Charanjit Singh, President;

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11/12 against the opposite parties on the allegations that the complainant is an employee of Government of Punjab and is working in Punjab Roadways Amritsar-II. The Government of Punjab, Department of Health and Family Welfare vide its Notification No.21/28/12-5HB5/268 dated 20.10.2015 is pleased to introduce a cashless Health Insurance Scheme  hereinafter referred as  Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses , specified daycare procedures and treatment or chronic diseases as specified or to be specified by State Government serving employees and pensioners on compulsory basis. The said scheme also ensures cashless all  Indoor medical treatment, pre and Post hosptalization specified as defined, Day  care procedures, and OPD medical expenses relating to chronic diseases up to a sum of Rs.3 lacs per family per year on floater basis. Medicine for chronic diseases will also be available on cashless basis from designated stores and hospitals in every District and Block. It is pertinent to mention that all preexisting diseases are also covered under this scheme as stated above. The complainant being an employee of Government of Punjab is fully covered alongwith his family Members under the above said scheme vide insurance policy duly issued by the opposite party No.2 who is concerned insurance company to grant insurance cover to the beneficiaries under the said policy No.231102/48/2016/769 issued by it, valid from the period w.e.f. 1.1.2016 to 31.12.2016 and the opposite party No.1 has been appointed as Third party Administrator ( TPA) and even in this respect an ID Card No.MD15-09464227390 was issued in the name of  the complainant and as such he is a consumer within the meaning of Consumer Protection Act. Unfortunately the wife of complainant namely Neelam Kaur fell ill and she was admitted in opposite party No.3 hospital on 25.06.2016 and was discharged on 01.07.2016 and during the course of said treatment the complainant spent about Rs.1,55,500/- towards treatment cost, hospitalization charges and medical expenses etc. and in this respect opposite party No.3 forwarded the claim of Rs.1,55,400/- for availing cashless facility for the complainant out of which the opposite parties No.1 and 2 paid only of Rs.57,200/-  directly to the opposite party No.3 and deducted Rs.98,200/- and the said amount was received by the opposite party No.3 from the complainant in cash. The complainant visited the office of opposite parties so many times and even the requests were also made by him telephonically but the opposite parties did not pay any heed to the genuine requests of the complainant and the opposite parties failed to pay the balance claim amount of Rs.98,200/- out of the total claim amount for the reasons best known to them especially when the partly claim amount of Rs.57,200/- has already been paid by the opposite parties  The opposite parties are under obligation to pay the balance amount of the impugned claim within a reasonable period but inspite of long duration and delay till date the opposite parties have not paid the claim amount to the complainant and this act on the part of opposite parties is a clear cut case of gross negligence, carelessness, deficiency in service and unfair trade practice and prayed that the following reliefs may be granted.

(i)      That the opposite parties may please be directed to pay the remaining amount of Rs98,200/- out of the total claim amount (partly amount of Rs.57,200/- already paid directly to opposite party No.3).

(ii)     The opposite parties may please be directed to pay compensation to the tune of Rs. 2,00,000/- to the complainant which the complainant has suffered on account of mental agony, pain and harassment.

