DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA 

                                                      RBT/Consumer Complaint No.325 of 2018

                                                            Date of institution: 11.05.2018

                                                            Date of Decision: 28.04.2022

Daljit Singh, son of Sh. Ram Rattan Singh, resident of Mandi Mullanpur, PS Dakha, District Ludhiana. 

….Complainant

Versus

1. MD India Health Insurance TPA Private Limited, Head Office At Survey No.46/1, Space, A2, BLDG Pune-411014, through its Director/Managing Director/Authorized Signatory
2. MD Health Insurance TPA Private Limited, B-38, Max Provisional order of assessment Infor Park, Industrial Area, Phase-I, Mohali-160056

                                                                                          ……..Opposite Parties

Complaint under Consumer Protection Act

Quorum:      Shri Ranjit Singh, President.

                              Mrs. Ranvir Kaur, Member

Present:        Sh. G.S. Grewal, Advocate, for complainant   

Sh. B.S. Rampal, Advocate, for OPs    

Order dictated by :-  Shri Ranjit Singh, President 

Order

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, received by way of transfer from District Consumer Disputes Redressal Commission, Ludhiana by the complainant against the Opposite Parties on the ground that the complainant obtained health insurance policy from the opposite parties bearing policy No.231102/48/2016/796, which was vailed from 1.1.2016 to 31.12.2016. The complainant treated for LAUMBAGO in two parts i.e. firstly from 17.8.2016 to 20.8.2016 and secondly from 18.11.2011 to 22.11.2016 for an amount of Rs.89,784/- and Rs.42095/- respectively. The concerned doctors asked him to pay the cash amount and get the same reimbursed from the opposite parties and in pursuance to the same and as per the basic requirement of the opposite parties, the complainant submitted his claim along with all the requisite bills and other documents but the opposite parties has repudiated the claim of the complainant without any reasonable probable and sufficient cause. Infact, the opposite parties after admitting their liability had reimbursed the second amount of Rs.42095/- for his treatment from 18.11.2016 to 22.11.2016, but to the utter surprise of the complainant, the opposite parties failed to pay an amount of Rs.89784/- to the complainant without giving any reasonable and probable cause and opposite parties had repudiated the claim vide their letter dated 13.2.2017. However, the complainant visited many a times to the office of the Ops to reimburse the amount, but the OPs have failed to do so. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-

1. To pay an amount of Rs.89,784/- along with interest @ 24% per annum to the complainant
2. To pay compensation of Rs.1,00,000/-.

3. Upon notice, the learned counsel for the OPs appeared and filed written reply taking preliminary objection; that the complaint is not maintainable in the present form; that the complainant has not come to this Hon’ble Forum with clean hands; that the complainant is not entitle for any compensation; that the complainant is estopped by his act and conduct from filing this complaint; that the complaint is bad for non joinder and misjoinder of the necessary parties; that this Hon’ble Forum has got no jurisdiction to try and decide the present complaint; . On merits, it is stated that the insurance policy in question has been issued on the basis of notification No.21/28/12-5HB5/268 dated 20.10.2015 issued by the Government of Punjab, Department of Health and Family Welfare from Oriental Insurance Company Limited, Chandigarh, for the benefits of Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS). The policy in question is sum of Rs.3 Lakhs and is vailed from 1.1.2016 to 31.12.2016 and it was issued subject to conditions, clauses, warranties and endorsements. Thus, alleging no deficiency in service on the part of the opposite parties and prayed for the dismissal of complaint in total
4. The complainant has tendered certain documents in the shape of evidence along with affidavit of the complainant. On the other hand, the OPs has tendered certain documents in the shape of evidence.
5. We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
6. The learned counsel for the complainant argued that the complainant had obtained the insurance policy and the complainant treated for LAUMBAGO in two parts and after that the complainant submitted his bill along with other required documents to the opposite parties but the OPs have repudiated the claim of the complainant without any reasonable and probable cause. Lastly prayed to allow the present complaint
7. The learned counsel for the OPs has also argued that the complaint of the complainant is not maintainable. The opposite parties have rightly repudiated the claim of the complainant because as per para No.4 of the notification of the Punjab Governement dated 20.10.2015, no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available and this case was failing in para No.4 of the said notification, so the claim of the complainant was not admissible as per policy clause and it was duly informed to the complainant vide letter dated 13.2.2017. Lastly prayed to dismiss the present complaint.
8.  In case we go through the documents placed on the record by the complainant, he has placed on the record the affidavit of the complainant Ex. CA, Medical reimbursement form Ex.C3, original bills Ex.C4 to Ex.C12, admit card Ex.C15, discharge summary Ex. C-16, Copy of Health Insurance Card Mark A. As per notification dated 20.10.2015, of the Government of Punjab, Department of Health and Family Welfare (Health –V Branch) in column No.4, the treatment can be taken by any enrolled beneficiaries in Government or in empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). No reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available, therefore, the complainant had taken the treatment from the hospital, which was not a Government Hospital or in empanelled Hospitals in Punjab, Chandigarh and Panchkula. Certainly, it is against the terms and conditions of the policy.  
9. In this present case, the complainant had taken the treatment from one Garg Hospital, which is not a Government Hospital or not empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). In this way, the complainant has violated the condition para No.4 of the notification of the Government of Punjab, Department of Health and Family Welfare dated 20.10.2015. 
10. Therefore, we are of the opinion that the claim of the complainant was not entitled for any reimbursement as he had violated the terms of the policy by not taking the treatment from the approved empanelled hospital of the Ops.  
11. The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be indexed and consigned to Record Room.   

                                                                           (RANVIR KAUR)

                                                                                 MEMBER

CC No.325 of 2018

                    Vide our separate detailed order of today, the complaint stands dismissed. Free certified copies of this order be sent to the parties, as per rules. The files be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

April,28 2022

(Ranjit Singh)

(Ranvir Kaur)