC again had some problem in the eyes and went to S.D. Mahavir Dal Hospital, Bathinda, for checkup and remained under consultation till 31.7.2013 and stated in Para D of the complaint that, on 12.7.2013, CC again had some problem in the eyes, so he went to the Grewal Hospital, for checkup and was operated upon in the same hospital for the left eye and was discharged from the hospital on the same day. In view of the Para C & D, it is not possible for the CC to visit the S.D. Mahavir Hospital, Bathinda and Grewal Hospital, as such the complaint was withdrawn by the CC, so the present complaint is not maintainable in the present form. Further, CC has got no locus-standi to file the present complaint. The jurisdiction of this Forum is also challenged and the complaint is bad for mis joinder of necessary parties. CC has not impleaded as party to Raksha TPA Pvt. Ltd., who repudiated the claim of the CC etc.
On merits, all the allegations of the CC are denied. However, it is admitted that, CC had obtained the mediclaim insurance from the O.P vide cover Note No. 544692. It is submitted that, CC submitted the bill for operation of Grewal Hospital to the tune of Rs. 58,000/- and the O.P already paid Rs. 57,750/- after due investigation.
It is further submitted that, CC admitted with complaint of Diabetic retinopathy at S.D Mahavir Hospital, Bathinda on 17.6.2013. It is submitted that, investigation was done by the O.P through Raksha TPA at SPS Apollo Hospital, under Neurology, which is not related to eye disease. Intravitreal injection given which is given on OPD basis and OPD based procedure falls under the permanent exclusion of the policy and even this does not fall under day care procedure as per policy terms and conditions. Therefore, the claim of the CC was not made as condition 1 and 3.2 of New India Policy. It is further submitted that, the CC filed the complaint with malafide intention against law and facts.
Thus, alleging no deficiency in service on its part, OP has prayed for the dismissal of complaint. Version of the O.P is signed and verified. Further, the version of the O.P is supported by an affidavit of Malchand Dhawal, Divisional Manager.
3. The CC in support of his complaint has tendered into evidence Ex.C-1 to Ex.C-41, which included affidavit of CC, copy of insurance cover note and policy, copy of summary of bills and documents, copy of intimation letter, copies of medical bills and record and closed the evidence.
4. On the other hand, O.P in support of its version has tendered into evidence Ex.O.P1 to O.P4, which included affidavit of M. Dhawal, copy of policy alongwith terms and conditions, copy of letter from TPA, copy of affidavit of Yadbinder Kumar and closed the evidence.
5. We have gone through the complaint, version filed by the O.P and hearing the arguments of the Ld. Counsels for the parties at length.
The main controversy in the present complaint is with regard to the non-payment of medical expenses, by the O.P. The case of the CC is that, CC had subscribed a mediclaim policy of the O.P in 2007 and since then the CC has regularly subscribed the policy in question. On 4.7.2013 CC suddenly fell ill and visited Sat Guru Apollo Hospital, Ludhiana, for the treatment and had spent a sum of Rs. 7,290/- on his treatment and again the CC had to visit S.D. Mahavir Dal Hospital, Bathinda, for checkup and remained under their consultation from 12.7.2013 to 31.7.2013. But subsequently on 18.7.2013, CC visited the Grewal Hospital, Chandigarh, for the eye treatment and the amounts spent by the CC on account of his eye treatment, has been reimbursed by the O.P to the Hospital. But the claim, which was submitted on 30.8.2013 has not been reimbursed by the O.P, till date.
In reply, the O.P has admitted that, the CC is the 'consumer' of the O.P and has submitted that the claim of the CC with regard to his treatment at Grewal Hospital, Chandigarh, has been reimbursed and the claim for the treatment of the CC at Sat Guru Apollo Hospital, Ludhiana, and S.D. Mahavir Dal Hospital, Bathinda, has not been paid, because the same was not covered under the policy, as per clause 1 & 3.2 of the policy.
After hearing the arguments of the Ld. Counsels for the parties and on the perusal of the documents placed on record, we find that, the CC had earlier filed a complaint on 23.4.2014, but the same was withdrawn on 14.10.2014, as per document placed on record. The Counsel for the O.P contented vehemently that, the present complaint be dismissed on account of non joinder of necessary parties, as the CC has not made Raksha TPA as a party, who had repudiated the claim of the CC. The Counsel for the CC has argued that, since the TPA is an inter se arrangement of the O.P, so there was no need to make him, as a party in the present complaint.
We have gone through the document Ex.C-2 and we find that, the name of the TPA has been very clearly mentioned on the policy document, which the CC has been subscribing regularly since 2007. Further, from the perusal of the documents, we find that, CC has submitted bills on plain paper with regard to his expenditure and without any counter signature from doctor concerned. The CC has also placed on record document Ex.C-33 to C-41, which are test reports and other tests with regard to the Neuro Department. There is no such evidence on record to show that, the treatment taken by the CC was necessary and on whose advice the medicines have been prescribed to the CC.
It has been admitted by both the parties that, the payment
with regard to the treatment at Grewal Hospital, Chandigarh, has been reimbursed. Further, on the perusal of the documents, we find that, CC remained under the treatment of Grewal Hospital, Chandigarh, on 15.7.2013 vide documents Ex.C-22 to Ex.C-26, but then on the very next day i.e. 16.7.2013 and 17.7.2013, CC went to the S.D. Mahabir Dal Hospital, Bathinda, for treatment as per document Ex.C-13. Then again the CC visited Grewal Eye Institute, Chandigarh, for treatment as per document Ex.C-27 to Ex.C-29, but from these documents we have not been able to understand as to why the CC started shifting from one hospital to other, as there was no emergency with regard to the treatment at different hospitals and neither there is any evidence on record that the treatment at different hospitals was necessary for the CC.
Further, CC in his complaint in Para 3 (d) has mentioned that, he remained under treatment from 12.7.2013 to 31.7.2013, but on the perusal of the documents placed on record, we find that, CC has been moving from one Hospital to other Hospital in between these dates.
From the facts mentioned above, we are of the opinion that, the O.P has rightly repudiated the claim of the CC, as the amount spent by the CC at Sat Guru Apollo Hospital, Ludhiana, was not prescribed/verified by any doctor neither any document produced by the CC from which it shows that, the treatment at S.D. Mahabir Dal Hospital, Bathinda, was the need of the CC. Further, CC has failed to bring on record any cogent, reliable and trustworthy evidence in support of his case.
So, keeping in view the facts stated above and in the lights of documents tendered by both the parties, we are of the opinion that, the CC has not been able to prove his version and accordingly, we dismiss the complaint. However, there is no order as to cost. Parties to bear their own expenditure. Copy of the order be supplied to the parties free of cost. The file after its due completion, be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
11th day of May, 2015
(Sukhpal Singh Gill)
President.
I do agree.
(Karnail Singh)
Member
(Vandna Sidhu)
Member
