Order dictated by:

Sh.S.S. Panesar, President.

1.       Vinod Mahajan, complainant has brought the instant complaint under section 12 and 13 of  the Consumer Protection Act, 1986  on the allegations that the complainant obtained a mediclaim family Insurance policy from opposite party No.1 through opposite party No.2 on  20.2.2015  valid uptil 19.2.106 bearing No. 233300/48/2015/5703. The complainant, his wife and two sons were covered by the said insurance policy and the same was cashless policy for Rs. 2,00,000/- each. Jatin Mahajan , son of the complainant became seriously ill  and on 29.9.2015 he had to be admitted in the hospital of opposite party No.3. Jatin Mahajan was discharged on 10.10.2015. At the time of the admission of the son of the complainant in the hospital, the hospital authorities  were shown the said cashless policy and intimation of the same was also given to opposite party No.1. At the time of admission of the son of the complainant, the complainant was told by the hospital authorities that they had contacts regarding cashless policy/scheme and no amount will be charged from the complainant for the treatment of his son. The treatment amount shall be claimed from opposite party No.1 and the complainant will not be asked for making the payment of the treatment of his son. The agent of opposite party No.1 came to the hospital on the very next day  for verification and told the hospital authorities that  complainant had cashless insurance policy and the payment of the treatment of the son of the complainant will be made by opposite party No.1. On 10.10.2015 when the son of the complainant was being discharged  the hospital authorities demanded Rs. 96,581/- from the complainant. The complainant told the doctor that he was having cashless  policy and the amount for the treatment of his son was to be paid  by the Insurance company. The complainant also approached opposite party No.1 to clear the amount of the hospital for the treatment of his son but the Insurance company was dilly dallying the matter on one pretext or the other without any reasonable cause and excuse. The hospital authorities did not allow the son of the complainant to leave the hospital and he was detained in the hospital till 12.10.2015 illegally and forcibly and was made to pay Rs. 72000/-  under the threat that the son of the complainant will not be discharged till the said amount is cleared. The complainant had been meeting/contacting the officers of the opposite party No.1 and asked them to settle the matter. However, they were assuring the complainant that the cheque will be given of the said amount which had been deposited by the complainant in the hospital but no action had been taken so far. The complainant had prayed for the following reliefs  vide instant complaint:-

(i)      Opposite parties be directed to pay Rs. 72000/- deposited by the complainant with opposite party No.3 with interest @ 18% p.a.

(ii)     Opposite parties be directed to pay Rs. 10000/- as compensation for mental agony and harassment caused to the complainant alongwith litigation expenses to the tune of Rs. 12000/-.

Hence, this complaint.

2.       Upon notice opposite parties appeared and contested the complaint by filing separate written statements.

3.       In written statement filed on behalf of opposite party No.1, certain preliminary objections were taken therein inter alia that complainant is stopped by his own act and conduct to file the present complaint and the complaint is not maintainable under law ; that complainant does not fall within the ambit of consumer  under section 2 of the Consumer Protection Act ; that no cause of action has been arisen to the complainant to file the present complaint as averments of the  complaint do not depict any consumer dispute inter-se parties ; that complainant has not  come to this Forum with clean hands and has suppressed the material facts  from this Court ; that present complaint is hopelessly barred by limitation  ; that present complaint is bad for non joinder of necessary party ; that  present complaint is not maintainable under the law as the same is premature complaint against the replying opposite party. On merits facts narrated in the complaint have been specifically denied. It is stated that the claim filed by the complainant is premature as the TPA of opposite party has not passed any order on the reimbursement of Insurance claim filed by the complainant and a prayer for dismissal of the complaint with cost has been made.

4.       In its written statement, opposite party No.2 also  took                                                  various preliminary objections  which have already been taken by opposite party No.1, therefore, there is no gain saying in repeating those allegations for the sake of brevity . On merits it is denied for want of knowledge that agent of opposite party No.1 came to the hospital on the next day for verification. It is also denied for want of knowledge that agent of opposite party No.1 told the hospital authorities that the complainant had cashless insurance policy or the payment of the treatment of the son of the complainant will be made by opposite party No.1. Remaining allegations made in the complaint have also been denied and a prayer for dismissal of the complaint with cost was made.

