Before the District Consumer Disputes Redressal Forum, Room No. 208 2nd Floor, District Administrative Complex, Tarn Taran
Consumer Complaint No : 29 of 2017
Date of Institution : 04.05.2017
Date of Decision : 09.05.2019
Joginder Singh son of Darshan Singh resident of VPO Magindpura, Tehsil & District Tarn Taran.
...Complainant
Versus
- M.D. India Health Care Service (TPA) Pvt. Ltd. Phase-I Industry Area, Mohali, Punjab through M.D.
- 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 Party No.1 Ex Parte
For Opposite Party No. 2 Sh. D.K. Kundra Advocate
ORDERS:
Charanjit Singh, President;
1 The complainant Joginder 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 and another (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to reimburse the whole sum assured amount of Rs. 2,84,105/- alongwith interest at the rate of 18% P.A to the complainant and prayed Rs.50,000/- as compensation and Rs. 20,000/- as litigation expenses.
2 The case of the complainant in brief is that the complainant is a retired government employee and was serving in Punjab Police at 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 Employee, after they pay the expenses for the pre and post hospitalization to their treatment. The complainant fell ill and was hospitalized with the Fortis Escort Hospital, on 03.10.2016 to 13.10.2016 and spent Rs.2,84,105/- on his treatment i.e. surgery of the heart which was paid by him to the Fortis Escort Hospital. After 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 the accounts Branch SSP Office Tarn Taran as per the procedure laid for the same. The cause of action has arisen in favour the complainant against the opposite parties on 16.3.2017 when the opposite parties sent a letter dated 16.3.2017 and denied the Insurance claim and reimbursement to the complainant hence this complaint. Feeling dissatisfied by the act and conduct of the opposite parties, the complainant perforce has filed this complaint against the opposite party.
3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 2 appeared through counsel and filed written version contesting the complaint on the preliminary objections that the present complaint is not maintainable in the eyes of law because there is no privity of contract between the complainant and the Insurance company. The complainant has not paid any premium to the insurance Company to cover the risk and therefore, the present complaint is liable to be dismissed. The complainant was also not covered under the Punjab Government Employee Pensioner Insurance Scheme because the enrollment is closed by 30.6.2016 and the claim has been rejected by the Opposite Party No.1. The complainant has got no locus standi to file the present complaint because alongwith the complaint there are no rules attached which will clarify that he is entitle for reimbursement as per his version the policy is for cashless and not for reimbursement. The complainant has no locus standi to file the present complaint because as per condition No.21 of the scheme the mechanism with regard to dispute Resolution and Grievance Redressal committee in each District which will constitute following members.
- Deputy Commissioner
- Civil Surgeon
- Deputy Medical commissioner
- Representative of Insurance Company.
The said committee will resolve the grievance within 20 days from the date of application. It has not taken prior to filling the present complaint. In these circumstance, the complainant cannot take benefit on his own wrongs and in the absence of any deficiency on the part of the complainant. The complaint is liable to be dismissed on this ground alone. On merits, the opposite party no. 2 has reiterated the stand as taken in the preliminary objections and denied the other contents of the complaint and prayed for dismissal of the complaint.
4 Notice sent to the opposite party No. 1 but none appeared on behalf of opposite party No. 1, therefore, the opposite party No. 1 was proceeded against exparte vide order dated 22.6.2017 of this Forum.
5 To prove his case, Ld. counsel for the complainant tendered in evidence affidavit of Joginder Singh complainant Ex. C-1 alongwith documents Ex. C-2 to Ex. C- 11 and closed the evidence. Opposite Party 2 tendered in evidence affidavit of Sh. R.K. Sharma Ex. OP2/1 alongwith documents Ex. OP2/2 , Ex. OP2/3 and closed the evidence.
6 We have heard the Ld. Counsel for the complainant and opposite party No. 2 and have gone through the evidence and documents placed on the file by the parties.
7 Ld. counsel for the complainant contended that the complainant is a retired government employee and was serving in Punjab Police at 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 Employee, after they pay the expenses for the pre and post hospitalization to their treatment. The complainant fell ill and was hospitalized with the Fortis Escort Hospital, on 03.10.2016 to 13.10.2016 and spent Rs.2,84,105/- on his treatment i.e. surgery of the heart which was paid by him to the Fortis Escort Hospital vide Ex. C-5. He further contended that after 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 the accounts Branch SSP Office Tarn Taran as per the procedure laid for the same. He further contended that the cause of action has arisen in favour the complainant against the opposite parties on 16.3.2017 when the opposite parties sent a letter dated 16.3.2017 and denied the Insurance claim and reimbursement to the complainant and prayed that the present complaint may be allowed.
