The titled complainant has retired as Head Teacher from the Punjab State Govt. Service U/B.P.E.O. Gurdaspur-I posted at Govt. School, Aujla (Gurdaspur) and as such she has been entitled to cover under Govt. Health Insurance Scheme for Retired Employees. On 22.02.2016, the complainant was hospitalized for implant of Heart Pace Maker at the Fortis Hospital, Amritsar and was discharged on 25.02.2016. The hospitalization-bills for an aggregate amount of Rs.2,86,735/- were paid by the complainant herself and in due course of time she filed the related hospitalization-claim # MD10018186 vide RMN # 9888427012 (Registered Mobile Number) with the OP Insurer TPA (Third Party Administrator) who did settle the same on 16.06.2016 but for Rs.1,02,759/- only sans assignment of any reasons/logic/calculations etc. Further, the complainant has been approaching the OP TPA on regular basis for release of the balance amount of Rs.1,83,976/- but has been kept on hold on one pretext or the other hence prompted the present complaint praying release of the withheld portion of the claim with interest, cost and compensation etc.
2. The complainant in order to accomplish the successful prosecution of her complaint has also filed her duly Sworn-in Affidavit (Ex.C1) along with copies of the related papers/documents exhibited herewith as Ex.C2 to Ex.C20 in evidence.
3. The titled opposite party (the OP Insurers TPA), in response to the commission’s summons appeared through their counsel who filed the duly sworn-out affidavit (Ex.OP1) of the Senior Manager Md. Samiyoddin Patel (authorized signatory) in lieu of the written statement along with the OP TPA Resolve (Ex.OP2) of the related claim and stating therein preliminary as well as other (on merits) objections, in evidence, as:
4. That the present complaint is not maintainable against the OP TPA as it is only the 3rd Party Claim Settlement Authority resolving the receipted claims under the terms of the PGEPHIS (Pb. Govt. Employees & Pensioners Health Insurance Scheme) to their Principals M/s Oriental Insurance Co. Ltd., who are liable pay the eligible claims in terms of its settled contracted agreements with the State Govt., in terms of the tendered premium rates etc. The hospitalization-claim, in question, was filed for Rs.2,93,362/- and the OP3 (the replying respondent) settled the same for Rs.1,02,759/- strictly in terms of the PGEPHIS and related Policy and the insurers had paid the same and presently nothing (no more amount) has been payable to the complainant. On merits, the OP TPA has admitted the bare facts on their face-value but have denied to comment/opine on the basics upon which the present impugned settlement stood based upon addressing these as matters of record or outside their purview/authority etc. and have finally sought dismissal of the complaint.
5. We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some of the documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put-forward/placed-forth by the learned counsels for their respective litigants.
6. We find that the present dispute has arisen on account of the impugned non-resolve/repudiation of the part portion of the complainant's hospitalization-claim and we observe that the OP TPA have admitted being the representative of the insurers and the claim-settlement authority have admittedly settled the claim at Rs.1,02,759/- in lieu of its face-value amount @ Rs.2,93,362/- without assigning any reason either to the sick retiree teacher complainant nor during the present proceedings. We note that the OP TPA have entertained the hospitalization-claim received directly from the claimant and resolved it further though partially as claim No. MD10018186 through RMN # 9888427012 thus they were responsible/duty-bound to follow it up till its culmination to its logical end and it's here that the OP TPA failed thus displaying deficiency in service, at its loudest volume.
7. We have minutely examined all the documents produced in evidence by the complainant and also by the OP Insurers TPA as produced and as collected by them during the course of their working/investigations and find that the OP TPA have not produced any document/evidence/basis based upon which they resolved the present claim; simply stating that the claim was resolved in terms of the PGEPHIS and the Policy does neither absolve them of their consumer-responsibility nor of their statutory-liability under the herein applicable statute. Moreover, the OP TPA also cannot wriggle out of their statutory consumer-relationship as they get paid from their Principals (insurers) who in turn get paid by the complainant's employer the State Govt., who deduct part of insurance premium from the employees' salary/pension. The OP TPA must realize that the claim-settlement delegated discretion bestowed upon them by virtue of the very nature of the allotted task/ duty has been neither a sovereign nor an absolute authority and their claim-resolves are certainly open to judicial review and these need be reached with application of mind and be self-contained and speaking in nature with a brief mention of logic and basics upon which these stood founded.
8. We disapprove the OP insurers' acts of omissions as well as that of commissions, in totality. And, of course we do not concur with the logic of the herein impugned 'resolve' in part withholding a substantial amount without assigning its logic/reason etc. We observe that the impugned partial resolve of the insurance-claim has been to assist the OP TPA's Principals' Resolve in their endeavor to somehow repudiate the claim so as to cause an unjust loss to the complainant. Thus, we hold both the OP TPA and its Principals Insurers responsible for causing financial-loss/harassment/ mental agony to the ailing complainant and also hold them liable to suffer an adverse award under the provisions of the herein applicable statute.
9. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the callous 'resolve' of the hospitalization-claim as display of ‘deficiency in service' and 'unfair-practices' at play and thus we partly allow this complaint and ORDER the OPs to pay the impugned claim at its full amount of Rs.2,93,362/- and pay the balance claim-amount of Rs.1,83,976/- to the herein complainant, in terms of the related policy with interest @ 6% PA from the date of complaint till actually paid, in full, besides to pay him Rs.15,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the aggregated amount shall attract an additional interest @ 3 % PA from the date of the orders till actually paid. The OP TPA shall however be at liberty to claim thus awarded amount from their principals in terms of their inter-Se arrangement.
10. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
11. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
OCT. 28, 2022. Member.
YP.
