State Consumer Disputes Redressal Commission
National Insurance Company Ltd vs Jaswant Singh on 27 July, 2012
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH
First Appeal No. 241 of 2010
Date of institution : 18.2.2010
Date of Decision : 27.7.2012
National Insurance Company Ltd., Regional Office SCO Nos. 332-334, Sector
34-A, Chandigarh through its duly constituted Attorney.
....Appellant.
Versus
1. Jaswant Singh aged about 50 years son of Shri Narinder Singh,
resident of Railway Road, Nangal, Tehsil Nangal, District Ropar.
2. Medsave Health Care (TPA) Limited, SCO No. 121-123, Second Floor,
Sector 34-A, Chandigarh.
...Respondents.
First Appeal against the order dated 22.12.2009 of
the District Consumer Disputes Redressal Forum,
Ropar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Jasbir Singh Gill, Member.
Present:-
For the appellant : Sh. Nitin Gupta, Advocate for
Sh. R.C. Gupta, Advocate
For respondent No.1: Sh. Lakhwinder Singh, Advocate
For respondent No.2: None.
INDERJIT KAUSHIK, PRESIDING MEMBER:
Appellant-National Insurance Company Ltd. filed this appeal against the impugned order dated 22.12.2009 passed by the District Consumer Disputes Redressal Forum, Ropar (hereinafter called, 'the District Forum').
2. Respondent No. 1-Jaswant Singh filed the complaint pleading that he is Member and Shareholder of 'The Nangal Co-operative Truck Operators Goods Carriers Transport Society Ltd., Nangal and Naya Nangal'(hereinafter called 'the Society'), Tehsil Nangal, District Ropar and his membership No. is 1435 and the share certificate is attached. Society insured of its Members including the respondent with the appellant under Bhai Ghanaya Sehat Sewa Scheme and his policy No. was 400104/46/08/85/00000096 valid from 1.10.2008 First Appeal No. 241 of 2010 2 to 30.9.2009. As per this policy, the Members can get the treatment of their ailment from a recognized hospital.
3. Respondent No. 1 fell ill and approached the recognized hospital of the appellant and got the treatment from Kidney Hospital Life Line Medical Institution, 63-64, Waryam Nagar Cool Road, Jalandhar and spent more than Rs. 35,000/- on his treatment and thereafter submitted the claim alongwith documents but the appellant illegally repudiated the claim. This is a clear cut deficiency in service on the part of the appellant and amounts to unfair trade practice. It was prayed that the appellant be directed to pay Rs. 35,000/- as treatment expenses, Rs. 25,000/- as compensation and Rs.8,000/- as cost of litigation alongwith interest @ 18% per annum.
4. In the reply filed on behalf of the appellant and respondent No. 2, preliminary objections were taken that the complaint is not maintainable in the present form and respondent No. 1 has no locus-standi to file the present complaint. Respondent No. 1 is denied by his own act and conduct and there is no deficiency in service on the part of appellant and respondent No. 2. Respondent No. 1 has not come to the District Forum with clean hands and misstated the facts. The true facts are that the Government of Punjab, Ministry of Co-operative Societies floated the Medical Benefit Scheme to the Members of the Cooperative Societies under the scheme known as "Bhai Ghanhya Sehat Sewa Scheme" and the appellant got insured the respondent No. 1 with certain terms. The Bhai Ghanhya Sehat Sewa Scheme is a Nodel agency setup under the Chairmanship of Cooperative Minister, Punjab for operating and executing Bhai Ghanhya Sehat Sewa Scheme for the Members or employees of eligible cooperative societies and other institutions across the State of Punjab and Chandigarh. The scheme was insured by the appellant and Medsave Health Care (TPA) Ltd., the 3rd party Administrator appointed by the appellant to implement the scheme. The claims are admissible as per the terms and conditions of the scheme.
5. Respondent No. 1 has taken a cashless policy in which authorization is sanctioned at the time of hospitalization if the request is received First Appeal No. 241 of 2010 3 by the concerned hospital. In the present case, respondent No. 2 received a cashless request of respondent No. 1 90112401700025Z from Kidney Hospital and Life Line Medical Institute, Jalandhar on 18.5.2009 from the date of admission as 18.5.2009, in response to which the query was raised to provide Society Membership proof. The hospital replied the appellant in which the copy of identity card, bank pass book of the respondent was sent. On the membership identity card the date of the issuance was not mentioned and on bank pass book the date was mentioned as 15.5.2009, which was after the inception of the policy. Respondent No. 1 had not submitted his Society Membership number at the time of the hospitalization and the complaint is not maintainable. The complaint is also bad for non-joinder of necessary parties and is liable to be dismissed. On merits, it was admitted that the Society has got insured its Members under the Bhai Ghanaya Sehat Sewa Scheme valid from 1.10.2008 to 30.9.2009. Other similar pleas were repeated. The allegations of respondent No. 1 were denied and dismissal of the complaint was prayed for.
