Punjab

Faridkot

CC/18/111

Bahadur Singh - Complainant(s)

Versus

The Dhilwan Kalan MPCASS Ltd. - Opp.Party(s)

Ashu Mittal

08 May 2019

ORDER

     DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :              111 of 2018

Date of Institution:    27.06.2018

Date of Decision :       8.05.2019

 

Bahadur Singh son of Jang Singh r/o Village Dhilwan Kalan, Tehsil Kotkapura District Faridkot.

                                                                                                    ...Complainant

Versus

 

1. The Dhilwan Kalan MP CASS Ltd, Village Dhilwan Kalan Tehsil Kotkapura District Faridkot through its Secretary.
2. Reliance General Insurance Co. Ltd., 19, Reliance Centre, Walchand Hirachand Marg, Ballard Estate, Mumbai 400001 through its MD.
3. MD India Health Care Services (TPA) Pvt Ltd Mohali Tower, 1^st Floor, Plot No. F-539, Phase-8 B, Industrial Area, Airport Road, Mohali.
4. Bhail Ghanhya Trust, SCO 175-187, Sector 34 A, Chandigarh.

                                                                                                            .......OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

                Smt Param Pal Kaur, Member.

 

Present:  Sh Ashu Mittal, Ld Counsel for complainant,

              Sh Iqbal Kaushal, Ld Counsel for OP-1,

    Sh Manohar Lal Chugh, Ld Counsel for OP-2 and 3,

              Sh Dilshad Singh Dhaliwal, Ld Counsel for OP-4,

 

 ORDER

(Ajit Aggarwal, President)

                                             cc no.-111 of 2018

                                            Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.2,94,081/- on account of insurance claim for expenditure incurred by complainant on his mother and for further directing OPs to pay Rs.50,000/-as compensation for harassment, inconvenience, mental agony and litigation expenses to complainant.

2                                                        Briefly stated, the case of the complainant is that being member of OP-1 for last many years, complainant was insured with OP-2 to 4 under Bhai Ghanaya Sehat Sewa Scheme through OP-1 vide card no. MD 15-BG SSS-00279132-M and as per terms and conditions of Policy in question, in case of any illness he and his family members were entitled for free treatment of any  disease or for reimbursement of medical expenses incurred in hospital, however, no terms and conditions were ever supplied to him by OPs. It is submitted that on 25.05.2017, OP-1 deducted Rs.4,400/-from the account of complainant as premium for insurance cover of entire family and insurance cards were issued in the name of complainant and his family members. It is submitted that name of mother of complainant is Angrej Kaur but OPs wrongly issued insurance card to her with name Angrej Singh. Complainant returned the said card to OP-1 to correct the name of her mother, but till today, OP-1 has not issued him card of his mother with correct name over it. It is further submitted that during the subsistence of insurance policy in question in January, 2018 mother of complainant suffered from cough and breathlessness and then, complainant immediately brought her to Rajan Hospital and Heart Centre, Kotkapura where after check up doctor referred her to Fortis Hospital, Ludhiana. There was threat to the life of his

 

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mother and to save her, on recommendations of doctor concerned, complainant got conducted operation of her mother in Fortis Hospital, Ludhiana and spent Rs.2,98,081.77 on her treatment. Complainant submitted before hospital authorities that his mother was insured with OPs, but due to non availability of card, they did not accept his request and therefore, he had to pay this amount to hospital. Thereafter, complainant requested OPs to reimburse the medical expenses incurred by him on treatment of his mother, but OPs kept putting off the complainant on one pretext or the other. Complainant also served legal notice dated 21.02.2018 to OPs wherein requested them to make reimbursement of medical expenses incurred by complainant on treatment of his mother, but that also served no purpose. This act of OPs amounts to deficiency in service and has caused harassment and mental agony to complainant for which he has prayed for accepting the complaint alongwith compensation and litigation expenses besides the main relief. Hence, the present complaint.

3                                                                  The counsel for complainant was heard with regard to admission of the complaint and vide order dated 3.07.2018, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                     On receipt of the notice, OPs No. 1 filed written statement taking objections that complainant has concealed the material facts from this Forum and they have been falsely dragged in present litigation. No cause of action arises against answering OP-1 and there is no deficiency in service on their part. Moreover, this Forum has no jurisdiction to hear and try the present complaint as complete financial and legal liabilities arising due to scheme rest unconditionally with Op-3 MD India and Op-2 Reliance GIS limited. It is further averred that Fortis hospital, Ludhiana from where mother of

 

cc no.-111 of 2018

complainant underwent treatment is not approved under present scheme to provide cashless treatment and even Fortis Hospital, Ludhiana has not been made party to this complaint. It is averred that Op-2 has been appointed by Trust as insurer which appointed MD India Health Care Services OP-3 as Third Party Administrator to implead Bhai Ghanaiya Sehat Sewa Scheme during the period from 15.03.2017 to 14.03.2018. OP-3 Third party Administrator is responsible for issuing Identity Cards to beneficiaries, for inspection of hospitals and then recommend them to be taken on panel of hospitals to grant authorization for settling the claim of hospital and beneficiaries, to make payment to empanelled hospitals, for providing cash less services to beneficiaries of scheme on receipt of money from insurer. However, on merits, OPs have reiterated the same pleadings taken by them as in preliminary objections and further averred that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

