BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 439 of 2015
Date of Institution: 15.7.2015
Date of Decision: 19.5.2016
Bhupinder Singh son of Rawel Singh, aged 45 years, resident of VPO Deo, Tehsil & District Tarn Taran
Complainant
Versus
- Oriental Insurance Co.Ltd., Madan Mohan Malviya Road, Amritsar through its authorized signatory
- E-Meditek Health Care Centre, Tehsilpura, Amritsar through its authorized signatory
- Sh.Guru Ram Dass Institute of Medical Science and Research, Amritsar through its authorized signatory
- Shiromani Gurudawara Parbhandak Committee, Amritsar through its Secretary
Opposite Parties
Complaint under section 12 of Consumer Protection Act, 1986
Present: For the Complainant :Sh.Simarjit Singh,Advocate
For the Opposite Party No.1: Sh.Rajinder Nayyar,Advocate
For Opposite Parties No.3&4 : Sh. M.S.Gill,Advocate
For Opposite party No.2 : Ex-parte
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Sh.Anoop Sharma,Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Bhupinder Singh has brought the instant complaint under section 12 of the Consumer Protection Act, 1986 on the allegations that he is working in the office of opposite party No.4 and is a permanent employee and as per the scheme of opposite party No.3, each and every family member of employee of opposite party No.4 is insured under a medical group insurance having policy No.235300/48/2014/1131 which is valid for the period from 1.1.2014 to 31.12.2014 with opposite party No.1. The premium for the said policy was being deducted by opposite party No.4 from the salary of the complainant and is paid to opposite party No.1 by opposite party No.4. As such the complainant falls under the definition of consumer of the opposite parties. Medical card is attached. On 17.7.2014 Gurlal Singh son of the complainant felt pain in his chest and the complainant visited in the hospital of opposite party No.3 for medical check up of his son. Doctor of opposite party No. 3 told the complainant that Gurlal Singh son of the complainant is suffering from some heart problem and advised for admission in the hospital. As per the advice of the doctors, complainant got his son admitted in the hospital on the same day and he was discharged from the hospital on 24.7.2014. At the time of admission, complainant showed the identity card issued by opposite party No.1 to opposite party No.3 for free medical checkup as the said hospital is duly listed in the authorized hospital of opposite party No.1. But employees of opposite party No.3 told the complainant that they will send the case for approval of free medical aid. At the time of discharge, the employees of opposite party No.3 demanded the medical expenses from the complainant as the case of the complainant was rejected by opposite party No.1. As such the complainant had to pay the whole expenses i.e. Rs. 12000/- to opposite party No.3 from his own pocket. The complainant demanded rejection letter from opposite party No.3 , but employees of opposite party No.3 refused to give the same to the complainant. Opposite party No.2 is third party agent of opposite party No.1 and the said opposite party No.2 dealt the case of the complainant. Opposite party No.1 has wrongly and illegally rejected the claim of the complainant . The abovesaid act and conduct of opposite parties amounted to deficiency in service and unfair trade practice for which they are liable to pay compensation to the complainant for mental harassment and financial loss to the complainant. The complainant has asked for following reliefs vide instant complaint :-
(i) Reimburse the medical expenses to the complainant.
(ii) Pay Rs. 50000/- as compensation on account of mental harassment, pain and agony.
(iii) Pay Rs. 11000/- as litigation expenses.
Hence, this complaint.
2. Upon notice opposite parties No.1,3 & 4 appeared and contested the complaint by filing separate written statements.
3. Opposite party No.2 despite due service did not opt to appear and contest the complaint and as such it was ordered to be proceeded against ex-parte.
4. In their written statement opposite party No.1 took certain preliminary objections therein inter-alia that the complainant has not approached this Forum with clean hands and is guilty of concealment of material facts from this Forum ; that the complainant is stopped by his own act and conduct from filing the present complaint. The complaint is pre-mature because after getting the information regarding the admission of son of the complainant at Sri Guru Ram Dass Medical College and Hospital for the treatment of the chest pain the opposite party No.2 has immediately informed the opposite party No.3 regarding denial of cashless facility regarding the treatment of Gurlal Singh son of the complainant. It was also duly informed that the patient made submit the hospitalization paper for reimbursement as per terms and conditions of the policy ; that the cashless facility regarding the hospitalization of son of the complainant was denied as per clause 4 Exclusions, which reads as under:-
“Section 4 Exclusions : (The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of : (4.8) Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal disease, international self-injury/suicide, all psychiatric and psychosomatic disorders and disease/accident due to and or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc.).
