Punjab

Rupnagar

CC/15/35

Mohinder Singh - Complainant(s)

Versus

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

Sh. Devinder Gorla, Adv

09 Sep 2015

ORDER

ORDER

                             MRS. NEENA SANDHU, PRESIDENT

                   Sh. Mohinder Singh has 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.’) praying for issuance of the following directions to them:-

i)       To pay the medical expenses of Rs.12,000/- as per the insurance scheme,

ii)      To pay damages to the tune of Rs.10,000/- on account of harassment caused to him,

iii)     To pay Rs.5000/- as litigation expenses.

 

 

2.                In brief, the case of the complainant is that he is a member

of the Society, namely, The Jagatpur MP CASS Ltd., Jagatpur, i.e. the O.P. No.3. The said O.P. No.3 had launched an insurance scheme under the name & style ‘Bhai Ghanhya Sehat Sewa Scheme’ under which all the medical expenses upto Rs.12,000/- of its members and also their family members were covered. He being a member of the said Society had got insurance cover for himself, as well as for other members of his family. He completed all the formalities, as prescribed by the O.Ps. No.1 to 3 for becoming a member under ‘Bhai Ghanhya Sehat Sewa Scheme’ under which all the medical expenses upto Rs.12,000/- were covered. He had also paid the insurance premium for availing the benefits under the said  insurance scheme. The O.P. No.3 had issued a card bearing No.MD-15-BGSSS-00271978-S, which is valid from 2014 to 2015 regarding said medical insurance policy and also issued a booklet/guidelines and list of approved Hospitals in various towns of Punjab and Chandigarh. The name of the O.P. No. 4 is also included in the said booklet. On 15.07.2014, he approached the O.P. No. 4 at its reception counter, for the treatment of Hernia, suffered by him and showed the above said card, issued by the O.P. No. 3 and asked, whether the health services provided by the O.P. No. 4 are covered under scheme of the O.P. No. 2. The doctor of the O.P. No. 4 advised him to fill-up the proposal form and to complete all the formalities, to get the benefit of insurance covered under ‘Bhai Ghanhya Sehat Sewa Scheme’. The doctors of O.P. No.4 had also told him that approximately, an amount of Rs.12,000/- would be spent on his treatment and the same is covered under the scheme launched by the O.P. No. 3. Thereafter, the doctors of the O.P. No. 4 checked-up him and on 30.07.2014, he got admitted in the Hospital i.e. O.P. No. 4 and his operation of Hernia was conducted and he was discharged from the said hospital on 07.08.2014. He being member of the O.P. Society and being covered under ‘Bhai Ghanhya Sehat Sewa Scheme’ is entitled to get reimbursement of the above said medical expenses incurred by him on his Hernia operation. He had visited the office of the O.P. No.3, so many times, along with medical record and requested to refund the amount incurred by him on his treatment, as per the scheme launched by it, but the O.Ps. had been putting off the matter on one pretext or the other, which amounts to clear cut deficiency in service on their part, due to which he has suffered mental agony, physical harassment & huge financial loss. Hence, this complaint.

 

3.                On being put to notice, the O.P. No. 1 filed written version in the shape of affidavit of Ms. Hemali Batra, Deputy Manager, taking preliminary objections; that the complaint is pre mature, because the answering O.P. has no knowledge regarding the claim of the complainant, therefore, question of repudiation of his claim does not arise and the complaint is not maintainable in the present forum; that there is no deficiency in service on the part of the answering O.P.; that in the absence of the original insurance policy, it is denied that the answering O.P. issued any policy to complainant; that this Forum has no jurisdiction to decide the instant complaint because complicated facts & questions are involved in it, which cannot be decided in summary nature, without recording evidence and cross-examination of the witnesses, and only the civil court has the jurisdiction to decide the same. On merits, it is stated that if the answering O.P. had issued the policy and card to the complainant, then directions be given to the complainant to produce the original insurance policy & card for verification and confirmation. In the absence of the original insurance policy and its verification, it is denied that the answering O.P. had issued any policy/card to the complainant. Rest of the allegations made in the complaint have also been denied and a prayer has been made for dismissal thereof, with cost.

 

4.                None having appeared on behalf of the O.Ps. No. 2 & 3, they were proceeded against ex-parte vide order dated 05.05.2015.

 

5.                Separate written version was filed on behalf of the O.P. No. 4 through Dr. Mohinder Singh, Senior Medical Officer, Civil Hospital, Ropar stating therein that only one health scheme i.e. ‘Rashtria Bima Suraksha Yojna’ is running in the Civil Hospital, Ropar and ‘Bhai Ghanhya Sehat Sewa Scheme’ is not covered in the said hospital.

