Haryana

Karnal

CC/347/2021

Navneet Kumar - Complainant(s)

Versus

Raksha Health Insurance TPA Private Limited - Opp.Party(s)

10 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                      Complaint No. 347 of 2021

                                                      Date of instt.23.07.2021

                                                      Date of Decision:10.04.2024

 

Navneet Kumar son of Shri Randhir Singh aged about 36 years, resident of H.No.769, Devi Garh Road, Street No.2, Om Shanti Nagar, Kaithal, 136027.

                                               …….Complainant.

                                              Versus

 

1.     Raksha Health Insurance TPA Pvt. Ltd. Through its Chief Executive Officer, Commerce House, 5^th Floor, 7-Race Course Road, Indore 452001.

2.     National Insurance Company Limited through its Branch Manager, Dwarka Branch, S-17, 2^nd Floor Sector-4, Plot No.5, Malik Plaza Dwarka (above Domino’s) 110075.

3.     Sarva Haryana Gramin Bank, through its Chairman, SHGB House, Plot NO.1, Sector-3, HUDA,  Rohtak.

…..Opposite Parties.

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Shri Vineet Kaushik…….Member

              Dr. Suman Singh……Member

          

Argued by:  Complainant in person.

                    OP no.1 ex-parte vide order dated 08.04.2022.

                    Shri Manjul Mishra, counsel for OP No.2.

                    Ms.Charu Dhingra, counsel for OP No.3.

 

                    (Jaswant Singh, President)

ORDER:     

                 The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant is having health insurance policy member ID No.M58343575SHGB issued by OP No.2, National Insurance Company Limited and OP No.1 is a third party administrator and is responsible for Health Insurance Claim processing for and on behalf of OP No.2 for the said policy Sarva Haryana Gramin Bank OP No.3 is the employer of complainant and purchased the policy for its employees including complainant. A group Health Insurance policy effective from 31.03.2021 to 30.03.2022 was purchased by OP No.3 from OP No.2 for its employee and their families. Complainant being its employee/officer scale II was also covered under the above said Health Insurance Policy. On 22.04.2021, the complainant fell from stairs of his house at Kaithal and his humerus bone was fractured and complainant visited Orthopaedic Surgeon at Kaithal and was informed that broken bone was to be fixed by inserting plates around it and for that immediate surgery was required and asked him to deposit Rs.40,000/- with the Hospital Administration as surgical and other expenses. Complainant was not having such a big amount as the above said hospital at Kaithal was not on the penal Hospital of OP No.1 and thus cashless cover for surgery was not available there. Complainant decided to get himself operated in any of the penal hospitasl of “Raksha TPA” thus, the complainant chose to get himself operated in Haryana Nursing Home, at Karnal which was on the penal Network Hospital of OP No.1. Due to unbearable pan, complainant reached Haryana Nursing Home at Karnal in early morning hours on 23.04.2021. The hospital administration forwarded the case for cashless facility under the insurance policy as the processing of cashless claim was slow by OP No.1, the hospital shifted the complainant into a private room and started preparing for the surgery. To the surprise and horror of complainant, OP No.1 communicated through e-mail and denied the cashless facility for surgery of the complainant. The hospital administration asked the complainant to deposit Rs.70,000/- for cost of surgery and Rs.10,000/- if the complainant wanted to get discharged without undergoing surgery. Feeling down and mentally disturbed with the above said situation, the complainant took Rs.70,000/- on interest from one of his relative and paid the same to the hospital. Because of the above said illegal, fraudulent and negligent acts of OPs, complainant had to suffer grave mental, physical as well as financial harm/injury. Hence, the present complaint.    

2.             Despite issuance of notice, none has appeared on behalf of OP No.1, hence, it was proceeded against ex-parte vide order dated 08.04.2022.

3.             OPs No.2 & 3 appeared. OP No.2 filed its separate written version raising preliminary objections with regard to maintainability; concealment of true and material facts, abuse of process of law, etc. On merits, it is pleaded that complainant obtained alleged insurance policy if any issued by the OP by misrepresentation and the claim has rightly been repudiated as the complainant was deleted from the policy by the insurance company on the recommendation of the Chief Manager, HRDD Sarva Haryana Gramin Bank vide letter dated 09.04.2021 in which the nine names of the persons including complainant Navneet Kumar was given. The fact is also mentioned in the endorsement No.361802502082J00148 which is valid from 09.04.2021 to 30.03.2022, thus the complainant was not covered under this policy at the time of admission in the hospital and he is not entitled to any medical claim.  There is no deficiency in service on the parts of OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             OP No.3 filed its separate written version raising preliminary objections with regard to maintainability; jurisdiction; barred by law of limitation, cause of action, locus standi, etc. On merits, it is pleaded that the complainant joined the services of bank at Branch Office, Gharrot on 15.03.2016 as Officer Scale II after completion of pre-joining formalities on 14.03.2016. Complainant served his resignation to bank on 01.08.2016 giving one month notice period and he was to be relieved from the services of the bank after notice period i.e. w.e.f. 01.09.2016. Complainant left the bank’s service in an unauthorized manner since 01.09.2016 without indemnifying the bank for Rs.2,00,000/- i.e. bond money. As per the terms and conditions of the appointment, the complainant was to remain in service for a minimum period of 3 years and in case of leaving the service before completion of minimum period of 3 years, as per terms and conditions of appointment, the complainant was under legal obligation to deposit bond money of Rs.2,00,000/- but he did not deposit the bond money of Rs.2,00,000/- with the bank and failed to indemnify the bank. The bank filed a civil suit against the complainant for recovery of Rs.2,00,000/- on account of indemnity bond alongwith interest. There is no deficiency in service on the parts of OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             Parties then led their respective evidence.

