State Consumer Disputes Redressal Commission
Harbhagwan Ram vs Manading Director India Health Care ... on 15 September, 2015
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.1103 of 2014
Date of institution : 06.08.2014
Date of decision : 15.09.2015
Harbhagwan Ram son of Jodha Ram, resident of # 77, Village
Saide Ke Mohank Tehsil Guruhar Sahai, District Ferozepur.
.......Appellant/Complainant.
Versus
1. Managing Director, India Health Care Services (TPA) Private
Limited Maxpro, Info Park, D-38, Industrial Area, Phase-I,
Mohali through its authorized signatory.
2. ICICI Lombard, Health Insurance ICICI Bank Tower, Plot no. 12,
Fianncial District, Nanakram Guda, Gachibowli, Hyderabad
(Andhra Pradesh) through its authorized signatory.
3. The Mohan Ke Hithar, CASS Limited, through its Authorized
Signatory Village Mohan Ke Hithar, Tehsil Guruhar Sahai,
District Ferozepur.
4. The Deputy Registrar, Co-operative Societies, Punjab,
Ferozepur District Ferozepur.
5. Amandeep Hospital, Model Town, G.T.Road, Amritsar, through
its Managing Director/authorized signatory.
........Respondents/Opposite Parties
First Appeal against the order dated
25.06.2014 passed by the District Consumer
Disputes Redressal Forum, Ferozepur.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Smt. Surinder Pal Kaur, Member
Present:-
For the appellant :Sh. Pervez Chugh, Advocate
For respondent No.1&2:Sh. Sandeep Suri, Advocate
For respondent No.3 :Sh.Mohan Lal, Secretary
For respondent No.4 :Ex-parte
F.A. No. 1103 of 2014 2
For respondent No.5 :Sh. SandeepKhunger, Advocate
MRS. SURINDER PAL KAUR, Member
ORDER
The appellant/complainant(hereinafter referred as the "complainant") has filed the present appeal against the order dated 25.06.2014 passed by District Consumer Disputes Redressal Forum, Ferozepur (hereinafter referred as "District Forum") in Consumer Complaint No.595 dated 13.12.2013 vide which complaint filed by the complainant was dismissed on the ground that there was no deficiency in services on the part of the OPs.
2. A consumer complaint was filed by the complainant under Section 12 of the Consumer Protection Act 1986(in short `the Act') against the Respondents/Opposite Parties (hereinafter referred as "Ops") on the averment that complainant was a member of Opposite Party No.3 and along with other family members he was covered under Bhai Ghanya Sehat Sewa Scheme for cashless hospitalization. OP No 3 also issued card no MD 15-BGSSS-00182198-S which was for the year 2012-2013. During subsistence of the policy, complainant met with an accident on 13.09.2013 and suffered injuries on the right leg. He was admitted in Amandeep Hospital i.e OP No.5 from14.09.2013 to 25.09.2013 and again on 05.11.2013 to 13.11.2013. He spent an amount of Rs.1,67,326/- on his treatment. Complainant was insured under the Bhai Ghanhya Sehat Sewa Scheme; being the member of the same, he was entitled for cashless facility. OP No.5 assured that they will provide cashless facility to the complainant as their hospital was on the panel of BGSSS, but lateron they charged the entire amount from the complainant. He approached OP No.1 & 2 for reimbursement of the amount spent on his treatment but they refused to release the amount. The above said act of F.A. No. 1103 of 2014 3 the OPs amounted to deficiency in services and unfair trade practices on their part. Hence, he filed the complaint before the District Forum seeking the following directions to OPs:-
(i) to pay an amount of Rs. 1,67,326/- spent on his treatment + Rs.10,000/- for transportation charges;
(ii) to pay Rs.50,000/- as compensation for mental tension and harassment;
(iii) to pay Rs. 11,000/- as litigation costs.
3. Complaint was contested by the OPs. OP No.1 & 2 filed their written reply taking the preliminary objections that complainant was not covered under the policy as he took the treatment from Amandeep Hospital, Amritsar, which was not empanelled hospital. As per clause 1.9.11 the treatment taken in non net work hospital was not covered under the Scheme. But the complainant took the treatment from non- empanelled hospital, as such, he was not entitled to get any claim. Complaint was false and frivolous in nature, therefore, liable to be dismissed under Section 26 of the Act. Complainant had not come with clean hands and had suppressed the material facts from the Forum and that the contract of the Insurance between the OPs and complainant was governed by its Policy terms and conditions. On merits, it was submitted that BGSSS was being run by Government of Punjab for the member of various eligible rural Cooperative Societies of Punjab to provide the medical health insurance. Under the said scheme M.D India Private Limited i.e. OP No.1 was the TPA (Third Party Administrator) for processing the claim. Under the said scheme OP No.2 i.e. ICICI Lombard General Insurance Company issued the group Health Insurance Policy (Floater) in the name of The Bhai Ghanhya valid for the period 20.11.2012 to 19.11.2013. As per the said scheme registered member of F.A. No. 1103 of 2014 4 the society who obtained the insurance policy and paid the requisite premium was entitled to get the benefit under the policy. The total insurance cover of the said policy was Rs. 1,50,000/- per family on floater basis. The guide book containing all the terms and conditions of the policy, the details of network hospital alongwith Health Card were duly supplied to every insured member by MD. India Health Care Services Ltd. It is totally wrong that under the scheme entire employees, account holder and their entire family are covered. There was no deficiency in services and unfair trade practices on their part and they prayed for dismissal of the complaint with costs.
