BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.513-14

Date of Institution: 19-09-2014

Date of Decision: 11-06-2015  

Ranjit Singh son of S.Santokh Singh, Sewadar Sachkhand Sri Harimandir Sahib, Sri Darbar Sahib, Sri Amritsar.

Complainant

Versus

1. The Divisional Manager, United India Insurance Company Limited, Division Office-1, M.M.Malviya Road, Amritsar.
2. Secretary, S G P C Amritsar, Teja Singh Samundri Hall, Amritsar.
3. Manager Sahib, Sachkhand Sri Harimandir Sahib, Sri Darbar Sahib, Sri Amritsar.  

Opposite Parties

Complaint under section 12, 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Deepinder Singh, Advocate

              For the Opposite Party No.1: Sh.P.N.Khanna, Advocate

              For Opposite Parties  No.2 and 3:Sh.M.S.Gill, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Ranjit Singh  under the provisions of the Consumer Protection Act alleging therein that he has been serving as Sewadar at Sachkhand Sri Harimandir Sahib, Sri Darbar Sahib, Sri Amritsar since long. Complainant alleges that he including his family was covered under the Medi Claim by his employer with the Opposite Party No.1 under the Alankit Health Care TPA Limited vide insurance policy No. 200200/48/10/41/00000706 and accordingly, the card No.29/AHUN02652019 valid from 1.1.2011 was issued in the name of complainant whereas card No. 20/AHIN02652020 was issued to Smt.Manjit Kaur wife of the complainant. Complainant further alleges that a female baby namely Gudia was born from the womb of Smt.Manjit Kaur, wife of  complainant on 12.9.2011 at Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar. Unfortunately, baby  Gudia suffered from ailment  since birth and she remained admitted  in Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar from 12.9.2011 and was discharged on 6.10.2011. The complainant has to incur more than Rs.1,05,372/- for the treatment of baby Gudia daughter of Ranjit Singh complainant and Manjit Kaur. The complainant submitted the medi claim file alongwith original bills to Opposite Party No.1 through Opposite Parties  No.2 and 3, but the file of medi claim was misplaced from the office of Opposite Party No.1 and Opposite Party No.1 asked the Opposite Parties  No.2 and 3 to submit the duplicate bills and as such, the complainant submitted the duplicate bills duly issued by Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar alongwith entire treatment file and other requisite documents and requested the Opposite Party No.1 to release and disburse him the aforesaid medical claim of Rs.1,05,372/- . But the Opposite Party No.1 has been delaying the matter with one or the other pretext.    Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party No.1 to pay Rs.1,05,372/- to the complainant alongwith interest since 12.9.2011. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party No.1  appeared and filed written version in which it was submitted that the policy in question is related to be dealt by the independent TPA i.e. Alankit Health Care TPA Limited. Said TPA immediately wrote letter dated 29.3.2013 to Opposite Party No.2 being the insured to provide the hospital main bill with break-up, original discharge summary, payment receipt and  all lab reports as well as reason for late submission. In the said letter, it was made clear that the said documents/ information  be supplied within 7 days so that  the claim of the complainant can be considered on merits. However, no steps were taken in this regard and as such, said TPA again sent reminder dated 13.4.2013 and 7.5.2013 to supply the requisite documents, but to no effect. Therefore, the claim could not be kept open for indefinite period and as such, the claim has been filed as ‘no claim’.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite Parties  No.2 and 3  appeared and filed written version in which it was submitted that  Ranjit Singh complainant  is working as Sewadar in Sri Darbar Sahib, Amritsar. He being an employee of Shiromani Gurdwara Parbandhak Committee, Amritsar is covered under the Group Insurance Medi Claim Policy of United India Insurance Company Limited for the period from 1.1.2011 to 31.12.2011 having cover note No. 594229 issued in favour of Manager, Sri Darbar Sahib, Amritsar and his name appears at serial No.55 of the list of insured employees. As per the terms and conditions settled by the representative of the Opposite Party No.1, the delivery case of the insured members of the family of the insured employee, including the new born is also covered under the aforesaid policy of the Opposite Party No.1. However, despite requests from the Opposite Parties  No.2 and 3, the Opposite Party No.1 failed to settle the medi claim of the complainant and pay the amount due under the said claim.  While denying and controverting other allegations, dismissal of complaint was prayed against Opposite Parties  No.2 and 3.
4. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C9 and closed the evidence on behalf of the complainant.
