| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 23 of 17.1.2019 Decided on: 4.5.2021 Mrs. Kiran Jain w/o 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 Sh.Krishan Jiwan Jain, authorized representative of the complainant. Sh.B.L.Bhardwaj, counsel for OP. ORDER JASJIT SINGH BHINDER, PRESIDENT - This is the complaint filed by Mrs.Kiran 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 husband of 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 husband of the complainant was enrolled for it vide ID card No.MD-15/094171-76116, policy No.221602/48/2016/769 from 1.1.2016 to 21.12.2016.
- It is further averred that the complainant had to undergo cataract surgery of both eyes i.e. on 15.4.2016 of right eye and on 21.4.2016 of left eye at Prem Eye Hospital, Barnala and spent Rs.36000/-. It is further averred that the bills for reimbursement of expenses were sent to the OP through registered post on 9.5.2016. The OP reimbursed Rs.10,000/- by credit to the saving bank account on 30.5.2016.The complainant made several requests to the OP for making full payment. The OP on 10.10.2016 told that payment could not be made for want of stickers of lens implanted in the eyes and advised to submit the same. Accordingly the stickers were sent through registered post on 14.10.2016 but the OPs failed to make the payment of remaining balance amount of Rs.26000/-.There is thus deficiency of 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.26000/- alongwith interest @12% per annum from 1.6.2016 till date of realization and also to pay Rs.10,000/- as compensation for causing mental agony and harassment alongwith Rs.5000/-as cost 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.18000/- were received by the TPA for admission on 15.4.2016 with date of discharge 16.4.2016 and the amount has been paid as per PGEPHIS schedule of cost and nothing is now payable by the TPA/insurance co.
- It is further submitted that another claim of Rs.18000/- was lodged for admission for 21.4.2016 with discharge date 22.4.2016 but the claim has not been disallowed or closed due to non submission of required additional information to the TPA for processing the claim for payment as per PGEPHIS rates and the TPA is ready to process the claim if the complainant submits the invoice and bar code of the implant and original bills in the 2nd claim case .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 her affidavit, Ex.CA alongwith documents Exs.C1 to C9 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 authorized representative of 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 Sh.Krishan Jiwan Jain has also been enrolled for the policy for the period from 1.1.2016 to 31.12.2016.He has further argued that the complainant i.e. his wife went for cataract surgery of both the eyes on 15.4.2016 and 21.4.2016 at Prem Eye Hospital, Barnala and surgery cost Rs.36000/-.He has further argued that Rs.10000/-were reimbursed and remaining amount of Rs.26000/- 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 the case Rs.6000/- were to be paid but the rate was changed so Rs.10,000/- was paid and nothing is due, so the complaint be dismissed.
- To prove the case, the complainant has tendered her affidavit,Ex.CA, Ex.C1 is the card of Kiran Jain, Ex.C2 is the bill of Prem Eye and Maternity Hospital,Barnala,Ex.C3 is also bill,Ex.C4 is registered notice,Ex.C5 is also registered notice,Ex.C6 is deposit of amount of Rs.10,000/-in the complainant’s account,Ex.C7 is letter written by the complainant to the OP,Ex.C8 is also letter written to MD India Health Car by the complainant,Ex.C9 is letter written by Chief Engineer/Irrigation to the OP.
- 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.18000/- were received but as the policy is a tender base policy so in this case amount has been paid as per PGEPHIS rates. It is further deposed that in the present case the amount was only Rs.6000/- but as the rate was changed so Rs.10,000/-were paid and deposited in the complainant’s account and now nothing is to be paid to the complainant.
- In the present case, the complainant through her husband has filed this complaint for recovery of Rs.26000/- for the cataract surgery of both the eyes. The complainant is wife of Krishan Jiwan Jain, who is retired Govt. pensioner. The Punjab Govt. in the year 2016 had insured the Govt. employees as per the PGEPHIS schedule of rates, which are Ex.OP2and the amount was to be paid as per PGEPHIS rates. In the present rate list the amount of cataract surgery is shown as Rs.6000/-.
- 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.18000/- were received for admission on 15.4.2016 and discharge on 16.4.2016.The another bill amounting to Rs.18000/-was received for the admission on 21.4.2016 with the date of discharge as 22.4.2016 by the TPA.As PGEPHIS is a tender base policy. The earlier package cost of the said medical treatment was Rs.6000/- but the rate was changed and Rs.10,000/- have been paid to the complainant .
- So it is clear that this is not a personal policy taken by the complainant. This policy was given by the Punjab Government and rates have been clearly mentioned in the documents, Exs.OP1 &OP2.So the OP company was to pay as per the PGEPHIS rate list and accordingly Rs.10,000/- were paid. This was contract 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.10000/-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 | |
