The titled complainant Smt. Rajni has filed the present complaint against the titled opposite parties being aggrieved at non-payment of hospital-expenses of her late husband amounting to Rs.1,71,228/- the related 'claim-cum-bills' of which stand duly submitted by her husband during his life-time. The Retired Govt. School Teacher Late Sh.Naresh Kumar (since demised in February' 2018) during his life-time had been a member of Punjab Govt. Employee and Pensioner Health Insurance Scheme (PGEPHIS) under administrative as well as supervisory/run-in control of the opposite parties having policy # 231102/48/2016/769 ID Card # MDIS-09464573054 valid w.e.f. 01.01.2016 to 31.12.2016. The then insured had fallen ill during his lifetime and stayed hospitalized w.e.f. 05.11.2016 to 18.11.2016 at K. D. Hospital Amritsar having paid there a sum of Rs.1,71,228/- as hospital-expenses.
2. As was requisite under the Punjab Civil Rules, Late Naresh Kumar the complainant's husband upon discharge from the Hospital had filed the medical-bills with the OP2 Office through registered post on 17.04.2017. He continued with his regular follow-up of medical -bills till his demise in February' 2018 and since then his widow, the present complainant had been continuing the futile follow-up with the OP2 Office and other related authorities who somehow have not yet been decisive in resolving the hospitalization-claim awaiting disposal at their end since the year 2017 i.e., for the last five years, in a row. Lastly, the complainant discloses having approached the OP2, in person, with request to consider and expeditiously resolve her pending/overdue claim but no fruitful results did ever follow in spite of their assurances and hence prompted the present complaint praying for full payment of the hospital-expenses (claim) @ Rs.1,71,228/- along with the suitable/matching compensatory cost. The complainant has also filed supporting papers exhibited here as Ex.C3 to Ex.C41 (that shall be duly discussed, as and when necessary) besides her present complaint (Ex.C1) along with her self-attested deposition (Ex.C2) etc.
3. The titled opposite parties 1 and 2 (the OP1 and the OP2) have somehow opted to stay absent in spite of the commission's summons/ notice duly served upon them and thus both were ordered on 25.11.2019 to be proceeded against ex-parte. However, the OP3 insurers in response to the commission’s summons appeared through their counsel and filed the written reply stating therein preliminary as well as other (on merit) objections as:
4. The present complaint is not maintainable against them (the OP3) as the deceased Naresh Kumar during his life-time had never been their consumer in the absence of any insurance-contract between them. The claim was rightly not considered by the OP2 TPA on account of violation of the PGEPHIS terms that warrant submission/ filing of claim within a period of 30 days from the date of discharge from Hospital whereas the impugned claim was filed by Naresh Kumar deceased on 22.04.2017 upon getting discharged on 18.11.2016. Further, on merits, the OP3 insurers have not subjected the contents of paragraphs 1 to 4 of the complaint to any comments/objections addressing these as matter of records.
5. Again, in response to the contents of paragraph '5' the OP3 have denied all liability to pay any amount in light of their preliminary objections that (in brief) are: i) absence of any contract of insurance and ii) delay in submission of the impugned claim to the OP2 TPA beyond the permissible period of 30 days of date of discharge from the Hospital. The claim had reached the OP2 TPA on 24.04.2017 though may have been dispatched on 17.04.2017.
The OP3 insurers have not accepted paragraphs 7 and 10 addressing these as absolutely/ totally wrong whereas paragraphs 6, 8 & 9 are not commented for want of knowledge. The paragraphs 11 and 12 are not disputed being the legal requisites and lastly the dismissal of the complaint has been prayed addressing these as without any merit. The OP3 has listed their documents placed forth in evidence as Ex.OP3/2 - Brief for OP advocates; Ex.OP3/3 Repudiation Letter by the OP2 TPA; and Ex.OP3/4 (Policy Schedule-Tailor made) besides affidavit/ deposition exhibited here as Ex.OP3/1 and closed their evidence re-praying for dismissal of the present complaint with costs. The exhibited documents as duly taken on records shall be duly examined and discussed threadbare as found requisite during the course of the present consideration.