5                                       OP-2 and 3 filed written statement through counsel wherein they denied all the allegations of complainant being wrong and incorrect and asserted that complainant never approached them for settlement of claim in accordance with terms and conditions of the policy. Even policy in question commenced from 15.03.2018 and treatment of patient was taken in January, 2018 and thus, complainant had sufficient time to get correct the card, if there was any printing mistake in it. Moreover, complainant took treatment from non network hospital without any prior intimation to Insurance Company or TPA because as per agreed terms and conditions of Policy, cashless treatment or reimbursement was to be provided to policy holder for treatment in network hospitals only. Treatment was required to be taken from network hospital only on package rate basis and

cc no.-111 of 2018

payment was also to be paid to hospital directly after verifying all the aspects of treatment through TPA. Total sum insured of coverage was Rs.1,50,000/-on higher side, but treatment was to be provided to beneficiaries on package rate of particular disease as per terms and conditions of the policy. Present complaint involves lengthy evidence which is not possible in summary proceedings of Consumer fora. Moreover, insurance is a bilateral contract and both insured and insurer are bound by terms and conditions of policy and complainant has violated the terms and conditions of the policy by taking treatment of his mother from the hospital which is not empanelled hospital of OPs and thus, as per terms and conditions of the policy in question cash less treatment or reimbursement is permissible only for treatment in hospitals which are on their panel, but complainant did not undertake treatment from network hospital and therefore, he is not entitled for any reimbursement of expenses incurred by him. there is no deficiency in service on the part of OP-2 and OP-3 and prayed for dismissal of complaint with costs.

6                                                OP-4 also filed reply wherein averred that complainant is not their consumer and there is no deficiency in service on their part. Complainant filed by complainant is false and frivolous and this Forum has no jurisdiction to hear and try the present complaint. Members/beneficiaries had been clearly informed that complete financial and legal liabilities, if any arising due to operationalization of scheme, shall rest exclusively and unconditionally with OP-3 and OP-2. Complainant has read and understood all the terms and conditions of the policy and is bound to abide by the same. Moreover, Fortis Hospital, Ludhiana has not been made party to present complaint and this hospital is not approved under policy in question to provide cashless treatment under sachem during the scheme period. it is further averred that complainant took treatment

cc no.-111 of 2018

from non network hospital, which was not approved under the scheme and there he is entitled to receive any reimbursement for treatment of his mother under the scheme. There is no deficiency in service on their part and prayed for dismissal of complaint with costs.

7                                              Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-12 and documents Ex C-1 to 11 and Ex C-13 and Ex C-14 and then, closed his evidence.

8                                               In order to rebut the evidence given by complainant, the ld Counsel for OP-1 tendered in evidence, affidavit of Gura Singh Ex OP-1/1 and closed the evidence. Ld  counsel for OP-2 and 3 tendered in evidence affidavit of Suryadeep Singh Thakur Ex OP-2, 3/1 and also closed the evidence on behalf of OP-2 and 3. Ld counsel for OP-4 tendered in evidence affidavit of Balbir Singh Ex OP-R-1 and closed the same on behalf of OP-4.

9                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

10                                           The case of complainant is that being member of OP-1, complainant alongwith his entire family was insured with OP-2 to 4 under Bhai Ghanaya Sehat Sewa Scheme and as per terms and conditions of Policy in question, in case of any illness he and his all family members were entitled for free treatment of any disease or for reimbursement of medical expenses incurred in hospital. OP-1 deducted premium of Rs.4,400/-from his account and issued  insurance cards in the name of complainant and his family members. However, on card issued in the name of mother of complainant Angrej Kaur, OPs wrongly

cc no.-111 of 2018

mentioned name of his mother as Angrej Singh and despite repeated requests, they did not correct the same. Complainant returned the said card to OP-1 to correct the name of her mother, but they did not rectify the same. During subsistence of insurance policy in question in January, 2018 mother of complainant suffered from cough and breathlessness and on advice of doctor of Rajan Hospital and Heart Centre, Kotkapura, complainant took her to Fortis Hospital, Ludhiana where on recommendations of doctor concerned, complainant got conducted her operation in Fortis Hospital, Ludhiana and spent Rs.2,98,081.77 on her treatment. After that, complainant requested OPs to reimburse the medical expenses incurred by him on treatment of his mother, but OPs did not pay a single penny and even legal notice dated 21.02.2018 issued to OPs bore no fruit. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of claim amount to him which amounts to deficiency in service. He has prayed for accepting the complaint alongwith compensation and litigation expenses. He has also stressed on documents produced by him as Ex C-1 to C-14. In reply, OP-1 stressed mainly on the point that complete financial and legal liabilities arising due to scheme rest unconditionally and exclusively with OP-3 MD India and OP-2 Reliance GIS limited. It is further averred that Fortis hospital, Ludhiana from where mother of complainant underwent treatment is not approved under present scheme to provide cashless treatment. OP-2 and OP-3 denied all the allegations of complainant and averred that complainant never approached them for settlement of  his claim. Policy in question commenced from 15.03.2018 and treatment of patient was taken in January, 2018 and thus, complainant had sufficient time to get correct the card, if there was any printing mistake in it. Even, complainant took treatment of his mother from non network hospital without any prior intimation to Insurance Company or TPA because as per terms and conditions of Policy, cashless treatment

