State Consumer Disputes Redressal Commission
Oriental Insurance Company Limited, vs Smt. Janak Rani on 23 May, 2014
2nd Addl. Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH
First Appeal No.785 of 2011
Date of institution : 16.05.2011
Date of Decision : 23.5.2014
Oriental Insurance Company Limited, Branch at Kotkapura, Tehsil and
District Faridkot, through its authorized signatory Chief Regional Manager,
Oriental Insurance Company Limited, Regional Office, SCO No.109-111,
Sector 17-D, Chandigarh.
...Appellant/OP
Versus
1. Smt. Janak Rani wife of Sh. Tilak Raj, Resident of House No. 162,
Mohalla Telian, Near Dr. Gursewak Clinic, Faridkot, Tehsil and
District Faridkot, Punjab.
...Respondent no.1/complainant
2. Alankit Health Care TPA Ltd. (Third Party Administration) through
Corporate Office, Alankit House, 2E/21, Jhandewalan Extension,
New Delhi.
3. Sahara Care House (A Unit of Sahara Services Limited), Tower-A,
Second Floor, DLF Infinity Towers, DLF Phase-II, Gurgaon-122001,
Haryana.
4. Ludhiana Medicity, Near Octroi Post, Ferozepur Road, Ludhiana
through its Authorized Signatory.
...Respondents/OPs
First Appeal against the order
dated 28.02.2011 of the District
Consumer Disputes Redressal
Forum, Faridkot.
First Appeal No.785 of 2011 2
Before:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Harcharan Singh Guram, Member
Argued by:-
For the appellant : Sh.Rahul Sharma, Advocate for
Ms. V.A.Talwar, Advocate
For respondent no.1 : Sh. Ashish Gupta, Advocate
For respondent no.2&4 : Ex-parte
For respondent no.3 : Sh. N.S. Sidhu, Advocate
ORDER
Gurcharan Singh Saran, Presiding Judicial Member This appeal has been filed by the appellant/ Opposite party no.3 (hereinafter referred as 'OP no.3') under Section 15 of the Consumer Protection Act, 1986 (herein after referred to as 'Act') against the order dated 28.02.2011 in consumer complaint no.262 of 2010 passed by the Learned District Consumer Disputes Redressal Forum, Faridkot (hereinafter called as 'District Forum') vide which the complaint of the complainant/respondent no.1 (hereinafter referred to as 'complainant') was partly accepted.
2. Brief facts of the case are that the complainant filed the complaint under the Act against the OPs on the averments that she purchased a Standard Mediclaim Group Cashless Policy from the OPs on 18th August, 2009 and an amount of Rs. 11,029/- was paid to the OP No. 2/respondent no.2 (hereinafter referred to as 'OP no.2'). It was pleaded that OP No. 1 and 2 had issued the cards to the complainant showing her policy No. 211201/48/10/1290 and bearing Health Care TPA Card No. AHOR0100280801 and other requisite information. The policy was valid from 11.9.2009 till 10.9.2010. At the time of purchase of the policy by the complainant it was told to her that the policy was purchased by the First Appeal No.785 of 2011 3 complainant is a cashless health policy from the approved hospitals of the opposite parties alongwith other benefits. It was pleaded that the complainant sustained knee problem in the month of May, 2010 for which she was admitted in Ludhiana Medicity, Ludhiana a Super Specialty Hospital and Trauma Centre where she was diagnosed OA (R+) knee as the complainant has been suffering pain in her right knee and had difficulty in walking in day to day life. She was admitted with the OP No. 4 which was paneled hospital of the opposite parties and they sought permission from the OP No. 1 for giving the cashless treatment to the complainant and on 24.5.2010 a written communication in the form of authorization letter was sent by the OP No. 1 to the OP No. 4 wherein authorization of Rs. 1,00,000/- was granted and it was further mentioned that the remaining amount would be paid after the full information given by the OP No. 4 to OP No. 1 in advance before discharge of the patient and on sending the final bill alongwith discharge summary for final authorization. Thereafter, the complainant was operated upon and before she could be discharged from the hospital on 29.5.2010. The OP No. 1 repudiated the health claim of the complainant in toto without any reason and rhyme. The complainant had to pay Rs. 2,00,000/- to the OP No. 4 from her own pocket as the OP No. 4 had refused to discharge the complainant until the amount of Rs. 2,00,000/- is paid. Thereafter, the complainant approached the OP No. 1 to 3 and requested them to repay the amount of Rs. 2,00,000/- against the policy so purchased by her but they flatly refused to accede to the request of the complainant, which amounts to deficiency in service and unfair trade practice. The complainant filed the complaint seeking directions to the OPs to pay Rs. 2,00,000/- incurred by the complainant on her knee replacement alongwith interest @18% p.a. from the date of payment till realization and to pay Rs. 22,000/- as litigation expenses.
