Punjab

Faridkot

CC/17/326

Gurmail Singh - Complainant(s)

Versus

Health And Family Welfare Punjab - Opp.Party(s)

Harlok Nath Muthreja

12 Feb 2019

ORDER

   DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :             326 of 2017

Date of Institution:     4.10.2017

Date of Decision :    12.02.2019

 

Gurmail Singh aged about 67 years, retired District Attorney, resident of H.No. 922, Green Avenue, Faridkot, Tehsil and District Faridkot.

 

                                                                          .........Complainant

Versus

1. Secretary to Government of Punjab, Department of Health & Family Welfare, Punjab, Chandigarh.
2. M D India, Health Care Services (TPA) Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali (Punjab).
3. Oriental Insurance, M D India, Health Care Services (TPA) Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali, Chandigarh.
4. District Co-ordinator, Oriental Insurance Co. Civil Hospital, Faridkot.
5. Director, Prosecution and Litigation, SCO 194, 195, Third Floor, Sector 17-C, Chandigarh.
6. District Attorney, District Courts Complex, Faridkot.
7. Civil Surgeon, Faridkot.
8. District Attorney, District Court Complex, Ferozepur, District Ferozepur.

                                                                         .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum:  Sh Ajit Aggarwal, President,

                Smt Param Pal Kaur, Member.

 

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Present: Sh Harlok Nath Mutheraja, Ld Counsel for Complainant,

              Sh Kashmir Lal, Ld Counsel for OP-1 and 7,

              Sh Vinod Monga, Ld Counsel for OP-2, 3 and 4,

              Sh Satnam Singh, ADA for Op-5 and 6,

              Sh Sonu, authorized representative on behalf of OP-8.

                          

ORDER   

(Ajit Aggarwal, President)

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of insurance claim  with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.15,000/-.

2                                   Briefly stated, the case of the complainant is that complainant retired as District Attorney from the office of District Attorney, Ferozepur on 31.12.2008 and he was covered under Punjab Government Employees and Pensioners Health Insurance Scheme having ID No.MD-098761-52477. As per policy, complainant was entitled for cashless treatment and OPs are liable to pay the insurance claim. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that complainant suffered brain problem for which he consulted doctor who advised MRI and after getting conducted his MRI, complainant was

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advised to consult a neurologist. Complainant got himself checked up from Dr Karanjit Singh, Neurologist at Medanta Hospital, Gurgaon, who suggested him surgery of brain and therefore, complainant was admitted there in acute emergency on 18.12.2016, operated on 19.12.2016 and was discharged therefrom on 24.12.2016. complainant was asked by said doctor to come after six weeks for further checkup. On 1.02.2017, complainant again got conducted his MRI and consulted Dr Karanjit Singh, Neurologist at Medanta Hospital, Gurgaon. Complainant spent Rs.3,78,492/- on his operation and Rs.7,600/-on after operation treatment and thus, total amount paid by his on his treatment is Rs,3,86,092/-. Thereafter, without any delay, complainant submitted his claim with OPs on 3.02.2017 i.e just after 22 days of his final check up, but OP-3 returned the same on 14.05.2017 after about  two and half months with objection that claim file is submitted after 30 days of discharge and they are unable to make reimbursement under PGEPHIS. It is further submitted that as per prevailing rules, claim can be lodged by insured employee of pensioner within 6 months and in present case, complainant lodged his claim just after 22 days of final check up and thus, objection raise by Ops is totally incorrect and illegal. Then, complainant submitted his representation with District Level Grievance Redressal Committee, Faridkot on 30.05.2017, who sent the matter for settlement to Civil Surgeon, Faridkot, but no fruitful result came therefrom. Thereafter, complainant submitted his claim in the office of District Attorney/Op-6 on 2.06.2017, but that office also returned his