6.                However, after filing of written version, none had appeared on behalf of the O.P. No. 4, therefore, it was proceeded against ex-parte vide order dated 21.5.2015.

 

7.                On being called upon to do so, the learned counsel for the complainant tendered affidavit of the complainant, Ex. C1, photocopies 

of documents Ex.C2 to Ex.C11 and closed the evidence. On the other hand, the learned counsel for the O.P. No. 1 tendered affidavit of Ms. Hemali Batra, Deputy Manager, Ex.OP-1, & some other documents Ex. OP-2 to Ex.OP-4 and closed the evidence.

 

8.                We have heard the learned counsel for the complainant and the contesting O.P. No. 1 and gone through the record of the file, including written arguments filed by the learned counsel for the complainant, carefully.

 

9.                The learned counsel for the complainant submitted that the complainant being member of the O.P. No. 3 Society was duly insured with the O.P. No. 1 under Bhai Ghanhaya Sehat Sewa Scheme. The O.P. No. 3 had also issued a card (Ex. C9) to that effect, which was valid for the years 2014-15 and had also supplied a booklet containing guidelines and list of approved hospitals in the State of Punjab. The O.P. No. 2 has been appointed as TPA.  The member under the said scheme can avail treatment from any of the Government hospitals situated in Punjab, Chandigarh and Delhi as is evident from Ex. C10. On 15.7.2014, the complainant had gone to the O.P. No. 4 for the treatment of Hernia and had shown his card issued by the O.P. No. 3. The concerned doctor of the O.P. 4 advised him to fill-in the proposal form and to complete all the formalities, in order to get the benefit under the said Scheme. He was got admitted in the O.P. No. 4 hospital on 30.7.2014 and was discharged from the said hospital after his operation on 7.8.2015, as is evident from Discharge Certificate, Ex.C7. Thereafter, he visited the office of the O.P. No. 3 alongwith medical record and requested to pay the amount of Rs.12,000/- as per the above said scheme, but no amount has been paid to him. As such, all the O.Ps. are deficient in providing services and the complainant is not only entitled to get reimbursement of the amount of Rs.12,000/- as per the insurance policy, but he is also entitled for compensation for harassment alongwith litigation expenses.

 

10.              The learned counsel for the the O.P. No. 1 submitted that the present complaint is premature because the complainant has not lodged any claim under the scheme in question, therefore, question of repudiation of the same did not arise at all and the complaint is liable to be dismissed being premature.

 

11.              Admittedly, the complainant being member of the O.P. No. 3 Society was got insured vide policy schedule Ex. OP2, which was valid for the period from 16.5.2014 to 15.5.2015 and he was also issued card (Ex. C9) under Bhai Ghanhaya Sehat Sewa Scheme 2014-2015, by the O.P. No.2. From the Discharge Certificate, Ex.C7, it is proved that the complainant was operated upon for Hernia in the Punjab Health Systems Corporation i.e. O.P. No. 4 and remained admitted there for the period from 30.7.2014 to 7.08.2014. As per Term No.1.9.4 of the Guidebook and List of Network Hospitals, Ex.C10, any member under the said scheme was entitled for reimbursement of amount upto Rs.12000/- in case of his operation for Hernia. As per the said Guidebook, the member under the said scheme, can also claim reimbursement of the amount incurred on availing  treatment from any Government hospital situated in the State of Punjab, but as per condition No. 2 mentioned at page No. 16 under the head—‘Reimbursement of the amount incurred on treatment taken in Government/Civil Hospitals’, it is categorically written that at the time of discharge from the hospital, the beneficiary under the said scheme has to pay the bill amount, for the treatment so taken, directly from his own pocket and thereafter, he can claim reimbursement of the said amount from the TPA. Further as per the next condition No.3, in order to get reimbursement of the amount, the member/beneficiary under the said scheme, shall submit his claim form alongwith requisite documents in the office of the District Co-ordinator, within a period of 45 days from the date of his discharge from the hospital. However, the complainant has not placed on record any document to prove that he had submitted his claim for reimbursement of the amount alongwith requisite documents to the concerned Co-ordinator, as per terms & conditions of the said Scheme.

Since he himself had failed to prove that he had lodged the claim alongwith the requisite documents, in the office of the District Co-ordinator, therefore, none of the O.Ps. can be held to be deficient in rendering service, in any manner. With these facts & circumstances, we find no merit in the complaint and accordingly, dismiss the same. The parties are left to bear costs of their own.

 

                    The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed & consigned to the Record Room.

 

ANNOUNCED                                           (NEENA SANDHU)

Dated 09.09.2015                                        PRESIDENT

 

 

                                                                                       (AMRINDER SINGH)

                                                                     MEMBER.