DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 299 of 29.7.2016
Decided on: 24.4.2018
- Harpal Kaur Kharbands, aged 62 years w/o Harbir Singh Kharbanda.
- Harbir Singh Kharbanda aged 66 years S/o Sh.Pritam Singh,Ex.Sr.Manager Punjab & Sind Bank.
Both residents of H.No.61,Green Lehal Colony, Patiala-147001,Punjab
…………...Complainants
Versus
- United India Insurance Co. Ltd., # 24, Whites road, Chennai, through its General Manager/Chief Operating Officer.
- United India Insurance Co. Ltd., Sai Market, Patiala through its Divisional Manager.
- E-Meditek ( TPA) Services Ltd., Plot No.557, Udyog Vihar, Phase-V, Gurgaon, 122002, Haryana through its Manager.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.M.D.Saini,Advocate,counsel for complainants.
Sh. D. P. S. Anand, Advocate,
counsel for Opposite parties No.1&2.
Opposite party No.3 ex-parte.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Complainants have filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.)
2. In brief, the case of the complainants is that Sh.Harbir Singh Kharbanda is a retired employee/Ex. Senior Manager of Punjab & Sind Bank. Accordingly he and his wife Smt.Harpal Kaur Kharbanda are covered under the mediclaim scheme for the retired employees of the bank under Staff Welfare Scheme, vide circulatory letter No.36 dated 20.5.2014. The same was renewed for the period from 11.5.2014 to 10.5.2015 and the services of M/s united India Insurance Co.Ltd. & M/s E-Meditek(TPA) Services Ltd were hired . It is stated that during the subsistence of the policy, Smt. Harpal Kaur Kharbanda, wife of the complainant No.2 got surgically operated her eye on 13.2.2015 at the P.G.I., Chandigarh. It is further stated that before undergoing surgery, she remained under medical care and supervision of the doctors of PGI, Chandigarh. The date of surgery was fixed as 12.12.2014. On the said date she was taken to the operation theatre by the doctors but at that moment the team of doctors decided to put off the surgery due to infection in the eye lid. It is stated that for the sake of operation, medicines and other equipments were purchased on 11.12.2014, as per prescription and advise of the doctors. Finally the operation of the eye of Smt.Harpal Kaur Kharbanda was conducted on 13.2.2015. Some more medicines were purchased for the said operation on 13.2.2015.After completion of the eye surgery of complainant No.1, she applied for mediclaim and submitted the original documents and pharmacy bills for medicines with the OPs. Vide letter dated 17.4.2015, the OPs enquired from complainant about the dates of surgery and pharmacy bills. The same was duly replied by the complainants vide letter dated 20.4.2015.But inspite of that the claim was wrongly refused by the OPs vide ‘No Claim ‘ letter dated 19.5.2015 on the ground of different dates of bills. Thereafter the complainants got issued legal notice dated 11.3.2016 upon the OPs for the release of the amount of claim amounting to Rs.50,000/- within 15 days of the legal notice but the OPs neither replied the legal notice nor paid a single penny to the complainants. They also visited the office of the OPs for payment of insurance claim but of no avail. That the act and conduct of the OPs is illegal, unjust and improper, which caused mental agony and physical harassment to the complainants. Hence this complaint with the prayer for giving directions to the OPs to pay Rs.50,000/-, the amount of claim; to pay Rs.25,000/- as compensation for causing mental agony and physical harassment; to pay Rs.10,000/- towards deficiency in services; to pay Rs.10,000/- as litigation expenses and also to grant any other relief which this Forum may deem fit.
3. On being put to notice OPs no.1&2 appeared and filed their written version whereas Op No.3 despite service failed to come present and was accordingly proceeded against exparte.
In the written version filed by OPs no.1&2, preliminary objections have been taken to the effect that the present complaint is premature; that the complainants have got no cause of action to file the present complaint; that the complicated questions of law and facts are involved in the complaint which can only be decided by the Civil Court. On merits , it is admitted that OPs had issued Personal Medi Claim Policy in favour of Sh. Harbir Singh Kharbanda, retired employee of Punjab & Sind Bank, for the period of 11.5.2014 to 10.5.2015, for a sum of Rs.3lacs and his wife Smt.Harpal Kaur Kharbanda was also covered, covering the risk of medical treatment for a sum of Rs.3lac. It is further stated that M/s Meditek TPA services Ltd. was appointed as a third party administrator. It is stated that the complainants failed to supply all the documents as demanded by OP No.3. It is further stated that the claim of the complainants was declared as ‘No claim’ on 19.5.2015, and were informed accordingly stating that there was variation in operation date as per attached documents, which showed that surgery was done on 13.2.2015 but receipts for cataract extraction were dated 12.12.2014 and also all medicines purchased on 11.12.2014. It was not believable as explained by the complainant that the surgery was postponed from 12.12.2014 to 13.2.2015 due to lower lid discharge and whatever she purchased was used at the time of operation on 13.2.2015. It is stated that as per format of billing, all the pharmacy was lying under non applicable hospitalization and only injection Ozurdex 0.7mg was matching with the date of operation which was not payable as no other amount was asked during this date. There was no deficiency of service on the part of the OPs. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.
