DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.
Complaint Case No : 34/2015
Date of Institution : 06.02.2015
Date of Decision : 18.08.2015
Jagraj Singh S/o Dharampal Singh R/o 373, Village Sanghera, Ward No. 1, Tehsil & District Barnala.
…Complainant
Versus
Sanghera CASS Limited Sanghera, District Barnala Through its Secretary/Authorized person.
MD India Health Care Services (T.P.A) Pvt. Ltd., Maxpro Info Park, D-38, Phase-1, Industrial Area, Mohali-160056 through its Managing Director.
United India Insurance Company Ltd., S.C.O No. 72, Phase 9, Mohali through its Branch Manager.
…Opposite Parties
Complaint Under Section 12 of Consumer Protection Act, 1986.
Present: Sh. R.K. Jain counsel for complainant.
Opposite party No. 1 exparte.
Sh. A.K. Jindal counsel for opposite parties No. 2 & 3.
Quorum.-
1. Shri S.K. Goel : President.
2. Sh. Karnail Singh : Member
3. Ms. Vandna Sidhu : Member
ORDER
(BY SHRI KARNAIL SINGH MEMBER):
The complainant namely Jagraj Singh has filed the present complaint under Consumer Protection Act, 1986 (hereinafter called as Act) against Sanghera CASS Limited Sanghera, District Barnala and others (hereinafter called as the opposite parties) on the ground that the opposite party No. 1 offered a group insurance scheme to its members under Bhai Ghanayia Sehat Sewa Scheme (Punjab) and obtained a group insurance policy which is retained by the opposite party No. 1. Complainant was accordingly issued a Card as a token of acknowledgment by the opposite party No. 2 being the administrator of the scheme. It is alleged that complainant is a member and an account holder of Sanghera CASS Limited and is insured under Bhai Ghanayia Sehat Sewa Scheme vide card No. 860117107455A valid from 27.3.2006. Thereafter, the complainant continuously insured with the opposite parties and presently holding the ID Card No. MD15-BGSSS-00302144-S for the period 2014-15.
2. It is further alleged that complainant fell ill and was taken to doctor at Barnala, who advised him that the proper treatment is within Fortis Hospital, Mohali. The family members of the complainant immediately took him to Fortis Hospital, Mohali and as per instructions of the society showed the card to the Hospital. It is alleged that the doctor advised immediate admission, but told the complainant that since the Bhai Ghanayia Sehat Sewa Scheme releases payment after much delay, so he will have to make the payment Hospital bill and then claim the amount from the Bhai Ghanayia Sehat Sewa Scheme. Under duress the complainant after informing the TPA MD India Health Care Services Pvt. Ltd., got admitted in the hospital and gave consent for the payment of bill of the hospital.
3. It is further alleged that the hospital charged Rs. 81,000/- from the complainant for the treatment by RF ablation and thereafter discharged the complainant from hospital on 13.12.2014. Complainant submitted all the necessary papers to the TPA, MD India Health Care Services Pvt. Ltd., and was assured that the payment would be made in few days. Thereafter, the opposite party No. 2 demanded photocopy of the Bank Passbook of the complainant, which was sent to them through courier vide receipt No. Z38711980 dated 15.12.2014 of DTDC courier. It is alleged that the opposite party No. 2 has telephonically informed the complainant that her claim has been rejected as it was not covered by the policy. But no written repudiation has been sent by them till date. Hence, the present complaint is filed seeking the following reliefs.
To pay a sum of Rs. 81,000/- alongwith interest @ 12% per annum.
To pay Rs. 50,000/- as compensation and Rs. 15,000/- as litigation expenses.
4. Upon notice one Bharpur Singh Secretary appeared and filed written version on behalf of opposite party No. 1. But on 4.6.2015 the opposite party No. 1 was proceeded against exparte due to non appearance. In written version the opposite party No. 1 has taken legal objections on the grounds that the complaint is misconceived and not maintainable, no cause of action etc. On merits, it is admitted that the complainant is a member and an account holder of opposite party No. 1. The complainant became a member of the above said scheme since long and currently is insured with the opposite party No. 3. All other allegations of the complainant are denied and prayed for the dismissal of complaint.
5. Upon notice the opposite party No. 2 also appeared and filed written version taking legal objections on the grounds that complainant has no locus-standi or cause of action, complaint is frivolous and vexatious, jurisdiction etc. On merits, it is denied that any employee of the opposite party No. 2 assured that the payment of the treatment has been released in favour of the complainant to the hospital. It is submitted that at the time of policy, detailed printed material has been supplied to the complainant and he further informed they are not liable to pay any compensation on account of OPD and admission for tests in any hospital, which were recognized under the policy. It is further submitted that the policy shall cover treatment of all medical/surgical diseases requiring minimum 24 hours hospitaliation upto an expenditure of Rs. 1,50,000/- per year per family on floater basis subject to the terms and conditions of the scheme. It is further submitted that in cover letter which was issued by the Regional Office of the opposite party No. 2 clearly mentioned at Page 2 that “as per policy terms and conditions, if patient is admitted in hospital for investigation only then claim is not payable. Hence, repudiated”. It is submitted that complainant deposited papers through opposite party No. 1 with them regarding his diagnostic and tests. The claim of the complainant has been repudiated by them on account of not covers under the policy and the same is duly informed to the complainant vide letter dated 20.2.2015. The claim of the complainant has been scrutinized by the panel of doctors and as per policy terms and conditions complainant was admitted in hospital for investigation, therefore the opposite party No. 2 repudiated the claim of the complainant. As such there is no deficiency in service on their part and finally prayed for the dismissal of complaint.
