Punjab

Sangrur

CC/558/2019

Balwinder Singh - Complainant(s)

Versus

The Kheri Multi Purpose Co-operative Agriculture Service Society (MPCASS) Ltd. - Opp.Party(s)

Sh.Amit Goyal

11 Dec 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No. 558

 Instituted on:   30.10.2019

                                                                         Decided on:     11.12.2023

 

Balwinder Singh son of Kaka Singh R/o Village Kheri, Tehsil and District Sangrur.

                                                         …. Complainant 

                                                 Versus

1.             The Kheri Multi Purpose Co-operative Agriculture Service Society (MPCASS) Ltd. Village Kheri, Tehsil and District Sangrur through its Secretary 148001.

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

3.             Bhai Ghanayia Trust through Deputy Registrar, Co-operative Societies, Punjab, Gill Road, Kartar Singh Sarabha Market, New Kartar Nagar, Ludhiana 141001.

4.             United India Insurance Company Limited, Divisional Office: SCO 72, Phase IX, Mohali through its Divisional Manager 160062.

                                                        ..Opposite parties

 

For the complainant    :       Shri Amit Goyal, Adv.

For the OP 1              :       Shri Raj Kumar Singla, Adv.

For the OP 2&3         :       Exparte.

For the OP 4              :       Shri G.S.Sibia, Adv.

Quorum                                           

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT:

 

1.             Shri Balwinder Singh, complainant  has preferred the present complaint against the opposite parties  on the ground that the complainant is the consumer of OPs as he had availed their services by becoming the member of the scheme i.e. Bhai Ghanhya Sehat Sewa Scheme through OP number 1 under which the OPs took medical insurance policy and identity card number MD-15-BGSSS-00299633-S was issued and the OP number 2 was appointed as TPA.  The case of complainant is that on 30.10.2014 he suffered severe chest pain and was immediately taken to Patiala Heart Institute Patiala by his family members being an emergency case, he was admitted in emergency and angiography was done which revealed RCA 99% stenosis and the complainant was feeling severe chest pain, so the treating doctor performed PTCA and stenting on the same day and complainant was discharged on 1.11.2014 and an amount of Rs.1,60,649/- was spent.  Thereafter the complainant submitted all the original bills alogwith treatment record to the OPs for payment of the claim amount, but the claim amount was not paid.  As such, the complainant filed a petition number 330 dated 1.11.2017 in the Permanent Lok Adalat, Sangrur which was decided on 10.4.2019 and the complainant was directed to submit the claim papers alongwith documents to OP number 2 through OP number 1 and OP number 2 was further directed to decide the claim within 2 months from the date of receipt of claim papers. Thereafter the complainant vide application dated 24.7.2019 submitted the documents to OP number 1.  Now, the grievance of the complainant is that OP number 4 repudiated the claim vide letter dated 27.9.2019 on the ground that treatment taken from non-network hospital is not covered under the policy, which is said to be totally wrong and illegal. 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.1,60,649/- along with interest from the date of discharge 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 no cause of action and locus standi to file the present complaint and that the complainant has dragged the OP into unwanted litigation. On merits, it is admitted that the complainant is insured being the member of the OP number 1, society. It is admitted that the direction was given by the Permanent Lok Adalat Sangrur to the complainant to submit the claim papers to the OPs through OP number 1.  It is stated that the claim has to be settled and paid by OP number 4 and nothing is to be done by OP number 1. Lastly, OP number 1 has prayed that the complaint be dismissed qua OP number 1. 

