DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)

Consumer Complaint No.316 of 2017

                                               Date of institution:  27.04.2017                                             Date of decision   :  05.07.2018

Joginder Kaur wife of Gurdev Singh, resident of House No.106, Block C-1, Kendriya Vihar, Sunny Enclave, Sector 125, Kharar, Mohali.

…….Complainant

Versus

1.     MD India Healthcare Service (TPA) Pvt. Ltd. through its Managing Director, Office address Max pro park, D38,  Mohali, Industrial Area, Phase-1, Mohali.

2.     The Oriental Insurance Company Ltd., Regional Office at Surendra Building, SCO 109-110-111, Sector 17-D, Chandigarh 160017.

3.     Economic and Statistical Organization Punjab, Office at SCO 35-36, Sector 17, Chandigarh.

                                                        ……..Opposite Parties

Complaint under Section 12 of

the Consumer Protection Act.

Quorum:    Shri G.K. Dhir, President,

                Shri Amrinder Singh Sidhu, Member

                Mrs. Natasha Chopra, Member.

Present:     Shri Tapish Kumar, counsel for the complainant.

                Shri B.R. Madan, counsel for OP No.1 and 2.

Shri Devinder Kumar, Deputy Economic and Statistical Advisor on behalf of OP No.3.

Order by :-  Shri G.K. Dhir, President.

Order

               OP No.1, Third Party Administrator (hereinafter referred as ‘TPA’) used to deal with health insurance sector of employees of OP No.3. OP No.2 appointed OP No.1 to assess the claims of employees of OP No.3, which is department of Govt. of Punjab. Complainant before retirement remained employed with OP No.3 as Deputy ESA. Complainant got herself enrolled alongwith her husband under insurance scheme with OP No.2. Complainant was issued an identity card by OP No.3 as pensioner. Husband of complainant Shri Gurdev Singh was hospitalized in SHHS Sohana Hospital during period from 15.06.2016 to 27.06.2016 and thereafter on 25.06.2016 he was advised to consult doctors at PGI Chandigarh. On advise of doctors of PGI, husband of complainant underwent certain tests and was diagnosed with DMII/HIN/LUDD/Hairy Cell Leukemia. For treatment of this disease, husband of complainant was hospitalized in PGI Chandigarh during period from 14.07.2016 to 17.07.2016. An amount of Rs.32,489.62 N.P. was incurred as expenditure on this treatment. As complainant was covered under the insurance scheme and as such she approached OP No.1 for claiming reimbursement of medical bills, but was denied the reimbursement on the ground that husband of complainant was alcoholic. It is claimed that some of the bills with respect to the same disease earlier were cleared by same company i.e. OP No.2. So denial of claim for reimbursement alleged to be arbitrary. Upon approach by complainant to doctors of PGI, they disclosed that the disease does not relate to alcohol consumption. OPs adopted unfair trade practice in not reimbursing the spent amount of Rs.32,489.62 N.P. and that is why this complaint for seeking direction to OPs to refund this amount and even to pay compensation for mental agony and harassment of Rs.15,000/-. Deterrent and punitive damages of Rs.20,000/- and litigation expenses of Rs.12,000/- more claimed.