5. Opposite Party No.1 tendered into evidence affidavit of Sh.Surinder Singh, Divisional Manager Ex.OP1/1 alongwith documents Ex.OP1/2 to Ex.OP1/ 5 and closed the evidence on behalf of the Opposite Party No.1.
6. Opposite Parties  No.2 and 3 tendered into evidence affidavit of  Sh.Hardev Singh, attorney Ex.OP2,3/1, affidavit of Sh.Harjinder Singh, Supervisor Ex.Op2,3/2 alongwith documents Ex.OP2,3/3 to Ex.OP2,3/7 and closed the evidence on behalf of the Opposite Parties  No.2 and 3.
7. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
8. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant being an employee of Shiromani Gurdwara Parbandhak Committee, Amritsar posted as Sewadar at Sachkhand Sri Harimandir Sahib, Sri Darbar Sahib, Sri Amritsar since long. Complainant alleges that he including his other family members  were covered under the Medi Claim by his employer with the Opposite Party No.1 under the Alankit Health Care TPA Limited vide insurance policy No. 200200/48/10/41/00000706 and accordingly, the card No.29/AHUN02652019 valid from 1.1.2011 was issued in the name of complainant whereas card No. 20/AHIN02652020 was issued to Smt.Manjit Kaur wife of the complainant. Complainant further alleges that a female baby namely Gudia was born to Smt.Manjit Kaur wife of the complainant on 12.9.2011 at Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar. Said  baby  Gudia suffered from ailment  since birth and she remained admitted  in Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar from 12.9.2011 till 6.10.2011 when she was discharged. The complainant has to incur more than Rs.1,05,372/- on the treatment of baby Gudia daughter of Ranjit Singh complainant and Manjit Kaur. After discharge from the hospital, the  complainant submitted medi claim file alongwith original bills to Opposite Party No.1 through Opposite Parties  No.2 and 3 with the request to reimburse the aforesaid amount of Rs.105372/- to the complainant, but the file of medi claim was misplaced from the office of Opposite Party No.1 and Opposite Party No.1 asked the Opposite Parties  No.2 and 3 to submit the duplicate bills. As such, the complainant submitted the duplicate bills duly issued by Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar alongwith entire treatment file as well as other relevant/ requisite documents  which were sent by Opposite Party No.2 to Opposite Party No.1 for the reimbursement of the aforesaid amount to the complainant, but the Opposite Party No.1 did not settle the claim of the complainant. A letter was written by Opposite Party No.2 to Opposite Party No.1 bearing No. 5671 dated 23.11.2012, but even then, the Opposite Party No.1 did not settle the claim of the complainant. Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite part No.1 qua the complainant.
9. Whereas the case of the Opposite Parties  No.2 and 3  is that the complainant  being an employee of Shiromani Gurdwara Parbandhak Committee, Amritsar is covered under the Group Insurance Medi Claim Policy of Opposite Party No.1 for the period from 1.1.2011 to 31.12.2011 vide cover note No. 594229 issued by  Opposite Party No.1 in favour of  Opposite Party No.3 and the name of complainant appears at serial No.55 of Ex.OP2,3/6. As such, the complainant and his family is covered under the aforesaid medi claim policy issued by Opposite Party No.1. Opposite Parties  No.2 and 3 further submitted that as per the terms and conditions settled by Opposite Party No.1, the delivery case of the insured members of the family of the insured employee, including the newly born baby is also covered under the aforesaid policy of the Opposite Party No.1. The complainant submitted his claim file alongwith relevant documents to Opposite Party No.2 which were sent to Opposite Party No.1 vide letter dated 3.11.2011 Ex.OP2,3/3.  Again on the request of Opposite Party No.1 that the claim file alongwith relevant documents of the complainant were not traceable in the office of Opposite Party No.1, so the complainant submitted  duplicate bills as well as other relevant records of the hospital to Opposite Party No.2 who further sent the same to Opposite Party No.1 vide letter dated 23.11.2012 Ex.OP2,3/4. So, it is the Opposite Party No.1 who did not settle the claim of the complainant. Ld.counsel for the Opposite Parties  No.2 and 3 submitted that there is no deficiency of service on the part of the Opposite Parties  No.2 and 3.
10. Whereas the case of the Opposite Party No.1 is that the claim was lodged with the TPA i.e. Alankit Health Care TPA Limited and the said TPA immediately wrote letter dated 29.3.2013 Ex.OP1/3 to Opposite Party No.2 being the insured to provide the hospital main bill with break-up, original discharged summary, payment receipt and  all lab reports as well as reason for late submission and they were requested to supply the relevant record within 7 days, but  no steps were taken by Opposite Parties  No.2 and 3 in this regard despite reminders issued to Opposite Parties  No.2 and 3. Resultantly,  the concerned TPA vide its closure letter dated 30.5.2014 Ex.OP1/4 informed Opposite Party No.3 that the claim of the complainant has been filed as ‘no claim’.  Ld.counsel for the Opposite Party No.1 submitted that there is no deficiency of service on the part of the Opposite Party No.1. 
