Punjab

Sangrur

CC/37/2015

Amarjeet Singh - Complainant(s)

Versus

The Cheema Multipurpose - Opp.Party(s)

Shri Rajinder Goyal

01 Jun 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

 

                                                Complaint No.    037

                                                Instituted on:      19.01.2015

                                                Decided on:       01.06.2015

 

Amarjeet Singh son of Labh Singh R/o Ballar Patti, Ward No.11, Village Cheema, Tehsil Sunam, District Sangrur.

                                                        ..Complainant

                                        Versus

1.             Secretary, The Cheema Multi Purpose Co-operative Agriculture Service Society (MPCASS) Ltd. Village Cheema, Tehsil Sunam, District Sangrur.

2.             Manager, MD India Health Care Services (TPA) Pvt. Ltd. Regional Office, D-38, Max Pro Info Park, Industrial Area, Phase I, Mohali 160056.

3.             Bhai Ghanayia Trust, through Deputy Registrar cooperative Societies, Central Coop. Bank, Patiala Gate, Sangrur.

4.             United India Insurance Company Ltd. Dhuri Road, Sangrur through its Branch Manager.

                                                        ..Opposite parties

 

For the complainant    :       Shri Rajinder Goyal, Adv.

For OP No.2&4         :       Shri Ashish Kumar, Adv.

For OP No.1&3         :       Exparte.

 

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Amarjeet Singh,  complainant (referred to as complainant in short) 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 the scheme, namely, Sehkari Kissan Credit Scheme which was launched by the OP number 1 vide account number 1326, card number 183 under which the OP number 1 took medical insurance policy for its members i.e. cashless treatment policy under the scheme named as Bhai Ghanayia Sehat Sewa Scheme. It is further averred that under the scheme the members of the family were also covered including spouse and other family members.  The policy number 112100/48/14/41/00000029 was issued by OP number 4. It is further stated that the Ops issued identity card/pre authorisation card to the complainant and his wife i.e. card number MD15-BGSSS-00307431-S and MD15-BGSSS-003074731-SP respectively.  It is further averred that wife of the complainant, Smt. Karamjeet Kaur suffered from cancer in the year 2006 for which she was treated upon and thereafter she suffered from heart ailment in the year 2007 for which she again took treatment.  It is further stated that now in the month of December, 2014, her cancer problem reoccurred along with plural effusion (chest infection) and was got admitted in DMC Hospital, Ludhiana (which is empanelled hospital of the OPs) by the complainant on 31.12.2014 for getting treatment for the same.  Complainant submitted the ID card issued by OPs and made a request through hospital authorities for pre authorisation for getting the above said treatment under the cash less treatment policy.  However, the complainant was surprised to receive a letter dated 1.1.2015 from the hospital authorities, which was issued by OP number 2 vide which the request of the complainant was declined on the ground that ‘the cash less hospitalisation is denied, as eligibility of claim under the policy cannot be ascertained, which is totally wrong and illegal’.  The complainant again made a request to the OPs through hospital authorities for reconsideration of the case, but nothing happened and ultimately, the complainant had to make payment of more than Rs.80,000/- on account of medicines and other expenses from his own pocket. It is further stated that the complainant incurred an expenditure of Rs.80,032/- in DMC Ludhiana and as such approached the OPs for making the payment, but the OPs flatly refused to do so.  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.80,032/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1, legal objections are taken up on the grounds that the complaint is not maintainable in the present form, that the complainant has no cause of action and locus standi to file the present complaint and that the complaint is false and frivolous one and should be dismissed with special costs.  On merits, it is admitted that the complainant and his wife were insured under the policy in question. However, any involvement of the OP number 1 in this case has been denied.  Any deficiency in service on the part of OP number 1 has also been denied.

 

3.             In reply filed by OP number 2 and 4, it is averred that on the request of Bhai Ghanhya Trust, OP number 4 issued a group medical policy for the period from 16.5.2014 to 15.5.2015 subject to the terms and conditions of the policy.  It is stated further that the Hero DMC Heart Hospital is empanelled only for cardiac, cataract and joint replacement treatment, but the wife of the complainant was treated for cancer disease. The above said hospital was not empanelled for cancer disease, as such, OPs have legally and rightly refused to pay the treatment charges. The complainant is not entitled to any claim.  The remaining allegations in the complaint have been denied.

