Punjab

Fatehgarh Sahib

RBT/CC/1176/2018

Jasbir Kaur - Complainant(s)

Versus

M.d India Health Insurance TPA Pvt Ltd. - Opp.Party(s)

Suresh Kumar

15 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

COMMISSION, FATEHGARH SAHIB

 

RBT No.	:	CC/1176/2018
Complaint No.	:	RBT/CC/1176 of 2018
Date of Institution	:	14/11/2018
Date of Decision	:	15/06/2023

               

Jasbir Kaur wife of Late Sh. Rattan Singh R/o House no.297, Sector 46-A, Chandigarh .

                                ………....Complainant

                                        Versus

1.  MD India Health Insurance TPA Pvt. Ltd., Mohali Tower, Plot no.F-539, Airport Road, Industrial Area, Phase VIII-B, Mohali , Punjab through its Managing Director.
2. Excise & Taxation Commissioner, Punjab, Bhupindra Road, Patiala, Punjab.                                                                                                                                                                                                                                                                                                                                                                                                          
3. The Assistant Excise & Taxation Commissioner, Excise Bhawan, Sector 69, SAS Nagar, Mohali, Punjab.

                                                                …………..Opposite Parties

Complaint under Section 12 of Consumer Protection Act 1986 (Old).

Quorum

Sh. S.K.Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

Present: None  for complainant.

     None for OPs.

          

PER MS. SHIVANI BHARGAVA, MEMBER:

      This complaint has been filed against the OPs (opposite parties) under Section 12 of Consumer Protection Act, 1986 (old) alleging deficiency in service with the prayer to give directions to the OPs to make the reimbursement of Rs.1,35,827/- along with interest @ 12% P.A., to pay Rs.20,000/-, as compensation, for harassment and mental agony and to pay Rs.15,000/-, as litigation expenses  to the complainant.

2.     The case of the complainant is that the husband of the complainant, Late Rattan Singh joined the office of OP No.2 in year 1980 and retired as Excise Inspector in October, 1999. The Punjab Government through Department of Health & Family Welfare, vide its notification No./21/28/12-5HB5/268 dated 20.10.2015 introduced a Cashless Health Insurance Scheme PGEPHIS-2016 i.e.  Punjab Government Employees and Pensioners Health Insurance  Scheme to  cover indoor medical treatment expenses, specified day care procedures and treatment of chronic disease as specified by the State Government.  The Insurance scheme covered the serving Punjab Government Employees including the pensioners and their family members, who got enrolled themselves under the said Scheme. The husband of the complainant complained regarding breathlessness and fever in November, 2016. He was taken to Govt. Medical College and Hospital, Sector 32, Chandigarh but due to non- availability of ventilator, he was shifted to Sri Guru Harkrishan Sahib Hospital, Sohana on 5.11.2016 for treatment. He died during the treatment on 11.11.2016. After his death, the complainant submitted the medical bills of Rs.1,35,827/- for reimbursement in May, 2017 to OP No.3. But OP No.3 did not accept the said medical bills on the ground that the same related to year 2016 PGEPHIS and according to the Govt. Instructions the reimbursement for the medical bills for the said period will be made by Health Insurance Company, vide letter dated 10.5.2017. The complainant visited OP No.1 and it refused to entertain the application for reimbursement of medical bill on the ground of delay in submitting the same.  The complainant served the legal notice dated 11.9.2017. OP No.1 replied that the claim was not submitted within 30 days of discharge from hospital and, as such, the claim was repudiated being time barred.  Hence this complaint.

3.     Notice of the complaint was given to the OPs through registered post. OP-1 appeared through counsel and filed written version. OPs No.2 and 3 appeared through their representative and filed joint version.

4.     OP 1 contested the complaint and filed written version raising various legal objections that the Government of Punjab,  Department of Health and Family Welfare had introduced Cashless Health Insurance Scheme (PGEPHIS), vide notification  No.21/28/12/5HB5/268 dated 20.10.2015 for covering indoor medical treatment expenses  through OP1.  There is no privity of contract between the complainant and OP no.1.  The complainant has not made the Oriental Insurance Company Limited, as a necessary party, which had issued the insurance Policy. The treatment was to be taken on cashless basis and no reimbursement was available to employee/pensioner in Punjab, Chandigarh and Panchkula where cashless treatment was available.  The State Government through tendering process had selected Oriental Insurance Co. Ltd. and the coverage was available for Rs.3,00,000/. The bills were submitted to OP no.1 but the same were returned back as the same were submitted after a delay of more than 30 days from the date of discharge from the Hospital.  The husband of the complainant expired on 11.11.2016 and the complainant approached OP No.1 on 10.5.2017 after the delay of 5 months, 4 weeks and 1 day.  Therefore, the claim file was returned back to the complainant. The complainant has submitted the bills after a considerable delay. Denying any deficiency in service on its part OP No.1 prayed for dismissal of the complaint with costs.