As such the present complaint is not maintainable and is liable to be dismissed. On merits, it is stated that after receiving information regarding admission of the son of the complainant from opposite party No.3, opposite party No.2 discussed the case of the complainant for granting cashless facility. But the same was denied by opposite party No.2 as per terms and conditions of the policy. The complainant was also informed that he can submit all documents with the opposite party for reimbursement of the claim. But the complainant has not submitted any documents with the opposite party regarding settlement of his claim. The complainant has directly filed this complaint in this Forum. It is denied that opposite party is ready to pay medical expenses, Rs. 50000/- as compensation on account of mental harassment and economic loss besides Rs. 11000/- as litigation expenses.
5. In its written reply, opposite party No.3 also took preliminary objections therein inter alia that the replying opposite party has been unnecessarily dragged into litigation by the complainant. The actual dispute is between the complainant and opposite parties No.1 & 2 regarding the rejection of cashless treatment of Sh.Gurlal Singh by opposite party No.2 which is TPA of opposite party No.1. There is no deficiency in service or unfair trade practice on the part of replying opposite party and this complaint qua replying opposite party is liable to be dismissed on this score alone. On merits, it is not disputed that the complainant is an employee of opposite party No.4 and he is member of Group Medical Tailor made Policy of opposite party No.1. It is denied that there was no scheme of replying opposite party No.3. As per cover note issued by opposite party No.1, five members of the each insured employee as per the list of insured employees is covered under the said mediclaim policy. It is not disputed that the premium for the said policy stood paid as is clear from the contents of the cover note and the said mediclaim policy. As such opposite party No.1 and opposite party No.3 which is TPA of opposite party No.1 are under obligation to provide the requisite services in terms of the said policy. It is not disputed that Gurlal Singh son of Bhupinder Singh was admitted in Sri Guru Ram Dass Charitable Hospital, Amritsar with the complaint of chest pain and palpitation and he was treated at the hospital as per the medical record for the said disease. Requisite tests were also conducted and the said patient was discharged on 24.7.2011 . Necessary information was given regarding the treatment of said Gurlal Singh to opposite parties No.1 & 2 as required on the basis of card No. 103011400011320 policy No.235300/48/2014/1131 as per the contents recorded by opposite party No.1 on the card issued by said opposite party favouring Gurlal Singh for free medical treatment. It is not disputed that opposite party No.3 is listed hospital of opposite party No.1 for treatment of the insured by the said insurer. Requisite information as demanded by opposite party No.1 i.e. TPA of opposite party No.1 was also provided. However, opposite party No.2 rejected the claim regarding treatment of said Gurlal Singh vide their communication dated 24.7.2014 with the following remarks :-
“We regret to inform, that your cashless request has not been sanctioned due to the below marked reasons.
“Section 4 Exclusions : (The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of : (4.8) Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal disease, international self-injury/suicide, all psychiatric and psychosomatic disorders and disease/accident due to and or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc.).”
6. Since the cashless claim regarding the treatment of Gurlal Singh was denied, replying opposite party had no other alternative except to receive the amount on account of treatment of the said patient from him/his attendants . Only minimum amount was charged for the treatment of the said patient in the given circumstances. Replying opposite party is not liable to pay any amount by way of compensation or any other amount as stated in the complaint. It is opposite parties No.1 & 2, who are liable to reimburse the medical expenses to the complainant and to pay other amount as may be ordered by this Forum.
7. In its written reply, opposite party No.4 took certain preliminary objections therein inter-alia that complainant is not the consumer qua the replying opposite party and this complaint against replying opposite party is liable to be dismissed ; that the complainant is an employee of replying opposite party is member of Group Mediclaim Tailor made Insurance Policy of opposite party No.1 and opposite party No.2 is TPA of opposite party No.1. As such the complainant is the insured and opposite party No.1 is insurer and complainant is consumer qua opposite party No.1. On merits it is not disputed to the extent that complainant is an employee of replying opposite party and he is member of Group Mediclaim Tailor made Insurance Policy of opposite party No.1 mentioned in para under reply. The premium in respect of group insurance of the said mediclaim policy has been paid to opposite party No.1. It is not disputed that complainant is a consumer only qua opposite parties No.1 & 2 with regard to the mediclaim policy. It is denied for want of knowledge that no document with regard to the treatment of the son of the complainant have been submitted by the complainant in the office of replying opposite party and neither any such document is available with the replying opposite party. Opposite parties No.1 & 2 are liable for such amount which should be paid by said opposite parties to the complainant as may be decided by this Forum. A prayer for dismissal of the complaint with cost was made.
