BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.7 of 2020
Date of Inst. 06.01.2020
Date of Decision: 12.11.2021
Raghbir Kaur wife of Karamjit Singh resident of Village Ismailpur, Tehsil Nakodar District Jalandhar.
..........Complainant
Versus
1. The Manager/Incharge, United India Insurance Company Limited, #19, Nungambakkam High Road, IV Lane, Chennai- 600034.
2. The Manager/Incharge, M. D. India Health Insurance, T. P. A. Pvt. Ltd., Mohali Towers, 1st Floor, Plot No.F-539, Phase 8-B, Industrial Area, Airport Road, Mohali.
3. Secretary to Government Punjab, Cooperative Department, Chandigarh.
4. Deputy Registrar, Cooperative Societies, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Smt. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. S. S. Turna, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for the OP No.1.
OPs No.2 & 3 exparte.
None for OP No.4.
Order
Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein alleged that her husband Sh. Karmajit Singh is the member of Multipurpose Cooperative Society, Ltd. Mehsampur and as per the Punjab Government’s instructions and their policies, the OP No.3 issued an insurance policy under the name of Bhai Ghanhya Sehat Sewa Scheme and also issued a card of insurance policy bearing Card No.MD15-BGSSS-00241245-SP as per the said card, entire scheme is look after by the OP No.2, under the supervision of United India insurance company Ltd. i.e. OP No.1 and premium of the insurance was paid by the member through its society to OP No.2 and 1 through OP No.4. As per the scheme, if any member of his family members suffered from any illness and got any injury in any accident will be treated by the hospital mentioned in the information book issued by the OP and that treatment is cashless treatment and have not to pay even a single penny. That complainant was suffering from heart disease and a pacemaker is fixed in the heart of the complainant and working of the said pacemaker became slow and the complainant was advised to change the cell of pacemaker and the complainant approached the Global Hospital, Jalandhar for the said purpose and after intimating to the authorities i.e. OPs No.2 & 4 and ultimately admitted to Global Hospital, Jalandhar on 25.03.2019 and operation was conducted in order to replace the Cell of Pacemaker and the complainant was discharged on 27.03.2019 and a bill of lump sum of Rs.50,000/- was issued by the Global Hospital, Jalandhar which was required to be paid by the OPs No.1 & 2 as per the insurance Scheme of Punjab government and claim was lodged with the OP No.2 regarding Rs.50,000/- by the complainant alongwith all required documents with the Assistant Registrar Cooperative Society, Nakodar on the advice of OP No.4 on 03.04.2019 and after that sent the document to Chief Executive Officer, Bhai Ghanya Sehat Sewa Scheme Trust, Chandigarh vide registered letter dated 26.07.2019. But OPs No.1 and 2 failed to give any reply to the claim lodged by the complainant with the OP. That as per the assurance given by the Punjab Government at the time of starting Bhai Ghanya Sehat Sewa Scheme, Punjab and also assurance given by the OPs No.1 & 2 that the treatment of the patient/member is cashless. However, OPs No.1 and 2 failed to pay the entire amount till today. Also OP neither gave the reply to the claim of the complainant. Whereas, the OP is legally bound to pay the amount of claim i.e. expenditure occurred by the complainant in replacing the Cell of Pacemaker. The complainant has a valid membership of the OP No.2, but in the present case, OPs No.1 and 2 intentionally and deliberately not paying the amount to the complainant and the complainant is legally entitled to recovery the amount of Rs.50,000/- spent by the complainant on her treatment in Global Hospital, Jalandhar alongwith Rs.30,000/- damages. That the complainant lodged a claim/complaint with the OP vide register letter dated 26.07.2019 in reply to telephonic message dated 28.05.2019 and sent the required document that is in door case paper, test report, receipt of Rs.50,000/- and report of Tagore Hospital, Jalandhar regarding pacemaker operation i.e. from 26.09.2010 to 29.09.2010, but the OP failed to take any action. That the OP without any reason failed to pay the claim of the complainant without any reason whereas as per the terms and conditions of the insurance policy, OP is liable to pay Rs.50,000/- as charges and operation charges and other expenditure but in the present complaint, OP failed to pay the compensation and wrongly held the claim of the complainant. The complainant also served a legal notice dated 21.09.2019 to the OP, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.50,000/- as compensation for medical treatment alongwith Rs.30,000/- for illegal harassment and mental agony and Rs.20,000/-as litigation expenses alongwith interest @ 12% per annum from the date of claim/operation against the OP.
