DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA 

                                                      RBT/Consumer Complaint No.311 of 2018

                                                            Date of institution: 07.05.2018

                                                            Date of Decision: 28.04.2022

Darshan Lal son of SH. Sant Ram resident of House no.1015/2, Street No.03, Geeta Colony, Jagraon, District Ludhiana 

….Complainant

Versus

1. MD India Health Insurance TPA Private Limited, through its Manager, resident of Survey No.46/1, E-Space, A2 BLDG, Third Floor, Pune Nagar Road, Wadgoan, Sheri, Pune 411014
2. Oriental Insurance Company through its Manager, Punjab-231102
3. JBT of Government School, Raikot, Jagraon.

                                                                                       ……..Opposite Parties

Complaint under Consumer Protection Act

Quorum:      Shri Ranjit Singh, President.

                              Mrs. Ranvir Kaur, Member

Present:        Sh. Darshan Lal, complainant in person

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 has retired from the post of JBT of government school Raikot, Jagraon, after the death of the wife of complainant has beneficiary of the pension of his wife as per the government rule the pensioner holder take all the benefit which were given to the pensioner holder and as per the rule Government pay medical expenses of the pensioner holder in the year 2016-17 government give tender regarding the medical claim to MDI Health Care Insurance Company TPA Private Limited and complainant is suffering from cancer diseased, complainant is also holder of the medical policy of oriental insurance company. The complainant is admitted in the hospital regarding his illness and claim to the Ops of all expenses which is bear by the complainant in the hospital. On 16.3.2016, Ops clear the claim amount of the complainant regarding the said diseased i.e. cancer and after that the complainant live his life but after some month the complainant again admitted in the hospital and on 21.5.2017 complainant claim to the Ops but the Ops never pass the claim of the complainant and denial the same with the reference the claim arose the treatment of papillary Carcinoma. In the Chronic Certificate is of Tata Memorial Hospital. but this centre is not authorized to issue the certificate particular in this policy, the claim is, hence repudiated. Complainant is valid policy holder, the Ops never clear terms and conditions which was imposed by the OP to complainant, Ops wrongly denial the claim of complainant as there is no particular condition imposed by Ops upon complainant regarding the said policy. 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 make the payment of claim Rs.40,383/- along with interest @ 24% per annum and total amount of Rs.90,383/- including compensation of Rs.50,000/- 

4. 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 Commission with clean hands;  that the complainant is stopped by his act and conduct from filing this complaint; that the complaint is also bad for non joinder and mis joinder of the necessary parties; that due services have been rendered in this case and claim of the complainant is found not payable as per the scheme of the Punjab Government Employees and pensioners health insurance and in this case, the claim arose to treatment of papillary Carcinoma, and the chronic certificate was issued by TATA memorial Hospital and this centre is not authorized to issue the certificate, particular and in this policy. so the case was not admissible as per policy clause and it was duly informed to the complainant vide letter dated 6.6.2017. On merits, it is stated that the insurance policy in question has been issued on the basis of notification 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 Employees and Pensioners Health Insurance Scheme. In this case, the policy is sum of Rs.3 Lakhs and is valid from 1.1.2016 to 31.12.2016 and it was issued subject to conditions, clauses, warranties and endorsements and as per the scheme of Punjab Government employees and pensioners health insurance. The complainant was admitted in Fortis Hospital Mohali from 12.9.2016 to 14.10.2016 for treatment of papillary carcinoma. After the receipt of the documents, on perusal/scrutiny of the said documents placed in the claim file of the complainant by MD India Health Insurance TPA Private Limited, a 3^rd party administrator appointed under the insurance policy in question, the claim of the complainant was found by the TPA not admissible as per scheme of the Punjab Government employees and pensioners health insurance wherein it has been specified that no reimbursement will be available for the treatment where the chronic disease certificate is not issued by the State Govt. Medical College, PGIMER Chandigarh, AIIMS Delhi and GMCH Chandigarh and in this case chronic certificate is of TATA Memorial hospital and this hospital is not authorized to issue the certificate, as such, they have shown their inability to admit the liability under the policy conditions. The complainant had never lodged any claim with the Oriental Insurance Company Limited and MD Health Insurance TPA Private Limited for any cashless treatment in terms of notification of Punjab Government. So, the repudiation of the claim of the complainant is legally valid and enforceable and is according to the notification of the Punjab Government and policy's terms and conditions and the scheme of the Punjab Government of employees and pensioner health insurance which was obtained by the complainant. Thus, alleging no deficiency in service on the part of the opposite parties and prayed for the dismissal of complaint in total.
5.  The complainant has tendered certain documents in the shape of evidence along with affidavit of the complainant. On the other hand, the OPs have tendered certain documents in the shape of evidence.
6. We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
7. The claim of the complainant has been repudiated on technical grounds which are mere or less based on presumption and surmises. Unambiguously, the expenses proved on record have been incurred by the complainant on follow up of the original treatment of cancer. The ground on which the claim of the complainant has been repudiated was not a condition in the original insurance agreement. The claim of the complainant is of meager amount. It is not the case of the OP that the complainant did not incur the relevant expenditure on the follow up treatment of original because of the cancer. It is proved on record that the OP has rather repudiated the claim of the complainant on mere technical and flimsy grounds. Insurance company has bigger pocket while the complainant is a victim and poor follow. While appreciating the principle of equity and natural justice the complainant deserves the award of compensation.
8. Consequently, he is hereby awarded the compensation of the expenses amounting to Rs. 40,383/- incurred by him on the follow up treatment along with interest @ 9% per annum from the date of repudiation of the claim of the complainant till its payment to the complainant by the Ops Noi.1 & 2 jointly and severally. The Ops No.1 & 2 are also directed to pay Rs.30,000/- as compensation and also for Rs.11000/- as litigation expenses. The Ops No.1 & 2 are further directed to comply with the said order within a period of 30 days from the date of receiving the certified copy of this order. The certified copies of this order be supplied to the parties forthwith, free of costs, as permissible under the rules and the file be sent back to the District Consumer Commission, Ludhiana for consigning the same to the Record Room.     

                                                                           (RANVIR KAUR)

                                                                                 MEMBER

CC No.311 of 2018

                    Vide our separate detailed order of today, the complaint stands allowed. 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)