8. In his bid to prove complainant tendered into evidence his affidavit Ex.C-1 , copy of Insurance card Ex.C-2, copy of discharge card of Sri Guru Ram Das Charitable Hospital, Asr.Ex.C-3, copies of cash receipts Ex.C-4 to Ex.C-7, copy of letter dated 24.7.2014 Ex.C-8.
9. To rebut the aforesaid evidence opposite party No.1 tendered affidavit of Sh.R.K.Sharma Sr. Divisional Manager Ex.OP1/1, copy of letter dated 24.7.2014 Ex.OP1/2, copy of policy schedule Ex.OP1/3, copy of terms and conditions Ex.OP1/4.
10. On the other hand Sh.M.S.Gill,Adv.counsel for opposite party No.3 tendered into evidence affidavit of Geeta Sharma, Principal Ex.OP3/1 alongwith documents Ex.OP3/2 to Ex.OP3/9.
11. Opposite party No.4 tendered into evidence affidavit of Sh.Manjit Singh,Secretary Ex.OP4/1 alongwith documents Ex.OP4/2 to Ex.OP4/6.
12. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
13. From the appreciation of the evidence on record, it becomes evident that the complainant was holder of Group Insurance Policy in dispute , copy whereof is Ex.OP1/3. It was cashless policy. It is also not disputed that Gurlal Singh son of the complainant felt chest pain on 17.7.2014 and he had to be hospitalized at Sri Guru Ram Dass Charitable Hospital for medical check up. It was disclosed to the complainant that Gurlal Singh was suffering from some heart problem and he was accordingly admitted in the hospital on 17.7.2014 and remained under the treatment of the hospital uptil 24.7.2014, copy of the bed head ticket accounts for Ex.C-3. It is also proved on record that Gurlal Singh was discharged from the hospital on 24.7.2014. The complainant at the time of admission of his son requested for cashless treatment. But, however, opposite party No.2 rejected the case of the complainant for cashless treatment of his son vide letter dated 24.7.2014 , copy whereof is Ex.C-8. It is also proved on record that the complainant had to pay the entire expenses on the treatment to the tune of Rs. 12000/- to opposite party No.3. The case of opposite party No.1 has been that cashless request was declined on account of section 4 Exclusion clause on account of the fact that psychiatric and psychosomatic disorders and diseases were not payable under the policy terms and conditions. But, however the treatment received by Gurlal Singh had nothing to do with psychiatric and psychosomatic disorders. Bed head ticket clearly shows that no such treatment was provided to Gurlal Singh patient in the hospital i.e. opposite party No.3. The other contention of opposite party No.1 has been that the complainant has not applied for disbursement of the medical expenses to opposite parties No.1 & 2. But,however, the said objection is also not tenable because as per exclusion clause 4, the case for cashless treatment had already been declined wrongly and as such there was absolutely no reason with the complainant to apply for reimbursement of the medical expenses when the case for grant of cashless facility has already been declined in view of the exclusion clause supra. In such a case the complainant was within his right to approach this Forum directly for reimbursement of the expenses as well as compensation and expenses for litigation. Since opposite parties No.1 & 2 have been deficient in service and have indulged in unfair trade practice,as such, the complainant is entitled to reimbursement of the medical expenses to the tune of Rs. 12000/-, compensation to the tune of Rs. 3000/- as well as litigation expenses for an amount of Rs. 2000/- from opposite parties No.1 & 2. Compliance of this order be made within a period of one month of the receipt of the copy of order ; failing which, the awarded amount shall carry interest @ 6% p.a. from the date of order until full and final recovery. However, no case has been made out against opposite parties No.3 & 4 and as such case against opposite parties No.3 & 4 fails and is dismissed accordingly. . Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated : 19.05.2016
/R/ ( S.S.Panesar )
President
( Kulwant Kaur Bajwa) (Anoop Sharma)
Member Member