 

4.                   Record shows that OP number 3 was proceeded exparte.

 

5.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-3 copies of ID cards, Ex.C-4 guide book, Ex.C-5 copy of repudiation letter, Ex.C-6 copy of discharge summary, Ex.C-7 copy of test report, Ex.C-8 to Ex.C-17 copies of bills, Ex.C-18 copy of discharge letter, Ex.C-19 copy of death certificate and closed evidence. On the other hand, the learned counsel for OP number 2 and 4 have produced Ex.OP2&4/1 copy of policy, Ex.OP2&4/2 copy of guidebook, Ex.OP2&4/3 copy of letter, Ex.OP2&4/4 affidavit and closed evidence.

 

6.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

7.             It is an admitted fact that the complainant as well as his wife Smt. Karamjit Kaur being the member of the cooperative society, OP number 1, were insured under  OP number 4 under the scheme named as Bhai Ghanayia Sehat Sewa Scheme vide policy number 112100/48/14/41/00000029.  It is also an admitted fact that the complainant and his wife were entitled to get treatment in the empanelled hospitals on cashless hospitalisation basis.  In the present case, the wife of the complainant Smt. Karamjit Kaur took treatment for her cancer problem from DMC hospital Ludhiana and she was admitted there on 31.12.2014 and spent an amount of Rs.80,000/- on her treatment and lodged the claim with the Ops for its reimbursement. But, the grievance of the complainant is that the Ops repudiated the claim of the complainant on flimsy grounds.  On the other hand, the learned counsel for the Ops has vehemently contended that the wife of the complainant Smt. Karamjit Kaur took treatment for her cancer disease from the HERO DMC Heart Hospital, which is not empanelled for cancer disease, as such it is stated that the claim of the complainant is not payable at all.  We may mention that in the para 3( c ) of the complaint, it has been mentioned by the complainant himself that Smt. Karamjeet Kaur suffered the problem of cancer again in the month of December, 2014.  However, the relevant portion of para 3 (c ) of the complaint is reproduced as under:-

“      That wife of the complainant Karamjeet Kaur suffered cancer in the year 2005, for which she was treated upon. Thereafter she suffered from Heart ailment in the year 2007, for which again she took treatment.  Now in the month of December, 2014, her cancer problem reoccurred along with plural effusion (chest infection) and she was got admitted in DMC Hospital, Ludhiana (which is empanelled hospital) by the complainant on 31.12.2014 for getting treatment for the same.  Complainant submitted the ID card issued by OP’s and made a request through Hospital authorities for pre-Authorisation for getting the above said treatment under the Cash Less treatment policy of the OP’s.”  

 

8.             It is the own case of the complainant that Smt. Karamjeet Kaur suffered problem of cancer on 31.12.2014 and as such, she was got admitted in  the DMC Hospital, Ludhiana where she spent an amount of Rs.80,000/- on her treatment.  After the treatment, the complainant lodged the claim with the Ops but the same was repudiated on the ground that DMC Hospital Ludhiana is not an approved hospital for treatment of cancer patients.   There is not even a single word in the complaint as well as in the affidavit of the complainant Ex.C-1 that Smt. Karamjeet Kaur was admitted in the hospital for any heart disease.   Moreover, in the affidavit Ex.C-1 in para 4, it is stated that cancer problem of Smt. Karamjeet Kaur reoccurred along with plural effusion (chest infection) and she was admitted in DMC Hospital Ludhiana by the complainant on 31.12.2014.   Under the circumstances, we find that the complainant has miserably failed to prove on record  whether Dayanand Medical College and Hospital Ludhiana was an empanelled hospital for treatment of cancer patients.  As such, we find that there is no deficiency in service on the part of the OPs in repudiating the claim of the complainant.

 

9.             In view of our above discussion, we find no merit in the complaint and the same is dismissed. However, the parties are left to bear their own costs. A copy of this order be supplied to the parties free of cost. File be consigned to records.

                Pronounced.

                June 1, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                                (K.C.Sharma)

                                                                    Member

 

                                                          

                                                                (Sarita Garg)

                                                                   Member