6. Parties led evidence in support of their respective contentions by way of affidavits and documents.
7. After going through the documents and material placed on file and after hearing the learned counsel for the parties, the learned District Forum observed that the responsibility of issuance of identity card is of TPA of Insurance Company, as such, for any lapse on the part of TPA to mention date of issue, the insured cannot be made to suffer. The identity of respondent no.1 was clearly established by the copy of his identity card which bears the photograph and other particulars and the refusal on the part of the appellant to provide cashless service to respondent no.1 despite receipt of written request from the hospital concerned, clearly amounts to deficiency in service due to which respondent no.1 had to make payment for his treatment in cash. The complaint was allowed and appellant and respondent no.2 were directed to pay a sum of Rs.35,000/- to respondent no.1 on account of reimbursement of amount paid by him along with interest @ 9% p.a. from the date of his admission in the hospital i.e. 15.04.2009 till realization and to pay Rs.1,000/- as costs of litigation. First Appeal No. 241 of 2010 4
8. Aggrieved by the impugned order dated 22.12.2009, the appellant has come up in appeal.
9. We have gone through the pleadings of the parties, perused the record of the learned District Forum and have heard the arguments advanced by the learned counsel for the appellant and respondent no.1.
10. None has appeared on behalf respondent no.2 at the time of arguments.
11. The plea of the appellant in the reply to the complaint as well as in the grounds of appeal is that on the membership identity card, the date of issuance was not mentioned and on the bank passbook, there was a date mentioned as 15.05.2009 and respondent no.1 did not submit the membership number at the time of hospitalization and the claim was not payable. As per the terms and conditions of the policy, the claim was repudiated and the appeal may kindly be accepted and the impugned order may be set aside.
12. On the other hand, submission of the learned counsel for the respondent no.1 was that the impugned order is legal and valid and there is no ground to interfere with the same and the appeal deserves dismissal.
13. We have considered the respective submissions advanced by the learned counsel for the appellant and respondent no.1 and have carefully gone through the entire record placed on file.
14. Ex.C-2 is the membership card, showing membership number of Jaswant Singh as 1435 and Ex.C-3 is the identity card issued by Bhai Ghanhya Sehat Sewa Scheme as per which he was insured under the policy for the period 01.10.2008 to 30.09.2009. Ex.C-5 is the certificate given by the society to establish that Jaswant Singh is member of the Society. Ex.C-6 is the share certificate of respondent Jaswant Singh in the society. All these documents clearly establish that respondent Jaswant Singh was a member of the society who took cashless policy from the appellant. Respondent no.1 was admitted in Kidney Hospital Life Line Medical Institution vide Ex.C-8, Ex.C-9 and OPD Outdoor and Discharge Record is Ex.C-7. Documents Ex.C-10 to Ex.C-18 prove the payments made by respondent no.1 to the said Kidney Hospital. All these First Appeal No. 241 of 2010 5 documents were ignored by the appellant and respondent no.2 just on the ground that the identity car was not bearing the date of issue and passbook has been issued later on, but these are no grounds to deny the payment as the identity card of respondent no.1 and purchasing of cashless policy through the Society is proved and the District Forum has rightly held the appellant and respondent no.2 liable for the same. The order passed by the District Forum is based on evidence and material placed on record and there is no ground to interfere with the same.
15. In view of above discussion, the appeal filed by the appellant is dismissed and the impugned order under appeal dated 22.12.2009 passed by the District Forum is affirmed and upheld. No order as to costs.
16. The appellant had deposited an amount of Rs.19,200/- with this Commission at the time of filing of the appeal. This amount with interest accrued thereon, if any, be remitted by the registry to the respondent no.1/complainant by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellant.
17. Remaining amount as per order of the District Forum shall be paid by the appellant and respondent no.2 to respondent no.1/complainant within 45 days of the receipt of copy of the order.
18. The arguments in this appeal were heard on 24.07.2012 and the order was reserved. Now the order be communicated to the parties.
19. The appeal could not be decided within the stipulated timeframe due to heavy pendency of court cases.
(Inderjit Kaushik) Presiding Member (Jasbir Singh Gill) Member July 27, 2012.
As/-(Gurmeet S)