J U D G E M E N T
The case of the complainant in a nutshell is as follows:-
That the complainant who was an employee of DSP (Charget) Nin No. 02509275 is a 69 years old hypertensive was forced to be admitted with advice of doctor of DSP Hospital on 18.6.2012 for treatment of low back pain and released him on 22.6.2012 and referred him to higher neuro science centre for better treatment. The complainant has reported to the National Neuro Sciences Centre, Calcutta on 26.6.2012 and the attending physician examined him and advised him to take admission and the complainant was admitted in the said hospital on 26.6.2012 and received treatment and diagnostic tests till 30.6.2012. They advised the complainant to take strict bed rest and also advised to avoid forward bending, squatting starting,
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straining or prolong sitting and use L.S. Belt. Due to such physical condition he had to hire ambulance for communication of treatment and medical tests which resulted a heavy cost of lumpsum amount. The authority of Neuro Science Centre, Calcutta raised a bill of Rs. 36,128=90 and he was once again admitted in the hospital as advised by the physicians on 02.8.2012 and released on 04.8.2012 and he had to pay an amount of Rs. 6,257=92. As per rules and norms of the Ops the complainant has submitted both the bills to the Durgapur Office of MD India Health Care Services (TPA) Pvt. Ltd. along with all supporting documents in original which are still lying with the custody of the Ops. Although a long time has been elapsed the complainant has not yet received any payment. Finding no other alternative the complainant once again informed with a request to make an arrangement for payment of bill vide letter dated 06.10.2012 & 08.11.2012 and the copy of the said letter was sent to Deputy Manager (P), DSP, In-charge, MD Health Care (TPA) Ltd. and In-charge, United India Insurance Co. Ltd. for getting proper redressal but no fruitful result yielded. From the gesture and posture of the Ops it seems to the complainant that his claim has been repudiated. As a matter of denying to take legal action before the appropriate authority the complainant sent a letter of request on 15.11.2012 to return back all the documents and original bills but it is curious enough the OP neither make arrangement for paying bill or return the original documents till to date rather they kept mum. The cause of the instant case arose after the treatment of DSP Hospital on 26.6.2012 and lastly on 12.10.2012 when the OP sent a letter of repudiation of claim of the complainant. Due to such type of behaviour the complainant has been facing severe trouble without the bonafide mediclaim. Not only that for the misdeed of the OP the complainant had to incur a huge amount of loss. Due to aforesaid deficiency in service and unfair trade practice the complainant has filed this complaint with a prayer for relief as under:
- To give direction to the OP to pay the bill amount of National Neuro Science Centre amounting to Rs. 36,128=90 + 6,257=92 = Rs. 42,386=92,
- Bill incurred for ambulance Rs. 12,000=00,
- Compensation amounting to Rs. 50,000=00 and
Interest of the amount paid by the complainant i.e. Rs. 54,386=00 + 12% interest.
The case have been contested by the OP-1&3 by filing separate written version denying the entire allegations made by the complainant in his petition of complaint. Though the notice was served upon the OP -3 and they received the same but did not appear to contest the case. So the case is being heard ex parte against the OP-2.
The OP-1 has stated in its written version that the complainant being an ex-employee of this OP consequent upon his retirement, became a member of insurance
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policy for providing insurance coverage along with other similar retired employees of SAIL. The role of this OP is only as a facilitator to help the ex-employee in procuring insurance coverage for medical benefit like treatment, medical examination and hospitalization. The position of this OP is more akin to that of complainant than that of the OP. The question of investigation or treatment by the medical unit and statement of the claim raised by the complainant against the Insurance Company is an inter se dispute between the insurer and the insured, in which this OP is neither a necessary party nor a proper party nor can throw any light. Thus the complaint is bad for mis-joinder of OP-1. The present case is also bad for non-joinder of necessary party as the United India Insurance Company being the insurer is required to be made necessary party in the present case for proper adjudication of this compliant. The claim, if any, can lie only against the United India Insurance Co. and/or OP-2. The instant complaint is vague and indefinite and does not disclose the actual state of affairs. The OP-1 has further stated that the complainant is not a consumer in terms of the C.P. Act, 1986. The OP-1 has prayed for dismissal of the complaint.