cc no.-111 of 2018

or reimbursement was to be provided to policy holder for treatment in network hospitals only. Treatment was required to be taken from network hospital and payment was also to be paid to hospital directly after verifying all the aspects of treatment through TPA. Sum insured of coverage was Rs.1,50,000/-on higher side, but treatment was to be provided to beneficiaries on package rate of particular disease. Complainant has violated the terms and conditions of the policy by taking treatment of his mother from the hospital which is not empanelled and thus, as per terms and conditions of the policy, cash less treatment or reimbursement is permissible only for treatment in hospitals which are on their panel, but complainant did not undertake treatment from network hospital and therefore, he is not entitled for any relief. As per OP-4, complainant is not their consumer and liability for insurance claims devolves only with Insurance Company OP-2 and OP-3. Members/beneficiaries were informed that complete financial and legal liabilities, if any arising due to operationalization of scheme, shall rest exclusively and unconditionally with OP-3 and OP-2. Complainant has violated the terms and conditions of the scheme and undertook treatment of his mother from non network hospital, which was not approved under the scheme and therefore he is entitled to receive any reimbursement for treatment of his mother under the scheme. There is no deficiency in service on their part and prayed for dismissal of complaint with costs.

11                                                      To prove his case complainant has relied upon documents Ex C-1 which is copy of card issued by OPs to complainant that clears the point that complainant was member of Bhai Ghanaya Sehat Sewa Scheme and he was insured under policy in question and was entitled for free treatment or for reimbursement of expenses incurred by him on treatment of his

cc no.-111 of 2018

mother. Ex C-2 is copy of statement of account of bank pass book of complainant that reveals that Rs.4400/-were debited by OPs from the account of complainant as premium for insurance policy in question. Ex C-3 is the prescription slip given by doctor Rajan wherein he has referred the Angrej Kaur mother of complainant to DMC/Fortis /Apollo Hospital, Ludhiana. Through ExC-5 copy of bill issued by Fortis Hospital, Ludhiana, complainant has proved his pleadings that he paid Rs.2,94,081/-on treatment of his mother in Fortis Hospital. Ex C-6 copy of legal notice that shows that complainant made request to Ops to process his insurance claim and to  reimburse the amount spent by him on treatment of his mother. Ex C-1 is copy of death certificate of mother of complainant that proves that exact name of his mother was Angrej Kaur. Through his affidavit Ex C-12 complainant has again narrated his grievance and made requests to the Forum to direct OPs  to process his insurance claim. Complainant has produced sufficient and cogent evidence to prove his pleadings. There is not even an iota of doubt that during the subsistence of mediclaim insurance policy in question, mother of  complainant suffered from some problem and being insured under the said policy, he was entitled to get insurance claim on account of expenses incurred by him on her treatment.

12                                                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant and his mother with OPs. Ops have themselves admitted that he alongwith his entire family was insured with them as per Mediclaim Insurance Policy issued by them. There is no doubt that name of mother of complainant is Angrej Kaur and Ops have wrongly issued card with name of his mother mentioning Angrej Singh. plea

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taken by Ops that complainant did not undertake treatment of his mother from panelised hospital has no legs to stand upon as they never supplied any list of hospitals to him and now they are trying to escape their liability to make payment of expenses incurred by him on treatment of his mother. Moreover, in case of emergency, the patient or his attendants immediately approach the nearest available hospital for their treatment and do not find hospital, which are empanelled with the Insurance Companies. In case of emergency, first priority of the patient and his attendants is to save the life of the patient and not to fulfil the terms and conditions of Insurance Companies. Act of non payment of insurance claim by OPs on the basis of false terms and conditions which were never supplied to complainant, amounts to deficiency in service.

13                                         From the above discussion, we are of considered opinion that act of OPs in not clearing the genuine claim of complainant for expenses incurred by him on treatment of his mother, amounts to deficiency in service and trade mal practice on their part. Complainant has fully succeeded in proving his case, therefore, complaint in hand is hereby allowed. Ld Counsel for complainant pleaded that complainant spent Rs.2,94,081/-on treatment of his mother, but under the Policy in question the maximum insured amount is Rs.1,50,000/- and complainant cannot claim anything more than Rs.1,50,000/- which is maximum sum assured under the Policy. Therefore, OPs are directed to make payment of Rs.1,50,000/-to complainant on account reimbursement of expenses incurred by complainant on treatment of his mother alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization. They are further directed to pay Rs.3,000/- to complainant as consolidated compensation for harassment and mental agony suffered by him

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including litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 8.05.2019

 

     (Param Pal Kaur)        (Ajit Aggarwal)

                                    Member                          President