State Consumer Disputes Redressal Commission
Nic Ltd. vs Harpal Singh on 15 May, 2015
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.1221 of 2011
Date of Institution: 16.08.2011.
Date of Decision: 15.05.2015.
1. National Insurance Co. Ltd. Regional Office-I, SCO no.332-
334, Sector 34-A, Chandigarh, through its Manager Sh. M.S.
Kalsi & others.
2. Med Save Health Care (TPA) Ltd. SCO no.121-123, IInd floor
Sector 34-A, Chandigarh.
.....Appellants/opposite party nos.1 & 2
Versus
1. Harpal Singh S/o Major Singh, R/o Village Bhai Desa, P.O.
Kotli Kalan Tehsil Mansa
.....Respondent no.1/complainant
2. The Additional Registrar (Credit) Co-operative Societies C/o
Registrar, Co-op Societies, Punjab, 17 bays building near main
Post Office Sector 17-C, Chandigarh.
3. The Kotli Kalan Co-operative Agriculture Service Society Ltd.,
Kotli Kalan, Tehsil & District Mansa through its Secretary.
....Respondent nos.2 &3/opposite party nos.3 &4
First appeal against order dated
08.07.2011 passed by the District
Consumer Disputes Redressal
Forum, Mansa.
Quorum:-
Shri J. S. Klar, Presiding Judicial Member.
Shri Vinod Kumar Gupta, Member.
Shri H.S. Guram, Member.
First Appeal No.1221 of 2011 2Present:-
For the appellant : Sh. G.D. Gupta, Advocate
For respondent no.1 : Sh. R.V.S. Chug, Advocate
For respondent no.2 : None
For respondent no.3 : Ex-parte.
.............................................. J. S. KLAR, PRESIDING JUDICIAL MEMBER:-
The appellants (opposite party nos.1 & 2 in the complaint) have directed this appeal against the respondent no.1 of this appeal (the complainant in the complaint) and respondent no.2 & 3 of this appeal (the opposite party nos.3 & 4 in the complaint), challenging order dated 08.07.2011 of District Consumer Disputes Redressal Forum Mansa (in short, "the District Forum"), accepting the complaint of the complainant by directing the OPs to pay the medical expenses Rs.65,959/- incurred by the complainant on the treatment of his son Sukhpreet Singh and to pay Rs.5,000/- as compensation for mental harassment and Rs.2000/- as litigation expenses.
2. The complainant has filed the complaint under Section 12 of the Consumer Protection Act, 1986 (in short "Act") against the OPs on the averments that Punjab Government Cooperative Department launched an insurance scheme for the welfare of members of the cooperative societies registered under cooperative society Act, 1961. Cooperative Department contracted with the National Insurance Company Ltd. and appointed Med Save Health First Appeal No.1221 of 2011 3 Care Ltd (TPA) to implement the insurance scheme named as 'Bhai Ghanhya Sehat Sewa Scheme Punjab'. The CASS Ltd. Kotli Kalan was also covered under this scheme and complainant being its member, paid the premium of insurance amount. The complainant and his family member were insured under the above scheme. Sukhpreet Singh minor son of the complainant was also covered under the above insurance scheme for the period from 01.10.2008 to 03.09.2009. The minor son Sukhpreet Singh of the complainant was admitted in Mediciti Hospital at Ludhiana due to pain in his left knee and left hip-joint and he received treatment there from 03.04.2009 to 07.04.2009. The above Mediciti Hospital Ludhiana is the empanelled hospital and listed at serial no.113 in guide book issued and printed by Med Save India Ltd. The complainant spent Rs.70,000/- on the treatment of his son Sukhpreet Singh. After discharge from the hospital, Harpal Singh complainant informed the Secretary of CASS Kotli Kalan regarding the treatment of his son Sukhpreet Singh. The complainant moved an application alongwith necessary documents regarding the treatment of his son to Med Save Health Care Ltd. and requested to make proper arrangement for Rs.70,000/-, which was incurred on the treatment of Sukhpreet Singh, but no response was received from the Med Save regarding it. The complainant sent reminder on 07.03.2011 to Med Save Health Care Ltd as well as to the Divisional Manager of Insurance Company, but to no effect. It was the duty of Insurance Company to provide financial expenses in First Appeal No.1221 of 2011 4 time, which were incurred on the treatment of Sukhpreet Singh son of the complainant, who was covered under the above said policy. The complainant has, thus, filed the complaint against the OPs.