8 The Ld. counsel for the opposite party No. 2 contended that the present complaint is not maintainable in the eyes of law because there is no privity of contract between the complainant and the Insurance Company. The complainant has not paid any premium to the insurance Company to cover the risk and therefore, the present complaint is liable to be dismissed. The complainant was also not covered under the Punjab Government Employee Pensioner Insurance Scheme because the enrollment is closed by 30.6.2016 and the claim has been rejected by the Opposite Party No.1. The complainant has got no locus standi to file the present complaint because alongwith the complaint there are no rules attached which will clarify that he is entitle for reimbursement as per his version the policy is for cashless and not for reimbursement. The complainant has no locus standi to file the present complaint because as per condition No.21 of the scheme the mechanism with regard to dispute Resolution and Grievance Redressal committee in each District which will constitute following members.
- Deputy Commissioner
- Civil Surgeon
- Deputy Medical commissioner
- Representative of Insurance Company.
He further contended that the said committee will resolve the grievance within 20 days from the date of application. It has not taken prior to filling the present complain. In these circumstance, the complainant cannot take benefit on his own wrongs and in the absence of any deficiency on the part of the complainant. The complaint is liable to be dismissed on this ground alone. Ld. counsel for the opposite party No. 2 has prayed for dismissal of the complaint.
9 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.
10 The other objection taken by the opposite party No. 2 is that the complainant has not paid any premium to the Insurance Company to cover the risk and therefore, the present complaint is liable to be dismissed. The complainant was also not covered under the Punjab Government Employee Pensioner Insurance Scheme because the enrollment is closed by 30.6.2016 and the claim has been rejected by the Opposite Party No.1. Rather the complainant has placed on record Ex. C-10 vide which the complainant sought information regarding forms sent under group insurance for the year 2015-16 to the Oriental Insurance Company Ltd. from Senior Superintendent of Police Cum Public Information Officer Tarn Taran under Right to Information Act. Senior Superintendent of Police Cum Public Information Officer Tarn Taran vide its letter No. 4009 PRTI dated 22.6.2018 has mentioned that the form of the complainant was deposited vide receipt No. 25235 dated 15.11.2015. The list of the forms sent to the insurance company are also given to the complainant. There is also one acknowledgement bearing receipt No.25235 dated 15.11.2015 for receiving 311+78=389 forms from the SSP office Tarn Taran and there is also seal with signatures of TPA representative. The certified copy of list annexed with C-10 shows that there is name of Joginder Singh ASI i.e. complainant at serial No. 64. In this way, the complainant has proved on record that the Police Department i.e. SSP office Account Branch Tarn Taran has sent the form of the complainant and the same has been acknowledged by the opposite party No. 1 vide receipt No. 25235 dated 15.11.2015. The opposite party No. 1 has received the total forms No. 389 including the form of the complainant as the name of the complainant is showing at serial No. 64 of the Form. As such, the plea of the opposite party No. 2 that the complainant is not insured with the opposite party No. 2 is totally false. The form with list containing the name of the complainant has been duly sent to the opposite parties. It is usual with the insurance companies to show green pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of excuses to deny the claim. Reliance in this connection can be had on the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All 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 clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.”
Therefore, repudiation of the claim of the complainant in such an event is not justified at all. The complainant has fully proved on record that he received some heart problem and he remained in the hospital as indoor patient and remained admitted in Forties Escort Hospital Majitha Verka Bypass Road Amritsar from 3.10.2016 to 13.10.2016 vide Ex. C-3, Ex. C-4, Ex. C-5, C-8 and the complainant has also proved on record that the complainant has spent Rs. 2,84,105/- on his treatment vide Ex. C-5 and the complainant has made the payment from his own pocket to the concerned Hospital.
11 In view of the above discussion, the present complaint is allowed and the opposite parties are directed to release a sum of Rs. 2,84,105/- (Rs. Two Lacs Eighty Four Thousand one hundred and five only) to the complainant. Complainant is also entitled to Rs. 10,000/- ( Rs. Ten Thousand only) as compensation on account of harassment and mental agony and Rs 5,000/- (Rupees Five Thousand only) as litigation expenses. Opposite Parties 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.
