PER:

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 Govt. 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 namely Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses, specified daycare procedures and treatment of chronic diseases as specified or to be specified by State Government. The scheme will be applicable to all the Government Serving employees (whether covered under old or new pension scheme) and pensioners on compulsory basis. The said scheme will ensure cashless all indoor medical treatment, pre  & Post hospitalization, specified as defined. DayCare procedures, (requiring less than 24 hours hospitalization)  and OPD medical expenses relating to chronic diseases up to a sum of Rs. 3.00 lacs per family per year on floater basis. Medicines for chronic diseases will also be made available on cashless basis from designated stores and hospitals in every district and block. All pre existing diseases will be covered. The opposite parties issued a family health Mediclaim insurance policy in the name of complainant through opposite party No. 2 vide policy valid for the period w.e.f. 1.1.2016 to 31.12.2016 against the requisite premium covering the medical risk of complainant and as such, the complainant is a consumer of the opposite parties as defined under Consumer Protection Act. The complainant is a holder of cashless medical hospitalization facilities under the aforesaid Government Scheme (PGEPHIS) as per Notification detailed above under the policy having Card No. MDI5-09815527718 issued by the opposite party No. 2. The opposite party No. 3 is the hospital provided by the opposite parties No. 1 and 2 to provide cashless hospitalization facilities to the holder of this card. During the validity period of the said policy, the complainant got admitted in the hospital of opposite party No. 3 on dated 5.1.2016 and awas being diagnosed for CAD-TVD/ACS/STEMI/STK+VE. At the time of admission the complainant presented the card issued by opposite parties, but the opposite party No. 3 refused the complainant to provide cashless facilities and insisted him to deposit the cash amount with him, although the opposite party No. 3 Nayyar Hospital is in the list of empanelled hospitals, but the said opposite party No. 3 did not provide cashless facility to the complainant. Even in this respect the complainant also talked to the customer care number 104 and they advised to take the treatment from the said hospital and to send the medical bills for the reimbursement of the same and as such, accordingly the father of the complainant got medical treatment from the said hospital and was discharged on 8.1.2016. The complainant spent total a sum of Rs. 5,27,634/- on his medical treatment and thereafter all the requisite bills along with other relevant documents as per demand of opposite parties No. 1 and 2 have been sent to the opposite parties No. 1 and 2 for reimbursement of the genuine and legitimate claim of the complainant under the impugned insurance policy which was in force at the relevant time. The impugned claim was lodged for reimbursement of medical expenses with the opposite parties No. 1 and 2 and all the requisite documents and original medical bills etc. were supplied to the opposite parties. But the opposite parties have failed to process the claim of the complainant within the stipulated period and rather on the contrary instead of paying the genuine claim opposite parties No. 1 and 2 are not giving any response towards the said claim of the complainant and have not made the payment of claim till date inspite of repeated requests and demands made by the complainant orally as well as in writing. Repudiation of claim is unlawful, arbitrary and without any basis. The complainant has prayed that the opposite parties may please be directed to pay a sum insured amount to the tune of Rs. 3,00,000/- along with interest at the rate of 12% per annum and compensation to the tune of Rs. 20,000/- may also be awarded to the complainant which the complainant has suffered on account of mental agony and harassment besides costs of litigation expenses to the tune of Rs. 10,000/-

