DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  671

                                                Instituted on:    21.12.2017

                                                Decided on:       12.06.2018

Inder Singh son of Bhan Singh R/O Village Kanjhla, Tehsil Dhuri, Distt. Sangrur.

                                                        …Complainant

                                Versus

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

2.             The Oriental Insurance Co. Ltd. through District Manager, Sangrur.

3.             State of Punjab through District Collector, Sangrur.

4.             Oriental Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh.

5.             Department of Health and Family Welfare Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh through its Director.

                                                        ..Opposite parties.

For the complainant  :       Shri Sanjeev Garg, Adv.

For Opp.Party No.1to3:    Shri Ashish Garg, Adv.

For Opp.Party No.4&5:     Ms. Amandeep Kaur, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

Order by : Sukhpal Singh Gill, President.

1.             Shri Inder Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a government retired employee and is a pensioner, as such he along with his family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09463562910 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, he took treatment from Dayanand Medical College and Hospital, Ludhiana for the period from 24.8.2016 to 29.8.2016, where he spent an amount of Rs.91,173/- and thereafter he submitted all the documents to the Ops, but the claim was not paid, despite his best efforts. 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.91,173/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1, 2 and 4, 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 complainant took treatment from Dayanand Medical College and Hospital Ludhiana from 24.8.2016 to 29.8.2016 due to malignant neoplasm of right ovary and submitted the bills to the tune of Rs.97,840/- for reimbursement, but the claim file is still pending due to non submission of the additional information i.e. discharge summary, biopsy report of kidney mass and all investigation reports, but the complainant did not bother to send the same.  As such, any deficiency in service on the part of the Ops has been denied.

3.             In reply filed by Ops number 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.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-4 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1,2 & 4  has produced Ex.OP1,2&4/1 to Ex.OP1,2&4/4 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 3 and 5 has produced Ex.OP3&5/1 to Ex.OP3&5/6 and closed evidence.  

5.             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.

6.             It is an admitted fact between the parties that the complainant was a Punjab Government employee and is a pensioner and as such he along with her family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09463562910 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 complainant remained admitted in the Dayanand Medical College and Hospital Ludhiana for the period from 24.8.2016 to 29.8.2016, where he spent an amount of Rs.91,173/- and submitted the bills for reimbursement.  In the present case, the learned counsel for the Ops number 1,2 and 4 has contended vehemently that the claim could not be settled due to non submission of the additional documents i.e. discharge summary, biopsy report of kidney mass and all investigation reports despite best efforts of the Ops number 1,2 and 4.  Since the complainant has not denied this fact by way of filing any rejoinder or in the affidavit, as such, we feel that ends of justice would be met, if the complainant is directed to submit the required documents as mentioned above.

7.             Accordingly, in view of our above discussion, we allow the complaint partly and direct the complainant to submit the additional information, such as, discharge summary, biopsy report of kidney mass and all investigation reports etc., if available with the complainant to the OP number 1 under proper receipt.  It is made clear that after receipt of the above said documents, the OP number 1 shall settle the claim of the complainant and intimate its decision to the complainant by registered post within a period of fifteen days of receipt of the documents from the complainant. Further, it is ordered that if thereafter the complainant still remains unsatisfied, then it is open for him to again approach this Forum, if so desired. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        June 12, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member