Punjab

Sangrur

CC/156/2018

Sukhwinder Kaur - Complainant(s)

Versus

Eden Critical Care Hospital - Opp.Party(s)

Sh.Lovepreet Walia

19 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No.156

 Instituted on:   02.04.2018

                                                                        Decided on:     19.09.2022

 

 

Sukhwinder Kaur wife of Gurmail Singh, resident of Village Sherpur, Tehsil Dhuri, District Sangrur.                                                           

                                                         …. Complainant.     

                                                 Versus

1.             Eden Critical Care Hospital, Plot No.115, Near Elante Mall, Industrial and Business Park, Phase-1, Chandigarh through its Manager.

2.             ICICI Lombard General Insurance Company Limited, Kaula Park, Sangrur through its Branch Manager.

3.             M.D. India Health Care Services (TPA) Pvt. Ltd. Max Pro Info Park, D-38, Phase-I, Industrial Area, Mohali 160056 through its Manager.

             ….Opposite parties. 

 

For complainant         : Shri Nem Kumar, Adv.              

For the OP 1              : Shri A.S.Dullat, Adv.

For the OP 2&3         : Shri G.S.Sibia, Adv.

 

Quorum                                           

JOT NARANJAN SINGH GILL: PRESIDENT

SARITA GARG                          : MEMBER

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT.

1.             Complainant has approached this Forum/Commission alleging inter-alia that husband of the complainant, namely, Shri Gurmail Singh was the member of the Sherpur MP Cass Limited and got the insurance under Bhai Ghanhya Sehat Sewa Scheme and accordingly card bearing number MD-15-BGSSS-00307029-SP was issued under which he and his family members were insured for Rs.1,50,000/- on floater basis.  The case of complainant is that on 16.6.2016 she suffered acute pain in the stomach and was immediately taken to OP number 1, who is the empanelled hospital of OP number 2 and 3. The health card was shown to OP number 1 and the OP number 1 stated that the hospital is not approved for cashless treatment. The complainant remained admitted in the hospital from 16.6.2016 to 21.6.2016.  Further the complainant remained admitted again in the hospital of OP number 1 for the period from 4.7.2016 to 11.7.2016 and spent about Rs.60,000/- on her treatment, but OP number 1 assured that they will send the documents to OP number 3 for release of the claim amount.  The complainant also lodged the claim with the OP number 3, but the claim was not paid.  It is further averred that the complainant earlier filed a complaint before this commission and in that case, OP number 2 and 3 filed the written statement wherein it has been stated that the claim amount of Rs.41,728/- has been released to OP number 1, then the complainant requested OP number  1 to pay the claim amount of Rs.41,728/- to the complainant alongwith interest, but of no avail.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that OP number 1 be directed to release the claim amount of Rs.41,728/- along with interest @ 18% per annum from the date of admission till realization and also for Rs.50,000/- on account of mental harassment and inconvenience and further an amount of Rs.5500/- as litigation expenses.

2.             In reply filed by OP number 1,  it is admitted that the complainant remained admitted twice in the hospital of OP number 1 and bill to the tune of Rs.59,373/- was raised against the complainant and she paid only an amount of Rs.20,000/- and the remaining amount remains outstanding against the complainant. However, it is stated that the complainant is not entitled to get the amount of Rs.41,728/- from the OPs. The other allegations leveled in the complaint have been denied.

3.             In reply filed by OPs number 2 and 3, preliminary objections are taken up on the grounds that the complaint is not maintainable as the complainant has not submitted the required documents. It is stated that OPs have already released the claim amount of Rs.41728/- to the OP number 1 and nothing is due against the OP number 2 and 3.  The other allegations leveled in the complaint have been denied.

4.             The learned counsel for the parties produced their respective evidence before this Commission in the shape of documents and affidavits.

5.             We have gone through the pleadings put in by both the parties along with their supporting documents with their valuable assistance.

6.             A bare perusal of the file reveals that the complainant has spent an amount of Rs.59,373/- on her treatment took by her twice from the hospital of OP number 1 and paid the amount from her own pocket to the hospital authorities i.e. OP number 1.  Further it is on the record that the Ops number 2 and 3 have settled the claim and an amount of Rs.41,728/- has already been paid to the OP number 1 as mentioned in the written reply of OP number 2 and 3 which fact has also been admitted in the reply of OP number 1.  Though case of OP number 1 is that OPs number 2 and 3 have paid the less amount, whereas the total bill was to the tune of Rs.59,373/- and out of which the complainant paid only an amount of Rs.20,000/- and the remaining amount has been recovered from Op number 2 and 3 and as such no amount is payable to the complainant.  Ex.OP-1/1 is the bill of OP number 1 for the Rs.49,248/-.  Though it is stand of OP number 1 that the complainant paid it an amount of Rs.20,000/- in advance and the remaining amount of Rs.39,373/- is still pending with the complainant, but we are unable to accept such a contention of OP number 1, as a bare perusal of copies of bills Ex.OP1/1 and Ex.OP1/5, no amount of Rs.20,000/- is shown having received from the complainant, as such we are unable to accept the document/bills Ex.OP1/1 and Ex.OP1/5 that no amount was paid by the complainant and further to believe the contention of the OP number 1 that the complainant has not paid the full amount to OP number 1.  Further we may reiterate that OPs number 2 and 3 have paid the amount of Rs.41,728/- to the OP number 1, whereas the said amount was required to be paid to the complainant as the complainant has already paid the hospital bill to OP number 1 from her own pocket.  In the circumstances, we find it to be a fit case where the OP number 1 is required to repay the amount of Rs.41,728/- to the complainant as the OP number 1 has recovered the said amount from the complainant as well as from OP number 2 and 3.  

7.             As a result of the above discussion, the present complaint is allowed and opposite party number 1 is directed to pay to the complainant an amount of Rs.41728/- alongwith interest @ 7% per annum from the date of filing of present complaint i.e. 2.4.2018 till its realization in full. Further, the opposite party number 1 is also directed to pay to the complainant an amount of Rs.2000/- as costs for mental tension, agony and harassment and an amount of Rs.2000/- as litigation expenses. Compliance of the order be made within the period of 60 days from the date of the receipt of the copy of this order.

8.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

9.             Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                                Pronounced.

 

                                September 19, 2022.