BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.114 of 2022
Date of Instt. 07.04.2022
Date of Decision: 17.07.2023
Manmohan Krishan aged about 81 years S/o Hans Raj Sood R/o House No.W.G. 307, G. T. Road, Islamabad, Jalandhar-144001.
..........Complainant
Versus
1. M.D. India Health Insurance TPA Pvt. Ltd. Office of S.No.46/1, E-Space, A-2 Building, 4th Floor, Pune Nagar Road, Vadgaonsheri, Pune 411014 through its Managing Director.
2. The Project Manager, F-539 Mohali Tower Phase 8-B Industrial Area Mohali 160071.
3. The Oriental Insurance Company Ltd through Divisional Manager, 32 GT Road, Opp. Narinder Cinema, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. G. S. Sodhi, Adv. Counsel for the Complainant.
Sh. Brijesh Bakshi, Adv. Counsel for the OPs No.1 & 3.
OP No.2 exparte.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant is retired Punjab Government employee and is covered under the Punjab Govt. Employee & Pensioners Health Insurance Scheme with the M.D. India Health Insurance TPA Pvt. Ltd through The Oriental Insurance Company Ltd. The complainant had filed the previous complaint u/s 12 of the Consumer Protection Act against the same OPs vide Complaint No.62 of 2019 and same had been decided by this Commission on 14.12.2021. This Commission had decided the above said complaint vide order dated 14.12.2021 and directed the complainant to submit the claim for reimbursement in a proper form alongwith the original documents required by the OPs, within 30 working days from the date of receipt of the copy of the order of this Commission and also directed to OPs to decide the Insurance Claim of the complainant for reimbursement within 30 days from the date of receipt of the documents, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant and further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then complainant is at liberty to file a fresh complaint. Complying the order passed by this Commission, the complainant had supplied all the documents to OPs vide letter dated 24.01.2022. In reply the OP issued a letter dated 25-01-2022 asking for original documents from the complainant. On receipt of this letter the complainant again visited the office of the OPs and explained that the original documents have already been submitted with M.D. India Health Insurance TPA Pvt. Ltd on 02- 08-2016. On 31-01-2022, the complainant again sent a complete reply by registered post on 01.02.2022 to the letter of OP's dated 25-01- 2022 that he has submitted all the original documents with the OP's. The OP still replied to the complainant that the original documents were not in their possession vide letter dated 03-02-2022. In reply to the letter of OP dated 03-02-2022, the complainant sent a final reply on 09-02-2022 by registered post and also spoke to OP No.1 MD India Health, who conceded that the original documents of the complainant are in the possession of the OP No.1. In response to reply of the complainant dated 09-02-2022, the OP no.3 issued a cheque No.513750 dated 18.02.2022 for sum of Rs.10,543/- drawn on Axis Bank Ltd in favour of the complainant for reimbursement of the his claim without any detail which is still lying in the possession of the complainant. The complainant claimed Rs.22,184/- as per the amount of the medical bills which were supplied to the OPs, but the OPs have failed to reimburse the full medical claim of the complainant as per the medical bills and have also failed to comply the order of this Commission dated 14.12.2021. Moreover, every time the complainant visited the office of the OP No. 3 to submit the reply or the documents asked for the OP No.3, the Divisional Manager refused to accept the documents and asked the complainant to send the documents by registered post. Due to the above said fraudulent act by the all opposite parties, complainant has suffered mental, physical and financial harassment. The act and conduct of the OPs amounts to deficiency in service and unfair trade practice and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the amount of Rs.22,184/- with interest @ 18% till the disposal of the present complaint or till the payment of the said amount and further may also be directed to pay compensation to the tune of Rs.20,000/- as per the order passed by this Commission, Rs.50,000/- on account of mental harassment plus Rs.30,000/- as litigation expenses or any other additional relief as this Commission may think fit.