2.             In reply filed by OP No.2, it is claimed that complaint is misconceived, groundless, frivolous and vexatious and is based on cooked up versions. Besides, it is claimed that complainant has not approached this Forum with clean hands. Terms and conditions of the insurance policy govern relationship of the parties. These terms to be strictly construed. Complainant has not paid any premium to OP No.2 for covering the risk and as such there is no privity of contract between complainant and OP No.2. Punjab Govt. formulated scheme known as ‘The Punjab Government Employees and Pensioners Health Scheme’ for covering risk of the employees. Punjab Govt. paid premium against which policy was issued by OP. So Punjab Govt. is insured and not the complainant. Complainant alleged to be having no locus standi to file the complaint. As per condition No.21 of the scheme, the mechanism with regard to dispute resolution and grievance redressal has been set up by providing Grievance Redressal Committee in each district. That committee consists of its members as Deputy Commissioner; Civil Surgeon; Deputy Medical Commissioner and Representative of Insurance Company. This committee to resolve the grievance within 30 days from the date of application. The party dissatisfied with the decision of that committee, may approach the State level Grievance Redressal Committee, whose decision will be final and binding on all the parties. So it is claimed that this Forum has no jurisdiction. No deficiency in service is there on part of answering OP. OP No.1 rightly repudiated the claim of complainant. As per Clause-13 to 15 of the scheme, OP No.2 is answerable to Nodal Department. No provision for cashless facility provided under the scheme except that on fulfillment of conditions laid in Clause-12 of the scheme. As per Clause-23 of the scheme, amount incurred on treatment is payable as per PGEPHIS rates irrespective of actual expenditure incurred by beneficiary. OP No.1 after going through medical records rightly came to the conclusion that treatment was necessitated due to alcohol abuse/drug abuse. Complainant herself never paid any premium to OP No.1 for covering the risk. Other averments of the complaint denied. Shri B.R. Madan, Advocate suffered statement that reply filed by OP No.2 be treated as reply of OP No.1, and as such the written statement filed on behalf of OP No.2 treated as written reply on behalf of OP No.1 also.

3.             In reply submitted by OP No.3, most of the facts are admitted, but by claiming that reimbursement claim to be dealt with by OP No.1 and 2. OP No.3 has no concern with the claim. It is admitted that complainant had been working with OP No.3 and the insurance policy got provided under the scheme formulated by Punjab Govt.

4.             Complainant to prove her case tendered in evidence her affidavit Ex.CW-1/1 alongwith documents Ex.C-1 to Ex.C-8 and thereafter her counsel closed evidence. On the other hand, counsel for the OP No.1 and 2 tendered in evidence affidavit Ex.OP-2/1 of Shri Charanjit Singh Deputy Manager alongwith documents Ex.OP-2/2 and Ex.OP-2/3 and thereafter closed evidence.  On behalf of OP No.3 Shri Devinder Kumar, Deputy ESA tendered in evidence affidavit Ex.OP-1/3 of Shri Parminder Singh Walia alongwith document Ex.OP-2/3 and thereafter closed evidence.

5.             Written arguments submitted by counsel for OP No.1 and 2 and not by any other parties. Oral arguments heard and records gone through.

6.             Complainant is staking claim regarding reimbursement of treatment for her husband under the insurance policy issued by OP No.2, on being approached by Govt. of Punjab. So virtually the claim is staked by complainant against OP No.2 and not against OP No.1.  OP No.1 being TPA only to process the claim, receive the documents and thereafter make recommendations regarding disbursement or non disbursement of the claimed amount. Recommendations of OP No.1 to be accepted by OP No.2 and as such virtually the claimed insurance amount is payable by OP No.2 only and not by any of the other OPs. So complaint against OP No.1 and 3 is not maintainable, but same is maintainable against OP No.2, the insurer only.

7.             Even if the premium amount paid by Punjab Govt. for insuring its employees, despite that beneficiaries are employees of the Govt. because premium paid by Punjab Govt. for benefits of its employees. Being so, even if there is no direct privity of contract between complainant and OP No.2, despite that liability of OP No.2 to pay insurance amount or of medical reimbursement amount remains as per terms and conditions of the insurance policy.

8.             Copy of the pensioner identity card of the complainant produced on record as Ex.C-1 and that of the health insurance card issued by OP No.2 is produced on record as Ex.C-2. So this documentary evidence certainly establishes that complainant being insured with OP No.2 after her retirement from office of OP No.3 became beneficiary of the insurance scheme. It is on account of this, that complainant submitted bill Ex.C-3 alongwith record of incurred medical expenses of the bills etc. for getting claim in question. These bills for reimbursement of the medical expenses on treatment of husband of complainant were submitted by her with OP No.1 through Ex.C-4 and acknowledgement of the same Ex.C-5 was issued.  However, the claim for medical reimbursement repudiated through letter Ex.C-6 issued by OP No.2 on the ground that claim raised due to use of alcohol abuse/drug abuse and as such the claim is not admissible as per PGEPHIS scheme. It was repudiation of claim through letter Ex.C-6 dated 06.01.2017 that gave cause of action to complainant to file this complaint. So virtually repudiation of the claim has not taken place because of non privity of contract between complainant and OP No.2. Rather repudiation of claim took place through letter Ex.C-6 on account of alleged exclusionary clause. Being so, plea regarding non privity of contract between complainant and OP No.2 is taken just as an afterthought.

