NATIONAL INSURANCE COMPANY LIMITED Vs. DHARAM SINGH

JUDGEMENT

(1.) THIS is an appeal filed by the OP No. 2 i.e. National Insurance Company Limited against order dated 6.4.2010 passed by District Consumer Disputes Redressal Forum -II, UT, Chandigarh (for short hereinafter to be referred as District Forum) passed in Complaint Case No. 1067 of 2009.

(2.) BRIEFLY stated the facts of the case are that the complainant was insured with Medical Insurance Scheme having policy bearing No. 400104/46/08/85/00000096,Card No. 9011222 45 00020F, Soc Code 2245, with a validity from 1.10.2008 to 30.9.2009 issued under Bhai Ghanhya Sehat Sewa Scheme, by Medsave Healthcare (TPA) Ltd. and National Insurance Co. Ltd. (OP Nos. 1 and 2). The complainant deposited the premium on 8.9.2008 with Machhli Kalan Co -op Agri. Service Society Limited, Machhli Kalan (Ropar) i.e.OP No. 4, which was further forwardedby the said society to the insurer. The complainant suffered acute heart problem on 2.10.2008 and admitted in Dayanand Medical College and Hospital, UNITHero DMC Heart Institute, Ludhiana for treatment. The complainant remained in hospital for his treatment from 2.10.2008 to 10.10.2008 and he was discharged on 10.10.2008. During this period, the complainant's heart was operated in the said hospital and the details of the complete medical record of the hospital was attached with the complaint as Annexure C -2. The complainant incurred an expenditure of Rs. 1,73,935 for his treatment. After his discharge, the complainant lodged his claim with the OPs under their Medical Insurance Scheme for medical expenses. It was submitted by the complainant that cashless medical facility was not afforded by the hospital to the complainant as he was not having his membership card on the date of his admission in the hospital, as the said card was delivered late to the complainant by the insurer itself. The membership card issued by the Insurance Company was valid from 1.10.2008 to 30.9.2009 and was received by the complainant on 14.10.2008 and no policy of the insurance was accompanying this card which was handed over to the complainant. The booklet issued by the OPs "Bhai Kanhaiya Sehat Sewa Scheme Punjab -Guide Book and List of Network Hospital" was given to him at an even later stage. The complainant after his discharge from hospital duly represented his case with the third party Administrator "Medsave" (OP No. 1) acting on behalf of insurer (OP No. 2) and lodged his claim for reimbursement of the amount incurred by him on his treatment. The complainant represented his case to the OPs 1 and 2 for reimbursement of the amount incurred on his treatment under the Medical Insurance Policy but no fruitful result was received from the side of OPs. Ultimately on 7.5.2009 the son of the complainant visited the office of OP No. 1, he was shocked to know that the claim of the complainant was rejected and the reason for rejection of the claim was "Rejected as reimbursement allowed in only Government Hospital". It was further submitted by the complainant that in the guidebook issued by the Insurer, the name of the DMC Hospital duly mentioned at Serial No. 126 in the list of Network Hospitals approved by the insurer for taking treatment under the Medical Insurance Policy. The complainant approached and requested the OPs time and again for the redressal of his grievances but to no avail. The above said act of OPs amounts to deficiency in service and hence, the complaint was filed.

(3.) REPLY was filed by OPs No. 1 and 2 and stated that complainant is not entitled to any reimbursement since all procedures with regard to his medical treatment were carried out in Hero DMC Heart Institute, Ludhiana and they rejected the claim on the ground that for the treatment of Acute Myocardial Infection, the reimbursement was allowed only in Government Hospitals and not in other hospitals where cashless facility was to be given by the empanelled hospitals. The Membership Card also issued to the complainant, which the complainant has not presented the card at the time of his treatment and this is a lapse on the part of complainant and not OP Nos. 1 and 2. They pleaded that though Hero DMC Heart Institute, Ludhiana is on the panel of the OP No. 1 but it was required to give cashless facility to the beneficiaries only if the card was shown to them and as per the scheme, the reimbursement is allowed only in Government Hospitals. They further pleaded that there was no delay on the part of answering OPs in delivery of Membership Card to the complainant and in case, the card could not receive by the complainant, he contacted the OP No. 1 at their Toll Free Number. It was further stated that the complainant could also collect the Policy/ Booklet from the Co -operative Society at any time and pleaded that there was no deficiency in service on their part and prayed for dismissal of the complaint.