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claim on 7.06.2017 with remarks that said cashless scheme was in force from 1.01.2016 to 31.12.2016 and advised to send the claim to Oriental Insurance Company/Op-3, but OP-3 flatly refused to admit the claim. Legal notice dated 1.09.2017 issued by complainant also served no purpose. Despite repeated requests, OPs have not cleared his claim, which amounts to deficiency in service and trade mal practice and has caused harassment and mental tension to complainant. He has prayed for directing   OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                               The counsel for complainant was heard with regard to admission of the complaint and vide order dated 10.10.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                               On receipt of the notice, the OP-1 and 7 filed written statement wherein asserted that Punjab Government launched health insurance scheme for employees and pensioners vide notification dated 20.10.2015. it is averred that Government has constituted Grievance Redressal Committees at District level as well as State level for redressing the complainant, but complainant has  not made any representation before any such committee for redressal of his grievance and thus, complaint filed by complainant is premature and is liable to be dismissed. it is further averred that issue regarding claim of treatment is between complainant and Oriental Insurance Company and

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there is no relation between complainant and answering OPs. However, it is admitted by OP-1 and 7 that they received claim for reimbursement from Deputy Commissioner, Faridkot, but they transmitted the same to Director, F & A Punjab Health System Corporation for advice, but no advice received therefrom and then, enquiry was conducted and during enquiry it was found out that as per rules of the Company, complainant has not submitted his claim within stipulated period of 30 days and therefore no claim is payable. Moreover, nothing is to be done by answering OPs and complaint against them is not maintainable and is liable to be dismissed. it is reiterated that complainant has not given any consideration to answering OPs and there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

 5                                            Ld Counsel for OP-2, 3 and 4 filed reply taking legal objections that complainant has committed breach of terms and conditions of Punjab Government Employees and Pensioners Health Insurance Scheme as he submitted his claim for reimbursement on 25.02.2017, but as per notification claim clause 26 of PGEPHIS, claim was to be lodged within 30 days from the date of discharge. Complainant was discharged from the Hospital on 24.12.2016, but he lodged the claim after a period of two months i.e on 25.02.2017. It is further averred that complainant is not entitled for reimbursement as he has not complied with the clause 26 of Insurance Scheme. Moreover, as per notification dated 20.10.2015, cashless scheme is available only in the listed or enrolled hospitals in the state of Punjab, but the claim of the

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complainant does not fall in the cashless category. Claim is admissible subject to submission of claim within 30 days, but in present case, complainant has filed his claim after a long period of two months. It is reiterated that there is no deficiency in service on the part of answering OPs and prayed for dismissal of complaint with costs.

 6                                 OP-5 and 6 filed reply taking preliminary objection that complaint in hand is not maintainable as no cause of action arises against them and even this Forum has no territorial jurisdiction to hear and try the present complaint as complainant has retired from District Attorney Office, Ferozepur. However, on merits ld counsel for OP-5 and 6 averred that claim of complainant is payable only by OP-3 Insurance Company as only Insurance Company is liable to reimburse the amount to the complainant as per agreement and notification of Punjab Government. Complainant has retired from the office of District Attorney, Ferozepur and he has to submit his bills in the office of OP-8 ie. D A Office, Ferozepur and reimbursement is to be paid by OP-3. All the other allegations of complainant are denied being wrong and incorrect and prayer for dismissal of complaint with costs is made.

7                                                 Ld Counsel for OP-8 filed written statement taking preliminary objections that complaint in hand is not maintainable in the present form as it is filed on vague and baseless grounds. It is averred that complainant neither filed any medical bill in

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the office of OP-8 nor applied for reimbursement of his claim to them. complaint filed by complainant is an abuse of process of law. Moreover, neither complainant resides in Ferozepur nor he has an pensionary account with them. Moreover, claim filed by complainant is payable only by the Insurance Company and they have no role in making payment of insurance claim of complainant. However, on merits OP-8 has denied all the allegations of complainant being wrong and incorrect and reiterated that there is no deficiency in service on their part and prayed for dismissal of complaint with costs.

8                                                        Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-16 and then, closed their evidence.

9                                                          In order to rebut the evidence of the complainant, ld counsel for OP-1 and 7 tendered in evidence affidavit of Dr Jagraj Singh as Ex Op-1 & 7/1 and document Ex OP-1 & 7/2 and closed the same. Counsel for OP-2 to OP-4 tendered in evidence affidavit of Ashwani Kumar Ex OP-2 to 4/1 and document Ex OP-2 to 4/2 and then, closed the evidence. Ld counsel for OP-5 and 6 tendered in evidence affidavit of Rajbeer Kaur as Ex OP-5 & 6/1 and documents Ex OP-5 & 6 /2 to Ex OP-5 & 6/3 and also closed the evidence on their part. Anil Kumar Sr Assistant of District Attorney Officer, Ferozepur tendered in evidence his affidavit Ex OP-8/1 and closed the same.