9.             Acknowledgement Ex.C-7 also produced on record alongwith certificate issued by Senior Resident Doctor of PGI Chandigarh Ex.C-8. After going through Ex.C-8, it is made out that the doctor concerned reported as if to the best of his knowledge, he could not find casual association between hairy cell Leukemia and alcohol intake. So certainly on the basis of this document Ex.C-8, submission advanced by counsel for complainant has force that the treatment got by husband of complainant was having no concern with the alcohol intake by husband of complainant. So repudiation of claim in view of this certificate Ex.C-8 of the treating doctor, is not as per terms and conditions of insurance policy.

10.            Copy of the insurance cover note Ex.OP-2/2 alongwith salient features of the scheme produced as Ex.OP-2/3. Perusal of Para 3 (c) of Ex.OP-2/2 reveals that benefits upto 7 days pre-hospitalization and upto 30 days post hospitalization respectively, which would cover all expenses relating to treatment of sickness for which hospitalization was done are permissible.  The beneficiary can avail this benefit on cashless basis in an empanelled hospital as per this clause. There is no dispute regarding the fact that virtually the expenditure in question claimed as per terms of this clause except that of amount of Rs.7,000/- spent on PET scan on 29.08.2016. That amount is not payable. Date of discharge in this case is 04.07.2016, but PET scan bill is of date 29.08.2016 and as such virtually this PET scan bill pertains to expenses incurred after 30 days of discharge. So claim with respect to this amount of Rs.7,000/- certainly is not payable. Bill of amount of Rs.7,000/- of PET scan date 29.08.2016 is in the shape of receipt issued by Ms. Monika Sharma, Senior Resident Internal Medicines, PGI Chandigarh.    Photostat copy of that receipt is part of bill Ex.C-3.

11.            Even if after decision of the State Grievance Redressal Committee constituted for redressal of grievances, the appeal maintainable before the State Level Grievance Redressal Committee, despite that the consumer complaint always maintainable before this Forum in case deficient services provided by the service provider. In this case before us, the whole claim repudiated despite the fact that certificate Ex.C-8 provides that treatment was not on account of alcoholic intake. So repudiation of claim is for unjust reasons, due to which this consumer complaint is maintainable because remedy available to consumer is in addition to the remedy available under any other law as per Section 3 of the Consumer Protection Act. After deducting this amount of Rs.7,000/-, balance payable amount comes to Rs.25,489.62 N.P. and as such the claim deserves to be allowed in that respect. The claim has been wrongly repudiated by OP No.2 and as such complainant entitled to interest @ 8% per annum on the adjudged amount in case payment not made within 30 days from date of receipt of certified copy of the order. Complainant also entitled to compensation for mental harassment and agony and to litigation expenses from OP No.2 only.

12.            No other point argued.

13.            As a sequel of above discussion, the complaint is allowed in terms that OP No.2 will reimburse the claimed amount to the extent of Rs.25,489.62 N.P. to the complainant on account of medical reimbursement expenses, within 30 days from the date of receipt of certified copy of the order, failing which OP No.2 will be liable to pay interest @ 8% per annum from today till payment. Compensation for mental agony and harassment of Rs.5,000/- and litigation expenses of Rs.5,000/- more allowed in favour of complainant and against  OP No.2.  Payment of amount of compensation and litigation expenses be made within 30 days from the date of receipt of certified copy of the order.  Complaint against OP No.1 and 3 is dismissed. Certified copies be supplied to the parties as per rules.  File be indexed and consigned to record room.

Announced

July 05, 2018.

                                                                (G.K. Dhir)

                                                                President

(Amrinder Singh Sidhu)

Member

(Mrs. Natasha Chopra)

Member