3. Upon notice, OP nos.1 to 2 appeared and filed joint written reply, raising preliminary objections that complaint is not the consumer of OP nos.1 and 2. The complainant has no cause of action to file the complaint. The complaint is bad for misjoinder and non-joinder of the parties. The complaint is false and frivolous. The complainant has suppressed the material facts from the Consumer Forum. It was averred that OP no.1 clarified about the cashless request of Sukhpreet Singh with date of admission i.e. 04.04.2009 to OP no.2, vide its letter dated 14.03.2011. As the disease mentioned on the pre-authorization letter of hospital was external congenital disease, it is not covered under the insurance policy in hand and cashless was rejected on that basis. Harpal Singh complainant lodged the reimbursement claim at the office of TPA. The file was rejected due to two reasons. First, as per the policy terms and conditions, reimbursement is not allowed from any private network hospital, whereas reimbursement is only allowed from Government hospitals of Punjab and Chandigarh. Second, as per the reimbursement file date of discharge is 7th April 2009 and file received after a long period i.e.29.01.2011. So, the claim could not be permitted. The complainant was intimated, vide letter dated First Appeal No.1221 of 2011 5 08.04.2011 by OP no.2 that claim was not admissible. OP nos.1 and 2 prayed for the dismissal of the complaint.
4. OP no.3 filed its separate written reply and it also contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable, as complainant is not the consumer. No cause of action accrued in favour of the complainant to file the complaint. The complainant duly read and understood all the terms and conditions of the insurance policy and scheme. He undertook to abide by terms and conditions of the insurance scheme, which were contained in the service level agreement executed between Trust and the insurer. The complainant unconditionally agreed that only the courts of Chandigarh should have the jurisdiction. It was further averred that the National Insurance Company was appointed as insurer by the Trust, which appointed OP no.1, as third party Administrator to implement the scheme for cashless treatment. It was further averred that under the scheme, only cashless treatment in the networked hospitals was allowed and all claims were settled by OP nos.1 and 2 not by OP no.3. OP no.3 prayed for the dismissal of the complaint.
5. OP no.4 filed its separate written reply, raising legal objections that the complaint has been filed with ulterior motive to harass the replying OP just to extort money. The complaint was First Appeal No.1221 of 2011 6 contested on merits by OP no.4. OP no.4 prayed for the dismissal of the complainant against it.
6. The complainant tendered in evidence his affidavit Ex.C-1 alongwith documents Ex.C-2 to C-27 and closed the evidence. As against it, OP nos.1 and 2 tendered in evidence affidavit of V.K. Sharma Divisional Manager Ex.OP-2 alongwith documents Ex.OP-3 to OP-8 and copy of letter dated 08.04.2011 Ex.OP-10 and closed the evidence. In rebuttal of evidence, OP no.3 tendered in evidence affidavit of Karam Singh Palne Ex.OP-9 and closed the evidence. OP no.4 tendered in evidence affidavit of Sukhdev Singh Secretary and closed the evidence. On conclusion of evidence and arguments, the District Forum Mansa accepted the complaint of the complainant, as stated above. Dissatisfied with the above order, OP nos.1 & 2, now appellants have preferred this appeal against the same.
7. We have heard learned counsel for the parties and have also examined the record of the case. The first submission raised by counsel for the OP nos.1 and 2, now appellants before us, is that Sukhpreet Singh was suffering from pre-congenital disease, which was not covered under contract of insurance. As such, the order passed by the District Forum is erroneous, much emphasis has been laid on this point by counsel for the appellant during arguments of this case. We have examined the documents on the record including the contract of insurance in this case. The literature of Perthes First Appeal No.1221 of 2011 7 disease is placed on the record of District Forum at page no.169 and 170 on the record : Perthes disease remains enigmatic. Its causes are unknown. Its natural history is unpredictable. Its treatments are controversial. This article hopes to clarify what is known and what is thought about Perthes disease for those in training, who seek a compromise between doing nothing for some good reasons and doing something for no good reason. The article is again written in question and answer format for clarity and to maintain a logical approach and to perhaps encourage the reader to seek more questions before applying more answers. Perthes disease is a condition of unknown etiology. It is, thus, evident from the literature of this disease, that the cause of disease is unknown. Before the use of radiographs, Perthes disease was hidden under the gambit of tuberculousis disease. Early suggestions for a cause included trauma, infection, and rickets. More recently, it has become apparent that there are many factors which contribute to the ultimate degeneration and subsequent regeneration of the femoral head. Most recently, Glueck has implicated a venous thrombolytic mechanism. His group has demonstrated deficiencies in protein C and protein S in patients with Perthes disease, as well as elevated lipoprotein A and hypofibrinolysis. These clotting mechanism disorders have not been confirmed. However, similar femoral head collapse and fragmentation is seen in sickle cell disease and thalassemia as well as leukaemia, lymphoma and idiopathic First Appeal No.1221 of 2011 8 thrombocytopenia. From the perusal of the literature of this disease on the record, we do not find it to be exclusively a pre-congenital disease, so as to exclude it from the ambit of the insurance. The District Forum has rightly examined this point and recorded the finding that his disease is not proved to be pre-congenital disease, as its etiology is still unknown. Consequently, the findings of the District Forum on this point cannot be said to be ramshackle in any manner. The findings of District Forum are sustainable on this point, that this disease is not pre-congenital disease, so as to exclude it from the ambit of the contract of insurance on the record.
