Punjab

Faridkot

CC/18/170

Parveen - Complainant(s)

Versus

United India Insurance Company Ltd. - Opp.Party(s)

Ashu Mittal

25 Sep 2019

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      170 of 2018

Date of Institution:   26.10.2018

Date of Decision :    25.09.2019

 

Parveen @ Parveen Goyal @ Parveen Mittal w/o Vipan Mittal, r/o Line Bazar, Street No.7, Faridkot.

 

...Complainant

Versus

 

1. United India Insurance Company, Faridkot through its Manager.
2. Department of Health and Family Welfare through Health System Corporation, SIHFW Complex, Phase-6, Mohali through its Managing Director.
3. State of Punjab through Deputy Commissioner, Faridkot.
4. M D India, Health Care Service TPA Pvt Ltd,  Maxpro Info Park D -38, Industrial Area, Phase-I,  Mohali.
5. Dr. Madhu Nursing Home and Scanning Centre, Bhan Singh Colony, Ferozepur Road, Faridkot through its Proprietor.

 .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

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Present: Sh  Ashu Mittal, Ld Counsel for complainant,

              Sh Ashok Monga, Ld Counsel for OP-1,

             Sh Kashmir Lal, Ld Counsel for OP-2 and 3,

              Sh Raj Kumar, Ld Counsel for OP-5,

              OP-4 Exparte.

 

ORDER

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs for deficiency in service in not making payment of Rs. 25,000/-of insurance claim on account of his treatment and for further directing OPs to pay Rs.25,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses.

2                                    Briefly stated, the case of the complainant is that complainant was insured under Bhagat Puran Singh Scheme vide card no 93045013409800219 and policy bearing no 112100486100000091 was issued to him for the period from 1.11.2016 to 31.10.2018. It is submitted that during the subsistence of said policy, complainant felt pain in abdomen and she approached OP-5 empanelled hospital under scheme and  after  checking concerned doctor told her that she is suffering from hysterectomy and advised for operation. Complainant showed the card issued to her under said scheme, but Dr Madhu told her that there is difference in age in the  card and adhar card and thus, she is not entitled for cashless scheme, but however, after operation she can get

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reimbursement for medical expenses. On advice of said doctor, complainant got conducted her surgical operation and was discharged therefrom on 18.06.2018 and thereafter, complainant completed all the requisite formalities and submitted documents to OP-1 to 4 for processing his claim, but OP-4 returned the same without any reason. Complainant made several requests to OPs to reimburse the expenses incurred by her on her treatment but all in vain. Action of Ops in not making payment of claim amount of Rs.25,000/ amounts to deficiency in service and it has caused harassment and mental agony to complainant for which she has prayed for accepting the complaint alongwith compensation and litigation expenses besides the main relief. Hence, the present complaint.

3                                                          The counsel for complainant was heard with regard to admission of the complaint and vide order dated 30.10.2018, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                              On receipt of the notice, OP-1  filed written statement wherein  they have denied all the allegations of complainant being wrong and incorrect and asserted that complainant is not their consumer and there is no relationship of consumer and service provider between them. It is averred that complainant did not give them requisite immediate intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and

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conditions of the policy in question. Complaint involves complicated questions of law and facts requiring lengthy evidence, which is not possible in summary procedure of this Forum. No cause of action arises  against answering Ops and present complaint is vague and is based on wrong facts and complainant has no locus standi to file the same. It is further averred that complainant was not insured with them at the relevant time and neither complainant nor other respondents provided them proper insurance particulars and therefore, they are not liable to make payment of any insurance claim. There are several regional offices, divisional offices and branch and micro offices and it is not possible to locate the insurance particulars without supply of the same by complainant or by other OPs. All the other allegations are denied being wrong and incorrect and asserted that there is no deficiency in service on the part of answering Ops and prayed for dismissal of complaint with costs.

