DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.02 of 2019
Date of institution: 02.01.2019 Date of decision : 15.01.2019
Gurmeet Singh R/o H.No. 581, Sector 78, Mohali working as a Senior Assistant at District Education Office (DEO) Elementary Punjab at Mohali
…….Complainant
Versus
- MD India TPA Pvt Ltd, office at Maxpro Info Park, D-38, First Floor, Industrial Area, Phase-1, Mohali, Punjab -160056 through Manager.
- MD India TPA Pvt Ltd, Mohali Tower, First Floor, F-539, Industrial Area, Phase-8-B, Mohalii-160071 through its Regional Manager.
- MD India TPA Pvt Ltd, S.No. 46/1, E-Space, A-2 Building 3rd floor, Puna Nagar Road, Vadgaonsheri, Puna 411014, through its Managing Director.
- Any other necessary party (Insurance Company) to be disclosed by the OP Nos.1,2 and 3.
……..Opposite Parties
Complaint under Section 12 of
the Consumer Protection Act.
Quorum: Shri G.K. Dhir, President,
Mrs. Natasha Chopra, Member.
Present: Shri Sandeep Singh Lakha, counsel for complainant.
Order by :- Shri G.K. Dhir, President.
Order
Complainant claims to be working as Senior Assistant in office of DEO Elementary Punjab at Mohali. As per the scheme of the Punjab Govt., Employees and Pensioners Health Insurance, the complainant is insured like other employees. On 21.11.2016 at about 9.00 A.M, son of the complainant namely Jatinderbeer Singh accidentally fell down from motorcycle near Gurudwara Singh Shahidan Sohana and as such treatment to him was got provided from Chawla Nursing Home, Phase-7 Mohali. Operation of the left leg of son of the complainant was performed and thereafter he was discharged on 25.11.2016. Total expenses on this treatment alleged to be of Rs. 61,000/-. In 2016, the Punjab Govt. had a pact with the OPs for disbursal of all the medical bills of the employees. So the complainant approached Op No.1 at Mohali on 05.01.2016 for submission of the bills, but OP No.1 refused to entertain these bills by claiming that submission of the claim must have been within 30 days from discharge from the hospital. Moreover OP No.1 claimed that pact with Punjab Govt. was up till December, 2016. Medical bills were signed by the concerned doctor on 05.01.2017 because of prior busy schedule of the doctor and that is why the bills submitted after being signed by the concerned doctor. OP No.1 returned the application by endorsing remarks that claims of the year, 2016 are to be reimbursed by the insurance company. Act of the OPs in not accepting the bills alleged to be unprofessional and deficiency in service and as such this complaint filed for seeking reimbursement of incurred medical expenses of Rs.61,000/-. Compensation for mental agony and harassments of Rs. 50,000/- and litigation expenses of Rs. 10,000/- more claimed.
2. Arguments for the purposes of admission heard.
3. Claim under the insurance pact by the insurer concerned with Punjab Govt. is maintainable against the insurance company and not against the TPA, to whom the claim for processing to be marked by the insurance company. Endorsement Ex C-9 is made by the Deputy District Education Officer (EE), Mohali and not by any of the OPs. So submission put forth through oral arguments or through affidavit or written complaint has no force that return of the medical bills was done by the Ops of this case . Rather the documentary evidence annexed with the complaint shows that return of the bills was made by the DEO, under whom the complainant is working. Even application Ex C-8 is addressed to DEO, SAS Nagar, Mohali for reimbursement of the medical bills. That DEO has not been impleaded as a party in this case. The claim is payable by the insurer and not by the claim processing agency and as such complaint against OP Nos. 1 to 3 is not maintainable.
4. Counsel for the complainant vehemently contends that OP Nos.1 to 3 alone can disclose the name of the insurance company with whom Punjab Govt. was having pact regarding reimbursement of the insurance claim of its employees. That submission has no force because the name of the insurer can be ascertained from the office of DEO or Director Health Services Punjab and as such submission advanced by counsel for the complainant has no force that only OP Nos.1 to 3 can disclose the name of the insurer. Name of the insurer can be got ascertained by filing application under RTI Act with the employer or with the Director Health Services Punjab but that effort has not been done at all by the complainant and nor any of them impleaded as party. MD India TPA Pvt. Ltd at the most is an agent of the insurer, whose name can certainly be ascertained by the complainant by making efforts as aforesaid and as such in view of Section 226 of the Indian Contract Act, the complaint against OP Nos. 1 to 3 is not maintainable. This is so because liability of reimbursing the incurred medical expenses remains of the insurer and not of the agent, who is just to process the claim at the asking of the insurer. As insurer, albeit is principal, but same has not been impleaded as a party and as such complaint against MD TPA Pvt. Ltd not maintainable because there is nothing produced on the record to suggest that OP Nos. 1 to 3 or any of them was ever approached by the complainant. Rather approach made to DEO as referred above by filing application Ex C-8 and as such prime facie case of deficiency in service of impleaded OPs is not made out.
5. As a sequel of the above discussion, complaint dismissed at admission stage itself but with the observation that the complainant after tracing the insurer may file fresh complaint. Certified copy of the order be supplied to the complainant as per rules and thereafter the file be consigned to the record room. Certified copies of the order be supplied to the complainant as per rules. File be indexed and consigned to record room.
Announced
January 15, 2019.
(G.K. Dhir)
President
(Mrs. Natasha Chopra)
Member
