DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR
Complaint No. 446
Instituted on: 23.10.2018
Decided on: 15.03.2021
Harminder Singh son of Karnail Singh, R/O Village Sular Gharat, Tehsil Sunam, District Sangrur.
…Complainant
Versus
1. Reliance General Insurance company through its Manager, SCO No.135-136, Sector 9-C, Madhya Marg, Chandigarh.
2. The Sular MPCASS Ltd. Village Sullar, Tehsil Sunam, Distt. Sangrur through its Secretary.
3. MD India Health Care Services (TPA) Pvt. Ltd. Max Pro Info Park, D-38, Phase-I Industrial Area, Mohali 160056 through its MD.
4. Bhai Ghanhya Trust C/o Punjab Institute Corporation Training, SCO No.16, Sector 7-C, Madhya Marg, Chandigarh through its CEO.
..Opposite parties
For the complainant : Shri S.S.Ratol, Adv.
For OP No.1 : Shri Amit Goyal, Adv.
For OP NO.2&4 : Shri Rajinder Sharma, Adv.
For OP No.3. : Exparte.
Quorum: Shri Jasjit Singh Bhinder, President
Shri V.K.Gulati, Member
Order by : Shri Jasjit Singh Bhinder, President.
1. Shri Harminder Singh, complainant has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is the member of society OP number 2 and was insured with OP number 1 under Bhai Ghanya Sehat Scheme as the complainant is holding a card bearing number MD15-BGSSS-00309573-S for the period from 14.3.2017 to 14.3.2018. The case of the complainant is that during the subsistence of the insurance policy, the complainant fell ill and was admitted in Phull Neuro and Multispecialty Hospital, Patiala for the period from 11.10.2017 to 16.10.2017 where he spent an amount of Rs.74,350/- on his treatment for paralytic attack and this amount was paid by the complainant to the hospital. Thereafter the complainant immediately intimated the Ops regarding the illness and submitted all the original bills with the company, but the claim was not paid. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.74,350/- along with interest from the date of admission till its actual payment and further claimed compensation and litigation expenses.
2. In reply filed by the OP number 1, legal objections are taken up on the grounds that the present complaint is not maintainable, that the complainant has not come to Commission with clean hands and that the complainant has dragged the Ops into unwanted litigation and that there is no deficiency in service on the part of the Ops. Insurance is a bilateral contract and both the parties to the contract are bound by the terms and conditions of the insurance policy. In the present case, the treatment by the complainant was taken from Phull Neuro and Multispeciality Hospital, which is not empanelled hospital of the Ops, as such no claim is payable to the complainant and that the complaint is vague in material particulars and does not disclose any cause of action against the Ops. On merits, it is admitted that the complainant was insured under the Bhai Ghanayia Sehat Sewa Scheme through OP number 2 and the health card was issued to the complainant. It is admitted that the complainant took treatment from Phull Neuro and Multispeciality Hospital from 11.10.2017 to 16.10.2017, but as per the terms and conditions of the policy only cashless hospitalisation is available in network/empanelled hospitals and non cashless/reimbursement facility is only in govt hospitals/medical colleges as specified in the scheme. As the complainant took treatment from non empanelled hospital, as such, the complainant is not entitled to any claim and the claim has rightly been repudiated vide letter dated 15.1.2018.
3. In reply filed by OP number 4, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complaint is false and frivolous and vexatious in nature and that the complainant has no cause of action to file this complaint. On merits, it has been admitted that the OP number 1 has been appointed as insurer for implementation of BGSSS during the period 15.3.2017 to 14.3.2018 which had appointed MD India Health Care Services as third party administrator, who is responsible for issuing of identity cards to the beneficiaries. It is further stated that Phull Neuro and Multispeciality Hospital in which the complainant is said to had taken treatment is not an approved hospital under the scheme. Since the Op number 4 is not to settle the claim, therefore question of having informed to the OP does not arise at all. However, any deficiency in service on the part of the OP number 4 has been denied.
4. Record shows that the OP number 3 was proceeded against exparte. No reply has been filed by Op number 2 and had made statement that OP number 2 does not want to file any written statement.
5. The learned counsel for the parties produced their respective evidence.
6. We have perused the complaint, version of the opposite parties and heard the arguments of the learned counsel for the parties.