2. Notice of the complaint was given to the OPs, but despite service OPs No.2 & 3 failed to appear and ultimately, OPs No.2 & 3 were proceeded against exparte, whereas OP No.1 appeared through its counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the present complaint is legally not maintainable as complainant has neither any cause of action to file the present complaint nor has any locus-standi to file the present complaint, as such, the same is liable to be dismissed. It is further alleged that the complaint of the complainant is pre-matured, as the claim of the complainant was under processing at the time of filing of the present complaint, which now stands repudiated vide letter of repudiation dated 23.03.2020 on the ground that the patient basically admitted for the replacement of battery/Cell in pacemaker, which is not covered under the policy. It is further averred that the complaint is bad for non-joinder of necessary party. It is the Karamjit Singh husband of the complainant who is the primary member of Multipurpose Cooperative Society, Mehsempur and insured under the Bhai Ghanya Sehat Sewa Scheme and who lodged the claim on behalf of Raghbir Kaur has not come forward to file the present complaint, as such the complaint is liable to be dismissed on this score only. It is further averred that there is no deficiency of service or unfair trade practice on the part of the insurance company, hence the complaint is liable to be dismissed at the outset for want of cause of action. It is further alleged that the claim of the complainant stands repudiated on the ground that the patient basically admitted for the replacement of battery/Cell in pacemaker, which is not covered under the policy. That the complaint is not maintainable against United India Insurance Co. Ltd./OP. On receiving claim intimation and lodging of claim by Karamjit Singh husband of the complainant, the claim was registered with MD India Health Insurance TPA Pvt. Ltd., a Third Party Administrator/OP No.2. It is an admitted fact that the expenses incurred and claimed are for replacement of battery/Cell of pace maker. As such expenses are not covered under the policy, as such the claim of the complainant stands repudiated vide letter dated 23.03.2020. The amount spent on replacement of battery/Cell of pace maker is maintenance of already implanted pace maker which falls under the Exclusion clause of the insurance policy and the claim has been rightly repudiated. Otherwise also, even if the entire pacemaker is replaced, the procedure of replacing the pacemaker is not covered under the insurance policy. On merits, the facts in regard to lodging of the claim with the OP No.2 for reimbursement of the expense for replace of Battery/Cell of Pacemaker is not denied and further submitted that the facility of cashless treatment is available in the network hospitals as pr scheme, but the complainant did not opt for cashless treatment rather lodged a reimbursement claim and further submitted that the liability of the OPs to cover the expenses on the treatment of any health problem is always subject to terms and conditions of the insurance policy, exclusions and limitations, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. OP No.4 filed its separate written reply and contested the complainant by taking preliminary objections that the present complaint is bad for mis-joinder of necessary party against OP No.4. The dispute regarding settlement of claim, if there is any, i.e. between complainant and the OPs No.1 and 2. On merits, it is admitted that the husband of the complainant is member of the Mehsampur Multipurpose Cooperative Agriculture Service Society, Ltd. and it is further admitted that the insurance was issued by OP No.3 and it is also admitted that the premium of insurance was paid by Member through its society to OPs No.1 and 2, but OP No.4 has no role in the deposit of money. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. Rejoinders to the written statement of OP No.1 and OP No.4 filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied those of the written statement.
5. In order to prove their respective versions, both the parties produced on the file their respective evidence.
6. We have heard the learned counsel for the respective parties and also gone through the written arguments as submitted by the counsel for the complainant as well as case file very minutely.
7. The present complaint has been filed by the complainant regarding the insurance policy issued by OP No.3 under the name of Bhai Ghanhya Sehat Sewa Scheme and claiming the expenditure borne by the complainant for changing the Cell of the pacemaker already installed in the heart of the complainant. The case of the complainant is that she submitted medical insurance claim to the OPs No.1 and 2, but despite submitting the required documents, representations and legal notice, the amount was not paid.