11. From the entire above discussion, we have come to the conclusion that the complainant being an employee of Shiromani Gurdwara Parbandhak Committee, Amritsar/  Sachkhand Sri Harimandir Sahib, Sri Darbar Sahib, Sri Amritsar was insured by their employer Opposite Parties  No.2 and 3 through Group Insurance Scheme Ex.OP1/5 and the name of the complainant appears at serial No.55 of the list Ex.OP2,3/6. It is also admitted case of all the parties that as per the terms and conditions of the policy, the delivery case of the insured members of the family of the insured employee, including the newly born baby is also covered under the aforesaid policy of the Opposite Party No.1 for the period from 1.1.2011 to 31.12.2011. The wife of the complainant namely Smt.Manjit Kaur gave birth to female baby namely Gudia on 12.9.2011 at Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar. But said  newly born baby  Gudia suffered from ailment  since birth and she remained admitted  in Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar from 12.9.2011 till she was discharged on 6.10.2011 and the complainant spent Rs.1,05,372/- on the treatment of baby Gudia daughter of Ranjit Singh complainant and Manjit Kaur. In this regard, the complainant produed the record of Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar Ex.C3, copy of detail of payment Ex.C4 and copies of bill-cum- receipts Ex.C5 (15 pages). The  complainant submitted medi claim file alongwith all the relevant documents/ hospital record to Opposite Party No.2 i.e. employer of the complainant who further sent the same to Opposite Party No.1 vide letter dated 3.11.2011 Ex.OP2,3/3 and requested the Opposite Party No.1 to reimburse this amount to the complainant. But said claim file of the complainant alongwith all the relevant documents/ hospital record was misplaced in the office of Opposite Party No.1 and could not be traced. Resultantly, on the request of the Opposite Party No.1, the Opposite Parties  No.2 and 3 again collected the claim file (duplicate) alongwith  duplicate copies of bills and hospital record from the complainant and sent the same to Opposite Party No.1 vide letter dated 23.11.2012 Ex.OP2,3/4 and requested  the Opposite Party No.1 to make the payment of the amounts spent by the complainant on the treatment of his newly born baby to the complainant at the earliest. But inspite of that, Opposite Party No.1 did not settle the claim of the complainant. The plea of Opposite Party No.1 that TPA namely  Alankit Health Care TPA Limited,  issued letter dated 29.3.2013 Ex.OP3 requiring certain documents i.e. hospital bill with break-up, original discharged summary, payment receipt and  all lab reports as well as reason for late submission of the claim, but the Opposite Parties  No.2 and 3 did not furnish the said material to the TPA, is not tenable because it is the Opposite Party No.1 who lost the claim file submitted by the complainant alongwith all the documents including the documents i.e. hospital bill with break-up, original discharged summary, payment receipt and  all lab reports, etc. Which were submitted by the complainant to Opposite Parties  No.2 and 3 who further supplied the same to Opposite Party No.1 on 3.11.2011 vide letter Ex.OP2,3/3 and again Opposite Parties  No.2 and 3 sent the duplicate copies of all the aforesaid required documents to the Opposite Party No.1 after collecting the same from the complainant vide letter dated 23.11.2011 Ex.OP2,3/4 and these documents were not rebutted by Opposite Party No.1. So, there was no delay in submitting  of the claim by the complainant to Opposite Party No.2 nor there is any delay on the part of the Opposite Parties No.2 and 3 for submitting the claim file alongwith relevant documents to Opposite Party No.1.
12. Resultantly, we hold that TPA i.e. Alankit Health Care TPA Limited of Opposite Party No.1 has wrongly treated the claim of the complainant as ‘no claim’ vide letter dated 30.5.2014 Ex.OP1/4.
13. Consequently, we allow the complaint of the complainant with cost and the Opposite Party No.1 is directed to reimburse the amount of Rs.1,05,372/- spent by the complainant on the newly born baby namely Gudia daughter of the complainant at  Kalra Hospital, Ajit Nagar, Sultanwind Road, Amritsar, within 2 months from the date of receipt of copy of this order, failing which the Opposite Party No.1 shall be liable to pay the interest @ 9% per annum on this amount from the date of filing the complaint till the payment is made to the complainant. Opposite Party No.1 is also directed to pay the costs of litigation to the tune of Rs.2000/- to the complainant. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 11-06-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member