Punjab

Fatehgarh Sahib

RBT/CC/714/2018

Mohinder Lal - Complainant(s)

Versus

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

Suraj Malbhatia

16 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                                    COMMISSION

                                FATEHGARH SAHIB

 

RBT No.	:	CC/714/2018
Complaint No.	:	RBT/CC/714 of 2018
Date of Institution	:	09/07/2018
Date of Decision	:	16/03/2023

                  

Mohinder Lal son of Sh. Late Sh. Tulsi Ram R/o H. No.1125, Pushpak Complex, Sector 49-B, Chandigarh.

                                                                                                                     …………....Complainant

                                                Versus

1.  MD India Health Insurance TPA Pvt. Ltd. Office of the Oriental Insurance Company, F-539, First Floor, Mohali Tower, Phase 8-B, SAS Nagar Mohali through its Authorized signatory.
2. Oriental Insurance Company Ltd., SCO no.99-100, First Floor, Sector 17-B, Chandigarh, through its Authorized signatory.
3. State of Punjab through the Secretary to Govt., Punjab , Education Department, Punjab Mini Secretariat, Sector 9, Chandigarh.
4. Director Public Instructions, Punjab (Secondary Education), Punjab Education Board Complex IX, SAS Nagar, Mohali.

                                                                              ..………....... 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: Sh.S.M.Bhatia, counsel for complainant (through VC).

     None for OP no.2.

     OPs no.1,3 and 4 Ex-Parte

     

Order By

 

MS.SHIVANI  BHARGAVA, MEMBER

 

 The 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 no.1  and 2 to make the reimbursement  of Rs.63,375/-  incurred on his Prostate surgery and to pay Rs.1,00,000/-  as compensation for harassment, mental pain and agony  to the complainant .

2.  The  complainant got  retired as a lecturer on 30.6.2012 from the department of Education, Punjab.  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 Govt. employees & Pensioners health  Insurance  Scheme (PGEPHIS)  to  cover indoor medical treatment expenses specified day care procedures and treatment of chronic disease as specified by the State Government.  The scheme was applicable to all the Punjab Government Employees including the pensioners on  compulsory basis.  This scheme covered medical expenses up to a sum of Rs.3.00 Lac for every employee/pensioner for the period from 1.1.2016 to 31.12.2016 complainant was insured by Oriental Insurance Company  & was issued MD ID  No.MDIS-09915646949. The complainant suffered from prostate disease in the year  2016  and he started his  treatment from the Govt. Medical College and Hospital, Sector 32, Chandigarh. He underwent an operation of prostate from the said hospital in November 2016. He spent Rs.63,375/- ( Rs.45939/- + Rs.17436/-) on his treatment. The complainant submitted the medical bills for reimbursement  in January, 2017 to his parent department i.e The Director Public Instructions, Punjab. The parent department of the complainant did not accept these medical bills on the ground that the same belongs to  PGEPHIS-2016.  The complainant then  submitted the bill on 21.3.2017 to OP No.1. for reimbursement. The Insurance Company  returned these bills to the complainant  vide letter dated 21.3.2017. The OP no.1 rejected the medical bills on the ground that  the bills were submitted in  the office of OP  no.1 after 30 days from date of discharge from hospital, so they are not able to entertain this case for reimbursement under PGEPHIS. Hence this complaint.
3. Notice of the complaint was given to the OPs no.1 to 4 through registered Post. OP no. 2 appeared  through his Counsel and filed  written version. OPs no.3 and 4 appeared through their representative and filed joint  version on 22.11.2018. OP no.1 did not appear despite service of summons as such OP no.1 was proceeded against Ex-Parte for non appearance vide order dated 20.9.2018. On the stage  of arguments, OPs no.3 and 4 did not appear  and  proceeded against  Ex-Parte vide order dated 1.2.2021
4.  The OP 2 filed written version raising legal  objections that there is no deficiency or illegality in repudiating the claim as per terms and conditions of the Insurance policy issued by Government of Punjab, Department of Health and family welfare.  Otherwise also there is no privity of Insurance contract between the complainant and OP no.2.  The claim was rightly repudiated by OP  as per the terms of Insurance Policy scheme. As per condition no.11.6 of terms of PGEPHIS,  the beneficiary shall  be eligible for reimbursement subject to submission of the claim to TPA within 30 days of the date of discharge from the hospital and the  reimbursement shall be  made at Govt. Hospital  rates or PGEPHIS rate, whichever is less.  The complainant  was admitted in hospital on 7.11.2016 and  discharged on 30.11.2016. The medical bills and treatment record was submitted to TPA after 30 days from the date of discharge from the hospital as such the claim was rightly repudiated by OP no.1 vide letter dated 21.3.2017 in accordance with terms and conditions of Insurance scheme.   Hence prayer for dismissal of complaint has been made by OP no.2.
5. The OPs 3 and 4 filed joint written version raising  legal  objections that dispute entirely pertains between  the complainant and OPs no.1 and 2. The complainant got his treatment  in November 2016 from the Government Medical College & hospital, Sec-32,Chandigarh. The Medical reimbursement is to be made by OPs no.1 & 2 under PGEPHIS-2016. Hence prayer of dismissal of complaint has been made.
6.                The complainant in support of his complaint tendered in evidence his  affidavit Ex.CW1/1 along with documents i.e  Ex.C1 copy of  notification  by Govt. Of Punjab, Department of Health and family welfare, Ex.C2 copy of  PGEPHIS e-card, Ex.C3 and Ex.C4  bills of treatment , Ex.C5 claim  rejection by TPA and closed the evidence.  In rebuttal the OP no.2 tendered in evidence Ex.OP2/1 affidavit of Renu Garg, Division Manager, Oriental Insurance Co.  Ltd., Chandigarh, Ex.OP2/2 affidavit of Md. Samiyoddin Patel authorized signatory of MD India Health Insurance TPA.,   alongwith copies of documents i.e Ex.OP2/3 notification by Department of Health & Family  welfare in Punjab  Govt. Gazette,  Ex.OP2/4 Insurance Policy, Ex.OP2/5 Terms of PGEPHIS, Ex.OP2/6 repudiation of claim and closed the evidence. OPs no.3 and 4   jointly tendered Ex.OP3/1 affidavit of Jyoti Chawla Assistant Director office of D.P.A(SE)SAS Nagar Mohali and closed the evidence
7.  Heard. Entire record perused.  
8.   Admittedly, Punjab Govt. launched a  scheme for cashless mediclaim  for their employees &  Pensioners  namely  PGEPHIS-2016 i.e Punjab Govt. Employees & Pensioners  Health Insurance Scheme and made a contract  with OPs no.1 and 2. The premium was paid by  State Govt. Being a Pensioner  of Punjab Govt. , complainant was beneficiary  under this Scheme. The Medical bills  were to be reimbursed by the Insurance Company not by the  department. OPs no.1 and 2 rejected his claim on ground of delay.