4. OP No.5 filed the separate written reply taking the preliminary objections that OP No.5 i.e. hospital was not empanelled hospital under the Bhai Ghanaya Sehat Sewa Scheme and this fact was told to the complainant and their family members. It was also informed that treatment in hospital would be chargeable and family members of the complainant had agreed for that. Previously, their hospital was an empanelled with Bhai Ghanaya Sehat Sewa Scheme but that term had expired on 30.09.2009 and after that, they never signed any MOU (Memorandum of Understanding) with OP No.1. However, by mistake the name of this OP continued to exist in the list of empanelled hospitals of OP No.1 upto 2010. Vide letter Ref: Mum/32886 dated 07.08.2010 issued by OP No.1 their hospital's name was removed from the list of empanelled hospitals and public notice to that effect was also published in "Punjabi Tribune" dated 06.05.2010. On merits, it was pleaded that at the time of taking the treatment of the complainant this OP was not the member of Bhai Kanhaya Sehat Sewa Scheme. Therefore, they are not liable to return the amount of treatment. There was no deficiency on their part and prayed for dismissal of the complaint.
F.A. No. 1103 of 2014 5
5. The parties were allowed by the learned District Forum to lead their evidence.
6. In support of the averments, the complainant had tendered into evidence his affidavit Ex C-1 along with other documents Ex.C-2 to Ex.C- 14 and closed his evidence. On other hand the OP No.1 & 2 had tendered into evidence affidavit of Meenu Sharma Authorised Signatory Of ICICI Lombard General Insurance Company as Ex.OP1 & 2/1 and Insurance Policy as Ex.OP1 & 2/2 and closed evidence. OP No.5 had also tendered into evidence affidavit of Dr Amandeep Kaur as Ex.OP-5/1 along with documents Ex.OP-5/2 to Ex OP5/4 and his evidence..
7. After going through the allegations alleged in the complaint, written reply filed by the OP No.1, 2 & 5 evidence and documents brought on the record, the learned District Forum dismissed the appeal as referred above.
8. Aggrieved against the order passed by the Ld. District Forum, the appellant/complainant has preferred the present appeal.
9. We have heard the learned counsel for both the parties and have gone through the evidence and documents placed on the record.
10. In the grounds of appeal complainant alleged that the name of the OP No.5 figured in the booklet issued by OP No.3 & 4 for cashless hospitalization under BGSSS, and that fact was admitted by OPs. Complainant had enquired about cashless facility in the said hospital and OP No 5 duly assured the complainant that they will provide the cashless facility as their hospital is empanelled hospital under BGSSS. But after treatment OP No.5 denied cashless facility and charged full amount from complainant. The Learned District Forum has not appreciated these facts and wrongly dismissed the complaint. Therefore, appeal be accepted. F.A. No. 1103 of 2014 6
11. Whereas on the other hand counsel for OPs have argued that District Forum has passed the correct order after appreciating the evidence on the record. Complainant had violated the policy terms and conditions. Therefore, complaint was rightly dismissed. The order be upheld.
12. OPs proved on record affidavit of Manu Sharma authorized signatory of ICICI Lombard General Insurance Company as Ex.OP-1 in which he deposed that Amandeep Hospital was not empanelled hospital and the treatment of the complainant was not covered under the policy. OPs have placed on record booklet of BSSS which was issued by ICICI Lombard Health Insurance in the year 2012-2013 as Ex.OP2/3 in which Amandeep Hospital was not listed. Further, affidavit of Dr. Amandeep Kaur, was placed on record as Ex.OP5/A in which she deposed that previously, hospital was empanelled with BGSSS but term had expired on 30.09.2009, thereafter they never signed any MOU with OP No.1. However, by mistake name of their hospital was listed as empanelled hospitals of OP No.1 w.e.f. 01.02.2010. Vide letter reference no. MUM 32886 dated 07.08.2010 OP No.1 informed that name of their hospital was removed from the list of empanelled hospitals and public notice in this regard was also published in the "Punjabi Tribune" dated 06.05.2010. A perusal of letter dated 17.08.2010(EXOP5/4) issued by ICICI Lombard General Insurance to Amandeep Hospital it has been mentioned that a public notice regarding the removal of name from the list of network hospital has been given by the M.D India Health Care Private Limited TPA in newspaper "Punjabi Tribune" on 06.05.2010,
13. It was alleged by the complainant that the name of the OP No.5 figured in the booklet issued by OP No.3 & 4 for cashless hospitalization under BGSSS, and that fact was admitted by OPs. Whereas, OPs proved on record booklet of ICICI Lombard General Health Insurance for the relevant period. In this booklet, hospital of OP No.5 was not listed as empanelled F.A. No. 1103 of 2014 7 Hospital. However, the complainant has placed on record Guide book of Network hospitals of Med Save India in which Amandeep Hospital was listed as empanelled hospital but Med save India is not a party to the complaint. It is not clear to which year this guide book pertains to. The case of the complainant was against the ICICI Lombard Health Insurance, as such, the Guide book of the Med Save India cannot be relied upon in the present case. When hospital of OP No.5 was not the empanelled hospital, then complainant was not entitled for treatment from the hospital as per clause 1.9.11. Accordingly, the treatment taken in non network hospital was not covered under the Scheme. The District Forum correctly appreciated the terms and conditions of the policy and rightly dismissed the complaint on the ground that the complainant had not taken the treatment from empanelled hospital and violated the terms and conditions of the policy. Therefore, claim of the complainant was rightly repudiated by the OPs. We do not see any illegality in the findings so recorded by the District Forum and affirm the same.
14. In view of the above discussion, there is no merit in the appeal and it is hereby dismissed.
15. The arguments in this appeal were heard on 02.09.2015 and the order was reserved. Now, the order be communicated to the parties as per rules.
16. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(GURCHARAN SINGH SARAN)
Presiding Judicial Member
(SURINDER PAL KAUR)
September 15, 2015 MEMBER
SK
F.A. No. 1103 of 2014 8