Punjab

Sangrur

CC/376/2018

Kashyap Kumar - Complainant(s)

Versus

M.D.India Punjab Govt, Employees and Pensioners Health Care Service Private Limited - Opp.Party(s)

Sh.J.S.Sahni

08 Nov 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                    

                                                Complaint No.  376

                                                Instituted on:    13.09.2018

                                                Decided on:       08.11.2019

 

Kashyap Kumar adopted son of Indra Rani daughter of Shri Ved Parkash; resident of Sekha Road, Street No.2, Barnala Tehsil and District Barnala.

                                                        …Complainant

                                Versus

 

1.             MD India Punjab Govt. Employees and Pensioners Health Insurance Scheme, Max Pro Info Park Industrial Area, Mohali 160056.

2.             District Education Officer (Secondary) Sangrur.

3.             The Oriental Insurance Company Ltd. First Floor, SCO No.48-49, Sector 17-A, Chandigarh.

4.             State of Punjab through Deputy Commissioner, Sangrur.

5.             Govt. of Punjab, Department of  Health and Family Welfare Punjab, State Institute of Health and Family Welfare Complex, Phase VI, Near Civil Hospital, Sahibjada Ajit Singh Nagar, Punjab. And

6.             The Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh.

                                                        ..Opposite parties.

 

 

For the complainant  :       Shri J.S.Sahni, Adv.

For OP No.1,3&6      :       Shri Ashish Garg, Adv.

For Opp.Party No.2  :       Shri Kunal, LA.

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

 

Quorum                                          

Shri Amrinder Singh Sidhu, President

Ms. Vandana Sidhu, Member

Shri Vinod Kumar Gulati, Member

 

ORDER BY:

       

Shri Amrinder Singh Sidhu, President.

 

1.             Shri Kashyap Kumar, 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 the real nephew of deceased Smt. Indra Rani and during her life time, she adopted to the complainant as her son and in this regard a judgment and decree dated 22.11.2013 was passed by the court of Shri Manoj Kumar, PCS, Additional Civil Judge (SD) Barnala in civil suit no.31 of 13.2.2012.  Further case of the complainant is that deceased Smt. Indra Rani daughter of Shri Ved Parkash was serving as Hindi Lecturer and at the time of her death she was posted at District Institute of Education and Training, Sangrur. Smt. Indra Rani was affected chronic disease and during her life time a certificate of chronic disease was also issued by the Govt. Medical College Patiala and the same is valid from 27.4.2016 to 26.4.2021.

2.             Further case of the complainant is that the Ops reimbursed the amount of medical bills to Indra Rani during her life time for the admission from 20.1.2016 to 9.3.2016 but the Ops failed to make the payment of medical bills of the admission from 7.8.2016 to 11.8.2016 for Rs.17,633/- and from 10.9.2016 to 24.9.2016 for Rs.75,671/- and from 17.12.2016 to 12.1.2017 for Rs.1,45,872/-, whereas she was insured with the Ops.  Further case of the complainant is that though the bills were sent to the Ops on 6.2.2017 through registered post, but the Ops failed to pay the claim.  It is further averred that the Ops failed to reimburse the medical claim of Indra Rani, which caused mental tension, agony harassment and physical pain as such during her life time, she filed a complaint before this Forum on 6.4.2017 but she died on 28.4.2017 and as such the complaint was withdrawn with permission to file fresh one on the same cause of action.  As such the complainant filed the present complaint being legal heir of the said Indra Rani.  Thus, the complainant has prayed that the Ops be directed to reimburse the medical claim amount of Rs.2,39,671/- along with interest @ 12% per annum and further to pay compensation and litigation expenses.         

3.             In reply filed by Ops number 1,3 and 6, 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 said Indra Rani mother of the complainant remained admitted in DMC Hospital Ludhiana and submitted the bills of Rs.17633/- for payment and further submitted the bills for Rs.75,671/-, but the insurance company rejected the claim of the complainant under para number 4 of notification dated 30.10.2015. It is further averred that the claim for Rs.1,45,872/- is still pending for want of additional documents i.e. detailed breakage bills of all expenses and laboratory investigation reports. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee.