(iii)    The costs of the litigation of Rs. 1,00,000/- be also awarded to the complainant which complainant has suffered on account of deficiency in service and unfair trade practice.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite party Nos. 1 and 2 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not legally maintainable as the complainant has not placed on record any cogent and convincing material supported with documentary evidence in order to substantiate the  pleas as alleged in the complaint much less the relief sought is available to the complainant on the basis of vague and ambiguous pleas without any basis. The complainant has not come to this commission with clean hands and has concealed material facts from this commission and as such the present complaint merits dismissal on this simple score only. Infact the opposite party No.1 has already settled the claim of the complainant as the payable amount was to the tune of Rs57,200/- which as paid under PGEPHIS Rates as per terms and as such it cannot be attributed that there is any lapse, shortcomings or any deficiency in service on the party of the replying opposite parties. The present complaint is an abuse of process of court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the replying opposite parties. No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant. The present complaint is bad for misjoinder of necessary parties as the replying opposite parties have been unnecessarily impleaded without any cause of action and even otherwise keeping in view the facts and circumstances of the case, no liability can be fastened upon the replying opposite parties and as such the present complaint merits dismissal on this simple score only. The complainant has not obtained any insurance policy personally from the Insurance Company but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) but the complainant has not made the State of Punjab as party to the present compliant. In the absence of necessary parities i.e. State of Punjab, the complainant alone has no cause of action to file the present complaint nor he is covered under the definition of Consumer. Even the Government of Punjab as per notification dated 21.09.2016 has sanctioned Grievance Committees at District Level as well as State Level Committee to redress grievance of the beneficiaries and other stake holders and from this notification it is clear that the complainant has the legal remedy to approach the District Level as well as State Level Committee from redressal of his grievance and once he has not availed of this legal remedy, the present complaint in nor maintainable. So far as medi-claim policies are concerned, obtained by the Punjab Government under Punjab Government Employees and Pensioner Health Insurance Scheme, in this regard it is submitted that specific memorandum of understanding was executed by the Government with the opposite party and as such anything contrary to the said memorandum of understanding as well as terms and conditions of the policies issued by the opposite parties are categorically denied. The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same.

4        The opposite party No. 3 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not legally maintainable against the opposite party No.3 as no relief can be given to the complainant on basis of the facts mention in the complaint. The opposite party No.3 is not liable to refund any of the amount to the complainant the contract for the payment of the expensive treatment is between the complainant and the opposite party No.1 & 2. There is not cause of action in the favour of the complainant against the opposite party No.3.  Neelam Kaur was admitted in the hospital of the opposite party No.3 for the treatment of T2 DM, HTN, Ileo- Femoral Thrombosis under the cashless policy of PGEHIS ( Punjab Government Health Policy) through TPA MD India. The patient treated and graft implanted in patient. This procedure cannot be done without graft and the cost of the treatment was Rs.1,55,400/-, final bill was submitted to TPA with graft invoice. Out of that amount Rs.57,200/- was paid by the opposite party No.1 & 2 as per the policy after settlement of claim as per PGEPHIS schedule of rates Para-4 cost of implants, stents, graft is reimbursable to the provider hospital and hence the remaining amount of Rs.98,200/- was paid by the complainant.. Pre auth sent to the TPA for patient documents verification, line of treatment and estimated cost of treatment. The opposite party No.3 has no concern regarding the deduction of Rs.98,200/- by the opposite parties No. 1 and 2 from total amount. The opposite party No. 3 was entitled to receive the full cost of the treatment from the patient and hence the balance amount of Rs.98,200/- was rightly paid by the complainant. The dispute is between complainant and the opposite party  No.1 & 2. The opposite party No. 3 has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party No. 3 had tendered in evidence affidavit of Sunil Dhar General Manager Ex. OP3/1 alongwith documents i.e. appointment of Mr. Sunil Dhar Ex. OP3/2, OT Notes Ex. OP3/3, Certificate Ex. OP3/4, Invoice Ex. OP3/5, OP3/6, PGPHIS Schedule of Rates Ex. OP3/7, Request for Pre authorisaction Ex. OP3/8.

5        To prove his case, the complainant tendered in evidence his affidavit Ex. C-1 copy of claim detail as well as payment detail Ex. C-2, copy of the M.D ID Card Ex. C-3, copy of the invoice Ex. C-4, copy of the discharge summary (2 pages) Ex. C-5 and closed the evidence. Ld. counsel for the opposite parties No. 1 and 2 tendered in evidence affidavit of Sh. R.K. Sharma Divisional Manager Ex. OP1, 2/1, copy of the claim status Ex. OP1, 2/2, copy of the PGEPHIS schedule of rates consisting of 4 pages Ex. OP1,2/3, copy of the notification dated 20.10.2015 Ex. OP1,2/4, copies of notification dated 20.10.2015 Ex. OP1,2/4, copies of notification dated 21.9.2016 Ex. OP1,2/5 and OP 1,2/6 and closed the evidence.

