Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  : 14 of  2017

Date of Institution                      : 22.03.2017

Date of Decision               : 04.04.2019

Harmanjit Kaur wife of Advocate Inderpal Singh resident of Golden Avenue Amritsar Sarhali Road District Tarn Taran

                                                ...Complainant

Versus

1. M.D. India Health Care Service (TPA) Pvt. Ltd. Phase I Industry Area, Mohali Punjab through its M.D
2. Oriental Insurance Company Ltd. Amritsar road Tarn Taran through its M.D.

…Opposite Parties.

Complaint Under Section 12 and 13 of the Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

                             Sh. Jatinder Singh Pannu, Member

For Complainant                     Sh. H.S. Sandhu Advocate

For Opposite Parties               Sh. Neeraj Kumar Advocate

ORDERS:

Charanjit Singh, President;

1        The complainant Harmanjit Singh has filed the present complaint under Section  12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against M.D. India Health Care Service (TPA) Pvt. Ltd. Phase I Industry Area, Mohali Punjab through its M.D and another (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to direct the opposite parties to reimburse the whole sum assured amounting to Rs. 50,000/- alongwith interest at the rate of 18% P.A. to the complainant. The complainant has also prayed Rs. 20,000/- as compensation and Rs. 10,000/- as litigation expenses.

2        The case of the complainant in brief is that he is a Government Employee and posted at ETT Teacher at Government Elementary School Opposite Madan Mohan Mandir, Tarn Taran District Tarn Taran. As per the policy of Punjab Government to provide Health Insurance Cover to its employees and their family members had contracted with the opposite parties. The opposite parties undertook to provide reimbursement for the expenses done by the Punjab Government Employees, after they pay the expenses for the pre and post hospitalization of their treatment.  The husband of the complainant- Inderpal Singh fell ill and was hospitalized with the Fortis Escort Hospital from 24.10.2016 to 28.10.2016 and spent Rs.49,287/- on his treatment which was paid by him to the Fortis Escort Hospital. After the husband of the complainant was discharged from the hospital, the complainant immediately forwarded the case for reimbursement of the expenses to the opposite parties alongwith the treatment record and bills of expenses paid to the Fortis Escort Hospital, through D.O. Education as per the procedure laid for the same. The complainant had been approaching D.O. Education for obtaining the reimbursement from the last 4 months but the opposite parties have been delaying the payment on one pretext or the other without any logical reason for the same. The cause of action has arisen in favour the complainant against the opposite parties on 28.09.2017 when the opposite parties refused to make any reimbursement to the complainant. Feeling dissatisfied by the act and conduct of the opposite parties, the complainant perforce has filed this complaint against the opposite parties.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties appeared through counsel and filed written version contesting the complaint on the preliminary objections that the present complaint is not legally maintainable as the complainant has not placed on record any cogent and convincing material supported with documentary evidence in order to substantiate the pleas as alleged in the complaint much less the relief sought is available to the complainant on the basis of vague and ambiguous pleas without any basis and on the basis of false and frivolous documents and as such the present complaint deserves dismissal on this simple score only. The present complaint is bad for misjoinder of necessary parties as the replying without any cause of action and even otherwise keeping in view the facts and circumstances of the case, no liability can be fastened upon the replying opposite parties and as such, the present complaint deserves dismissal on this simple score only. Infact the complainant has not obtained any insurance policy personally from the Insurance Company but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and pensioners Health Insurance Scheme (PHEPHIS) but the complainant has not made the State of Punjab as party to the present complaint. In the absence of necessary parties i.e. State of Punjab, the complainant alone has no cause of action to file the present complaint nor she is covered under the definition of consumer. The complainant has not come to this Forum with clean hands and has concealed material facts from this Forum and as such, the present complaint merits dismissal on this simple score only. The present complaint is an abuse of process of Court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the replying opposite parties and as such, the present complaint merits dismissal on this simple score only. No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant against the opposite parties and even from the perusal of entire complaint it becomes quite evident that it does not disclose any cause of action and merits dismissal with special costs as envisaged under section 25 of the Consumer Protection Act, 1986. So far as medi-claim policies are concerned, obtained by the Punjab Government under Punjab Government employees and Pensioners Health Insurance Scheme (PGEPHIS) and “As per para No.4 of the Notification No.21/28/12-5HB5/268 dated 20.10.2015, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available”. And as such, the complainant is not entitled to relief as claimed for keeping in view the facts and circumstances of the case and documents. There is no deficiency in service on the part of the opposite parties No.1 and 2 and as such, claim of compensation, claim amount as well as interest is not  payable under the provisions of Consumer Protection Act and the opposite parties are liable to be deleted from the array of opposite parties. The present case involves complicated questions of facts and law and the voluminous evidence is required and the cross examination of witnesses etc. is essential alongwith recording of detail evidence and the controversy involved cannot be adjudicated in a summary proceedings and such like controversy can be adjudicated by Civil Court only which is a proper Forum, On merits, it was pleaded that even otherwise the policy in question under this scheme was a cashless policy in question under this scheme as a cashless policy as per the terms and conditions and the payment could have only been made to the concerned hospital but the same cannot be reimbursed later on for any reasons and all the other allegations in the complaint have been denied by the opposite parties and prayer was made for dismissal of the complaint with costs. 

4        In order to prove the case of the complainant, Ld. counsel for the complainant tendered in evidence affidavit of complainant alongwith documents Ex. C-2 to Ex. C-5 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Sh. R.K. Sharma Ex. OPs/1,  alongwith documents Ex. OPs/2 to Ex. OPs/6 and closed the evidence.