First Appeal No.785 of 2011 4
3. Upon notice the OP no.3 filed written reply by taking preliminary objections that the complainant never purchased any Mediclaim Cashless Policy from the OP no.3. The OP no.3 never issued any policy to the complainant, so the complaint is liable to be dismissed. On merits, it is denied that the complainant had purchased any standard Mediclaim Group Cashless Policy from the OP no.3 on 18.8.2009. The OP no.3 has no contract with the OP No. 1, 2 and 4 for the treatment of the complainant. There is no deficiency or unfair trade practice on the part of the OP no.3. All other allegations were also denied and prayed for dismissal of the complaint.
4. OP No. 4 also filed written statement taking preliminary submissions that no specific allegations with regard to deficiency has made by the complainant against the OP No. 4. The patient was properly examined and treated by the OP No. 4 diligently with due care as per the prescribed standard norms of general practice, so there is no deficiency on the part of the OP no.4. On merits, it was admitted that at the time of admission of the complainant with respondent No. 4 hospital, the respondent No. 1 firstly pre-authorized respondent No. 4 to extend credit facilities up to the extent of Rs. 1 lacs strictly in accordance to coverage under the policy of the patient but at the time of discharge of the patient/complainant the OP No. 1 specifically wrote a letter to the MS of the OP No. 4 stating that the Oriental Insurance Company had withdrawn the TKR facility for all the patients and the earlier grant of Rs. 1 lac was inadvertently allowed. It was admitted that before discharge from the hospital of the OP No. 4 on 29.5.2010 the OP No. 1 repudiated the health claim of the complainant. There was no deficiency or unfair trade practice on the part of OP no.4. All other allegations were also denied and prayed for dismissal of the complaint.
First Appeal No.785 of 2011 5
5. Despite serving of notice through registered post none appeared on behalf of the OP No. 1 and 2, so the OP No. 1 and 2 were proceeded against exparte vide order dated 12.10.2010.
6. Parties were allowed by the District Forum to lead their evidence.
7. In support of his allegations complainant filed her affidavit Ex.C-1, invoice Ex.C-2, Health Care Card Ex.C-3, Membership card Ex.C- 4, letter dated 24.5.2010 Ex.C-5, letter dated 29.5.2010 Ex.C-6, bill dated 29.5.2010 Ex.C-7, bill dated 29.5.2010 Ex.C-8, discharge summary Ex.C-
9. On the other hand, OP filed affidavit of Balbir Singh Sekhon M.D. Ex.R- 1, copy of pre hospitalization form Ex.R-2, copy of membership card Ex.R- 3, copy of letter dated 19.5.2010 Ex.R-4, copy of letter dated 24.5.2010 Ex.R-5, copy of letter dated 24.5.2010 Ex.R-6, copy of letter dated 29.5.2010 Ex.R-7, letter dated 29.5.2010 Ex.R-8 and evidence of the opposite party No. 4 was closed by this Forum vide order dated 11.2.2011. The opposite party No. 3 tendered in evidence affidavit of S.K. Sharma Divisional Manager OIC Ex.R-9.
8. After hearing the learned counsel for the parties and going through the allegations in the complaint written reply filed by the OPs, evidence and documents brought on the record, the complaint filed by the complainant was allowed vide impugned order dated 28.02.2011 with a direction to the opposite parties No. 1 and 3 to disburse the amount of Rs. 2,00,000/- incurred by the complainant on her Knee replacement alongwith compensation to the tune of Rs. 10,000/- on account of mental tension, harassment and litigation expenses totaling Rs. 2,10,000/- to the complainant within the period of one month from the date of the receipt of the copy of this order, failing which the opposite parties No. 1 and 3 shall pay the above mentioned amount of Rs. 2,10,000/- alongwith interest at First Appeal No.785 of 2011 6 the rate of 9% per annum from the date of order till realization of the amount.