5.       In its written statement on behalf of opposite party No.3, preliminary objections have already taken by opposite party No.1, were taken and there is no gain saying in repeating those allegations for the purpose of brevity. On merits, it is stated that the treatment was cashless subject to  approval by opposite party No.1 . If opposite party No.1  raise any objection,  then purported complainant will have to make payment of the treatment expenses and get the same reimbursed from opposite party No.1 within the norms of policy in question. It is denied  that any agent of opposite party No.1 ever visited opposite party No.3 hospital and directed that treatment  of the patient in question was to be cashless or that the treatment expenses were to be borne  by opposite No.1 only. Infact there is no procedure for any oral sanction for reimbursement of treatment expenses by any Insurance company, as alleged. It is denied that there was  any threat from the hospital authorities that son of the complainant  will not be discharged until the amount of the bill stood paid. The purported complainant made payment of Rs. 72000/- against bill of Rs. 96,581/- and the balance amount of Rs. 24,581/-  is still outstanding .Further the receipt dated 15.10.2015 for Rs. 30000/- out of admitted payment of Rs. 72000/- clearly proves that the purported complainant made the payment of the amount mentioned  even after three days of leaving the hospital. The complaint is meritless , therefore, the same is liable to be dismissed.

6.       In his bid to prove the case Sh.Vishal Khanna ,Adv.counsel for the complainant has tendered into evidence duly sworn affidavit of the complainant Ex.C-1 , copies of postal receipts Ex.C-2/A, Ex.C-2/B and Ex.C-2/C alongwith documents Ex.C-3 to Ex. C-42 and closed the evidence on behalf of the complainant.

7.       To rebut the aforesaid evidence Sh.Subodh Salwan,Adv.counsel for opposite party No.1 tendered into evidence affidavit of Sh.Gurdip Singh,Divisional Manager Ex.OP1/A, copy of Insurance policy Ex.OP1/1 , copies of intimation letters Ex.OP1/2 to Ex.OP1/4.

8.       On the other hand opposite party No.2 tendered into evidence affidavit of Sh.Sukhdev Joshi,Sr.Manager, Punjab National Bank Ex.OP2/1, copy of account statement Ex.OP2/2 and closed the evidence on behalf of opposite party No.2.

9.       Opposite party No.3 through its Counsel Sh.Updip Singh tendered into evidence affidavit of Sh.P.S.Bhandari Ex.OP3/1, copy of application of the complainant for cashless facility from opposite party hospital Ex.OP3/2 and closed the evidence on behalf of opposite party No.3.

10.     We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

11.     There is no denying the fact that Jatin Mahajan, son of the complainant, got admitted in the hospital of opposite party No.3 and he remained  under the treatment of opposite party No.3 w.e.f. 29.9.2015 to 10.10.2015. It is also not disputed that the treatment expenses of Jatin Mahajan came to be Rs. 96,581/-.  The hospital bills/invoices pertaining to the hospital expenses are Ex.C-6 to Ex. C-41 on record. It is also not disputed that the complainant had obtained mediclaim policy , copy whereof is Ex.C-4 which was in operation during the treatment of Jatin Mahajan, son of the complainant. It was a cashless policy. However, opposite party No.3 did not get the hospital expenses from opposite party No.1 as per terms and conditions of the Insurance policy in dispute. It is in evidence that it was the complainant, who made part payment  to the tune of Rs. 72000/- to the hospital authorities  at the time of discharge of his son from the hospital. The complainant applied for reimbursement of the hospital expenses with opposite party No.1 after submitting certain documents. But, however, opposite party No.1 has not settled the claim of the complainant so far. It has been the objection of opposite party No.1  in the written statement that no order regarding the settlement  of the Insurance claim has been made by opposite party No.1 so far, therefore, instant complaint was premature. We also conform to the view of opposite party No.1 in this regard & hold instant complaint to be premature. As such complainant is directed to submit copies of the documents detailed in letter Ex.OP1/3 dated 31.1.2016, within 15 days  of the supply of copy of this order while opposite party No.1 shall settle the claim of the complainant within a further period of two months therefrom. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.  Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Forum

Dated : 29.08.2016

/R/