| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 28 of 17.1.2019 Decided on: 4.5.2021 Krishan Jiwan Jain, Senior Design Engineer (Retired –Punjab Govt. Pensioner ) Resident of # 202, Phase-1, Urban Estate, Patiala-147002. …………...Complainant Versus M.D.Health Care India Ltd. Oriental Insurance Company D-2, Industrial Area, Phase-2, S.A.S.Nagar …………Opposite Party Complaint under Section 12 of the Consumer Protection Act, 1986. QUORUM Sh. Jasjit Singh Bhinder, President Sh.Y.S.Matta, Member ARGUED BY Complainant in person. Sh.B.L.Bhardwaj, counsel for OP. ORDER JASJIT SINGH BHINDER,PRESIDENT - This is the complaint filed by Krishan Jiwan Jain (hereinafter referred to as the complainant) against M.D.Health Care India Ltd. Oriental Insurance Company (hereinafter referred to as the OP/s).
- The brief facts of the case are that the complainant is Punjab Govt. Pensioner. It is averred that the OP had signed a memorandum of understanding(MOU) with the Punjab Govt. to provide medical insurance to its employees and pensioners including their dependents, accordingly the complainant was enrolled for it vide ID card No.MD-15/094171-76116, policy No.231102/48/2016/769 from 1.1.2016 to 21.12.2016.
- It is further averred that the complainant suffered from massive heart attack on 30.11.2016 and had to under go cardiac procedure Coronary Angioplasty at Max Hospital, Mohali. The hospital billed Rs.2,74,496/- but the OP released Rs.1,19,817/- to the hospital and did not make the balance amount of Rs.1,54,679/- There is thus deficiency in service on the part of the OP. Hence this complaint with the prayer to accept the same by giving direction to the OP to make the payment of balance amount of Rs.1,54,679/- alongwith interest @ 12% per annum from 2.12.2016 till actual payment and also to pay Rs.15000/- as compensation for causing mental agony and harassment and also to pay Rs.5000/-as costs of litigation.
- Notice of the complaint was duly served upon the OP who appeared through counsel and contested the complaint by filing written statement having raised preliminary objections that the present complaint is not maintainable; that the complainant has no cause or reason to file the present complaint and has not come to the Hon’ble Forum with clean hands; that the complaint is bad for non joinder of necessary parties.
- On merits, it is admitted that the complainant and her family members were insured under the subject medical policy for the period from 1.1.2016 to 31.12.2016 as per Govt. of Punjab notification dated 20.10.2015 vide which the employees/pensioners and their dependant family members are covered subject to the reimbursement of the payment at Govt. hospital rates or PGEPHIS rates whichever is less but no reimbursement shall be made as per para 4 of the notification dated 20.10.2015 of Govt. of Punjab.
- It is pleaded that bills amounting to Rs.2,74,496/- were received by the TPA and the amount of Rs.1,19,817/-has been paid as per PGEPHIS schedule of cost under package details by the TPA and complainant is not entitled for any balance amount of Rs.1,54,679/- . It is pleaded that as the amount has already been paid , there is no deficiency of service on the part of the OP and has prayed that the complaint may be dismissed.
- In evidence, the complainant has tendered his affidavit, Ex.CA alongwith documents Exs.C1 to C3 and closed the evidence.
- On the other hand, the ld. counsel for the OP has tendered in evidence affidavit Ex.OPA of Mukesh Malhotra, Divisional Manager alongwith documents Exs.OP1 to OP3 and closed the evidence.
- Written arguments on behalf of the OP have also been filed. We have gone through the same, heard the complainant and the ld. counsel for the OP and have also gone through the record of the case, carefully.
- The complainant has argued that the OP company has signed a memorandum of understanding with the Punjab Government to provide medical insurance to its employees and pensioners including their dependents and he has also been enrolled for the policy for the period from 1.1.2016 to 31.12.2016.The complainant has further argued that he underwent for cardiac procedure coronary angioplasty at Max Hospital Mohali and the surgery cost Rs.2,74,496/-.He has further argued that Rs.1,19,817/-were reimbursed and remaining amount of Rs.1,54,679/- is still to be paid. So the complaint be allowed.
- The ld. counsel for the OP has argued that Krishan Jiwan Jian and his family members were enrolled under the subject medical policy from 1.1.2016 to 31.12.2016 as per Govt. of Punjab notification No.21/28/12SHB5/268 dated 20.10.2015 and they were covered under the subject insurance policy subject to reimbursement of the payment which shall be made to the insured at Govt. hospital rates or PGEPHIS rates, whichever is less. The ld. counsel further argued that the bill was received but the payment has been made as per PGEPHIS, which was tender base policy, to the complainant and in this case Rs.1,19,817/-were paid and nothing is due, so the complaint be dismissed.
- To prove the case, the complainant has tendered his affidavit,Ex.CA, Ex.C1 is the insurance card of the complainant , Ex.C2 is the bill of Max Hospital ,Ex.C3 is the letter written by Chief Engineer Irrigation to OP company.
- On behalf of the OP Sh.Mukesh Malhotra, Divisional Manager has tendered his affidavit, Ex.OPA and he has deposed that the complainant has no cause or reason to file the present complaint. It is further deposed that complainant and family members were insured under the subject medical policy for the period from 1.1.2016 to 31.12.2016 as per Govt. of Punjab Notification No.21/28/12-SHB5/268 dated 20.10.2015, subject to reimbursement of the payment which shall be made to the insured at Govt. hospital rates or PGEPHIS rates whichever is less but no reimbursement shall be made as per para 4 of the said notification. It is further deposed that bills of Rs.2,74,496/- were received but as the policy is a tender base policy so in this case amount of Rs.1,19,817/- has been paid as per PGEPHIS rates and now nothing is to be paid to the complainant.
- The present complaint has been filed by the complainant for the recovery of Rs.1,54,679/-the balance amount for the surgery of coronary angioplasty. The complainant is retired Govt. pensioner. The Punjab Govt. in the year 2016 had insured the Govt. employees as per the PGEPHIS schedule of rates and according to the rate list of PGEPHIS the OP has made the payment of Rs.1,19,817/- which the complainant has also admitted.
- So as the complainant and family members were insured under the subject insurance policy, the reimbursement was to be made as per Govt. hospital rates or PGEPHIS rates whichever is less. The bills amounting to Rs. 2,74,496/- were received for admission on 30.11.2016.As PGEPHIS is a tender base policy, so the OP company has made the payment of Rs.1,19,817/- according to PGEPHIS rate list .
- So it is clear that this is not a personal policy taken by the complainant. This policy was given by the Punjab Government. So the OP company was to pay as per the PGEPHIS rate list and accordingly Rs.1,19,817/- were paid. This contract was between the insurance company and the Govt. and the insurance company was bound by the contract and there was no contract between the complainant and the insurance company. So accordingly PGEPHIS rate list Rs. 1,19,817/- were paid as the complainant was entitle only for this amount as the policy was tender base policy.
- So due to our above discussion the complainant is not entitled for any other amount and the complaint is dismissed accordingly.
ANNOUNCED DATED:4.5.2021 Y.S.Matta Jasjit Singh Bhinder Member President | |