2. Notice of the complaint was given to the OPs, but despite service OP No.2 did not appear and ultimately OP No.2 was proceeded against exparte, whereas OPs No.1 & 3 appeared through its counsel and filed joint written reply and contested the complaint by taking preliminary objections that the above noted complaint is not maintainable under the law and liable to be dismissed with costs. It is further averred that the complainant has got no cause of action to file the present complaint against the answering respondents. There has been no default or undue delay, on the part of the answering respondents in processing the claim of the applicant. After the due compliance of the requisites as per the earlier orders of the learned Commission the claim was promptly processed and paid. It is pertinent to mention that PGEPHIS was a tender based policy where rates are defined for everything. As per tender rates, claim is payable for Rs.10543/-. The reimbursement is also only as per the prescribed rates for various medical facilities and treatments as per the scheduled rates of the Scheme. As such while processing the claim on account of the above reasons deductions were made. It is further averred that the claim was promptly processed and passed for payment and reimbursed vide Cheque no.513750 dated 18.02.2022 for the sum of Rs.10,543/-. The payment can only be made as per the Schedule of Rates and OPs are not liable to reimburse any excess payment. Reference is drawn to FA No.870 of 2017 of State Commission decided on 22.05.2018. It is further averred that the complainant is barred by his own act, conduct, laches and negligence from filing the present case and claiming the relief as prayed herein. It is further averred that the complainant is guilty of concealment of material facts and has not approached the Forum with clean hands and as such is not entitled to any relief. The OPs No.1 & 2 have been dragged in to unnecessary litigation hence they are entitled for special compensatory costs of Rs.20,000/-. There is complicated question of law and facts involved in the matter and the same cannot be adjudicated in summary proceedings, therefore this Forum has got no jurisdiction to try and decide the present complaint. It is further averred that from the allegations of the complaint the complainant does not fall under the definition of 'Consumer' under the Consumer Protection Act and thus the complaint is liable to be dismissed. No amount of premium has been charged from the complainant and the Scheme was provided by the Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab as a Health Benefit Scheme free of cost or any kind of charges to its employees and being a beneficial Scheme there is no question of complainant being a consumer of the OPs. It is further averred that the policy was issued in favour of Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab, but the complainant has not impleaded it in the present complainant, therefore the present complaint is liable to be dismissed on this short score alone. It is further averred that it is the prerogative and right of Respondents to process and verify claim as per policy terms and conditions along with prescribed requisites and valuable right conferred by agreement between the parties i.e. the Government and the opposite parties cannot be taken away and as such the present complaint is not maintainable and deserves to be dismissed. On merits, the factum with regard to issuing of medical claim policy by the OP to the complainant is admitted. It is also admitted that the complainant had filed previous complaint and the same was decided, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. As per order passed by this Commission Ex.C-1, the complainant was directed to submit claim for reimbursement in a proper form alongwith original documents. In compliance with this order, the complainant had lodged the claim for reimbursement alongwith documents. As per the letter dated 25.01.2022 Ex.C-5, the OP had admitted the receipt of the documents mentioned in the letter Ex.C-5 and again demanded the original documents. In reply to the letter, the complainant has again written a letter to the OP Ex.C-6, vide which he has mentioned that the documents have already been submitted to the OPs. The complainant has proved on record the correspondence Ex.C-7 to Ex.C-10 between the OP and the complainant. Vide letter Ex.C-11, the claim of the complainant was settled and the amount of Rs.10,543/- was sent to the complainant vide cheque. The claim of the complainant was of Rs.22,184/-, but the complainant was given the amount of Rs.10,543/- as per the alleged prescribed rates for various medical facilities. In the bill breakup mentioned in the written statement, the OP has not given the payment of bill charges, registration charges, dietician charges etc. as the same are not prescribed.
7. The OPs has relied upon the notification Ex.O-1 and Copy of Tender Document/RFP-PGEPHIS Ex.O-2, in which the relevant pages have been mentioned as 1, 2, 9, 14 and 35. Perusal of Ex.O-3 i.e. PGEPHIS shows that in the relevant pages as mentioned in the written statement, there is no rate charges have been mentioned, if one is diagnosed as CAD, Post PTCA to LCX and unstable angina. So, the document Ex.OP-3 relied upon by the OPs is not applicable to the complainant. The OP has failed to prove on record, the schedule of rates of a person suffering from chest pain, dyspne on exertion etc. Thus, the case of the complainant is not covered under exclusion clause. The complainant has submitted all the medical bills to the OP as mentioned in the Ex.C-6. Thus, the act of the OP in not making the payment of the medical bills is a deficiency in service and the OP has failed to point out as to why the less amount from the billed amount has been given to the complainant, therefore, the complainant is entitled for the relief.
8. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay the amount as per bills with interest @ 6% per annum from the date of filing complaint till its realization. If any payment has already been made to the complainant, then the balance amount be paid to the complainant. Further, OPs are directed to pay a compensation to the complainant for mental agony and harassment caused to the complainant, to the tune of Rs.10,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
17.07.2023 Member Member President