6. We have examined the available documents/ evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants.
7. We perceive the non-appearance/absence of the OP1 Service Providers and the OP2 TPA through the time-tested and accepted legal proposition/judicial presumption by virtue of a plethora of senior court judgments/ rulings that the litigants opting to absenting themselves by choice have nothing substantial to plead in prosecution of their defense.
8. However, we observe vide the 'pleadings cum evidence' as put forth by the OP3 insurer that the impugned claim (dispatched on 17.04.2017) was duly received by the OP2 TPA on 22.04.2017 and repudiated (Ex.OP3/3) by them under advice to the OP3 insurers.
9. We find that the complainant as well as her late husband Naresh Kumar insured both fall under the category of statutory 'beneficiary' by virtue of Group Mediclaim Tailor-made Policy Schedule (Ex.OP3/4) and thus both of them have been statutory 'consumers' of the titled opposite parties including the OP3 Insurer and there did exist, for sure, an implied-contract of insurance between the OP3 insurer and the insured Naresh Kumar (during his life-time) by virtue of the Principal Contract of Insurance with Govt. of Punjab, (Ex.OP3/4) Department of Health & Family Welfare and thus all the titled opposite parties including the OP3 insurers are legally bound to honor and pay compliance to the legislated provisions of the herein applicable statute.
10. Next, we find that the impugned claim was recommended for repudiation by the OP2 TPA on the ground of 'delay' in submission of the claim beyond 30 days, as prescribed vide the PGEPHIS Rules. However, no resolve did follow the recommendation by the OP2 TPA and the impugned claim lies unsettled as the TPA authority has been limited only to recommendations. The OP3 insurers have been simply sitting over the claim sans a resolve, either way. Here, we observe that the OP have overlooked the health status/condition of the deceased-claimant at that point of time. He had fallen seriously ill and was admitted to K D Hospital and diagnosed for Right Frontal Hematoma (Ex.C7 & Ex.C40). Hematoma, to a layman be stated as 'a solid painful swelling of clotted blood within the tissues (under the skin) and can manifest itself over any part of the human body and usually turns into/gets associated with cancerous growth'. The same is addressed as 'Right Frontal Hematoma' if firmed-up on RHS side of Head/Forehead. The patient Naresh Kumar deceased stayed admitted in the Hospital w.e.f. 05.11.2016 to 18.11.2016 diagnosed for RFH & discharged sans surgery left to fate for of cancerous expanse and advised bed rest up to 19.12.2016 and breathed his last a year later on 10.02.2018. We see there's a number of formalities to be complied with and a lot of papers to be collected/ procured in order to compile and file an insurance-claim and the indisposed and terminally ill claimant accomplished all that single handed and only then could file his hospital-expenses claim on 17.04.2017.
11. We see the patient Naresh Kumar deserved and has been legally entitled to a liberal condo-nation of delay at the hands of the OP insurers but that was not to be.
12. We as of now statutorily condone the 'delay' incurred in submission of impugned hospital-expenses claim with the OP1 insurers/ OP2 TPA and that removes all impediments from the path of a judicious resolve to the widowed complainant.
13. The OP insurers must realize that bald technicalities for that matter the terms and conditions/rules and regulations are formulated for mutual convenience and to facilitate administrative functioning on a smoother plat-form but these may not be extended so as to hamper delivery of justice to the needy and deserving. And, further their administrative decisions in settling insurance claims are open to judicial review and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. The facts in issue need be appreciated while awarding sanctity to the current applicable law. And, nothing may be more worse to unwanted deferments to resolves and the unnecessary non-communication to the claimants, held on the avoidable wait.
14. Finally, in the matter pertaining to the present complaint and in the light of the all above, we partly allow the present complaint and set aside the OP2 TPA repudiation and ORDER the OP1 insurers to pay the claim amount of Rs.1,71,228/- to the complainant along with interest @ 6% PA from the date of claim till paid in totality besides Rs.10,000/- as compensation for the undue harassment inflicted upon the widow complainant besides a sum of Rs.5,000/- as cost of litigation; within 45 days of receipt of the certified copy of these orders otherwise the entire awarded amount including cost and compensation shall attract an additional interest @ 3 % PA form the date of filing of the present complaint till actually paid.
15. 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.
16. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (B.S.Matharu)
JULY 08, 2022. Member.
YP.