4. On being called to do so, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant No.1, Ex.CB affidavit of complainant No.2 alongwith documents Exs.C1 to 23 and closed the evidence of the complainants.
The ld. counsel for OPs No.1&2 has tendered in evidence Ex.OPA affidavit of Sh.Dinesh Goel, Dy.Manager alongwith documents Exs.OP1 to OP5 and closed the evidence of the OPs.
We have heard the ld. counsel for the parties, gone through the written arguments filed by the ld. counsel for the complainants and have also gone through the record of the case, carefully.
6. Admittedly the complainant No.2 being the Retd. Bank employee and his wife i.e. complainant No.1, being the spouse of complainant No.2, were duly insured with the OPs under Mediclaim, Staff Welfare scheme. The complainant No.1 had been taking treatment for her eyes, from PGIMER, Chandigarh, as is evident from the copies of documents issued by the PGIMER i.e. Exs.C6,C7,C11 & C13. From the receipt dated 12.12.2014,Ex.C6, it is evident that the complainant No.1 had deposited a sum of Rs.1000/- with the Ophthalmology department of PGI for cataract extraction. From the prescription slip, Ex.C7, it is evident that on 11.12.2014, the doctor concerned had prescribed some medicines. From the bill dated 11.12.2014, Ex.C8, it is evident that the complainants had purchased the medicines, for an amount of Rs.16025/-. From the copy of card/prescription, Ex.C7, it is evident that on 12.12.2014, the cataract surgery of complainant No.1 was postponed by the doctor concerned, due to discharge from lower lid. From the copy of certificate,Ex.C13, issued by the PGIMER, Chandigarh, it is evident that complainant No.1 had taken treatment vide CR No.2014 0443 6357 and phaco + PCIOL +IVT Ozurden surgery of the left of the complainant No.1 was conducted on 13.2.2015. From the copy of invoice ,Ex.C12,it is evident that the complainant had also purchased the medicines of Rs.19,444/-on 13.2.2015. From the perusal of claim form, Ex.C14, it is evident that the complainant had lodged the claim with the OPs to the tune of Rs.44,469/- i.e. 19,444/-+16025+Rs.8000/-+1000/-. In order to settle the claim, the OP No.3 vide letter 17.4.2015,Ex.C15, asked the complainant No.2 to clarify this fact that the operation was conducted on 13.2.2015 but the bill for the medicines was of 11.12.2014 and also to clarify as to why there was cut on some medicines mentioned in bill dated 11.12.2014. As per the ld. counsel for the complainants, some medicines purchased on 11.12.2014 were used in operation theatre on 12.12.2014 and some were used on 13.2.2015, when the operation was conducted. The said fact was clarified by the complainant No.2 vide letter dated 20.4.2015, Ex.C17. It may be stated here that no cogent document has been placed on record by the OPs to the effect that either the medicines purchased on 11.12.2014 were not used by complainant no.1 or the same were returned to the seller. Un- doubtly the operation of the left eye of the complainant No.1 could not be conducted on 12.12.2014, due to some medical problem but the same was conducted on 13.2.2015, therefore, the OPs are liable to indemnify the complainants for the expenses incurred by them on the operation of the left eye of complainant No.1. In term No.1.2.1 of terms and conditions of the policy document Ex.OP5, it is clearly mentioned that the insured is entitled to get actual expenses incurred or 25% of the sum insured whichever is less for hospitalization benefits for the cataract surgery. It is an admitted fact that the complainants were insured for Rs.3lac. Since the expenses incurred by the complainants for the cataract surgery of complainant No.1 is less than 25% of the policy amount, therefore, the OPs are liable to pay the actual expenses incurred on the cataract surgery of complainant No.1. From the bill dated 11.12.2014, it is evident that the complainants had purchased IOL, worth Rs.7500/-. The complainants have also claimed Rs.8000/- for the lens vide claim form,Ex.C14. It may be stated here that the complainants have not placed on record to show that they have purchased the lens for an amount of Rs.8000/-. Therefore, the complainants are not entitled to get Rs.8000/- as claimed in the claim form but are entitled to get Rs.16025+19444/-+ Rs.1000/- i.e. Rs.36469/-. Taking these facts and circumstances into consideration, we are of the view that the OPs were not justified in repudiating the claim of the complainant and are liable to pay Rs.36469/- to the complainants. They are also liable to compensate the complainants for the mental agony and physical harassment suffered by them alongwith litigation expenses.
7. In view of the aforesaid discussion, we hereby allow the complaint and direct the OPs in the following manner:
- To pay Rs.36,469/-, the actual expenses incurred, on the cataract surgery of left eye of complainant No.1;
- To pay Rs.5000/-as compensation for causing mental agony and physical harassment to the complainants;
- To pay Rs.5000/-as litigation expenses.
The ops are further directed to comply with the said order within a period of 45 days,from the date of the receipt of the certified copy of the said order, failing which they shall be liable to pay interest @7% p.a. on the amountof Rs.36,469/-, from the date of this order i.e. 24.4.2018 till its realization. The certified copies of this order be sent to the parties free of cost under the Rules.
ANNOUNCED
DATED:24.4.2018
NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