5.     OPs Nos.2 and 3 contested the complaint and filed joint written version by raising various legal objections that the husband of the complainant retired as Excise Inspector from Excise Department. The complainant approached the OPs in the month of May, 2017 for reimbursement of the medical bills of her husband. Department of Health and Family Welfare of Punjab Government had introduced Cashless Health Insurance Scheme (PGEPHIS) 2016, vide notification No.21/28/12/5HB5/268 dated 20.10.2015 for covering indoor medical treatment expenses, specified day care procedures and treatment of Chronic diseases as specified by the State Govt. for the year 2016. The Insurance Scheme covered the serving State Govt. Employees and pensioners and their family members.  As such the complainant was advised, vide letter dated 22.5.2017 to approach insurance Company for reimbursement of the medical bills. Hence OPs no.2 and 3 prayed for dismissal of complaint.

6.     The complainant in support of her complaint produced her own affidavit dated 29.10.2018 along with documents i.e. copy of  notification by Govt. Of Punjab, Department of Health and Family Welfare as Ex.C-1, copy of death summary of husband of the complainant as of Ex.C-2, copy of Death Certificate as Ex.C3, copy of Claim Application as Ex.C4, copy of letter dated 22.5.2017 issued by OP No.3 as Ex.C5, copy of legal notice as Ex.C6, copy of reply dated 14.11.2017 as Ex.C7, copy of letter dated 13.11.2017 as Ex.C8 and copy of essential certificate showing the amount of Rs.1,35,827/- as Ex.C9. 

7.     In rebuttal OP No.1 produced the affidavit of Md. Samiyoddin Patel, Authorized Signatory for MD India Health Insurance TPA Pvt. Ltd and documents along with written reply i.e. copy of Insurance Policy as Ex.OP1/1 and copy of e-mail dated 20.6.2019 as Ex.OP1/2.  OPs Nos.2 and 3 tendered affidavit of Paramjit Singh, Assistant Excise and Taxation Commissioner along with copies of documents i.e. reply to legal notice as Annexure OP2/1 and copy of letter No.793 dated 22.5.2017 as Annexure C-5.          

8.     As none appeared for the parties and the case belongs to year 2018, we have proceeded to decide this complaint by going through the pleadings of the parties and the evidence on record.  We have carefully gone through the records of the case.    

9.     Admittedly, Punjab Govt. launched a scheme for cashless mediclaim  for its employees and  Pensioners;  namely,  PGEPHIS-2016 i.e. Punjab Govt. Employees and Pensioners  Health Insurance Scheme. The premium was paid by State Government. Being a Pensioner of Punjab Government the husband of the complainant was beneficiary under the said Scheme. The husband of the complainant died in November, 2016 during his treatment in Hospital, which is evident from the Death Summary, Ex.C2, issued by Sri Guru Harkrishan Sahib (C) Eye Hospital (Trust), Sohana.  The complainant spent Rs.1,35,827/- on treatment of her husband in hospital and the details of bills have been given in Essential Certificate, Ex.C9. She filed claim for reimbursement in May 2017. OP1 repudiated her claim on the ground of delay i.e. not submitted within 30 days from date of discharge from hospital and as such the claim was repudiated being time barred and in violation of  terms and conditions of Insurance Scheme, which is clearly mentioned in reply dated 14.11.2017, Ex.C-7 to the legal notice issued by the complainant.

10.      From the perusal of the record, we find that the complainant is an old widow.  After the death of her husband i.e. beneficiary of the insurance policy being pensioner of the Government of Punjab, she was in shock and she did not know about the PGEPHIS-2016. She filed claim to OP Nos.2 and 3 being the concerned Department.  We are of the considered opinion that rejection of claim purely on technical ground will result in policy holder’s losing confidence in Insurance Companies, giving rise to excessive litigation.  Insurance Companies should not repudiate the claim unless they are convinced that claim would not have been admissible even if reported within the specified time-frame. As per circular issued by Insurance Regulatory Development authority- IRDA/HLTH/MISC/CIR/216/09/2011, a genuine claim cannot be outrightly rejected on ground of delay.  The insurer is required to  enquire from the claimant as to what was the reason for delay in submission of the claim.

12.       As a corollary of our above discussion and keeping in view the facts of present complaint, the same is hereby partly allowed.  Therefore, OP No.1 is held liable for deficiency in service. OPs Nos.2 and 3 are not held liable to pay claim being the concerned Department because in year 2016, Punjab Government started PGEPHIS, cashless mediclaim scheme for its employees/pensioners and claim related to year 2016 as per Ex.C9. OP1 has not furnished any list showing the payment after deduction as per rules. Thus,  the amount submitted by complainant is to be taken as correct. So OP no.1 is liable to pay the insurance claim. OP no.1 is directed as under:-

[a]        To  reimburse the amount of Rs.1,35,827/- paid by the husband of the complainant  on his treatment along with interest @ 9% P.A. from the date of filing of complaint till actual realization to the complainant within a period of 30 days from the date of receipt of certified copy of this order, failing which rate of interest shall be 12% P.A. instead of 9% P.A. and

[b]       To pay a sum of Rs.30,000/-, as compensation, for harassment and mental agony to the complainant including litigation expenses.

Compliance of the order shall be made by OP No.1 within a period of 30 days from the date of receipt of certified copy of this order, failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19 and paucity of staff.  Copy of this order be sent to the parties as per rules. File be sent to District Consumer Disputes Redressal Commission, Mohali, for consignment.

 

(S.K. AGGARWAL)

     PRESIDENT

 

 

 

(MS. SHIVANI BHARGAVA)

                MEMBER

 

 

 

 (MANJIT SINGH BHINDER)

                MEMBER

Pronounced on : 15.06.2023