6.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of group insurance policy Ex.C1, copy of medical card Ex.C2, copies of treatment record Ex.C3 to Ex.C5, copy of repudiation letter Ex.C6, copy of e-mail Ex.C7, Discharge summary Ex.C8, copies of bills Ex.C9 to Ex.C15, copies of treatment records Ex.C16 to Ex.C34, copies of healty insurance policy schedule Ex.C35 and Ex.C36 and closed the evidence on 24.04.2023 by suffering separate statement.

7.             On the other hand, learned counsel for the OP No.2 has tendered into evidence affidavit of Reena Basak, A.O. NIC Ex.RW2/A, copy of policy Ex.OP2/1, copy of letter dated 09.04.2021 Ex.OP2/2 and closed the evidence on 27.07.2023 by suffering separate statement.

8.             Learned counsel for the OP No.3 has tendered into evidence affidavit of Mithilesh Kumar Jha, General Manager, Sarva Haryana Gramin Bank Ex.RW1/A, copy of judgment and decree sheet dated 29.10.2021, passed in civil appeal Ex.RW1, copy of order dated 15.07.2022 Ex.RW2 and closed the evidence on 11.12.2023 by suffering separate statement.

9.             We have heard the complainant and learned counsel for OPs No.2 & 3 and perused the case file carefully and have also gone through the evidence led by the parties.

10.           Complainant, while reiterating the contents of the complaint, has vehemently argued that a group health insurance policy was purchased by OP No.3 from OP No.2 for its employees and their families and complainant was covered in the said policy. The complainant had undergone surgery from Haryana Nursing Home, Karnal and spent Rs.80,000/-. As in the said policy cashless facility was available, therefore, the complainant had applied for cashless treatment from the said hospital, but the OP denied the cashless facility without any reason and rhyme, therefore, there is deficiency on the part of OPs and lastly prayed for allowing the complaint. 

11.           Per contra, learned counsel for the OP No.2, while reiterating the contents of written version, has vehemently argued that the name of complainant has been deleted from the policy by the insurance company on the recommendation of the Chief Manager HRDD, Sarva Haryana Gramin Bank vide letter dated 09.04.2021. Hence, the claim was rightly repudiated and lastly prayed for dismissal of complaint.

12.           Learned counsel for OP No.3, while reiterating the contents of written version, has vehemently argued that as no employer employee relation exists between the OP and the complainant, therefore, complaint is nothing but has been filed to grab the money from the insurance company. The complainant has resigned from his job, therefore, the complainant is not covered under the insurance policy, therefore, the claim of the complainant has been rightly repudiated by the insurance company and lastly prayed for dismissal of complaint.    

13.           We have duly considered the rival contentions of the parties.

14.           The claim of the complainant has been repudiated by the OP No.2, vide repudiation letter Ex.C6 dated 23.04.2021, the relevant portion of the said letter is reproduced as under:-

“After primary perusal of the documents we regret to inform you that cashless facility cannot be sanctioned due to the following reason:

Case Summary

Case of cough fever breathlessness managed conservatively, member deleted”.

 

15.           The claim of the complainant has been repudiated by the OP No.1 on the ground of member deleted.

16.           The question for consideration which arises before this Commission is that whether the complainant was employee of OP No.3 at the time of taking treatment or not?

17.           The onus to prove its case was upon the OP. The OP No.3 has alleged that the complainant has resigned from his job from the bank, therefore, they have sent a letter to OP No.2 for exclusion of his as well as other employees name from the group insurance scheme. In order to prove its case OP has placed on file letter Ex.OP2/2 dated 09.04.2021 written by Chief Manager, HRDD Sarva Haryana Gramin Bank to the Branch Manager, National Insurance Company (OP No.2) regarding exclusion of staff members from medical insurance policy. In that letter, the name of complainant is mentioned. Therefore, it is clear from the said letter that the name of complainant has been excluded from the group insurance scheme obtained by the OP no.3 from the OP No.2 on 09.04.2021. The complainant has alleged that he has obtained treatment from the Haryana Nursing Home, Karnal, on 23.04.2021 but on the date of treatment, the complainant was not covered under group insurance scheme, purchased by OP No.3 from insurance company.

18.           The OP No.3 has also alleged that the complainant has left the job in an unauthorized manner without indemnifying the bank for Rs.2,00,000/- and in this regard the bank has filed a civil suit for recovery of Rs.2,00,000/- from the complainant, wherein the complainant has filed counter claim, which was partly allowed. The bank has filed an appeal against the said judgment and decree dated 16.09.2019 before the court of learned Additional District Judge, Palwal, and the said appeal was allowed and the complainant was directed to pay Rs.2,00,000/- to the OP No.3. The said fact has been duly proved from the copy of judgment and decree Ex.RW1 dated 02.10.2021. Moreover, during the course of arguments, complainant has placed on file copy of order dated 07.12.2021, passed by Hon’ble High Court of Punjab and Haryana, Chandigarh. But in the said order, neither there is any stay order nor any other direction which goes in favour of the complainant.  Since, the complainant was not the member of the Group Insurance Policy and he had left the job before the date of treatment, thus, the complainant is not entitled to anyu medical claim as alleged by him.

19.           In view of the above discussion, the present complaint is devoid of any merits and deserves to be dismissed and same is hereby dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 10.04.2024

                                                          President,

                                             District Consumer Disputes

                                             Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

                          Member                     Member