4.             In reply filed by Op number 2, legal objections are taken up on the grounds that the present complaint is not maintainable against the Ops, that the complainant has unnecessarily dragged the Ops into unwanted litigation, that the complainant has got no locus standi and that there is no deficiency in service on the part of the Ops.  On merits, it is stated that the OP number 2 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.

5.             In reply filed by Ops number 4 and 5, legal objections are taken up on the grounds that the present complaint is not maintainable, that the complainant has no cause of action to file the present complaint, that the complainant has not come to the Forum with clean hands and that this Forum has got no jurisdiction to try and entertain the present complaint. On merits, it is admitted that the complainant is insured with the insurance company. It is stated that if any claim is payable then the same is payable by the Ops number 1, 3 and 6.   The other allegations levelled in the complaint have been denied.

 

6.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-28 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1,3and 6  has produced Ex.OP1,3&6/1 to Ex.OP1,3&6/5 copies of documents and affidavits and closed evidence. The learned counsel for OP number2 has produced Ex.OP2/1 to Ex.OP2/2 copy of notification and affidavit and closed evidence. 

7.             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 acceptance, for these reasons.

8.             It is an admitted fact between the parties that Smt. Indra Rani being a Punjab Government employee was working as Hindi Lecturer in the office of District Institute of Education and Training, Sangrur and as such she along with her family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme for the period from 1.1.2016 to 31.12.2016.  It is also not in dispute that during the subsistence of the insurance policy Smt. Indra Rani was patient of complicated chronic disease and on different dates as mentioned above she remained admitted in Dayanand Medical College and Hospital Ludhiana and spent an amount of Rs.2,39,671/-, as is evident from the copies of the bills produced on record.  It is also the admitted case of the parties that though the complainant submitted the total bills for Rs.2,39,671/-, but the claim was not paid by the Ops to the complainant who is the adopted son of Smt. Indra Rani.  Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 1 to 2 for reimbursement to the tune of Rs.2,39,671/-, but the OPs paid nothing nor settled the claim of the complainant. The complainant has produced on record the medical record including the copies of the bills as Ex.C-5 to Ex.C-20, as such it is contended by the learned counsel for the complainant that the claim to the tune of Rs.2,39,671/- has wrongly been withheld by the OPs.  On the other hand, the stand of the OPs number 1,3 and 6  is that the claim has rightly been rejected by the Ops under clause 4 of notification dated 20.10.2015. But we are unable to accept such a contention of the learned counsel for the OPs that the claim has rightly been rejected, as Smt. Indra Rani was the patient of chronic disease is as is evident from the certificate Ex.C-4 and it is not open for the Ops to reject/withheld the claim of the complainant

9.             During the arguments, the learned counsel for the complainant has placed on record the copy of the letter written by the complainant to the insurance company regarding the reimbursement of  medical claims of Indra Rani along with  three number detailed medical bills of Rs.17633/-, Rs.76671/- and Rs.1,45,872/-, which are alleged to be paid by the Ops.  Further, while going through the bills submitted by the complainant, it has been observed that the patient was admitted on the emergency basis on all three number occasions in the non empanelled hospital at the relevant time.  We are of the view that the treatment taken in the speciality hospital cannot deprive the patient to claim the reimbursement only on the ground that the hospital is not in the panel of govt/insurance company especially when the insured/patient is suffering from a chronic disease. Further the patient was admitted in the hospital and treatment was taken in the speciality hospital would not deprive a person to claim reimbursement on the ground that the said hospital is not on the penal of the insurance company.  Also it is admitted fact that the person was admitted in the hospital, treatment taken and payment made and this has been supported by the relevant documents, once it is on the record, claim cannot be repudiated on technical grounds. 

10.           Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111   held that the insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims.

 

11.           Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1,3 and 6  to pay to the complainant the claim amount as per the terms and conditions of the insurance policy along with interest @ 9% per annum from the date of filing of the present complaint i.e. 13.09.2018 till realisation.  We further order the OPs number 1,3 and 6 to pay to the complainant an amount of Rs.5,000/- in lieu of consolidated amount of compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses.

12.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        November 8, 2019.

 

(Vinod Kumar Gulati)  (Vandana Sidhu) (Amrinder Singh Sidhu)

          Member                  Member                 President