5                                                        OP-2 and OP-3 also filed reply through counsel and have denied all the allegations of complainant being wrong and incorrect and asserted that as per Bhagat Puran Singh Sehat Bima Yojana, eligible claimant is entitled to get the benefit of scheme on treatment of rupees upto 50,000/- and if bill exceeds Rs.50,000/-, then remaining amount would have to be paid by the claimant. There is no relationship between complainant and answering OPs as documents necessary for processing the claim are required to be submitted by

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complainant to OP-1, 4 and 5 and answering OP-2 and Op-3 have no role in making payment of claim amount to him. All the other allegations of complainant are totally denied being wrong and incorrect and it is reiterated that there is no deficiency in service on the part of answering Ops. Prayer for dismissal of complaint is made.

6                                    OP-5 also filed reply wherein submitted that no cause of action arises against answering OP and  it is bad for misjoinder of necessary parties as complainant has impleaded OP-5 wrongly and incorrectly, however, it is admitted that hospital of answering OP is empanelled under Bhagat Puran Singh Sehat Bima Yojana. It is also admitted that complainant was holding card issued under Bhagat Puran Singh Sehat Bima Yojana and she took surgical treatment for Hysterectomy from her hospital and was discharged from there on 18.06.2018. It is submitted that complainant wanted to undertake treatment under BPSSBY and showed master card issued to her under the scheme, but on checking it was found that as per master card, her age was 25 but as per Adhar Card, her age was 49 years and as per provisions of scheme in question, patients below the age of 40 years cannot get treatment of hysterectomy without prior approval of TPA of BPSSBY i.e OP-4. Complainant was asked to  provide documents like adhar cards of all family members, self declaration of the patient, ultrasound report and application from the patient with recommendation of concerned senior medical officer that complainant failed to supply. During or after the

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treatment, complainant did not raise any resentment and asked OP-5 to treat her as private patient. Answering OP did not deny cashless facility under BPSSBY to complainant, rather she herself preferred to be treated as private patient as she was not eligible under provisions of said scheme and showed her inability to furnish requisite documents. It is reiterated that there is no deficiency in service on the part of OP-5. All the other allegations of complainant are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

7                                                        Registered cover containing summons and copy of complaint alongwith relevant documents was sent to OP-4, but it did not receive back undelivered and it was presumed to be served. No body appeared in the Forum either in person or through counsel on date fixed on behalf of OP-4 and therefore, after long waiting till 4 O’ Clock, OP-4 was proceeded against exparte vide order dated 18.12.2018.

8                                              Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence her affidavit Ex.C-11 and documents Ex C-1 to 10 and then, closed his evidence.

9                                                In order to rebut the evidence given by complainant, the ld Counsel for OP-1 tendered in evidence affidavit of Kamaljit Kaur Ex OP-1/1 and document Ex OP-1/2 and closed the same.

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Ld counsel for OP-2 and 3 tendered in evidence affidavit of Dr. Rohini Goyal Ex OP-2,3/1 and closed evidence on behalf of OP-2 and 3. Counsel for OP-5 tendered in evidence affidavit of Dr Madhu Goyal Ex OP-5/2 and also closed the evidence on behalf of OP-5.

10                                            We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents placed on the file.

11                                               After careful perusal of the record available on file and going through the evidence led by parties, it is observed that case of the complainant is that she was insured under Bhagat Puran Singh Sehat Bima Yojana for the period from 1.11.2016 to 31.10.2018 and during the subsistence of said policy, she suffered from Hysterectomy and on advise of OP-5, she got conducted surgical operation for said trouble from OP-5 and thereafter, she completed all formalities and submitted requisite documents to OPs for processing her claim for reimbursement of expenses incurred by her on her treatment, but OPs rejected the same without any reason and returned the documents furnished by complainant. Grievance of complainant is that despite repeated requests, Ops have not reimbursed her the amount of Rs.25,000/-spent by her on her treatment. On the other hand, plea taken by OP-1 is that all the allegations of complainant are incorrect and complainant is not their consumer. As per OP-1, complainant did not give them timely