6. Upon notice the opposite party No. 3 has also raised legal objections on the grounds of locus-standi or cause of action, complaint is frivolous and vexatious, misconceived, jurisdiction etc. On merits they denied the case of complainant. It is submitted that at the time of purchase of policy, detailed printed material has been supplied to the complainant. Even the agent of opposite party No. 2 disclosed the benefit of policy and he further informed the complainant that the opposite party No. 3 is not liable to pay any compensation on account of OPD and admission for tests in any hospital, which were recognized under the policy. It is further submitted that in cover letter which was issued by the Regional Office of the opposite party No. 2 clearly mentioned at Page 2 that “as per policy terms and conditions, if patient is admitted in hospital for investigation only then the claim is not payable”.
7. In reply it is admitted that the complainant deposited papers through opposite party No. 1 with the opposite party No. 2 regarding his diagnostic and tests. It is denied that the opposite party No. 2 assured the complainant that the payment of bill has been paid in few days. It is further submitted that the opposite party No. 3 is not liable to pay any amount of Rs. 81,000/- alongwith interest @ 12% per annum etc., and finally prayed for the dismissal of complaint.
8. In order to prove his case complainant tendered in evidence his own affidavit Ex.C-1, copy of passbook Ex.C-2, copy of guidebook of MD India Ex.C-3, copies of card issued by opposite party Ex.C-4 (3 pages), copy of claim form Ex.C-5, copies of hospital record Ex.C-6 to Ex.C-16, copy of courier receipt Ex.C-17 and closed the evidence.
9. In order to rebut the case of complainant the opposite party No. 1 tendered in evidence his own affidavit Ex.O.P1/1. The opposite parties No. 2 & 3 also tendered in evidence affidavit of Shubham Patiyal Ex.O.P2.3/1, affidavit of Balwinder Singh Ex.O.P2.3/2, copy of Bhai Ghanhya Sehat Sewa Scheme Guidebook Ex.O.P2.3/3, copy of policy schedule Ex.O.P2.3/4, copy of rejection letter Ex.O.P2.3/5 and closed the evidence.
10. We have heard the Ld. Counsels for the parties and have gone through the evidence tendered by the parties.
11. It is the case of the complainant that Sanghera CASS Limited Sanghera, District Barnala, had offered medical insurance benefit to all its members under Bhai Ghanayia Sehat Sewa Scheme and complainant is a member of said scheme under card No. MD15-BGSSS-00302144-S for the period 2014-15. Complainant remained admitted in hospital from 12.12.2014 to 13.12.2014 for treatment of Supera Ventricular Tachycardia by way of RF ablation after electrophysiological study and for this the complainant paid Rs. 81,000/- to the hospital. The claim papers were submitted to the TPA as per procedure of opposite party for the settlement of claim, but the opposite parties even after the assurance for the payment of claim refused to pay the claim and even did not issue a repudiation letter after informing the complainant telephonically that his claim falls outside the purview of the policy.
12. The case of the opposite parties is that amount charged by the FORTIS from the complainant on account of diagnostic procedure was done in cardiac electrophysiology laboratory, which is not covered under the policy. Further, as per policy terms and conditions, “if patient is admitted in hospital for investigation only then claim is not payable. Hence, repudiated”.
13. The complainant in support of his case tendered in evidence his detailed affidavit Ex.C-1, copy of passbook Ex.C-2, which shows that he is the member of Sangera CASS Limited and the same is not disputed by the opposite parties. Ex.C-3 is the copy of guidebook of Bhai Ghanaya Sehat Sewa Scheme, Punjab, which shows that the Fortis Hospital is falls under the scheme. Ex.C-4 is copies of card issued by the opposite party No. 2 to the complainant. Ex.C-5 is the copy of claim form, wherein the date of admission and date of discharge is mentioned. Ex.C-6 to Ex.C-16 are the copies of hospital record, which shows that the complainant has paid Rs. 81,090/- to the Hospital.
14. On the other hand the opposite parties No. 2 & 3 have tendered in evidence affidavit of Subham Patiyal M.D and affidavit of Balwinder Singh Divisional Manager, which are nothing but word to word repetition of the written version filed by the opposite parties No. 2 & 3. The opposite parties have claimed that the terms and conditions of the policy were supplied to the complainant, but failed to bring on record the affidavit of that person who had explained the same to the complainant.
15. We are of the view that the opposite parties have failed to bring on record any cogent and reliable evidence that the procedure of RF Ablation was not a curative procedure but a diagnostic procedure for SUPERA VENTRICULAR TACHYCARDIA.
16. In view of the above discussion, there is a merit in the complaint, therefore the same is accepted against the opposite party No. 3. Accordingly, the complainant is entitled to Rs. 81,000/- alongwith interest @ 9% per annum from the date of discharge i.e. 13.12.2014. He is further entitled to Rs. 3,000/- as compensation on account of mental tension and Rs. 2,100/- on account of litigation expenses from the opposite party No. 3. This order of ours shall be complied within 30 days from the date of the receipt of this order. Copy of this order be supplied to the parties free of costs. The file after its due completion be consigned to the records.
ANNOUNCED IN THE OPEN FORUM:
18th Day of August, 2015.
(S.K. Goel)
President.
(Karnail Singh)
Member.
(Vandna Sidhu)
Member.
