Punjab

StateCommission

A/313/2018

Oriental Insurance Company Ltd. - Complainant(s)

Versus

Deep Singh - Opp.Party(s)

Ram Avtar

05 Dec 2018

ORDER

                                                               FIRST ADDITIONAL BENCH

 

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,   PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH

 

                   First Appeal No.313 of 2018

 

                                                          Date of Institution   : 22.05.2018             

                                                            Order Reserved on : 30.11.2018

                                                          Date of Decision     : 05.12.2018

 

Oriental Insurance Company Limited, Oriental House, A-25/27, Asaf Ali Road, New Delhi, R.O 109-110-111, Surendra Building 17-D, Chandigarh-160017 through its authorized signatory.

 

Now through Manager, Oriental Insurance Company Ltd., Regional Office, Surendra Building, SCO No. 109-111, Sector 17-D, Chandigarh.

 

                                                            ..Appellant/Opposite party no.3           

                   Versus

 

1.      Deep Singh son of Narayan Singh, resident of House No. 133, Haji Building-1, Ferozepur City.

 

                                                          ..Respondent no.1/Complainant

 

2.      Punjab Government through Secretary, Health Department, Punjab Chandigarh.

 

3.      Managing Director, Punjab Government Employee and Pensioners Health Insurance Scheme, Ist Floor, M.D India TPA D-38, Max Pro Info Park India, Phase-1, Mohali Punjab Contact no. 0172-2274024

 

                             ..Respondents no.2 & 3/Opposite parties no.1 &2

 

4.      M.D India TPA, D-38, Max Pro Info Park India, Phase-1, Mohali through its authorized signatory.

 

                                … Respondent no.4/Opposite party no.4

 

5.      Fortis Hospital, Amritsar through its Director/Managing Director/Authorized Signatory.

 

                                                                   …Respondent no.5

First Appeal against order dated 23.02.2018 passed by the District Consumer Disputes Redressal Forum,  Ferozepur.

 

Quorum:-

          Shri J. S. Klar, Presiding Judicial Member

Present:-

          For the appellant                     :  Sh.Ram Avtar, Advocate

          For the respondent no.1         :  Sh.K.S Brar, Advocate

          For the respondents no.3,4&5 :  Ex-parte vide order dated

                                                                07.09.2018 passed by this

                                                                Commission.

          For the respondent no.2         :   None.

         

. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

                    Challenge in this appeal by appellant is to order dated 23.02.2018 of District Consumer Disputes Redressal Forum Ferozepur, directing appellant and respondent no. 4 of this appeal to pay remaining amount of Rs.1,36,863/- towards expenses to respondent no.1 of this appeal with interest @ 9% per annum from the date of filing of the complaint till its realization, besides composite amount of compensation of Rs.3000/-. Respondent no.1 of this appeal is complainant in the complaint  and respondents no.2 and 3 are opposite parties no.1 and 2 before District Forum, respondent no.4 of this appeal is opposite party no.4 therein and respondent no.5 of this appeal is not a party in the complaint and they be referred as such hereinafter for the sake of convenience.

2.                The complainant has filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against OPs on the averments that he has been an employee of the Punjab government and registered member of Punjab Government Employee and Pensioners Health Insurance Scheme  launched by OPs no.2 to 4. Being retired employee of the Punjab government, he was issued Card No.MD15-07089460916  with policy period from 01.01.2016 to 31.12.2016 GPF/PPO number 7803PB and remained entitled to get all the benefits for cashless scheme from OPs. He was heart patient being old aged and was admitted in Fortis Hospital Chandigarh Road Ludhiana for heart surgery for change of ball in his heart under the above said insurance scheme. All expenses were to be incurred by OPs and Punjab Government under Punjab Government Employee and Pensioners Health Insurance Scheme. His treatment was successfully and satisfactory conducted by the doctors at Fortis Hospital Ludhiana and bill expenses of Rs.3,01,888/-  were raised by the hospital along with medicines of Rs.35/40,000/-  from him.  OPs paid him Rs.1,12,224/- only whereas he had to pay the balance amount of Rs.1,89,663/- from his own pocket to the hospital. He approached OPs many time to pay the balance amount of Rs.1,89,663/-  to him, but to no effect.  He served a legal notice dated 16.12.2016 upon OPs no.1 and 2 through his counsel, but to no effect. He has filed complaint directing OPs to pay the balance amount of Rs.1,89,663/- towards his heart surgery with interest @ 18% per annum from September 2016 and further prayed for a sum of Rs.50,000/- as compensation for mental harassment and Rs.33,000/- as costs of litigation.

3.                Upon notice, OPs no.1 and 2 appeared and filed written reply  and contested the complaint of the complainant by raising preliminary objections that present complaint is not maintainable in the present form. The complaint is false, frivolous and vexatious. The complainant has suppressed the material facts from the Forum. On merits, it was admitted by OPs that Government of Punjab has formed a scheme for medical treatment of the employees and pensioners and complainant being retired employee is entitled to the benefits thereof. It was further averred that the complainant has not followed the proper procedure as enshrined in the Act. Any deficiency in service was denied by OPs no.1 and 2 and they prayed for dismissal of the complaint.

4.                OPs no.3 and 4 appeared and filed their separate written reply and contested the complaint of the complainant by raising legal objections that complaint is not maintainable. The complainant does not fall under the definition of the ‘Consumer Protection Act’. There is no insurance contract existing  between the complainant and the insurance company. There is no consideration/premium taken from the complainant under this scheme.  The Punjab Government has sponsored this scheme for its employees and pensioners and no consideration is deducted from their salary/pension as premium. OPs no.3 and 4 controverted  the other averments of the complainant even on merits and they prayed for dismissal of the complaint.

