BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,  PANCHKULA.

Yudhvir Singh s/o Sh.Dharam Singh, R/o H.No.1090/A, Sector-4, Panchkula.

                                                                                      ….Complainant

Versus

1. New India Assurance Company, Abbot Building, IInd Floor, near Ashoka Hotel, King’s Road, Ahmednagar.

2.       Balaji Medi-Centre, SCO No.114, Sector-25, Panchkula through Dr.Bhavna Aggarwal.

                                                                        ...Opposite Parties

COMPLAINT UNDER SEC. 12 OF THE CONSUMER PROTECTION ACT, 1986.

Quorum:               Mr.Dharam Pal, President.

              Mrs.Anita Kapoor, Member.

For the Parties:     Mr.Randhir Singh Hooda, Adv., for the complainant.

                             Mr.J.P.Nahar, Adv., for the Op No.1.

                             Mr.Naren Partap Singh, Adv., for the OP No.2.

ORDER

(Anita Kapoor, Member)

1. Initially, the complainant filed a complaint before this Forum which was dismissed as this Forum has no territorial jurisdiction to try and entertain the complaint. The complainant filed an appeal before the Hon’ble State Commission as first appeal No.979 of 2014 vide which the appeal was accepted, the impugned order was set aside and the case was remanded to this Forum to decide it afresh in accordance with law.
2. The complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 against the Ops with the averments that he is on-roll employee of Videocon Telecommunications Ltd. and his company has retained a Group Medical Policy bearing No.151800/34/12/04/00000004 for its employees from Op No.1. The complainant was also policy holder vide membership No.MD15-0008286343 which was valid for the period from 22.07.2012 to 21.07.2013. By virtue of the policy, the complainant is entitled to get reimbursement of the medical expenses incurred by him on the medical treatment indoor or outdoor for himself or any member of his family mentioned by him in the policy and the Op No.1 is liable to reimburse the medical expenses. The name of complainant’s wife has been mentioned in the policy as member of his family. On 29.10.2012, wife of the complainant suffered irregular bleeding and the complainant took her to renowed gynecologist-Dr.Bhavna Aggarwal, who is MBBS, DGO, DNB, MDDGS & Gold Medalist-Obsterician & Gynecologist having registration No.1587 and practicing as Private Doctor at Balaji Medicentre ENT & Gynae Care Centre, SCO No.114, Sector-25, Panchkula. Balaji Medicentre-OP No.2 has indoor treatment facilities like Operation theatre, an approved MTP Centre, facility of ENT and Gyanae emergency. The OP No.2 has 5 beds, fully equipped Operation theatre and 24 hours qualified nursing staff and attending doctor on duty. Dr.Bhavna Aggarwal examined the wife of the complainant physically and ultrasound was also done. Thereafter, she prescribed certain medicines and called for follow up. The complainant’s wife visited Dr.Bhavna Aggarwal till 04.11.2012 and was given due medical care by the doctor and examined the condition very diligently, conducted ultrasound, other tests and prescribed regular medications. On 04.11.2012, Dr.Bhavna Aggarwal also conducted ultrasound of complainant’s wife and she found that complainant’s wife has Lt.Adnexal Mass & Fluid in the P.O.D., which resulted into Ectopic Pregnancy. Thereafter, she was given vaccinations and other advance medical care, however, the said mass & fluid persisted. On 02.12.2012, after thorough medical examination, the doctor told the complainant that the condition has not improved rather it is deteriorating. The doctor has conceded that the medication could not treat ailment and condition had deteriorated, hence immediate surgery was necessary. The doctor also informed that in the given situation surgery is highly warranted lest it could cause critical medical problem, it could cause danger to life too. Therefore, the complainant adhered to the expert advice given by the expert doctor and got his wife admitted at Balaji Medicentre for surgery on 02.012.2012 in emergent nature. On 03.12.2012, the complainant informed opposite party No.1 regarding his wife’s treatment and admission in Balaji Medicentre for surgery which was registered by Ops as claim intimation No.1473847 dated 03.12.2012. The complainant’s wife underwent laproscopic left salpingectomy with peritoneal lavage on 02.12.2012 wherein her left fallopian tube was removed. The wife of the complainant felt well to the emergent treatment given by the expert doctor i.e. Op No.2 and she was discharged on 04.12.2012. On 22.12.2012, the complainant submitted all the necessary documents to Op No.1 for medical reimbursement of the expenses for Rs.65,975/- spent by him for emergent treatment of his wife. The complainant also requested Op No.1 for earliest reimbursement of his medical claim. On 08.01.2013, the OP No.1 demanded certain additional documents i.e. hospital registration certificate or