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties No. 1 and 2 appeared through counsel and filed written version and contested the complaint by interailia 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 abscess of vague and ambiguous pleas without any basis and on the basis of false and frivolous documents and as such, the present complaint merits dismissal on this simple score only. The present complaint is bad for misjoinder of necessary parties as the opposite parties No. 1 and 2 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 opposite parties No. 1, 2 and as such, the present complaint merits dismissal on this simple score only. The complainant has not obtained any insurance policy personally from the opposite parties No. 1 and 2 but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) from Insurance Company but the complainant has not made the State of Punjab as party to the present complaint. In the absence of necessary parties 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. 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. Even the Government of Punjab as per notification dated 21.9.2016 has constituted Grievance Committees at District Level as well as at 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 for redressal of his grievance and once he has not availed of this legal remedy, the present complaint is not maintainable and deserves outright dismissal. The present complaint is an abuse of process of commission as it is settled principle of law that the process of Consumer commission cannot become a tool in the hands of unscrupulous persons who file complaints merely with a view to extract money in the garb of compensation. It is settled as well as an essential requirement of equity that one who alleges must prove the allegation that the complainant can not make this commission reach the conclusion as he desires on the basis of distorted facts. 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 opposite parties No. 1 and 2. The complainant is not a consumer much less he is covered under the definition of consumer to maintain the present complaint and even the complainant has not lodged any claim with the opposite parties No. 1 and 2  and as such, the present complaint is liable to be dismissed on this ground alone. So far as medi-claim policies are concerned, obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) and “As per Para No. 8 of the notification No. 21/28/12-5HB5/268 dated 20.10.2015, it has been specified that Enrollment under this scheme will start from immediate effect and will be completed by 31.12.2015 and the benefit under this scheme will start from 1.1.2016 and will be available up to 31.12.2016 initially. Every employee/ petitioner will ensure his/her enrollment along with dependents before 15.12.2015 enabling the insurance policy to deliver the enrolled insurance cards up to 31.12.2015. No fresh enrollment of the serving employees and pensioners shall be allowed after the date of expiry of enrollment period except for any exceptional circumstances or in case of any employee who has joined the service after the enrollment period i.e. after 15.12.2015, under such circumstances, coverage as well as payment of premium of such employees/ pensioners shall be allowed on prorata basis. In the present case in hand, the MD India Card was issued to the complainant for the period 1.2.2016 to 31.12.2016 as he had joined the scheme after the enrolled period and whereas as per the version of the complainant as mentioned in the complaint itself that he has taken the treatment from 5.1.2016 to 8.1.2016 i.e. prior to his covering period and when the premium for the period of January 2016 was not received by the insurance complainant in that eventuality the question regarding payment of the claim for the period January 2016 i.e. prior to the period of enrollment does not arise. There is no deficiency in service on the part of the opposite parties and as such claim of compensation, claim amount as well as interest is not payable under the provisions of Consumer Protection Act. No consumer dispute services between the parties much less any cause of action has arisen in favour of complainant and as such, the present complaint being without any cause of action merits dismissal with special costs.  The opposite party Nos. 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 has filed written version by interlia pleadings that the complaint is not maintainable either on the facts alleged or under the law against opposite party No. 3, hence is liable to be dismissed on this score alone. The complainant does not disclose any cause of action against the opposite party No. 3. No specific negligence or deficiency in service has been attributed to the opposite party No. 3. The opposite party No. 3 was not a partner hospital with the Government of Punjab, Department of Health and Family Welfare in the said cashless health insurance scheme for Punjab Government Employees and Pensioners Health insurance scheme at the relevant time and it was made clear to the complainant at the very outset when the complainant came to opposite party No. 3 hospital for treatment. Since opposite party No. 3 hospital was not an empanelled hospital, so no cashless treatment could be provided to the complainant. The complainant was at liberty to get paid treatment. The complainant opted for paid treatment and willingly paid hospital charges without any objection or demur.  The opposite party No. 3 Hospital is / was not the empanelled hospital for the treatment of Punjab Government employees, hence was not obliged to provide cashless treatment to the complainant. The complainant having himself opted for paid treatment and having made payment of the hospital expenses on his own, is estopped from filing the present complaint against the opposite party No. 3.  During the period in question, opposite party No. 3 hospital was not an empanelled hospital with the Government of Punjab and thus was not obliged to provide cashless treatment to the complainant. the opposite party No. 3 hospital from 5.1.2016 to 8.1.2016 and was treated for CAD/DVD/HTM/PTC A + STENT to LAD & LCX. Since opposite party Hospital  is/ was not the empanelled hospital for the treatment of Punjab Government Employees, the opposite party hospital authorities immediately informed the complainant at the very outset when the complainant came for treatment that they being not the empanelled hospital were not obliged to provide cashless treatment to the complainant. But the complainant could not get the treatment on payment to which complainant agreed and made payment of the hospital bill stating that he will get reimbursement of the expenses paid from the concerned agencies/ insurer. It was complainant’s personal, voluntary decision without any pressure. Nobody had insisted upon complainant to deposit the expenses but the reason for same was stated to the complainant. Even before taking the decision the complainant had talked to the insurer helpline and only after  taking their advice opted for paid treatment. The opposite party No. 3 has no fault in this.  The total expenses for treatment were to the tune of Rs. 5,20,000/- . But this amount the complainant paid out of his free will on his own without any duress or pressure from the opposite party No. 3. He had taken this decision to go in for paid treatment with a cool mind after taking advice from the insurer helpline. The opposite party No. 3 had extended all the help to the complainant and provided all the record that was needed to get reimbursement from insurer. The opposite party No. 3 has no role to play in acceptance or repudiation of the claim for reimbursement submitted by the complainant. the opposite party No. 3 has denied the other contents of the complaint and prayed for dismissal of the same.  