9. In the grounds of appeal, it has been stated that the order so passed by the learned District Forum is liable to be set-aside on the grounds that the learned District Forum has failed to consider that the respondent/complainant never purchased any Mediclaim Group Cashless Policy. They had no knowledge if the complainant had paid a sum of Rs. 11,029/- to respondent No. 2, therefore, the complainant was never insured with the appellant. The documents Exs. C-3, C-4 & C-5 has been wrongly interpreted by the learned District Forum. Therefore, there was no deficiency in services on the part of the appellant and the order so passed by the learned District Forum against the appellant be set-aside.
10. In case we go through the pleadings of the parties, the complainant has stated that he had taken the mediclaim policy No. 211201/48/10/1290 having Health Care TPA Card No. AHOR0100280801 coverage from 11.9.2009 to 10.9.2010 and cards were issued by OP Nos. 1 & 2 and this fact has been proved on the record by the complainant by filing her affidavit Ex. C-1, invoice cum acknowledgment slip Ex. C-2 vide which the payment of Rs. 11,029/- was issued by OP No. 2 and Health Care TPA Card was issued to the complainant by OP Nos. 1 & 2 Ex. C-3 and Membership Card issued by Op No. 2 is Ex. C-4 and TPA Health Insurance Authorisation Letter has been issued by OP No. 1 giving a reference of having insurance with OP No. 3 and coverage amount of Rs. 1,00,000/- Ex. C-5. It shows that there was 3rd party agreement between OP Nos. 1 & 2 on the one side and OP No. 3 on the other side. On the basis of that abovesaid documents, cards were issued. The appellants are only relying upon the document Ex. C-6 vide which it has been stated that Oriental Insurance Co. had withdrawn this TKR facility from all the patients without giving notice to the Cardholders and in case it was so then under First Appeal No.785 of 2011 7 what circumstances, authorization letter to the extent of Rs. 1,00,000/- was issued by OP No. 1 in the name of the Ludhiana Medicity having coverage of Rs. 1 lac with OP No. 3/appellant. In case OP Nos. 1 & 2 have taken the premium and issued the Policy Card as well as Membership Card in the name of the complainant and lateron they cannot withdraw it without any reason. However, as per the Authorisation Letter, the coverage was upto is Rs. 1 lac. No document has been placed on the record by the complainant/respondent No. 1 that her coverage was to the extent of Rs. 2,00,000/-, therefore, the findings of the learned District Forum to the extent that coverage has been considered upto Rs. 2,00,000/-, in fact it is upto Rs. 1,00,000/-, otherwise there is no merit in the contention raised by the appellant/OP No. 3 that there was no TPA insurance with the appellant/OP No. 3.
11. In view of the above circumstances, we partly accept the appeal so filed by the appellant and the order so passed by the learned District Forum is modified to the extent that OP Nos. 1 to 3 will pay a sum of Rs. 1,00,000/- alongwith compensation and costs of Rs. 10,000/- and the interest as ordered by the learned District Forum.
12. The arguments in this appeal were heard on 15.05.2014 and the order was reserved. Now the order be communicated to the parties.
13. The appeal could not be decided within the stipulated timeframe due to heavy pendency of court cases.
14. The appellant/OP no.3 has deposited an amount of Rs.25,000/- with this Commission at the time of filing the appeal. Registry is directed to assess the interest on the modified amount as per the order of the District Forum and remit the same to complainant/respondent no.1, by way of a crossed cheque/demand draft after the expiry of 45 days, subject to stay, if any, by the higher Fora/Court. In case the interest amount is above than Rs. 25,000/- then the remaining amount shall be First Appeal No.785 of 2011 8 paid by the appellant/opposite parties No. 1 to 3 to respondent No. 1 within 30 days from the receipt of the copy of the order. If the interest amount is less than Rs. 25,000/-, then the extra amount from Rs. 25,000/- be refunded to the appellant as per the direction in the order dated 25.5.2011.
(Gurcharan Singh Saran) Presiding Judicial Member (H.S.Guram) Member May 23, 2014 as First Appeal No.785 of 2011 9