DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 672
Instituted on: 22.12.2017
Decided on: 30.07.2018
1. Smt. Shiksha Goyal widow of Ram Bhagat Goyal
2. Surinder Pal Goyal son of Ram Bhagat Goyal, both residents of 124, Street No.4, Punia Colony, Sangrur.
…Complainant
Versus
1. M.D. India Health Care (TPA) Pvt. Ltd. MAXPRO INFO PARK, D-38, 1st Floor, Industrial Area, Phase-I, SAS Nagar (Mohali) 160056 through its Manager.
2. Punjab Health Systems Corporation through its MD, Phase-6, Mohali, District Mohali.
3. Chief Medical Officer, Civil Surgeon, Sangrur.
4. District Education Officer (Elementary) Sangrur.
5. State of Punjab through Deputy Commissioner, Sangrur.
6. The Oriental Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Branch Manager.
..Opposite parties.
For the complainant : Shri Inderjeet Singh, Adv.
For Opp.Party No.1&6: Shri Ashish Garg, Adv.
For Opp.Party No.2,3&5: Ms. Amandeep Kaur, Adv.
For OP NO.4 : Smt. Sunita Rani A/A.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Order by : Sukhpal Singh Gill, President.
1. Smt. Shiksha Goyal and Shri Surinder Pal Goyal, complainants (referred to as complainant in short) have preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the husband of complainant number 1 and father of complainant number 2, namely, Shri Ram Bhagat Goyal was a government pensioner as he retired as Central Head Teacher (Primary) from Police Lines, Sangrur in the year 1992 and died on 10.10.2017. Further case of the complainant is that the deceased along with his family members was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-01672230594 for the period from 1.1.2016 to 31.12.2016. The case of the complainant is that during the subsistence of the insurance policy, the deceased suffered from Hepatitis-C and to this effect he was issued a certificate by the PGI regarding complicated chronic disease on 8.2.2016. Further case of the complainant is that to cure his disease, he purchased medicines to the tune of Rs.83,760/- and also submitted bills to the department for Rs.83,760/- on 13.10.2016 duly verified by the doctor, but the OP number 4 returned the bills to the complainant with the objections and after clarifying the objections, the deceased again submitted the bills to the OP number 4 . Further case of the complainant is that the bills to the tune of Rs.61,210/- for the period from 1.1.2016 to 11.10.2016 have not been reimbursed despite the fact the complainants approached the Ops so many times. 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 the claim amount of Rs.61,210/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply filed by OPs number 1 and 6, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable. On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis. It is further stated that as per the schedule, the liability of the company is to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room. It is admitted that the deceased took treatment from PGI Hospital, Chandigarh from 1.1.2016 to 11.10.2016 due to Hepatitis C and submitted the bills for Rs.61210/- on 31.5.2017 for reimbursement, but the OP number 1 rejected the claim of the complainant as the deceased submitted the claim after 30 days of discharge/consuming medicines. As such, any deficiency in service on the part of the Ops has been denied.
3. In reply filed by Ops number 2, 3 and 5, legal objections are taken up on the grounds that the present complaint is premature and that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint and that the complainant has got no locus standi to file the present complaint. On merits, it is stated that the OP has no liability to reimburse the medical claim/bills as alleged by the complainant. It is stated that as per the policy, the liability to pay the claim is of the insurance company. The other allegations levelled in the complaint have been denied in toto.
4. In reply filed by OP number 4, legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has unnecessarily dragged the OP into unwanted litigation, that the complainant has got no locus standi to file the present complaint. On merits, it is admitted that the deceased Ram Bhagat Goyal was a pensioner and was insured with the OP as stated above. Further it is stated that medical bills for the period from 1.1.2016 to 11.10.2016 were sent to OP number 1 on 31.5.2017 for Rs.61,210/-. However, any deficiency in service on the part of the OP number 4 has been denied.
5. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-22 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 & 6 has produced Ex.OP1&6/1 to Ex.OP1&6/4 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 2, 3 and 5 has produced Ex.OP2,3&5/1 to Ex.OP2,3&5/6 and closed evidence.
6. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits part acceptance, for these reasons.
7. It is an admitted fact between the parties that the deceased Ram Bhagat Goyal was a pensioner and as such he along with his family members was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-01672230594 for the period from 1.1.2016 to 30.12.2016. It is also not in dispute that during the subsistence of the insurance policy the deceased Ram Bhagat Goyal took treatment from PGI Chandigarh, where he spent an amount of Rs.61,210/- and further submitted the bills to OP number 4 for payment, who further forwarded the bills to OP number 1 for encashment being the deceased was insured with it.
8. In the present case, the learned counsel for the OPs number 1 and 6 has contended vehemently that the claim could not be settled due to late submission of the claim to the OP number 1, whereas as per the terms and conditions of the policy, the claim case should be submitted to the OP number 1 within a period of thirty days from the discharge date from the hospital. But, in the present case, the learned counsel for the complainant has contended vehemently that the deceased submitted the bills to the OP number 4 immediately and who further forwarded the same to the OP number 1 for encashment of the bills, which fact is also admitted by OP number 4 in their written reply. In the circumstances, we feel that the deceased/insured being an old man cannot be held responsible for non submission of the bills to OP number 1 immediately when he sent the bills to OP number 4 for further submission to OP number 1, whereas the medical bills remained under objections with the OP number 4 and the deceased cannot be held responsible for late submission of bills to OP number 4. Now, we feel that ends of justice would be met, if the OP number 1 and 6 are directed to reconsider the claim of medical bills to the tune of Rs.61,210/- submitted by the deceased and inform the complainants about their decision by registered post.
9. Accordingly, in view of our above discussion, we allow the complaint partly and direct OPs number 1 and 6 to reconsider the claim of medical bills to the tune of Rs.61,210/- submitted by the deceased and inform the complainants about their decision by registered post within a period of thirty days from the date of receipt of copy of this order. If the complainants still remains unsatisfied, then it is open for the complainants to come again before this Forum, if they so desired. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
July 30, 2018.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