6        We have heard the Ld. counsel for the complainant and opposite party and have gone through the record on the file.

7        Ld. counsel for the complainant contended that the complainant is an employee of Government of Punjab and is working in Punjab Roadways Amritsar-II. The Government of Punjab, Department of Health and Family Welfare vide its Notification No.21/28/12-5HB5/268 dated 20.10.2015 is pleased to introduce a cashless Health Insurance Scheme  hereinafter referred as  Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses, specified daycare procedures and treatment or chronic diseases as specified or to be specified by State Government serving employees and pensioners on compulsory basis. The said scheme also ensures cashless all  Indoor medical treatment, pre and Post hosptalization specified as defined, Day  care procedures, and OPD medical expenses relating to chronic diseases up to a sum of Rs.3 lacs per family per year on floater basis. Medicine for chronic diseases will also be available on cashless basis from designated stores and hospitals in every District and Block. He further contended that all preexisting diseases are also covered under this scheme as stated above. The complainant being an employee of Government of Punjab is fully covered alongwith his family Members under the above said scheme vide insurance policy duly issued by the opposite party No.2 who is concerned insurance company to grant insurance cover to the beneficiaries under the said policy No.231102/48/2016/769 issued by it, valid from the period w.e.f. 1.1.2016 to 31.12.2016 and the opposite party No.1 has been appointed as Third party Administrator ( TPA) and even in this respect an ID Card No.MD15-09464227390 was issued in the name of  the complainant. Unfortunately the wife of complainant namely Neelam Kaur fell ill and she was admitted in opposite party No.3 hospital on 25.06.2016 and was discharged on 01.07.2016 and during the course of said treatment the complainant spent about Rs.1,55,500/- towards treatment cost, hospitalization charges and medical expenses etc. and in this respect opposite party No.3 forwarded the claim of Rs.1,55,400/- for availing cashless facility for the complainant out of which the opposite parties No.1 and 2 paid only of Rs.57,200/-  directly to the opposite party No.3 and deducted Rs.98,200/- and the said amount was received by the opposite party No.3 from the complainant in cash. The complainant visited the office of opposite parties so many times the opposite party no. 1 has not made the payment of remaining amount to the complainant and prayed that the present complaint may be allowed.

8        On the other hands, Ld. counsel for the opposite parties No. 1 and 2 contended that The opposite party No.1 has already settled the claim of the complainant as the payable amount was to the tune of Rs57,200/- which as paid under PGEPHIS Rates as per terms and as such it cannot be attributed that there is any lapse, shortcomings or any deficiency in service on the party of the opposite parties No. 1, 2. The complainant has not obtained any insurance policy personally from the Insurance Company but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) but the complainant has not made the State of Punjab as party to the present compliant. In the absence of necessary parities i.e. State of Punjab, the complainant alone has no cause of action to file the present complaint nor he is covered under the definition of Consumer. Even the Government of Punjab as per notification dated 21.09.2016 has sanctioned Grievance Committees at District Level as well as State Level Committee to redress grievance of the beneficiaries and other stake holders and from this notification it is clear that the complainant has the legal remedy to approach the District Level as well as State Level Committee from redressal of his grievance and once he has not availed of this legal remedy, the present complaint in nor maintainable. So far as medi-claim policies are concerned, obtained by the Punjab Government under Punjab Government Employees and Pensioner Health Insurance Scheme, in this regard it is submitted that specific memorandum of understanding was executed by the Government with the opposite party and as such anything contrary to the said memorandum of understanding as well as terms and conditions of the policies issued by the opposite parties are categorically denied and prayed that the present complaint may be dismissed. 