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10                                                        We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

11                                                               Ld Counsel for complainant vehementally argued that complainant retired as District Attorney from D A Office, Ferozepur on 31.12.2008 and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme having ID No.MD-098761-52477. As per policy, he was entitled for cashless treatment and OPs are liable to pay the insurance claim. Complainant suffered brain problem for which he after conducting his MRI, consulted Dr Karanjit Singh, Neurologist at Medanta Hospital, Gurgaon, who suggested him surgery of brain and therefore, complainant was admitted there in acute emergency on 18.12.2016. He was operated on 19.12.2016 and was discharged therefrom on 24.12.2016. He was asked by said doctor to come after six weeks for further checkup. On 1.02.2017, complainant again got conducted his MRI and consulted Dr Karanjit Singh, Neurologist at Medanta Hospital, Gurgaon. He spent Rs.3,78,492/- on his operation and Rs.7,600/-on after operation treatment and thus, total amount paid by his on his treatment is Rs,3,86,092/-. Thereafter, complainant submitted his claim with OPs on 3.02.2017 i.e just after 22 days of his final check up, but OP-3 returned the same on 14.05.2017 after about two and half months with objection that he lodged claim late i.e after 30 days of discharge and they are unable to make reimbursement under PGEPHIS. Ld counsel for

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complainant contended that as per prevailing rules, claim can be lodged within 6 months and in present case, claim is lodged within time i,e only after 22 days of final check up and thus, objection raised by Ops is totally incorrect and illegal. After that, complainant submitted his representation with District Level Grievance Redressal Committee, Faridkot on 30.05.2017, who sent the matter for settlement to Civil Surgeon, Faridkot, but all in vain. Thereafter, complainant submitted his claim in the office of District Attorney/Op-6 on 2.06.2017, but that office also returned his claim on 7.06.2017 with remarks that said cashless scheme was in force from 1.01.2016 to 31.12.2016 and advised to send the claim to Oriental Insurance Company/Op-3, but OP-3 flatly refused to admit the claim. Legal notice dated 1.09.2017 issued by complainant also bore no fruit. Despite repeated requests, OPs have not cleared his claim, which amounts to deficiency in service and has caused harassment and mental agony to him. He has prayed for accepting the complaint.

12                                                      To controvert the allegations of complainant, ld counsel for OPs No. 2 and 3 stressed mainly on the point that claim lodged by complainant is not within stipulated period as complainant submitted his claim after expiry of two months from discharge from hospital, but as per rules and terms and conditions of government notification date d20.10.2015, stipulated time for submission of claim is 30 days after discharge from the hospital. All the other parties i.e OP-1, 4, 5, 6, 7 and 8 asserted that entire issue pertaining

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to settlement of insurance claim regarding expenditure spent by complainant on his brain surgery, is between complainant and OP-3 Insurance Company and they have no role to play in making reimbursement of said claim. All the parties reiterated that there is no deficiency in service on their part and prayed for dismissal of complaint.         

13                                                       The case of the complainant is that being a retiree from District Attorney Office, complainant was insured under the policy in question. He suffered from some brain problem and on advice of a Neurologist, complainant underwent brain surgery and remained admitted in Medanta Hospital, Gurgaon from 18.12.2016 to 24.12.2016 and also got check up and re-conducted his MRI after surgery on 1.02.2017. Amount paid by him on his treatment is Rs.3,86,092/-. Thereafter, complainant lodged his claim with OPs within stipulated period, but  OPs did not pass his claim. OPs kept sending him to one opposite party to another but nothing needful was done by any OPs to clear his claim. Grievance of complainant is that despite several requests and submission of his representations before District Level Grievance Redressal Committee, Faridkot on 30.05.2017, to Civil Surgeon, Faridkot, and office of District Attorney/Op-6 on 2.06.2017 and to Oriental Insurance Company/Op-3, but all refused to admit the claim. Legal notice also served no purpose. As per rules, claim can be lodged within 6 months and complainant duly submitted his claim before OPs within stipulated period i,e only after 22 days of final check up and thus, objection raised by Ops that claim is time barred is wrong and