5.                The complainant tendered in evidence his affidavit  Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-8 and closed the evidence. As against it; OPs no.1 and 2 tendered in evidence affidavit of Dr. Renu Singla Deputy Medical Commissioner Punjab Health System Corporation   along with copies of documents Ex.OP-1&2/1 to Ex.OP-1&2/4 and closed the evidence. OPs no.3 and 4 tendered in evidence  affidavit of Ashwani Kumar Divisional Manager Oriental Insurance Company as Ex.OP-3&4/1 along with copies of documents Ex.OP-3&4/2 to Ex.OP-3&4/7 and closed the evidence.  On conclusion of evidence and arguments, the District Consumer Forum Feorzepur accepted the complaint of the  complainant by virtue of order dated 23.02.2018. Aggrieved by above order of the District Forum Ferozepur, opposite party no.3 now appellant, has carried this appeal against the same.

6.                We have heard learned counsel for the parties and have also examined the record of the case.

7.                The submission of counsel for the respondent no.1 in this appeal is that complainant was insured under the above scheme launched by OPs no.3 and 4 being retired employee of the Punjab Government. He incurred the expenses of Rs.3,01,888/-  on his treatment of cardiac surgery. It has further transpired that insurance company has only paid Rs.1,12,224/- to him and remaining amount of Rs.1,89,663/- was withheld without any valid reason. The version of the complainant as unfolded through his counsel is that OPs withheld the balance amount of complainant, which is deficient in service on their part. The counsel for the appellants countered the version of the complainant by contending that complainant had the remedy to approach District Authority in the light of notification issued by Punjab Government dated 21.09.2016 in the State Level Grievance Redressal Committee (SGRC) under Punjab Government Employees & Pensioners Health Insurance Scheme (PGEPHIS)  for redressalof the grievance.  He submitted that complaint in the presence of above constitution of the committee is not tenable. There is no dispute of this fact in this case that complainant remained employee of the Punjab Government  and has since retired therefrom. Punjab Government launched the scheme in collaboration with OPs no.3 and 4 called Punjab Government Employees and Pensioners Health Insurance Scheme for providing cashless treatment to its serving and retired employees. The complainant’s version is that he incurred Rs.3,01,888/-  on his above cardiac surgery, whereas OPs only paid him the amount of Rs.1,12,224/- out of the same. He clamoured for the payment of balance amount to him to supplement the expenses incurred by him on his above treatment.

8.                The only point for controversy in this case canvassed before this Commission in this appeal is whether complainant is entitled to actual expenses under this cashless insurance scheme launched by Punjab Government in collaboration with OPs no.3 and 4 for the benefit of serving and retired employees. The submission of OPs is that under cashless scheme as per PGEPHIS  rates for his treatment at Fortis Hospital, the complainant is entitled to Rs.1,12,224/-only.  He is not entitled to any other amount beyond the scheduled rates as above. The claim settlement letter Ex.OP-3&4/4 is on the record. As per this letter, OPs made the payment of Rs.1,65,024/-  to complainant, but have not paid the remaining amounts of expenses. The complainant spent Rs.3,01,888/- for his treatment, which he actually paid to hospital authorities, but OPs have not given the breakup of settlement claim. We find from perusal of record that insurance policy is a contract entered into between the parties. OPs placed strong reliance upon Annexure XX namely PGEPHIS Schedule of Rates, which are applicable to indoor patients in the hospitals by the authorities. Different rates have been prescribed  for  the purpose of treatment in it. These rates have been fixed by the Government of Punjab as per approved rates for various diseases. Testing on the touchstone of PGEPHIS schedule rates, claim of the complainant, when considered by OPs was found to the extent of Rs.1,12,224/- as admissible under above PGEPHIS scheduled rates. The complainant seeks actual expenses from OPs under this cashless insurance scheme and cashless reimbursement whereunder was to the extent of Rs.3 lac only and not beyond  it. On the other hand, submission of appellants is that rates as approved have to be given in the cashless treatment to the complainant and no amount beyond the permissible rates fixed by Government can be awarded. We are of this view that PGEPHIS schedule rates contained in Annexure XX on the record, details of rates per item are  approved by the government authorities. No amount in excess of them is permissible. The District Forum has overlooked these PGEPHIS schedule rates, while awarding the balance amount to complainant.  We rely upon above-referred rates of the government for providing different  treatments under different ailments in the cashless insurance policy and order of the District Forum in accepting the complaint is not sustainable in the eyes of law. There is no question of unawareness of the complainant to the terms and conditions of the policy. The terms and conditions of the policy were put on the website of Government of Punjab and were made available thereon to all serving and retired employees of the Punjab Government. This plea holds no water that complainant was not aware about the terms and conditions of the cashless policy. In this view of the matter, OPs no.3 and 4, which are insured under the contract with Punjab Government for reimbursement of its serving and retired employees, have already provided claim to complainant to the tune of Rs.1,12,224/-. Rest of the claim amount claimed by complainant is not as per approved rates by the government authorities and cannot be held to be admissible beyond the same.

9.                For the reasons recorded above, order of the District Forum Ferozepur is not sustainable in the eyes of law. Appeal of the appellant is accepted by setting aside the order of the District Forum Ferozepur, resulting in dismissal of the complaint of the complainant.

10.              The appellant had deposited an amount of Rs.25,000/- in this Commission at the time of filing the appeal and further deposited Rs.55,000/- as per compliance of the order of this Commission. Both these amounts with interest, if any, accrued thereon, be remitted by the registry to the appellant of this appeal by way of crossed cheque/demand draft after the expiry of 45 days.

11.              Arguments in this appeal were heard on 30.11.2018 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

12.              The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                       (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                    

                                                                  

December  5, 2018                                                             

(ravi)