5        We have heard the Ld. Counsel for the complainant and opposite parties and have gone through the evidence and documents placed on the file by the parties.

6        Ld. counsel for the complainant contended that he is a Government Employee and posted at ETT Teacher at Government Elementary School Opposite Madan Mohan Mandir, Tarn Taran, District Tarn Taran. As per the policy of Punjab Government to provide Health Insurance Cover to its employees and their family members had contracted with the opposite parties. The opposite parties undertook to provide reimbursement for the expenses done by the Punjab Government Employees, after they pay the expenses for the pre and post hospitalization of their treatment.  He further contended that the husband of the complainant- Inderpal Singh fell ill and was hospitalized with the Fortis Escort Hospital from 24.10.2016 to 28.10.2016 and spent Rs.49,287/- on his treatment which was paid by him to the Fortis Escort Hospital. After the husband of the complainant was discharged from the hospital, the complainant immediately forwarded the case for reimbursement of the expenses to the opposite parties alongwith the treatment record and bills of expenses paid to the Fortis Escort Hospital, through D.O. Education as per the procedure laid for the same. He further contended that the complainant had been approaching D.O. Education for obtaining the reimbursement from the last 4 months but the opposite parties have been delaying the payment on one pretext or the other without any logical reason for the same. He further contended that the cause of action has arisen in favour the complainant against the opposite parties on 28.09.2017 when the opposite parties refused to make any reimbursement to the complainant and the complainant that the present complaint may be allowed.

7        Ld. counsel for the opposite party contended that the present complaint is not legally maintainable as the complainant has not placed on record any cogent and convincing material supported with documentary evidence in order to substantiate the pleas as alleged in the complaint. He further contended that the present complaint is bad for misjoinder of necessary parties as the replying without any cause of action and even otherwise keeping in view the facts and circumstances of the case, no liability can be fastened upon the opposite parties and as such, the present complaint metis dismissal on this simple score only. He further contended that the complainant has not obtained any insurance policy personally from the Insurance Company but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and pensioners Health Insurance Scheme (PHEPHIS) but the complainant has not made the State of Punjab as party to the present complaint. In the absence of necessary parties i.e. State of Punjab, the complainant alone has no cause of action to file the present complaint nor she is covered under the definition of consumer. He further contended that the complainant has not come to this Forum with clean hands and has concealed material facts from this Forum. The present complaint is an abuse of process of Court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the opposite parties. No consumer dispute survives between the parties. Even from the perusal of entire complaint it becomes quite evident that it does not disclose any cause of action. He further contended that so far as medi-claim policies are concerned, obtained by the Punjab Government under Punjab Government employees and Pensioners Health Insurance Scheme (PGEPHIS) and “As per para No.4 of the Notification No.21/28/12-5HB5/268 dated 20.10.2015, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available”. And as such, the complainant is not entitled to relief as claimed for keeping in view the facts and circumstances of the case and documents. There is no deficiency in service on the part of the opposite parties No.1 and 2 and as such, claim of compensation, claim amount as well as interest is not  payable under the provisions of Consumer Protection Act and the opposite parties are liable to be deleted from the array of opposite parties. The present case involves complicated questions of facts and law and the voluminous evidence is required and the cross examination of witnesses etc. is essential alongwith recording of detail evidence and the controversy involved cannot be adjudicated in a summary proceedings and such like controversy can be adjudicated by Civil Court only which is a proper Forum. Ld. counsel for the complainant prayed for dismissal of the complaint.

8        In the instant case insurance is not disputed. The complainant has produced on record Card Ex. C-2 issued by Punjab Government Employee and Pensioners health Insurance Scheme (PGEPHIS) in which the policy period has been written as 1.1.2016 to 31.12.2016 and during the period of policy i.e. on 24.10.2016 the husband of the complainant namely Inderpal Singh remained admitted in Forties Escort Hospital and he discharged on 28.10.2016  which is very much clear from the document Ex. C-5 issued by Forties Escort Hospital. The complainant has also placed on record Bill dated 28.10.2016 Ex. C-5 which shows that total amount of Rs. 49,287/- has been incurred on the treatment of Inderpal Singh.   As such, the complainant has proved on record that her husband Inderpal Singh took the treatment during the period of Insurance policy in question.

9        Ld. counsel for opposite parties argued that complainant does not fall under the definition of consumer and the present complaint is not maintainable. The policy in question was issued in favour of Government of Punjab, Department of Health and Family Welfare. However, it is also 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 employee of Punjab Government, the complainant was beneficiary under this scheme. The husband of the complainant took treatment during the policy period. The complainant lodged claim for the reimbursement of medical expenses borne by him with opposite parties.

10      Ld. counsel for the opposite party has argued that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and argued that vide Ex. OPs/5 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 the present complaint.

11      Ld Counsel for complainant argued that the opposite parties are liable to make the payment of Rs. 50,000/- and they cannot deduct any amount from the complainant out of claimed amount 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 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. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.  So deficiency stand proved and the opposite party Nos.1 & 2 have incorrectly refused the payment of the claim.

12      In view of the above discussion, the present complaint is allowed and the opposite parties are directed to make the payment of Rs. 49,287/-  (Rs. Forty Nine Thousand two hundred and eighty seven only) i.e. amount of treatment to the complainant. Complainant is also entitled to Rs.5,000/-  (Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs 3,500/- (Rupees Three thousand and five hundred only) as litigation expenses. Opposite Parties No. 1 and 2 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.