3. In reply filed by OP number 4, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has filed the present complaint by concealing true and material facts from this Commission, that the complainant has unnecessarily dragged the OP number 4 into unwanted litigation. On merits, it is admitted that under the above mentioned scheme, persons who have become members were entitled for treatment within one year from any network hospital as mentioned in the list/booklet given by the OPs by showing the identity card/pre-authorisation card to the hospital authorities or in the event of taking treatment in Govt. hospitals, the expenses were to be reimbursed by the OPs later on.  It has been denied that the complainant has submitted all the original bills alongwith treatment record and requested for settlement of his claim and for payment of the claim mount. It has been admitted that the complainant filed a petition before the Permanent Lok Adalat and the documents were submitted. Thereafter vide letter dated 27.9.2019 the claim of the complainant was repudiated as he had taken treatment from non- network hospital which was not covered under the Bhai Ghanhya Sehat Sewa Scheme. Any deficiency in service on the part of the OP number 4 has been denied. Lastly, the OP number 4 has prayed that the complaint be dismissed with special costs.

4.             Record shows that the OP number 2 and 3 were proceeded against exparte.

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex-8 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP1/1 affidavit and closed evidence.  The learned counsel for OP number 4 has produced Ex.OP4/1 to Ex.OP4/4 documents and affidavit and closed 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 vehemently that the complainant is a consumer of OPs as he had availed their services by becoming the member of the scheme i.e. Bhai Ghanhya Sehat Sewa Scheme through OP number 1 under which the OPs took medical insurance policy and identity card number MD-15-BGSSS-00299633-S was issued to the complainant and the OP number 2 was appointed as TPA.  Further the learned counsel has argued that on 30.10.2014 the complainant suffered severe chest pain and was immediately taken to Patiala Heart Institute, Patiala by his family members being an emergency case and was admitted and treated there  so the treating doctor performed PTCA and stenting on the same day and complainant was discharged on 1.11.2014 and an amount of Rs.1,60,649/- was spent which was paid by the complainant himself.  Further the learned counsel has argued that thereafter the complainant submitted all the original bills alogwith treatment record to the OPs for payment of the claim amount, but the claim amount was not paid.  As such, the complainant filed a petition number 330 dated 1.11.2017 in the Permanent Lok Adalat, Sangrur which was decided on 10.4.2019 and the complainant was directed to submit the claim papers alongwith documents to OP number 2 through OP number 1 and OP number 2 was further directed to decide the claim within 2 months from the date of receipt of claim papers. Thereafter the complainant vide application dated 24.7.2019 submitted the documents to OP number 1. The learned counsel for the complainant has further argued that OP number 4 has repudiated the claim vide letter dated 27.9.2019 on the ground that treatment taken from non-network hospital is not covered under the policy, which is said to be totally wrong and illegal. Thus, the complainant has prayed for acceptance of the complaint.

8.             On the other hand, the learned counsel for OP number 1 has argued that the complainant is insured being the member of the OP number 1, society. It is admitted that the direction was given by the Permanent Lok Adalat Sangrur to the complainant to submit the claim papers to the OPs through OP number 1.  It is further argued  that the claim has to be settled and paid by OP number 4 and nothing is to be done by OP number 1. 

9.             The learned counsel for OP number 4 has admitted that under the above mentioned scheme, persons who have become members were entitled for treatment within one year from any  network hospital as mentioned in the list/booklet given by the OPs by showing the identity card/pre-authorisation card to the hospital authorities or in the event of taking treatment in Govt. hospitals, the expenses were to be reimbursed by the OPs later on.  It has been denied that the complainant has submitted all the original bills alongwith treatment record and requested for settlement of his claim and for payment of the claim mount. It has been admitted that the complainant filed a petition before the Permanent Lok Adalat and the documents were submitted. Thereafter vide letter dated 27.9.2019 the claim of the complainant was repudiated as he had taken treatment from non- network hospital which was not covered under the Bhai Ghanhya Sehat Sewa Scheme. Any deficiency in service on the part of the OP number 4 has been denied. Lastly, the OP number 4 has prayed that the complaint be dismissed with special costs.