declaration from hospital authorities stating number of beds, availability of fully equipped operation theatre, 24 hour qualified nursing & qualified attending doctor. The complainant obtained the requisite certificates from Balaji Medicentre-Op No.2 and supplied the same to the Op No.1. On 13.02.2013, the Op No.1 demanded additional documents from complainant which was also supplied. Even then, the complainant once again supplied all the documents to the Op No.1 but the Op No.1 repudiated the medical claim of the complainant on the ground that the hospital where wife of the complainant was treated, was having less than 15 beds and is not registered with local authorities. The complainant submitted that the Op No.1 has never intimated the terms and conditions to him nor ever the policy has been supplied till date. The IRDA (Insurance Regulatory and Development Authority) has withdrawn a circular excluding hospital with fewer than 15 beds from the medical insurance cover as it has been adjudicated by the court of law as “absolutely arbitrary”.  This act of the opposite parties amounts to deficiency in service on their part. Hence, this complaint.
3. The Op No.1 appeared before this Forum and filed written statement and taken the objection and submitted that the complainant is an employee of Videocon Telecommunications Ltd. and the employer obtained a Group Mediclaim Policy No.151800/34/12/04/00000004 and the complainant is also member of Group Mediclaim Policy having membership No.MD15-0008286343. It is submitted that the Op No.1 had issued the terms and conditions to the policy holder Videocon Telecommunications Ltd and also intimated the terms & conditions to all the members of Group Mediclaim Policy. It is submitted that the policy holder was Videocon Telecommunications Ltd. and the Op No.1 has issued the terms and conditions to the insured. It is submitted that it was necessary to implead as a party to insured i.e. Videocon Telecommunications Ltd. It is submitted that wife of the complainant was covered under the policy subject to the terms and conditions of the policy. It is submitted that the Op No.2 did not have the required number of bed at her hospital and the complainant himself also admitted that the hospital was having only 5 beds so, the hospital did not fall under the definition of hospital given in the policy. It is submitted that the expenses incurred were not paid because the treatment taken at the hospital did not fulfill the requirements of the policy issued by the Op No.1. It is submitted that the claim was rightly repudiated vide letter dated 20.02.2013 on the ground that the hospital from where treatment was taken did not fulfill the condition of beds as required by the policy issued by the Op No.1 at Ahmednagar.  It is denied that the IRDA has withdrawn circular excluding hospitals with fewer beds from the medical insurance. It is submitted that as per definition 3.2, it was clearly mentioned that the minimum requirement of beds is 10 besides the other conditions, to be considered as Hospital/Nursing Home and either it should be registered with the local authorities or complies with minimum criteria as laid down. It is submitted that the hospital from where treatment has been taken was neither registered nor it complied with the minimum criterion laid down. Thus there is no deficiency in service on the part of the Op No.1 and prayed for dismissal of the complaint with costs.
4. Upon notice, Op No.2 appeared before this Forum and filed written statement. It is submitted that the dispute between the complainant and the Op No.1 with regard to repudiation of a claim for medical re-imbursement. It is submitted that no relief has been claimed against the Op No.2. It is submitted that no allegation of any deficiency in service has been made against the OP No.2 and no relief has been claimed against the OP No.2. It is submitted that the complainant had earlier filed complaint case No. 88/2014 before the Ld. District Consumer Disputes Redressal Forum-I, U.T., Chandigarh, which was dismissed on the ground of territorial jurisdiction and there the OP No.2 was not impleaded as a party. It is submitted that the OP No.2 is neither a necessary nor proper party to the complaint. It is submitted that the Op No.2 has no concern with the medical policy and has not liable to make any reimbursement. Thus, there is no deficiency in service on the part of the OP No.2 and prayed for dismissal of the complaint.
5. In order to prove his case, the counsel for the complainant has tendered the evidence by way of affidavit Annexure C-A alongwith documents Annexure C-1 to C-12, C12-A to C12-D and C13 and closed the evidence. On the other hand, counsel for the Op No.1 has tendered the evidence by way of affidavit Annexure R1/A alongwith documents Annexure R1/1 and R1/2 and closed the evidence. The counsel for the Op No.2 has made a separate statement in which he stated that his written statement might be read as his evidence and closed the evidence.
