DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANSA. Complaint No.91/18.05.2007 Decided on : 21.05.2008 Gurjant Singh S/o Sh.Visakha Singh, Village Bachhoana, Tehsil Budhlada, District Mansa. ..... Complainant. VERSUS 1.The Bachhoana CASS Limited Bachhoana, Tehsil Budhlada District Mansa, through its Secretary. 2.Med Save Health Care Limited, S.C.O.No.121to 123, 1st Floor, Sector 34-A, Chandigarh. 3.I.C.I.C.I. Lombard, General Insurance Company, Regd.Office ICICI,1, Bank Tower, Bandra, Kurla Complex, Mumbai. 4.Dr.Kuldeep Singh through D.M.C.Hospital, Civil Lines, Tagore Nagar, Ludhiana. 5.Chairman, Punjab Cooperative Bank Limited, Sector 34-A, Chandigarh. ..... Opposite Parties. Complaint under Section 12 of the Consumer Protection Act, 1986. ..... Present: Sh.B.S.Dhaliwal, counsel for the complainant. Sh.B.N.Goel, counsel for the opposite party No.1. OP No. 2 exparte. Sh.S.K.Mehta, Counsel for Opposite Party No.3 Sh.Manmohan Singh, Counsel for Opposite Party No.4. Sh.Sunil Kumar Bansal, counsel for Opposite Party No.5. Before: Sh.Sarat Chander, Member. Smt.Neena Rani Gupta, Member. Contd........2 : 2 : ORDER: Gurjant Singh (hereinafter called as the complainant) has filed the present complaint against the Bachhoana CASS Limited Bachhoana, Tehsil Budhlada District Mansa, through its Secretary, as well as Med Save Health Care Limited, Sector 34-A, Chandigarh; I.C.I.C.I. Lombard, General Insurance Company, Kurla Complex, Mumbai; Dr.Kuldeep Singh through D.M.C. Hospital, Ludhiana and Chairman, Punjab Cooperative Bank Limited, Sector 34-A, Chandigarh (hereinafter called as the opposite parties No.1,2,3,4 & 5 respectively) for issuance of a direction to the opposite parties to pay him Rs.1,40,598/- along with interest @ 12% per annum on account of expenditure incurred by him on his treatment along with Rs.30,000/- as compensation on account of mental agony. Brief facts of the complaint are that the complainant is a Member of OP No.1 Cooperative Agricultural Society, Bachhoana. OP No.2 Trust had floated a scheme for providing Health Care Facilities to the Members of the Punjab Cooperative Societies registered under the Punjab Cooperative Societies Act, 1961 and under the Chairmanship of Chief Secretary of Punjab State a Trust known as Sanjivni Trust has been formed which was a nodal agency. To provide insurance cover to this scheme, ICICI Lombard General Insurance Company had offered its services. The Members of this Society were to be provided indoor treatment of their ailments through the hospitals on the panel. The complainant had become a Member of the said Sanjivni Trust through OP No.1 by depositing a sum of Rs.440/- for insurance cover to the tune of Rs.2,00,000/- and a Membership Card No.86011100126459A had also been issued to the complainant which was valid upto 30.03.2007 to enable the complainant to get free treatment upto Rs.2,00,000/- from the hospitals Contd.......3 : 3 : on the panel of OP No.2. It is alleged by the complainant that in December, 2006, he had developed Sugar and when he approached Dr.Raikhi at Mansa for the treatment, he referred him to the D.M.C. Hospital, Ludhiana where he was admitted on 10.01.2007 and remained under treatment till 24.02.2007. An intimation was sent to OP No.2 during this period regarding the admission of the complainant, but OP No.2 refused to bear the expenditure on the ground that the complainant did not gave prior intimation of the disease and the treatment taken by him . A FAX message was sent to OP No.2 to disburse the amount of expenditure to him, but OP No.2 refused to pay the amount incurred by the complainant on his treatment. According to the complainant, he had spent Rs.80,673/- on his treatment by the hospital and on account of various laboratory tests and Rs.59,925/- regarding purchase of medicines. The total expenditure incurred by him amounted to Rs.1,40,598/-. On the refusal of the opposite parties to pay the amount, he alleges to have suffered mental harassment also for which Rs.30,000/- has been claimed on account of compensation. Hence this complaint. OP No.1 in its written version has contended that it has never assured the complainant for granting any claim. The complainant is not entitled for any claim because he did not abide by the terms and conditions of the scheme . According to it, the claim of the complainant, if any, is to be paid by OP No.3. All other allegations were denied by it. Ops No.2 did not appear despite service and, as such, was proceeded against exparte. OP No.3 though had appeared through counsel, but it failed to file any written version and, as such, its defense was struck off vide order dated 18.12.2007. Contd........4 : 4 : OP No.4 has admitted the admission of the complainant in D.M.C. Hospital, Ludhiana and his treatment as claimed by him.,but the expenditure incurred by him was disputed by this opposite party. According to this opposite party, the hospital had sent a FAX to Medsave Group on pre-authorization form on 18.01.2007 for issuing cashless facility to the complainant, but this opposite party refused to issue authorization for cashless treatment to the complainant on the ground that the patients request was received after 48 hours and, as such, the complainant had been asked to deposit the hospital dues. The complainant himself had violated one of the pre-conditions of the policy by not sending the information immediately on admission and, as such, OP-2 had rightly rejected his claim This opposite party, therefore, was stated to be well within its right to seek payment of the hospital dues from the complainant. All other allegations were denied by this opposite party also and a prayer for dismissal of the complaint was accordingly made. OP No.5 in its written version has contended that the present complaint is not maintainable against the replying opposite party