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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Shri J.S. Klar, Presiding Judicial Member and Shri J.S. Gill, Member
PLATINUM NURSING HOME PVT. LTD. - Appellant
Versus
GURWINDER KAUR - Respondent
First Appeal No.1506 of 2012
Decided on : 19-05-2016
Consumer Protection Act - Medical Treatment - Section 12 of the Consumer Protection Act, 1986 - [Section 12]
Fact of the Case:
The complainant filed a complaint against various parties under the Consumer Protection Act, alleging that she received unauthorized medical treatment and was not reimbursed for the expenses incurred.
Finding of the Court:
The District Forum accepted the complaint against one of the parties, but the appellate court reversed the decision, stating that the hospital where the complainant received treatment was not authorized under the scheme, and therefore, the complainant was not entitled to reimbursement.
Issues: Unauthorized medical treatment, reimbursement of expenses, liability of the parties under the Consumer Protection Act.
Ratio Decidendi: The complainant was not entitled to reimbursement as the hospital where she received treatment was not authorized under the scheme.
Final Decision: The appeal was accepted, the order of the District Forum was set aside, and the complaint of the complainant was dismissed.
ORDER
Mr. J.S. Klar, Presiding Judicial Member - The appellant has directed this appeal against the respondents of this appeal, challenging order dated 05.10.2012 of the District Consumer Disputes Redressal Forum, Sri Muktsar Sahib (in short the "District Forum"), vide which, the complaint of the complainant was accepted against OP No. 5 by directing him to pay the amount of Rs. 30,000/- to the complainant and dismissed qua other OPs. The appellant is opposite No. 5 in the complaint, respondent No. 1 of this appeal is complainant in the complaint and respondents No. 2-6 are the opposite parties No. 1-4 & 6 in the complaint and they be referred as such hereinafter for the sake of convenience.
2. The complainant has filed the complaint under Section 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that OP no.2, Bhai Kanhaya Sehat Sewa Scheme launched a scheme, which was to be regulated and operated by OP No. 1, the MD India Health Care Services (TPA) Private Limited. The complainant was policy holder, vide policy no.MD15-BGSSS-00041403-SP under above scheme. OP No. 3 is the society and complainant is the member thereof. OP No. 4 has tie up for insurance purpose of the policy with OPs No. 1 and 2 and insured the persons at their instructions. OPs No. 5 and 6 are the authorised hospitals under the above scheme for treating the various patients/insurance holders. The complainant developed some physical problem during the currency of the policy and contacted Dr. Sanjeev Chugh and she was admitted in the Hospital of OP No. 6. The complainant was illiterate and was unaware about the name of the hospitals. Dr. Sanjeev Chugh showed her that his hospital was authorised under the scheme and she would be entitled for medical treatment thereunder. She got treatment from 27.07.2011 to 29.07.2011 from Dr. Sanjeev Chugh. After treatment, it was told to the complainant by Dr. Sanjeev Chugh that request of cashless treatment was not accepted by the higher authorities of OPs. No. 1 and 2 and hence she should pay the amount of medical treatment to him. The complainant would get the medical reimbursement of the bills from OPs. The complainant got her treatment on the assurance of Dr. Sanjeev Chugh and reimbursement certificate was also issued to her by above doctor, but the same was of Platinum Hospital, but actually SSBK Multispeciality Hospital Tibbi Sahib Road Muktsar was the empanelled hospital for the cashless treatment of the insurers. The above said both hospitals are being run by Dr. Sanjeev Chugh and complainant got her medical treatment from Dr. Sanjeev Chugh under good faith. The medical slips were issued in the name of Platinum Hospital and due to this reason, OP no.5 was wrongly mentioned whereas it was actually SSBK Multispeciality Hospital. The complainant incurred total expenditure approximately Rs. 25,000/- on her treatment including medicines etc. The complainant submitted the claim for reimbursement with other OPs, but they did not reimburse it. The OPs put off the matter under the lame pretexts even the complainant moved an application to the OPs on 13.09.2011 in this regard, but till date OPs have not paid even a single rupee from the amount in question to the complainant. The complainant has, thus, prayed that OPs be directed to pay Rs. 24,520/- for medical treatment, besides to pay Rs. 50,000/- as compensation for mental harassment.
3. OP No. 1 appeared and filed written reply by averring that complaint is not maintainable as Platinum Hospital OP No. 5 was not the authorised hospital, as mentioned in the guide book. The cashless treatment was available only in approved hospitals. Any deficiency in service was denied by OP No. 1. The complaint is to be alleged false and frivolous. It was further averred that no claim has been received by OP no.1 till date. The complainant herself violated the terms and condition of policy and as such she is not entitled for any claim from OP no.1. OP
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