Complainant Janak Raj has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to honour his claim and to make the payment of amount spent by him on his treatment in terms of Insurance Policy alongwith interest @ 18% P.A. from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation and above mentioned expenses being incurred by him  besides the amount in question on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he obtained Insurance Policy from the opposite parties bearing Policy No.231102/48/2016/769 valid from 01.01.2016 to 31.12.2016.  All of sudden he fell ill and remained under treatment from PGI Chandigarh and remained admitted on 25.10.2016. He spent about Rs.17,007/- on his treatment. Thereafter, he submitted his claim for the reimbursement of the amount to the opposite party, but the opposite party no.1 had repudiated the claim vide letter dated 24.04.2017 on false and frivolous grounds, whereas he is legally entitled to claim to the amount spent by him on his treatment.  Act of the opposite parties of repudiating claim is illegal, null and void. He also served registered AD notice dated 26.03.2019 to the opposite parties but all in vain. Thus, there is deficiency in service and unfair trade practice on the part of the opposite parties who did not pay insured amount to him.

 3.          Notice of the complaint was issued to the opposite parties.  Opposite party no.1 and  2 appeared through their counsel and filed their written reply taking the preliminary objections that the present complaint  of the complainant  is not maintainable  as there is no insurance contract exits between the complainant and opposite parties, hence there is not any contractual liability of the opposite parties against the complainant under the Consumer Protection Act. On merits, it was denied that the complainant fell ill and the remained under treatment from PGI Chandigarh. It was also denied that the complainant remained admitted in this hospital on 25.10.2016. The complainant spent Rs.17,007/- on his treatment. Actually the complainant has not submitted his claim for reimbursement alongwith the requisite documents to the MD India Health Insurance TPA Pvt.Ltd. Mohali, within stipulated period of 30 days from the date of discharge from the Hospital, which is the mandatory condition under the terms and conditions of the Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEHIS). Hence, the MD India Health Insurance TPA Pvt.Ltd., has rightly not entertained the claim under the terms and conditions of the PGEHIS. Hence, the opposite party Insurance Company is not liable to pay the claim under the provisions of the scheme. It was submitted that the refusal of the opposite parties is still justified. The opposite party no.2 MD India Health Insurance TPA Private Limited has not entertained the claim of the complainant under the provisions of the scheme, hence, there is no deficiency in service on the part of the opposite parties.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.          As per report of Ahlmad R.C. of opposite party no.3 had not been received back. Case called several times, but none had appeared on behalf of opposite party no.3. Hence, the opposite party no.3 was ordered to be proceeded against exparte vide order dated 16.7.2019.

5.       Alongwith the complaint, complainant has filed his own affidavit Ex.CW-1 and copies of documents Ex.C-1 to Ex.C-22.

6.      Alongwith the written statement ld.counsel for the opposite party no.1 and 2 filed affidavit of Sh.Harbans Lal, Divisional Manager, O.I.C. Ltd. Pathankot Ex.OP-1,2/A alongwith documents Ex.OP-1,2/1 to Ex.OP-1,2/3.

7.          Rejoinder filed by the complainant.

8.         Written arguments have been filed by complainant.

9.          We have carefully gone through the pleadings of counsel for the both parties; written arguments as well as oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the complainant for the purposes of adjudication of the present complaint.

10.       After hearing both the parties, we find merit in the case. Opposite party had wrongfully withheld the genuine claim of the complainant.

11.     The complainant had duly submitted the claim. Opposite party was bound to settle the claim as per terms and conditions laid down in the service conditions of the parent department of the complainant and also read in conjunction with the memorandum agreed upon with Oriental Insurance Co. Ltd. and M.D. Health Insurance TPA Pvt.Ltd..

12.    Claim form Ex.C-15 amounting to Rs.17,007/- is for treatment of Sh.Janak Raj complainant at PGI Chandigarh. The very fact that the complainant sought the treatment at PGI Chandigarh an Institute of high repute clearly underlines the fact that the treatment sought was urgent and genuine. Opposite party no.1 and 2 had no reason to doubt to genuineness of the claim.

13.    We are of the considered opinion that the genuine complaint of the  complainant be settled forthwith by opposite party no.1 and 2 as per the claimed amount Ex.C-15 alongwith interest of 7% p.a on the claimed amount from the date of submission of the bill, till the actual realization.   Further opposite party no.1 and 2 is directed to pay an additional sum of Rs.10,000/- on account of litigation expenses and harassment of the complainant due to delay in settling the claim. Compliance of the order be made within 45 days from the date of receipt of the order.

14.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

15.    Copy of the order be communicated to the parties free of charges. After compliance, file be consigned.                                                                                                                                                         

            (Naveen Puri)

                                                                            President   

Announced:                                                   (R.S.Sukhija)

May 05, 2022                                                       Member

*MK*