Punjab

Sangrur

CC/366/2018

Jasvir Kaur - Complainant(s)

Versus

M.D.India Health Care Service Private Limited - Opp.Party(s)

Sh.Rajav Kapil

18 Jan 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR                                           

               

                                                Complaint No.  366

                                                Instituted on:    05.09.2018

                                                Decided on:       18.01.2021

 

Jasvir Kaur wife of Balbir Singh, resident of Village Kamalpur, Tehsil Sunam, District Sangrur.

                                                        …Complainant

                                Versus

1.             M.D. India Health Care Services (TPA) Pvt. Ltd. through its Managing Director, PGEPHIS, Claim Department, Maxpro Infro Park,D-38, First Floor, Phase-I, Industrial Area, Mohali 160055.

2.             United India Insurance Co. Ltd. through its District Manager, Sangrur 148001.

3.             United India Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh 160030.

4.             State of Punjab through District Collector, Sangrur 148001.

5.             Department of Health and Family Welfare, Punjab Pariwar Kalyan Bhawan, Sector 34, Chandigarh 160022.

                                                                ..Opposite parties

 

For the complainant  :               Shri Rajan Kapil, Adv.

For OP No.1 to 3      :               Shri Ashish Garg, Adv.

For OP NO.4&5                :               Shri Vinay Jindal, Adv.

 

Quorum:   Shri Jasjit Singh Bhinder, President

                Shri V.K.Gulati, Member

Order by : Shri Jasjit Singh Bhinder, President.

 

1.             Smt. Jasvir Kaur, complainant  has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that Opposite party number 4 in collaboration with OP number 1 and 5 launched a smart card cashless health insurance scheme called “Bhagat Puran Singh Sehat Bima Yojna” in Punjab and the scheme covers those families of Punjab which are covered under the Atta Dal Scheme of Punjab Govt.  Opposite party number 4 appointed OP number 2 and 3 to provide the insurance cover for Bhagat Puran Singh Sehat Bima Yojna.  The complainant and her husband namely Balveer Singh were also the member of the said scheme under smart card number 0305300485039819. It is further averred that the accidental death of head of family was also covered in the above said scheme and Rs.5 lacs were to be given to the family.  Further it is averred that in this regard a news item was also published in Ajit newspaper on 5.6.2016.  Further case of the complainant is that the husband of the complainant met with an accident and died on 13.6.2017 and after accident he was admitted in the PGI.  DDR number 26 dated 28.8.2016 was also recorded at Police Post Ram Nagar, PS Sadar, Samana.  Further the complainant approached the Ops for payment of the insurance claim amount of Rs.5,00,000/- but nothing was paid. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.5,00,000/- along with interest from the date of death till its actual payment and further claimed compensation and litigation expenses.

 

2.             In reply filed by the Ops number 1 to 3, legal objections are taken up on the grounds that the complainant has dragged the Ops into unwanted litigation, that there are complicated questions of law and facts involved in the present complaint, that the complainant is not a consumer of the Ops and that the complaint is not maintainable before this Forum as such prayed for dismissal of the complaint with special costs.

 

3.             In reply filed by Ops number 4 and 5, legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has got no cause of action, that the complainant has not come to the Forum with clean hands and that this Forum has got no jurisdiction to hear and try the present complaint.  On merits, it is admitted that health card in question was issued in the name of complainant Jasvir Kaur only under the scheme launched by Govt. of Punjab under Bhagat Puran Singh Sehat Bima Yojna.  As per terms and conditions, only Jasvir Kaur being card holder is insured and being head of the family vide policy number 11210048161800000106.  The OP wrote a letter dated 11.7.2017 to the Senior Divisional Manager of United India Insurance Co. Ltd. to extend the above said policy upto 31.3.2018 and made the necessary payment as insurance premium to OP number 1.  As per this policy only head of the family is entitled to get any claim. Balbir Singh deceased was not head of the family, so the complainant is not entitled to get any claim of her husband Balbir Singh. It has been denied that husband of the complainant was a member of the said scheme.  It is also denied that the card in question was issued in the name of husband of the complainant as the card was issued in the name of Jasvir Kaur only. It is stated further that the claim has rightly been repudiated.  Lastly, the Ops have prayed for dismissal of the complaint with special costs.

 

4.             The learned counsel for the parties produced their respective evidence.

 

5.             We have perused the complaint, version of the opposite parties and heard the arguments of the learned counsel for the parties.

 

6.             The learned counsel for the complainant has argued that opposite party number 4 in collaboration with OP number 1 and 5 launched a smart card cashless health insurance scheme called as “Bhagat Puran Singh Sehat Bima Yojna” in Punjab and the scheme covers those families of Punjab which are covered under the Atta Dal Scheme of Punjab Govt. The  Opposite party number 4 appointed OP number 2 and 3 i.e. United India Insurance Co. Ltd. to provide the insurance cover for Bhagat Puran Singh Sehat Bima Yojna.  Further the learned counsel argued that Jasvir Kaur was the card holder and her husband died in an accident.  The learned counsel further argued that despite that no claim amount has been paid to the complainant, as such it is prayed that the complaint be allowed. 

 

7.             On the other hand, the learned counsel for the Ops have argued that as per the rules and regulations the accidental death cover is available only to the head of the family of the enrolled beneficiary family.  The learned counsel for the Ops further argued that except head of the family in whose name the card is standing, no claim is payable.  The learned counsel further argued that the remaining members are entitled for the accidental benefit and not death benefits, as such it is stated that the complaint be dismissed.

 

8.             To prove her case, the complainant has tendered her affidavit Ex.C-1. The scheme of the State Govt. is Ex.OP2&3/1 and at page number 35, it is mentioned :-

“ACCIDENTAL DEATH AND PERMANENT DISABILITY COVER:

 

1.     This cover shall be available to the Head of the family of the enrolled Beneficiary Family Unit and will include accidental death, and permanent total disability resulting solely/and directly from any kind of accident caused by external and visible means, such accidents occurring within the period of insurance policy, that will include the following:-

 

1. Burning
2. Ashyxia caused by room heating
3. Drowning
4. Washing away in floods, avalanches, landslides
5. Electrocution
6. Snake/insect bite
7. Attack by wild/rabid animals
8. Earthquakes
9. Cyclones
10. Acts of terrorism
11. Collapse of roof”

 

 

9.             As per the rules and regulations, accidental death cover can only be available to the head of the family of the enrolled Beneficiary Unit.  So, it is clear that in the present case, as per the card Ex.C-3 of Bhagat Puran Singh Sehat Bima Yojna and as per the rules as mentioned above, the accidental death claim cover is available only to the head of the family.  In the present case, it is clear that the complainant Jasvir Kaur cannot claim the death benefit of her husband Balbir Singh.  The remaining members can avail the policy benefit in case of illness.  So, as per the card Ex.C-3, it is in the name of Jasvir Kaur and as stated above the death benefit can only be given in case of death of head of the family. As such, we find that the complaint deserves dismissal.  

 

10.           In view of this, we dismiss the complaint of the complainant. However, the parties are left to bear their own costs.  A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                January 18, 2021.

 

 

        (Vinod Kumar Gulati)      (Jasjit Singh Bhinder)

                 Member                           President