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intimation preventing them to gather first hand information and to inspect the spot, which is violation of terms and conditions of the policy and even she was not insured with them at the relevant time and neither complainant nor OP - 2 to 4 supplied insurance particulars to them and therefore, they are not liable to pay any insurance claim and there is no deficiency in service on their part. Moreover, as per terms and conditions of the policy, there is no provision for reimbursement of amount spent on treatment as it is a cashless policy. As per BPSSBY, beneficiary can only avail cashless treatment from the empanelled hospitals, but no reimbursement is admissible to the beneficiaries. OP-2 and OP-3  have denied all the allegations of complainant being wrong and incorrect and asserted that there is no deficiency in service. OP-5  admitted before the Forum that complainant was having master-card issued under Bhagat Puran Singh Sehat Bima Yojana and she took surgical treatment for Hysterectomy from her hospital and was discharged from there on 18.06.2018. It is brought before the Forum that complainant wanted to undertake treatment under BPSSBY, but as per master card shown by her, her age was 25 but on Adhar Card, her age was mentioned as 49 years. As per terms and conditions of BPSSBY, patients below the age of 40 years cannot get treatment of hysterectomy without prior approval of TPA of BPSSBY i.e OP-4. Complainant failed to provide documents like adhar cards of all family members, self declaration of the patient, ultrasound

 

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report and application from the patient with recommendation of concerned senior medical officer. OP-5 did not deny cashless facility under BPSSBY to complainant, rather she herself preferred to be treated like private patient as she was not eligible under provisions of said scheme and showed her inability to furnish requisite documents. It is reiterated that there is no deficiency in service on their part.

12                                   In order to prove her pleadings, complainant has stressed on document Ex C-1 copy of card issued by OPs under Bhagat Puran Singh Health Insurance Scheme that clearly depicts that policy in question was issued in the name of complainant and she was insured under said scheme. Ld Counsel for complainant further stressed on document Ex C-9, which is copy of Adhar Card that bears the date of birth mentioned over it as 10.11.1968 meaning thereby at the time of said surgical operation, age of complainant was forty nine years seven months and five days and plea taken by OPs that at the time of operation her  age was 25 years has no legs to stands upon. Adhar Card is self explanatory and proves that complainant was entitled for cashless treatment of hysterectomy under said scheme. It is also admitted that she undertook treatment during the subsistence of said policy. There is no denial that card issued to complainant under said scheme was  valid for the period from 1.11.2016 to 30.11.2018. From the bill Ex C-10 issued by OP-5 to complainant for her treatment in their hospital, it is crystal clear that complainant paid Rs.25,000/-to hospital authorities from her own pocket

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and benefit of cashless treatment for which she was entitled was not granted to her. Though she was insured under said scheme, but she was deprived of the cashless treatment facility on false grounds, which amounts to deficiency in service on the part of OPs. Original envelop Ex C-8 returned by OPs to complainant further proves the pleadings of complainant that she completed all formalities and submitted all requisite documents to Ops for processing her claim, but OPs rejected her genuine claim. Complainant has placed on record sufficient and cogent evidence to prove her pleadings. There is no reason to doubt that complainant has suffered huge harassment and mental agony by action of OPs in not making payment of insurance claim on account of expenses incurred by her on her treatment.

13                                    From the above discussion and in the light of evidence produced by the respective parties, we are of considered opinion that complainant has succeeded in proving her case. Act of OP-1 and OP-4 in not making reimbursement of amount spent by complainant on her treatment, amounts to deficiency in service on their part and therefore, complaint in hand is hereby allowed against OP-1 and OP-4 and they are directed to reimburse the amount of Rs.25,000/-alongwith interest at the rate of 9 % per anum from the date of filing the present complaint till final realization to complainant who was insured with OPs against policy in question. OP-1 and 4 are further directed to pay Rs.3,000/- to complainant as consolidated compensation for harassment and mental agony suffered

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by her as well as for litigation expenses. Complaint stands dismissed against OP-2, OP-3 and OP-5 as they have no role in making payment of expenditure incurred by complainant on her treatment. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 25.09.2019       

(Param Pal Kaur)            (Ajit Aggarwal)  

 Member                         President