The Ld. Counsel for the complainant has placed reliance upon the Judgement by Punjab & Haryana High Court in Taro Devi Vs Chief Engineer 2017-4 PLR-299. Where in it has been held that reimbursement can not be denied on the ground of delay in submitting the medical bills.

This argument of the complainant wasrebutted by the Ld. Counsel for the OP no.2 and hehas placed reliance upon the Judgement byHon’ble Supreme Court in M/s Suraj Mal Ram  Niwas  Oil Mill Vs. UIIC 2011 AIR SC (Civil)903, Vikram Green Tech (I) Ltd & another Vs. New India Assurance Co. Ltd. 2009(2) RCR (Civil)817, where in it has been held that

the contract of Insurance , rights & obligations are strictly governed by the terms ofthe Policy and no exceptions of relaxation can be given on the ground of equity.

9.  From the perusal of the record, we find  that  complainant    had lodged  his claim with  OP no.1. OP no.1 rejected his claim on ground of delay vide Ex.OP2/6. We are of the considered opinion that rejection of claim purely on  technical ground will result  in policy holder’ loosing  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 with in specific time  frame. It is also necessary to mention that  it would not be fair &  reasonable to reject  genuine claim.   As per circular issued by Insurance Regulatory Development authority- IRDA/HLTH/MISC/CIR/216/09/2011, a genuine claim  can not 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 .

According to notification issued by Punjab Govt, Department of Health & Familywelfare dated 20.10.2015, Clause-5 there are certain treatments which are not covered under health insurance as per the insuranceRegulatory Development Authority (IRDA) vide Ex.OP2/3.

If treatment is given under the guidelines laid down by IRDA as mentioned in notification then one can not escape from its liability to reimburse the claim becauseIRDA Under Section -34(I) of Insurance Act, 1938 vide no IRDA/NL/MISC/CIR/214/10/2016dated 28.10.2016 clarifying that the circular dated 20.09.2011 is binding upon the Insurer. The OPs have not furnished any list showing the paymentafter deduction as perrules. Therefore,the amount submitted by the complainant is to be taken as correct. There is no averment against OPs no.3 and 4. They arejust proforma OPs.

10.        As a corollary of our   above discussion, the  present complaint is partly allowed.  OP no.2 is held liable for deficiency in service. OP  no.1 is claim processing agency who is just to process the claim at the asking of the  Insurer i.e OP no.2. The cashless mediclaim  is to be reimbursed by OP no.2 i.e Oriental Insurance Company. So OP no.2 is liable to pay the claim. The OP no.2 is directed:-

[a] Toreimburse the amount of Rs.63,375/- paid by the complainant on his treatment along with interest @ 6% P.A from the date of filing of complaint within 30 days failing which interest @ 9% P.A. shall be payable.

[b] To paya sum of Rs. 10,000/- as compensation for harassment and mental agony to the complainant.

Compliance of the order be made by the OP no.2 within 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 due to pandemic of Covid-19. Copy of this order be sent to the complainant and the OPs as per rules. File be sent to District Consumer Disputes Redressal Commission, Mohali, for consignment .

Pronounced 16 March 2023                 

                                                                           (S. K. Aggarwal)

                                                                              President

                                                                    

    

                                                                                   (Shivani Bhargava)

                                                                              Member

 

                                                                                    ( Manjit Singh Bhinder )

                                                                                                                                       Member