8. It is admitted and proved fact that the complainant was a heart patient and she remained under the treatment in the Global Hospital and got changed the Cell of pacemaker from the Global Hospital. The contention of the Ld. Counsel for the OP No.1 is that the complaint is pre-mature as till the filing of the complaint, claim of the complainant was pending for consideration and the claim has been repudiated vide letter dated 23.03.2020 on the ground that the patient was admitted for the replacement of battery/Cell in pacemaker, which is not covered under the policy. The contention of the Ld. Counsel for the OP No.1 is that this is not a surgery and the same is just the maintenance of the equipment which is not covered under the policy as per rules, but this contention of the Ld. Counsel for the OP No.1 is not tenable.
9. The complainant has produced on record the documents i.e. Ex.E to Ex.G, which is the record of Global Hospital. There is the certificate issued by the Managing Director of the Global Hospital as Ex.N, which shows that pacemaker was implanted against free replacement of pacemaker on 25.03.2019 and they charged for procedure and not for the pacemaker. As per the Discharge Summary Ex.K, the complainant was admitted in the hospital on 25.03.2019 and she was discharged on 27.03.2019. As per the history of the complainant she was admitted for elective PG replacement due to ERI and she was advised the medicines also. The bills of the medicines have also been proved on record by the complainant. As per the claim of the complainant she has mentioned the charges spent for the general tests and doctor visit at nursing care and the charges for the procedure. As per the certificate only charges for the procedure have been taken by them. So there is no claim of any charges given for the replacement of pacemaker, which was done free. The contention of the Ld. Counsel for the OP is that it was not a surgery, but this contention is not tenable as as per the record of the Global Hospital, the operation was conducted as there was end of life of PPI (Permanent Pacemaker Implantation). The meaning of surgery in medical terms is the branch of medical practice that treats injuries, diseases and deformities by the physical removal, repair or readjustment of organs and tissues often involving cutting into the body. So, the operation conducted by the doctors of the complainant is very much covered under the medical term of surgery and this is not only the maintenance of the pacemaker as alleged by the counsel for the OP No.1. Ex.P is the document to show that the insurance policy was issued by the OP No.3 and this fact has been admitted by OP No.4 also in their written statement.
10. So far as the contention of the counsel for the OP No.1 regarding the pre-mature of the complaint is concerned, this contention is not tenable as the policy was issued by the OP No.3 and the operation of the complainant was conducted on 25.03.2019. Claim was filed by the complainant before the office of OP No.1, but no order was passed by the OP No.1. The complainant sent the documents on 25.06.2019, as per telephonic message dated 28.05.2019 received by her vide Ex.R & R1 and Ex.Q & Q1. Thereafter the legal notice was served upon the OPs No.1 to 4, vide Ex.C on 21.09.2019, but when no response was given by the OP No.1 and 2, the present complaint was filed on 06.01.2020. Till 06.01.2020 neither any claim was settled nor any order was passed on the claim of the complainant. OP No.1 appeared in the Forum (now Commission) on 17.02.2020 and availed about six opportunities to file the written statement in Forum (now Commission) and ultimately on 02.06.2020, the written statement was filed by the OP No.1. During this period, the OP No.1 repudiated the claim of the complainant on 23.03.2020 i.e. after the appearance of the OP No.1 in the Forum (now Commission). This clearly shows the intention of the OP No.1 to frustrate the claim of the complainant and this action of the OP No.1 is arbitrary, uncalled for and against the principle of natural justice.
11. The complainant has placed on the record the bills Ex.H, Ex.I, Ex.J and she has also placed on record the summary of the medicines purchased by the complainant, during her admission period and has also produced on record the summary of the bills spent by her for the purpose of Post PPI/for changing the Cell of pacemaker and this bill comes to Rs.50,000/- as claimed by the complainant and the same is covered under the policy, which was valid from 15.08.2018 to 14.08.2019. Thus, we find that she is entitled for the above said amount alongwith interest as well as compensation and litigation expenses.
12. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs No.1 & 2 are directed to pay medical expenses i.e. Rs.50,000/- with interest @ 6% per annum from the date of payment till its realization and further OPs No.1 & 2 are directed to pay compensation to the tune of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The compliance of the order be made within 45 days from receipt of copy of this order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.
Dated Jaswant Singh Dhillon Jyotsna Harveen Bhardwaj
12.11.2021 Member Member President