6. A conjunctive perusal of the pleadings made by the parties indicates that there is no dispute that the employer company (wherein the complaint is employed) has ‘retained a Group Medical Policy bearing number 151800/34/12/04/00000004 for it’s employees from the OP No.1 and membership number of the complainant therein is MD15-0008286343, that the complainant is entitled to the reimbursement of the expenditure incurred upon his own treatment (outdoor or indoor) and that of his wife and other members of his family indicated in the course of the policy documentation and that the policy was valid for the period 22.07.2012 to 21.07.2013.
7. OP No.1 does not, however, agree that “the complainant is entitled to medical expenses in all eventualities”. The denial is only in respect of the averment made by the complainant that “O.P. is liable to reimburse the said medical expenses”.
8. Though OP No.1 does not dispute that the wife of the complainant is entitled the benefit of the policy ‘but subject to the terms and conditions of the policy’, it repudiated the claim on in averment that the hospital from where the wife of the complainant obtained treatment was not a registered hospital and that it had only a 5-bed indoor facility which does not correspond to the eligibility definition of a ‘hospital’, in accord with the terms and conditions of the Insurance Policy.
9. The averments made by the complainant in the course of Para-6 to 10 with regard to the nature of treatment obtained by his wife were not controverted in the course of corresponding paras of the written statement. The repudiation of the claim was, thus, reiterated by OP No.1 on averments which are extracted hereunder
10. OP No.1, by way of preliminary objections, challenge the locus-standi of the complainant to file the complaint for want of any privity of contract between them and also averred the non-maintainability of the complaint for want of impleadment of the employer of the complainant as a party respondent.
11. OP No.2 asked for compensation from the complainant as it had been incorrectly impleaded as a party respondent, without there being any averment in the complaint about the deficiency of service on the part of that respondent.
12. We have heard the Ld. Counsel for the parties and have carefully perused the pleadings of the parties as also the documentation placed by them on record. We find adequate reasons to allow the complaint and to thereby negate the resistance offered by OP No.1. We proceed to record the reasoning in support of that conclusion.
13. It is beyond the pale of controversy that the hospital where the wife of the complainant was treated is not registered with the local authorities. The complainant has, on his own, placed on record Annexure C-7 vide which the Director-General, Health Services, Haryana, informed him “that there is no Policy of State Govt. where by the Private Hospitals / Nursing Homes are registered”. Thus, that condition of the Insurance Policy is not proved on record.
14. The Ld. Counsel appearing on behalf of OP No.1 vehemently argued that the relevant hospital being a 5-bed infrastructure, does not entitle to be described as a Hospital, within the meaning of Annexure C-12 (as also in terms of the terms and conditions of the Insurance Policy).
15. The plea was contested by the Ld. Counsel appearing for the complainant who argued that a Division Bench of Hon’ble Bombay High Court had quashed the definitive provision of the minimum number of beds in a judgment dated 05.07.2013, rendered by Hon’ble Mr. Justice S.J.Vazifdar (presently Hon’ble Chief Justice of Punjab and Haryana High Court) and Hon’ble Mr. Justice M.S. Sonak. The relevant averment is contained in Para No.19 of the complaint. The complainant has also placed on record Annexure C-12 (C-12/A, C-12/B, C-12/C and C-12/D) which contain a reporting of the relevant judgment under the nomenclature “No ‘minimum-beds hospital’ condition for mediclaim”. The fact and the implication of that judgment could not be controverted by the Ld. Counsel for OP No.1 during the course of hearing.
16. The following facts, thus, can be culled out from the preceding paras of this judgment.
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17. As already noticed, OP No.1 has not controverted the averments with regard to the nature and duration of treatment obtained by the wife of the complainant.
18. In allowance, thus, of the complaint against OP No.1, we direct as under: -
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19. OP No.1 shall comply with this order within a period of one month from the date its communication to it comes about. A copy of this order shall be forwarded, free of cost, to the parties to the complaint. File be consigned to record room after due compliance.

Announced

14.05.2015               ANITA KAPOOR                             DHARAM PAL

Note: Each and every page of this order has been duly signed by me.

ANITA KAPOOR