8. The next point forcefully submitted before us, is that the complaint of the complainant is barred by time. We find that the period to file the complainant is two years from the date of accrual of cause of action. The complaint cannot said to be barred by time, if it is brought within two years from the date of accrual of cause of action. We find from perusal of record and the pleadings of the parties, that Sukhpreet Singh was discharged on 07.04.2009, after discharge with some delay, the insurance claim was lodged by the complainant. The insurance claim was not finalized and was kept pending. The instant complaint was filed on 06.04.2011 within two years period from the date of discharge summary Ex.C-7 on the record. Consequently, it cannot be said that it is barred by time, as it has been filed within two years from the date of accrual of cause of action.
First Appeal No.1221 of 2011 9
9. The next point strenuously argued by the counsel for the appellant before us is that reimbursement of the claim is admissible only by the Government hospital and not by the private hospital, as per contract of insurance. Much emphasis has been laid on this point by counsel or the appellant. This fact is not disputed that complainant is member of CASS Ltd. Kotli Kalan. He has paid the premium under the insurance policy. His entire family members including his son Sukhpreet Singh are duly covered under the Bhai Ghanhya Sehat Sewa Scheme. The various bills of medicines and treatment record of Sukhpreet Singh, are Ex.C-8 to C-27 on the record establishing that sum of Rs.65,959/- was spent on the treatment. Affidavit Ex.C-1 is also on the record to this effect. Consequently, the complainant lodged the insurance claim on 25.01.2011 and on his sending reminder Ex.C-3 dated 07.03.2011 to OP nos.1 & 2, the complainant received letter dated 08.04.2011 from OP no.2 alongwith an enclosed letter of OP no.1, rejecting the reimbursement claim, on the ground that claim of complainant did not fall within the terms and conditions of the policy. Reimbursement is not allowed from any private hospital, whereas, reimbursement is allowed from Government hospital Punjab and Chandigarh only. On the other hand, the submission of counsel for the complainant, now respondent no.1 in the appeal, is that the terms and condition with the policy were never supplied to the complainant, who is a rustic villager. We find that the complainant was not intimated the terms First Appeal No.1221 of 2011 10 and conditions in detail and hence, he cannot be said to be bound by them. The next submission of counsel for the appellants, is that the claim was lodged after expiry of the insurance policy. We find that the period of reimbursement pertains to that period, when it was enforced. It was the fault of the OPs, that they have not sanctioned the claim. Most illiterate and rustic villagers are not aware about the niceties of law and unless and until, the terms and conditions of the contract of insurance are conveyed to them, they cannot be said to be binding on them. We are in agreement with the finding of the District Forum on this point that it was the duty of empanelled hospitals and insurer to provide cashless treatment to the complainant and they committed default therein. The disease is not pre-congenital, so as to be excluded from the terms and conditions of the policy. The complainant was led from pillar to post due to the act of the OPs. Sukhpreet Singh son of the complainant was admitted in the Mediciti Hospital at Ludhiana on 03.04.2009 and remained under treatment for 3-4 days and he was put to "Varus derotational Osteotomy and fixation with 6 hole RC place with 11/2 spen cast application under GA". It cannot be expected from a patient to go for cashless treatment by forcing the hospital authorities, leaving aside his own critical health condition, it is so evident from Ex.C-1, the affidavit of complainant on the record. We do not find that under such circumstances, the complainant would have insisted upon the cashless treatment from Mediciti Hospital, First Appeal No.1221 of 2011 11 when the condition of his son was quite grave and serious. This condition constitutes hardship to the complainant, who is poor and illiterate villager.
10. The Consumer Protection Act is a consumer oriented legislation meant to protect the interests of the consumer. Mostly consumers are illiterate and laymen and they are not aware about the nuances of procedure. The complainant spent money on the treatment of his son Sukhpreet Singh and it is proved on the record. The OP nos. 1 and 2 are not entitled to reject the claim of the complainant on technical matters. The order of District Forum is not found to be suffering from any illegality in our view and it is rather an equitable order. We affirm the order of the District Forum Mansa dated 08.07.2011, under challenge in this appeal.
11. As a result of our above discussions, we find no merit in the appeal of the appellants and the same is hereby dismissed.
12. The appellant had deposited the amount of Rs.25,000/- with this Commission at the time of filing the appeal. The above said amount with interest, which accrued thereupon, if any, be remitted by the registry to the complainant, now respondent no.1, by way of a crossed cheque/demand draft after the expiry of 45 days. Remaining amount shall be paid by OP nos.1 & 2 to the complainant, as per the order of the District Forum within 45 days from the date of receipt of certified copy of this order.
First Appeal No.1221 of 2011 12
13. Arguments in this appeal were heard on 11.05.2015 and the order was reserved. Now the order be communicated to the parties. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR) PRESIDING JUDICIAL MEMBER (VINOD KUMAR GUPTA) MEMBER (H.S. GURAM) MEMBER May 15, 2015.
(MM)