Punjab

Fatehgarh Sahib

CC/55/2019

Amrish Kumar - Complainant(s)

Versus

United India Insu - Opp.Party(s)

Preetinder Singh

25 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                                    COMMISSION

                                FATEHGARH SAHIB

 

Consumer Complaint no.		CC/55 of 2019
Date of Institution	:	02/09/2019
Date of Decision	:	25/04/2023

               

Amrish Kumar aged about 39 years son of Sh. Bhajan Dass, resident of Village Khaniyan, Tehsil Amloh Distt. Fatehgarh Sahib.

                                                                                                     …………....Complainant

 

                                        Versus

 

1.  The United India Insurance Company Limited, Branch Office, Bank  of India Building , Floor No.1, G.T. road, Mandi Gobindgarh 147301 , Distt. Fatehgarh Sahib, Punjab through its Manager/ authorized Person.
2. M.D. India Healthcare Service ( TPA) Pvt. Ltd: Street No.46/1, E Space, A-2 wing, 3^rd Floor ,  Pune-Nagara road, Vadgaon Shrei Pune 411014, through its Manager/authorized Person.
3. The  United India Insurance Company Limited Divisional Office bus stand, RANI Hospital, Floor no.1,opp. Grand Trunk Rd. Khanna , Punjab 141401 through its Manager/authorized Person.
4.  The   United India Insurance Company Limited,  Registered & Head office United India Insurance Co. Ltd; 24 ,  Whites Road, Chennai-600014 through its Manager/Authorized Person,
5.  The  Khaniyan M.P.C.A.S.S. Ltd; Khaniyan , Tehsil Amloh Distt. Fatehgarh Sahib , through  its  authorized signatory.
6. Satguru Partap Singh Hospital , Ludhiana, Distt. Ludhiana through its authorized signatory.
7. The Prolife Hospital Super Specialty & Trauma Care, Village Gill, Malerkotla road, Ludhiana , Distt. Ludhiana through its Authorized signatory.

 

                                                           ……....... Opposite Parties

 

Complaint under Section 12 to 14 of Consumer Protection Act 1986(Old)

Quorum

Sh. S.K.Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

Present: Sh.Preetinder Singh Koharh, counsel for complainant.

     Sh.A.K.Verma, Counsel for OPs no.1,3  and 4.

      Sh. Rajinder Singh Khurmi, counsel for OP no.5.

     OPs no.2, 6 and 7 Ex.-Parte vide order dated     

     29/10/2019 .

 

 The complaint has been filed against the OPs (opposite parties)  under Section 12 to 14 of Consumer Protection Act-1986(old) alleging deficiency in service with the prayer to give directions to the OP no.1 and 2  to  reimburse the Medical expenses of Rs.2,55,705/-  , to  pay Rs.90,000/- as compensation for harassment, mental agony , to pay Rs.22,000/- as litigation expenses.