5        To prove his case, Ld. counsel for the the complainant has placed on record affidavit of complainant Ex. C-1 alongwith documents Ex. C-1 to Ex. C-20 and closed the evidence.  On the other hands, the opposite parties No.1 and 2 have placed on record affidavit of Sh. OP 1, 2/A, copy of notification Ex. OP1, 2/1, copy of notification dated 21.9.2016 Ex. OP 1,2/2 and OP 1,2/3 and closed the evidence. Ld. counsel for the opposite party No. 3 has placed on record affidavit of Dr. Shashi Nayyar Ex. OP3/1 and closed the evidence.

6        We have heard the Ld. counsel for the parties and have gone through the record on the file.

7        From the combined and harmonious reading of pleading and documents this is going to prove on record that the complainant being a Govt. employee obtained a Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses, specified daycare procedures and treatment of chronic diseases as specified or to be specified by the State Government. The said scheme insures cashless all indoor medical treatment, pre and post hospitalization, specified as defined, day care procedure and OPD medical expenses relating to chronic disease up to a sum of Rs. 3,00,000/- per family per year on floater basis and as per the notification the said policy was valid for period w.e.f. 1.1.2016 to 31.12.2016 against the requisite premium. During the validity period of the said policy complainant was admitted in the Hospital of opposite party No. 3 on dated 5.1.2016 and was diagnosed for CAD-TVD/ACS/STEMI/STK +VE and on the said treatment the complainant spent a sum of Rs. 5,27,634/- and thereafter, all the requisite bills along with other relevant documents as per the demand of opposite party Nos. 1 and 2 were sent to the opposite parties for reimbursement of the claim. But the claim of the complainant has been properly settled.

8        The opposite parties No. 1 and 2 in their reply stated that every employee/ petitioner will ensure his/her enrollment along with dependants before 15.12.2015 enabling the insurance policy to deliver the enrolled insurance cards up to 31.12.2015. No fresh enrollment of the serving employees and pensioners shall be allowed after the date of expiry of enrollment period except for any exceptional circumstances or in case of any employee who has joined the service after the enrollment period i.e. after 15.12.2015, under such circumstances, coverage as well as payment of premium of such employees/ pensioners shall be allowed on prorata basis. In the present case in hand, the MD India Card was issued to the complainant for the period 1.2.2016 to 31.12.2016 as he had joined the scheme after the enrolled period and whereas as per the version of the complainant as mentioned in the complaint itself that he has taken the treatment from 5.1.2016 to 8.1.2016 i.e. prior to his covering period and when the premium for the period of January 2016 was not received by the insurance complainant in that eventuality the question regarding payment of the claim for the period January 2016 i.e. prior to the period of enrollment does not arise as such the complainant is not entitled to relief as claimed for keeping in view the facts and circumstances of the case and documents.