7. The learned counsel for the complainant has argued that the complainant is the consumer of the Ops as he is a member of society OP number 2 and was insured with OP number 1 under Bhai Ghanya Sehat Scheme. The learned counsel for the complainant has further argued that earlier he was insured through ICICI Lombard General Insurance company Limited. Now, the complainant is holding a card bearing number MD15-BGSSS-00309573-S for the period from 14.3.2017 to 14.3.2018. The learned counsel for the complainant has argued that during the subsistence of the insurance policy, the complainant fell ill and was admitted in Phull Neuro and Multispecialty Hospital, Patiala for the period from 11.10.2017 to 16.10.2017 where he spent an amount of Rs.74,350/- on his treatment for paralytic attack and this amount was paid by the complainant to the hospital. Thereafter the complainant immediately intimated the Ops regarding the illness and submitted all the original bills with the company, but the claim was not paid. As such, the complainant has prayed for acceptance of the complaint. The complainant has relied upon the judgment of the Hon’ble Punjab State Commission in Sukhdev Singh versus The New Karian Pehalwal Cooperative Agriculture Society and others 2017(3) CLT 120, wherein it has been held as Deficiency in service. Unfair trade practice. Bhai Ghanhya Sehat Sewa Scheme applicable for employees eligible cooperative societies. Cashless hospitalisation. Heart surgery and Angiography. Repudiation on ground that complainant took treatment from a non empanelled hospital. Complaint before District Forum dismissed. Challenged. Held, clause shows in guide book that treatment should be taken from Government or empanelled hospitals, but when there is emergency, one cannot wait to find empanelled hospital and lose his life by time, when he is not in a position to find said hospital nearby. Right to life is a fundamental right, as defined in Article 21 of Constitution of India. In emergency cases, insured person has right to get treatment from nearby hospital, but expenses limit will be to expenses, which are being charged by Government hospital or empanelled hospitals.
8. The learned counsel for the complainant has further cited Shiva Kant Jha versus Union of India 2018(2)SCT 529, wherein it has been held Medical bills, Reimbursement. Petitioner took treatment in non empanelled hospital. Though Special Technical Committee not found implant of CRT-D device justified, keeping in view emergency nature of case competent authority approved reimbursement of implant at AIIMS rate. Treatment of petitioner in non empanelled hospital genuine because of no option left with him at relevant time. Respondent State directed to reimburse balance amount.
9. On the other hand, the learned counsel for the OP number 1 has argued that the complainant took treatment from non empanelled hospital, as such, the complainant is not entitled to any reimbursement of the expenses. The learned counsel for the OP number 1 has further argued that as per terms and conditions, the complainant was to take treatment from the empanelled hospital only and as such, the claim has rightly been repudiated.
10. To prove this case, the complainant has tendered his affidavit Ex.C-1 and has deposed as per the complaint, Ex.C-2 is the card of the scheme of the complainant Harminder Singh, Ex.C-3 is another card of ICICI Lombard General Insurance Co. Ltd. Ex.C-4 is the card of Reliance GIC Ltd. and Ex.C-5 is the card of Bhagat Puran Singh Sehat Bima Yojna, Ex.C-6 is the bill of Phull Neuro and Multispeciality Hospital from where the complainant took treatment, Ex.C-7 is the registration, Ex.C-8 is the history sheet, Ex.C-9 is the claim form whereby the complainant claimed an amount of Rs.74,350/- and Ex.C-9 to Ex.C-15 is the medical record and bills.
11. On behalf of the OP number 1, Shri Suryadeep Singh Thakur, has tendered his affidavit Ex.OP1/1 and has deposed as per the written version wherein he has stated that the complainant is bound by the terms and conditions of the insurance policy and the complainant took treatment from the non empanelled hospital. ExOp1/3 is the group medical policy and Ex.OP1/4 is the repudiation letter. Ex.OP1/5 is the copy of agreement. As such, it is argued that the claim has rightly been repudiated.
12. Admittedly, the complainant is a member of the society and as such was insured under the scheme with the OP number 1. As per the complainant, he fell ill and was admitted in Phull Neuro and Multispeciality Hospital, Patiala and spent an amount of Rs.74,350/-. As stated above, the complainant has already proved all the documents including the charges of the hospital, purchase of medicines etc. Op number 1 has declined the claim of the complainant on the allegation that he took treatment from the non empanelled hospital.
13. It has been clearly held by the Hon’ble Supreme Court of India in Shiva Kant Jha versus Union of India 2018(2)SCT 529 (supra), that in case of emergency, then the treatment can be taken from non empanelled hospital also and the claim cannot rejected saying that the treatment was taken from non empanelled hospital. This view was also taken by the Hon’ble Punjab State Commission in Sukhdev Singh Nagpal versus The New Karian Pehalwal Cooperative Agriculture Service Society (supra).
14. So, in view of our above discussion, we allow the complaint and direct OP number 1 to pay to the complainant an amount of Rs.74,350/-spent on the treatment alongwith interest @ 6% per annum from the date of filing of the present complaint i.e. 23.10.2018 till its realisation. We further direct OP number 1 to pay to the complainant an amount of Rs.15,000/- on account of compensation for mental tension, agony and harassment and further an amount of Rs.15,000/- on account of litigation expenses. This order be complied with within a period of sixty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
March 15 , 2021.
(Vinod Kumar Gulati) (Jasjit Singh Bhinder)
Member President