1. The  complainant is the member of  Khaniyan M.P.C.A.S.S Ltd. Khaniyan i.e OP no.5. and having  Card no.MD 15-B, GSSS-00211247-S.  The complainant was insured with the  United India Insurance Co. Ltd. under Bhai Ghanaiya  Sehat Sewa Scheme , Punjab and paid the requisite membership fee/premium. As per the terms and conditions of the above said Policy , OPs1to5 are bound to bear the Medical expenses of their members.  The complainant suffered from Small Bowel obstructions with stricture ar lleo Caecal Junction with Multiple Bands . On 24.12.2018 in emergency he was admitted  in SPS Hospital Ludhiana i.e OP6 and was discharged on  31.12.2018 . The complainant paid  Rs.1,70,248 as medical expenses to OP6.  On 3.4.2019, the complainant  again suffered from same  problem and  was admitted to Prolife Hospital  , Ludhiana i.e OP no.7 . He was discharged on 8.4.2019  and paid  Rs.85,457/-  as medical expenses to OP7.  Despite repeated requests , the OP5 failed to reimburse the claim amount of Rs.2,55,705 under the said scheme. Hence this complaint.
2. Notice of the complaint was given to the OPs through registered Post . OPs  2,6 and 7  did not come forward to contest the complaint. They were proceeded against Ex-Parte vide order dated 29.10.2019 . OPs no.1,3,4 and 5 appeared through their counsel and filed written version.
3. The OPs no.1,3 and 4 filed joint  written version raising legal objections. The complainant  had not furnished the particulars of the insurance Policy  and the requisite documents  for the settlement of the claim as such the complaint is Pre-mature. Hence prayed for dismissal of complaint.
4. The OPs no.5 filed written version raising legal objections. Complainant  got treatment  from the Hospital  which  does not come under  the  empanelled list of Network Hospitals of Bhai Ghanaiya Sehat  Sewa Scheme, Punjab and as such the complainant is not entitled for any Medical claim.  The OPs prayed for dismissal of complaint with cost.
5. The complainant in support of his complaint tendered in evidence his  affidavit Ex.CW1/1, along with Photo  copies of documents i.e   Ex.C1 Card no.MD 15-B,GSSS-00211247-S issued by OPs, Ex.C2 discharge summary, Ex.C3 patient bill summary Ex.C4 to Ex.C19 medical record,  Ex.C20  application for  reimbursement of claim amount  and closed his evidence .
6. In rebuttal ,the OPs no.1, 3 and 4 tendered in evidence , Ex.OP1/1 affidavit of  Shiv Kumar, Administrative Officer of OPs.  The OP no.5 tendered in evidence Ex.OP5/A affidavit of  Amritpal Singh Manager of OP no.5, Ex.OP5/1 guidebook  and closed their evidence.
7. Admittedly , the complainant is beneficiary of Bhai Ghaniya  Sehat Sewa Scheme being run by the Punjab Govt.  for  members of the Cooperative Societies to provide medical heath Insurance vide Ex.C1. The complainant spent Rs.2,55,705 on his medical treatment . OPs 1, 3 and 5 submitted that complainant did not lodge  any claim with them   i. e  United India Insurance  Co. Ltd.   OP5 rejected claim on the ground  that complainant was admitted  in non  empanelled Hospital   under Scheme .
8. From the  perusal of the record on the file , we find that complainant  remained admitted twice in Hospital. Once in  SPS  Hospital , Ludhiana on 24.12.2018 to 31.12.2018  and spent Rs.1,70,248/- vide Ex.C3.  On 3.4.2019 , the complainant was again  admitted in  Prolife  Hospital  , Ludhiana & spent Rs.85,457/-  vide Ex.C5 to Ex.C19.  The complainant submitted his Medical claim to Ops 2 &5 vide Ex.C20. The right to medical claim can not be denied merely because the name of  the  Hospital  is not included in the empanelled list . The real test must be the  factum of treatment .  Before any  medical  claim is honoured , the  authorities  are bound to ensure as  to whether the claimant had actually taken the treatment & factum of treatment is supported by records duly certified by Doctors /Hospitals  concerned.   Rejection of claim  purely on the  technical ground  will result in  Policy Holder’ loosing  confidence  in Insurance Companies & giving  rise to excessive litigation. In the present case , concerned officials took  a very  inhuman approach .   The relevant authorities are  required to  be more responsive and cannot   act in  a mechanical  manner to deprive  an employee of his  legitimate  reimbursement .  Insurer’ decision to reject a claim shall be based on  some logic & valid grounds.
9. The OPs have not furnished any list showing the payment after deduction as per Policy  rules. The complainant himself admitted in complaint that  he is entitled  for treatment expenses up to Rs.2,00,000/-  under the said scheme.  OPs 5,6 , 7 are proforma OPs.  OP no.2 is only claim processing  agency.  The cashless mediclaim is to be reimbursed by the Insurance Company  .  Therefore ,   Insurance Company  i.e OPs1,3,4 are held  liable for  deficiency  in service.
10.  As  a corollary of our above discussion  and keeping in view the facts of the case , the present complaint is partly allowed against OPs no.1,3,4. The OPs no.1,3,4 are directed:-

[a] To reimburse the amount of Rs. 2 Lacs jointly& severally.

[b] the complainant is also directed to lodge the claim toOPs 1,3,4 by submittingall the requisite documents within10 days from the date of receipt of copy of order. Thereafter the Ops no.1,3,4 are directed to reimburse the claim of complainant within 30 days from the date of lodging of the claim.

            [c]  To Pay Rs.15,000/- as compensation for harassment & litigation expenses

Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19 and paucity of staff. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record room.

Pronounced 25 April1 2023

                                                        (S.K. Aggarwal)

                                                                 President

                                                                    

    

                                                                (Shivani Bhargava)

                                                                 Member

 

                                                                ( Manjit Singh Bhinder )

                                                                          Member