The OP-3 has stated in its written that his OP had issued a Group Insurance Mediclaim Policy for the period from 01.01.2012 to 31.12.2012 under Group Mediclaim Scheme to extend the medical benefits to the retired employees of SAIL and their spouses. Be it mentioned that the OP-2 is the authorized agency to offer TPA services and for the purpose of claim settlement, the bills and other related documents should be directly sent to any of the opted centers of MD India and in this particular case the complainant being an insured member had filed a claim form before the OP-2 – Durgapur Branch along with some papers and documents regarding his alleged treatment. The OP-3 further submits that that the panel doctors of OP-2 have scrutinized the aforesaid claim and they observed that:
- As per claim documents received it is observed that the treatment given to the patient does not support the need for hospitalization. Patient can be treated on O.P.D. basis, hence claim is repudiated.
- As per policy terms and conditions, claim is not payable, under Clause No. 9.7.
OP-2 has prepared the claim rejection /repudiation statement on 26.9.2012 and informed its decision to the OP-3 on 08.11.2012.
As such as per aforesaid policy terms and conditions hospitalization for investigations without active line of treatment is not payable, as per Clause no. 9.7 of Group Mediclaim Policy. This OP is not liable to make any payment in respect of any expenses whatsoever incurred by the complainant as there was no active line of
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treatment and thus his claim was/is not payable at all. This OP further submits that there has/have not been any deficiency in service or negligence and as such the complaint petition is liable to be summarily dismissed with cost.
During argument the OP-3 has pointed out that the complaint is barred by territorial jurisdiction as none of the Ops are situated under the territorial jurisdiction of Burdwan district. Accordingly this ld. Forum has no authority to adjudicate this matter.
In this connection we may refer Section 11 (2) of the C.P. Act:-
11. Jurisdiction of the District Forum.-
(2) A complaint shall be instituted in a District Forum within the local limits of whose jurisdiction,-
- the opposite party or each of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides or [carries on business or] has a branch office or personally works for gain, or
- any of the opposite parties, where there are more than one, at the time of the institution of the complaint, actually and voluntarily resides, of [carries on business or has a branch office,] or personally works for gain, provided that in such case either the permission of the District Forum is given, or the opposite parties who do not reside, or [carry on business or have a branch office,] or personally work for gain, as the case may be acquiesce in such institution; or
- The cause of action, wholly or in part, arises.
On going through the complaint it is seen by us that the complainant has filed this complaint against The Senior Manager (P), SAIL Mediclaim Department, Ispat Bhaban, Lodhi Road, New Delhi – 110 003 as OP No. 1, The Branch Manager, MD, India Health Care Services (TPA) Pvt, Office at: 169 Sarat Chandra Bose Road, 3rd Floor, Kolkata – 700 026 as OP no. 2 and The Branch Manager “UNITED INDIA INSURANCE COMPANY”, DP-XI, E-85, Himalaya House, 8th Floor, K.G.Marg, New Delhi, PIN – 110 003 as OP No. 3. So it is crystal clear that all the OPs are residing outside the district of Burdwan which is the territorial jurisdiction of the Ld. Forum. Though the complainant has stated in his POC that he deposited the medical bills and documents to the MD
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India Health Care Services (TPA) Pvt. Ltd., Durgapur Branch and such averment has been corroborated by the OP-3, but very surprisingly the complainant has not made a party to this case the MD India Health Care Services (TPA) Pvt. Ltd, Durgapur.
From the amended complaint field by the complainant on 06.01.2014 and from the submission of the Ops during argument it is seen that this Forum has no jurisdiction to adjudicate this matter, and as such we are not going into the merit of the case. Accordingly, it is
O r d e r e d
that the petition of complaint filed by the complainant is dismissed on contest on the point of jurisdiction as per Section 11(2) of the C.P. Act, 1986. There is no order as to costs.
(Asoke Kumar Mandal)
Dictated and corrected by me. President
DCDRF, Burdwan
(Durga Sankar Das)
Member
DCDRF, Burdwan
(Silpi Majumder) (Durga Sankar Das)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