9        Ld. counsel for the opposite party No. 3 contended that the present complaint is not legally maintainable against the opposite party No.3 as no relief can be given to the complainant on basis of the facts mention in the complaint. The opposite party No.3 is not liable to refund any of the amount to the complainant the contract for the payment of the expensive treatment is between the complainant and the opposite party No.1 & 2. There is not cause of action in the favour of the complainant against the opposite party No.3.  Neelam Kaur was admitted in the hospital of the opposite party No.3 for the treatment of T2 DM, HTN, Ileo- Femoral Thrombosis under the cashless policy of PGEHIS ( Punjab Government Health Policy) through TPA MD India. The patient treated and graft implanted in patient. This procedure cannot be done without graft and the cost of the treatment was Rs.1,55,400/-, final bill was submitted to TPA with graft invoice. Out of that amount Rs.57,200/- was paid by the opposite party No.1 & 2 as per the policy after settlement of claim as per PGEPHIS schedule of rates Para-4 cost of implants, stents, graft is reimbursable to the provider hospital and hence the remaining amount of Rs.98,200/- was paid by the complainant.. Pre auth sent to the TPA for patient documents verification, line of treatment and estimated cost of treatment. The opposite party No.3 has no concern regarding the deduction of Rs.98,200/- by the opposite parties No.1 and 2 from total amount. The opposite party No. 3 was entitled to receive the full cost of the treatment from the patient and hence the balance amount of Rs.98,200/- was rightly paid by the complainant. The dispute is between complainant and the opposite parties  No.1 & 2 and prayed that the present complaint may be dismissed.

10      In the present case insurance is not disputed because after admitting the insurance the opposite parties No. 1 and 2 have made the payment of Rs.57,200/- to the complainant. As per complainant, he spent amount of Rs.1,55,400/- on the treatment and the opposite party has made only Rs. 57,200/- to the complainant, but the opposite party has deducted Rs. 98,200/- from the claim of the complainant and the complainant prayed that for payment of Rs. 98,200/- from the opposite parties. Now question arises as to whether the complainant is entitled to Rs. 98,200/- i.e. remaining claim amount from the opposite parties or not. As per version of the opposite parties that Neelam Kaur was admitted in the hospital of the opposite party No.3 for the treatment of T2 DM, HTN, Ileo- Femoral Thrombosis under the cashless policy of PGEHIS ( Punjab Government Health Policy) through TPA MD India. The patient treated and graft implanted in patient. This procedure cannot be done without graft and the cost of the treatment was Rs.1,55,400/-, final bill was submitted to TPA with graft invoice. Out of that amount, an amount of Rs.57,200/- was paid by the opposite party No.1 & 2 as per the policy after settlement of claim as per PGEPHIS schedule of rates Para-4 cost of implants, stents, graft is reimbursable to the provider hospital and hence the remaining amount of Rs.98,200/- was paid by the complainant. Therefore amount of Rs. 98,200/- was deducted. To support their version, the opposite parties have placed on record PGPHIS Schedule of Rates Ex. OP,2/3 in which the rate of Aorta femoral bypass is mentioned as Rs. 52,000/-. Therefore, the opposite parties No. 1 and 2 have made the payment to the complainant as per rates applicable and admissible as per policy.  The opposite parties have made the payment to the complainant as per terms and conditions of the policy. Both the parties are bound by the terms and conditions of the policy. The terms and conditions of the Insurance Policy have to be strictly construed. Hon’ble Supreme Court in the case of Export Credit Guarantee Corporation of India vs. Garg Sons International 2013 (1) SCALE 410 (SC) held in Para Nos.8 to 11 as under:

“8.  It is a settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567). 

9.  The insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829). 

10.   In Vikram Greentech (I) Ltd. & Anr. v. New India   Assurance Co. Ltd. AIR 2009 SC 2493, it was held:  “An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. (See also: Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).” 

11.  Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.” 

11      While repudiating the claim of the complainant qua the remaining amount, the opposite parties No. 1 and 2 have not committed any deficiency in service and unfair trade practice and the claim has been validly repudiated.

12      In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.

 Announced in Open Commission

21.10.2022