10.            After perusal of the case file and hearing the arguments of the learned counsel for the parties, we find that it is admitted fact that the complainant is insured with OP 4 for an amount of Rs.1,50,000/- for medical treatment being the member of the society i.e. OP number 1 as is evident from the identity card on record as Ex.C-2 and Ex.OP4/4. Ex.C-3 to Ex.C-4 are the copies of discharge card and certificate. Ex.C-3 is the discharge card of Patiala Heart Institute wherein it is mentioned that the complainant admitted in the hospital on 30.10.2014 and discharged on 01.11.2014. Ex.C-4 is the certificate dated 01.11.2014 wherein Dr. S.S. Sarin certified that  Mr. Balwinder Singh was admitted on 30.10.2014 vide Regd. No.248634 as an emergency case with severe   chest    pain. ECG shows abnormality. Coronary angiography done which revealed RCA 99% stenosis. Primary PTCA and stenting to RCA done in same setting in view of ongoing chest pain with DES (Biomime Aura). He was discharged from the hospital on 1/11/2014 with advice regular medical follow up.  Ex.C-5 is the copy of order dated 1.11.2017 of Permanent Lok Adalat Sangrur. Ex.C-8 are the copies of various medical bills. All these documents are duly supported by the affidavit Ex.C-1. On the other hand,  Ex.OP4/2 is the copy of repudiation letter dated 27.9.2019 wherein it has been stated that “treatment taken in non network hospitals except in Govt. Hospital is not covered. Only cashless hospitalisation in network hospital and reimbursement in Government Hospitals are to be covered. Treatment at Govt. Hospital shall be covered at Govt. Hospital rates.” Ex.OP4/4 is the list of network hospitals and other details including, it is mentioned in the scheme at point number 1.1 that  the facility will be available for a family on floater basis for Rs.1,50,000/-.

11.            In the present case, it is evident from Ex.C-3 and Ex.C-4 that the complainant was got admitted in the private hospital due to emergency condition i.e. he was having the heart problem and stent was also inserted.  The complainant has argued vehemently that it was due to emergency only and there was no treatment in the govt. hospital at that time for the heart disease, so the complainant had no option to get the treatment.  The learned counsel for the complainant to support her contention has cited Vijay Kumar Khanna versus Deputy Director of Education and others 2018(4)621 CLT Delhi State Commission, wherein repudiation of the claim was done on the ground that the treatment was not taken from Govt. empanelled hospital but from Govt. approved hospital. It was held that complete heart blockage is an emergency situation. The complainant could have gone to any of the renowned institute of his choice without taking any prior approval. Complaint allowed.  Similarly, the Hon’ble Punjab State Commission in Sukhdev Singh Nagpal versus New Karian Pehalwal Cooperative Agriculture Service Society and others 2017(3) CLT 120 has held  that when there is an emergency, one cannot wait to find empanelled hospital and lose his life by the time, when he is not in a position to find the said hospital nearby. The right to life is a fundmental right, as defined in Article 21 of the Constitution of India. In emergency cases, the insured person has right to get treatment from the nearby hospital, but the expenses limit will be to the expenses, which are being charged by the Government hospital or the empanelled hospitals.

12.            As discussed above and in view of the legal position we find that in the emergency conditions, the complainant has no option except to approach the non empanelled hospital to get the treatment as it was heart blockage case, which is required to be treated immediately to save the life of the complainant. 

13.            Now, coming to the point of quantum of compensation. The complainant has claimed an amount of Rs.1,60,649/- in the complaint, but we may mention that the policy in question is only for Rs.1,50,000/- as is evident from the guide book on record as Ex.Op4/4. Now, we are of the considered opinion that the complainant is entitled to claim an amount of Rs.1,50,000/- only.

 

 

14.            So, in view of our above discussion, we allow the complaint and direct OP number 4 to pay to the complainant an amount of Rs.1,50,000/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 30.10.2019 till its realisation.  We further direct OP number 4 to pay to the complainant an amount of Rs.5,000/- on account of compensation for mental tension, agony and harassment and further an amount of Rs.5,000/- on account of litigation expenses.

 

15.            This order be complied with within a period of sixty days of its communication.

 

16.            The complaint could not be decided within the statutory time period due to heavy pendency of cases.

 

17.            Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                        Pronounced.

 

                       December 11, 2023.