9        The opposite party No. 3 has admitted the complainant was admitted in the hospital from 5.1.2016 to 8.1.2016 and was treated for CAD/DVD/HTM/PTC A+ STENT to LAD & LCX.

10      The whole controversy revolves around the point as to whether on 5.1.2016 the complainant was insured or not. The complainant has placed on record a copy of Hindustan times (e paper) whereby it is clearly proved that the health insurance scheme i.e. PGEPHIS was extended till January 15. It is pertinent to mention here that the said scheme was floated by the Punjab Govt. for the year 2016. The opposite parties No. 1 and 2 have taken the stand that  the policy period of the complainant was from 1.2.2016 to 31.12.2016 as per Identity card issued by the concerned authority. The counsel for the complainant stated that this Identity card was issued late. However, the complainant was insured on the said date as the said scheme was started from 31.12.2015 as the last date for enrollment was also extended till Jan. 15 and benefit under this scheme was commenced from 1.1.2016 to 31.12.2016. This fact is cleared from the notification of Health Insurance Scheme issued by Punjab Govt.  In the said notification it is clearly mentioned that the insurance policy coverage/ Policy plan period shall commence from 1st January 2016 and will expire on midnight 12.00 am of 31.12.2016. The opposite parties No. 1 and 2 have not proved on record that the complainant was not insured on the said date. The opposite parties No. 1 and 2 have taken the specific objection that the complainant has not approached the District Level Committee to redress his grievance. Since the Consumer Act provides the additional remedy for the Redressal of his grievance, he has rightly approached this Commission.

11      On the one hand opposite parties No. 1 and 2 have categorically denied that on the said date the complainant was not insured, on the other hands, after admitting the insurance claim, the opposite parties No. 1 and 2 have reimbursed the part payment of treatment i.e. an amount of Rs.32,820/- which is proved from account statement of complainant Ex. C-19. Two entries have been shown on 27.12.2016 for an amount of Rs. 15,253/- and second entry dated 7.1.2017 for an amount of Rs. 17,567/- . The opposite parties No. 1 and 2 have failed to prove that how they have calculated the amount. The opposite parties No. 1 and 2 have not placed on record list of charges which would show how the said amount was calculated and reimbursed by them. The opposite parties No. 1 and 2 have miserably failed to produce any cogent and convincing document which proves that how they have calculated the amount of Rs. 32,820/-  No detail of amount of Rs. 32,820/- has been provided to complainant that is on which basis this much amount has been reimbursed. Further it is very much clear from the notification that the members of the said policy are under the coverage for meeting all expenses relating to hospitalization of beneficiary member up to Rs. 3,00,000/- per family.  From the perusal of documents placed on record it clearly proves that the complainant was insured on the said date and the opposite parties No. 1 and 2 have made the part payment to the complainant for the said treatment which was taken by the complainant from the opposite party No. 3. The complainant has spent an amount of Rs. 5,27,634/-, however, the sum assured is only to the tune of Rs. 3,00,000/-. Hence the complainant is entitled to remaining amount of Rs. 2,67,180/-.

12      Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

13      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties No. 1, 2 are directed to reimburse the remaining expenses i.e. Rs. 2,67,180/- paid by the complainant during hospitalization to the complainant. The present complaint against the opposite party No. 3 is dismissed. The complainant has been harassed by the opposite parties No.  1 and 2 unnecessarily for a long time. All applications pending are disposed of. The complainant is also entitled to Rs.5,000/- ( Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs 4,500/- ( Rs Four Thousand five Hundred only) as litigation expenses. Opposite Parties No. 1 and 2 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  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

23.08.2022