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illegal. He has prayed for accepting the complaint. In reply, OPs-1, 4,5, 6, 7 and 8 have stressed mainly on the point that claim  filed by complainant is payable only by OP-3 Insurance Company and they have no role in making reimbursement of claim in question. Op-2 and 3 took plea that claim lodged by complainant is not within stipulated period and he has not complied with the terms and conditions of insurance policy and Punjab Government Employees and Pensioners Health Insurance Scheme and did not got operated himself from the empanelled hospital of Ops. OP-2 and OP-3 stressed mainly on the point that claim was to be lodged by complainant within 30 days but complainant filed his insurance claim after expiry of two months from the date of discharge from the said hospital. All the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

14                Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being the pensioner of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that the complainant took treatment from Medanta Hospital, Gurgaon from 18.12.2016 to 24.12.2016 and spent an amount of Rs.3,86,092/-on his treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by him on his treatment. He lodged claim for the

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reimbursement of medical expenses borne by him with OPs, which was repudiated by them. Now, the first objection of opposite parties is that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and Grievance Redressal Committees are constituted to settle the dispute, but the complainant did not approach to these committees and filed the present complaint before this Forum. It is settled principle of law that the remedy under Consumer Protection Act is an additional remedy other than available remedies. If there is any contract of arbitration or to settle any dispute by settlement committee under the scheme in that case also the complainant can approach to this Forum instead of arbitrator or dispute settlement committee. In that event the jurisdiction of this Forum is not barred and this Forum can entertain and decide the present complaint.                    

15                                                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that he was insured with them as per Cashless Health Insurance Scheme launched by Punjab Government. OPs argued that complainant did not lodge the claim for insurance within stipulated period of 30 days, rather he filed his claim for insurance after two months from the date of discharge of said Medanta Hospital. It is admitted that complainant spent Rs.3,86,092/- with hospital authorities on account of expenditure incurred on his treatment for brain surgery.

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16                                   Ld Counsel for complainant argued that OPs cannot repudiate the claim of complainant on the ground of late submission of claim documents as complainant has submitted his claim documents with time. Even if it is presumed that complainant submitted documents late then in that case also, the Ops cannot repudiate the claim of complainant merely on the ground of late submission of documents because as per guidelines of IRDA, the Insurance Companies are instructed to decide each and every claim on merits and not to decline the claim on mere technical grounds. As such, Insurance Companies are directed by IRDA to settle the claim on merits of each and every claim even if the claim documents are submitted late than the stipulated period. Ld Counsel for complainant argued that the OPs cannot repudiate insurance claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1) CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that

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Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy.

17                                                   From the above discussion and case law produced by the complainant, we are of considered opinion that Ops have wrongly and illegally repudiated the insurance claim of complainant on false grounds of terms and conditions of policy  though he was covered under the Mediclaim insurance policy. Plea taken by OPs that there is late submission of claim by complainant, has no legs to stand upon because as per their own version and notification dated 20.10.2015, the claim is required to be lodged within 30 days from the date of treatment and in present case, complainant got conducted his last treatment and new MRI on 1.02.2017 and submitted his claim with OPs on  25.02.2017 i.e within prescribed period of thirty days. Meaning thereby, there is no late submission of claim on the part of complainant and thus, action of OPs in rejecting the claim of complainant amounts to deficiency in service and it has caused harassment and mental agony to him. Complainant has succeeded in proving his case and therefore, complaint in hand is hereby accepted. OP-2 and OP-3 are directed to settle and pay the claim of complainant as per PGI rates alongwith interest at the rate of 9 % per anum from 4.10.2017 i.e from the date of

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filing the present claim till final realization. OP-2 and OP-3 are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.2000/- as litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Complaint against OP-1 and OP-4 to OP-8 stands hereby dismissed. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 12.02.2019

(Param Pal Kaur)         (Ajit Aggarwal)

                                       Member                      President