since there is no link between them and the complainant. The replying opposite party is only operating the account of this scheme. All other allegations were denied by this opposite party also and a prayer for dismissal of the complaint was accordingly made. The complainant had tendered into evidence his affidavit, as well as other documents Exhibits C-1 to C-130. OP No.3 had tendered into evidence copy of policy containing terms and conditions. OP No.1 had tendered into evidence an affidavit of Sh.Harbhajan Singh, Secretary, CASS Bachhoana. OP No.4 had also tendered certain documents. We have considered the arguments advanced by the learned Contd........5 : 5 : counsel for the complainant, as well as the contesting opposite parties and have carefully gone through the entire evidence on record. From the written version filed by OP No.1, it is evident that the complainant, being a Member of OP No.1 Cooperative Society, had been enrolled as a Member of the Sanjivni Health Care Scheme floated under the Sanjivni Trust by OP No.2 and Card bearing No.53, copy of which is Exhibit C-130, had been issued to the complainant by OP No.2 with regard to insurance policy No.4016/0000968 valid upto 30.03.2006. Under this scheme known as Sanjivni Health Care Scheme cashless hospitalization in Network Hospitals could be obtained in conjuction with this card and authority letter issued by MHCL. Exhibit C-131 is the Guide book and list of Network hospitals in Punjab under the Sanjivni Health Care Scheme floated by OP No.2. OP No.4 hospital figures at Sr.No.106 of the list of the hospitals. From the written version of OP No.4 it also stands established that the complainant had remained hospitalized with OP No.4 from 10.01.2007 to 24.02.2007 Exhibit OP-4 and OP-5 are the pre-authorization forms sent by OP No.4 to OP No.2 for seeking necessary instructions, but the claim of cashless facility to the complainant had been declined by OP No.2 vide letter exhibit OP-6 The ground of rejection in this letter is that, the patient PAL is received after 48 hours. The cashless facility vide letter exhibit OP-6 had been denied to the complainant only on the ground that, the patient PAL is received after 48 hours and, as such, was not covered under the policy. Surprisingly, no other evidence has come on record from the side of Ops 2 and 3 to that effect. To the contrary, the son of the complainant, namely, Jagsir Singh, had made a request to OP No.2 on 18.01.2007 (within the period of treatment of his father) regarding his failure of bringing the card at the time Contd........6 : 6 : of admission in the hospital because of unawareness. Dr.Kuldeep Singh OP No.4 has deposed in its affidavit exhibit OP-1 that the above request of the son of the complainant was sent to OP No.2 along with the pre-authorization form on 18.1.2007, but OP No.2 had rejected the claim. Exhibit 131 is the Guide Book issued by OP No.2 and in Instruction No.8 on page No.8 of this Guide Book, it has been clearly mentioned that within 7 days of the discharge of the patient, documents are to be submitted by the Net Work hospital. In the present case Dr.Kuldeep Singh (OP No.4) has deposed in its affidavit ( exhibit OP-1) that the documents had been sent by him along with the pre authorization form on 18.01.2007 to OP No.2 i.e within 8 days of the admission of the complainant in his hospital. The complainant has been discharged by this doctor on 24.02.2007 thereby meaning that the pre-authorization form was sent in time by OP No.4 to OP No.2. Failure of OP No.2 to contest this claim also makes its bonafides doubtful and it appears that the remarks that, the patients PAL is received after 48 hours from the complainant has been made a ground to reject the claim of the complainant with malafide intentions. Ops No.2 and 3 thus are held to be deficient in service towards the complainant in refusing the cashless facility to the complainant. Ops No.1,4 and 5 are not directly liable for providing cashless facility to the complainant as there was no privity of contract between the complainant and these opposite parties. OP No.4 was justified in claiming the hospital dues from the complainant in the absence of authorization to provide cashless facility to the complainant. The complainant has placed on record Exhibit C-4 to C-129, the details of the expenditure incurred by him on his treatment. These documents included the bills issued by OP No.4, as well as the cash memos Contd........7 : 7 : regarding the purchase of the medicines from the Drug Store of New Dayanand Hospital, Ludhiana. The total amount of the expenditure incurred by the complainant comes to Rs.1,40,598/-, whereas the expenditure incurred by him on clinical and laboratory tests comes to Rs.80,673/- and on the purchase of medicines as Rs.59,925/-. He is entitled to recover the amount from Ops No.2 and 3. Failure of Ops No.2 and 3 to provide cashless facility to the complainant for his treatment definitely is a cause for mental harassment to the complainant for which the complainant is entitled to the compensation. As a consequence of the foregoing reasons, we are constrained to allow this complaint with a direction to Ops No.2 and 3 to pay an amount of Rs.1,40,598/- jointly and severally to the complainant on account of expenditure incurred by him on his treatment. They shall also pay a sum of Rs.20,000/- by way of compensation on account of mental harassment, as well as litigation costs. Ops No.1, 4 and 5 , being not directly liable to the complainant , the complaint against them is dismissed. Compliance of the order be made within one month from the date of receipt of the copy of the order which shall be provided to the parties free of charges under the rules and file be arranged, indexed and consigned to record. Pronounced: 21.05.2008 Neena Rani Gupta, Sarat Chander, Member. Member.
