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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 08.04.2011 by OP no.2 that claim was not admissible. OP nos.1 and 2 prayed for the dismissal of the complaint.

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 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 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.

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 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, when the condition of his son was quite grave and serious. This condition constitutes hardship to the complainant, who is poor and illiterate villager.