DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

Complaint Case No : RBT/CC/2018/110

Date of Institution   : 16.02.2018/29.11.2021

Date of Decision    : 16.08.2022

 

Mrs. Raghbir Kaur widow of Sh. Gurdial Singh resident of H.No. 481, Green Avenue, Amritsar.   

                 …Complainant Versus

1.M.D. India Health Care Service Pvt. Limited, Maxpro Info Park, D-38, 1st Floor, Industrial Area, Phase-1 Mohali (Punjab), Through its Chairman/Managing Director/Principal Officer.

2.The Oriental Insurance Company Limited, Through Its Chairman/Managing Director/Principle Officer Service Through Its Branch Office At 26, Court Road, Amritsar Through its Branch Manager.  

              …Opposite Parties

Complaint Under Section 12 & 13 of Consumer Protection Act, 1986. As Amended Upto Date.

 

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. Subodh Salwan Adv counsel for O.Ps-1 & 2.

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : Member 

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT): 

 

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against M.D. India Health Care Service Pvt. Limited & others (hereinafter referred as opposite parties).

2. Brief facts of the case are that the complainant got Health Benefit mediclaim insurance for her deceased husband and herself from the opposite parties by virtue of the Punjab Government employee and pensioner health insurance scheme. It is alleged that the husband of the complainant unfortunately fell ill and was to be hospitalized at FORTIS ESCORT HOSPITAL, AMRITSAR from 21.1.2016 till his demise 22.1.2016 and on the treatment the cost came to Rs. 1,14,780/- and the opposite parties were immediately informed about the above said hospitalization and all the treatment record alongwith medical bills were furnished to the opposite parties. The sum insured for the medical benefit is for Rs. 3 lacs. It is further alleged that unfortunately husband of the complainant expired on 22.1.2016 and thereafter the complainant visited the office of the opposite parties till filing the present complaint but the opposite parties have failed to settle the genuine claim of the complainant, as such the conduct of the opposite parties amounts to deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay the amount of Rs. 1,14,780/- alongwith interest @ 12% per annum from the date of filing the claim till realization. 

ii)To pay Rs. 50,000/-  as compensation alongwith litigation expenses.   

3. Upon notice of this complaint, Sh. Subodh Salwan Advocate appeared on behalf of opposite parties No. 1 & 2 as per order dated 26.3.2018. On 9.4.2018 power of attorney as well as written version on behalf of opposite party No. 2 filed. But the opposite party No. 1 has failed to file written version within the period of 45 days from the date of service, as such the right of the opposite party No. 1 to file written version stands forfeited vide order dated 26.4.2018. 

4. The opposite party No. 2 filed written statement by taking preliminary objections interalia on the grounds of maintainability, complaint is baseless and frivolous, act and conduct, suppressed of material facts, jurisdiction, no cause of action, the complaint is bad for non-joinder for necessary parties etc. It is further alleged that the complaint contains the averments with regard to treatment taken from the Fortis Escort Hospital, Amritsar by the complainant. However, the said Hospital has not impleaded as party in the present complaint. It is alleged that any policy holder who had opted for the medical treatment from any private hospital, the treatment provided shall be mandatory on cashless basis as per the clause 11.6(i) and if the policy holder had taken the medical treatment from a Government Hospitals in Punjab and Chandigarh the reimbursement has to be claimed within 30 days from the discharge of hospital. In case where the claim has been lodged within a stipulated period as per the condition No. 21 of the scheme, the mechanism with regard to dispute resolution and grievance Redressal has been setup by providing grievance Redressal committee in each district and the said committee will resolve the grievance within 30 days from the date of application. However, the complainant has not filed the same prior to the filing of present complaint. It is further alleged in the preliminary objections that the present complaint is hopelessly time barred. On merits, it is submitted that no documentary evidence in the shape of copy of claim form or any other document, which proves that the complainant has ever lodged claim in question with the opposite party No. 2. The complainant has failed to mention date, month, year on which the reimbursement claim has been lodged with the opposite parties. All other allegations of the complainant are denied and prayed for the dismissal of complaint. 

5. In order to prove the case the complainant tendered into evidence her own affidavit Ex.C-1, copy of the acknowledgment Ex.C-2, copy of the medical claim Ex.C-3 and closed the evidence. 

6. To rebut the case of complainant the opposite party No. 2 tendered into evidence affidavit of Sh. O.P. Dhawan, Divisional Manager Ex.O.P1.2/1, copy of the notification of Pb. Govt. dated 20.5.2016 Ex.O.P1.2/2, copy of tender notice Ex.O.P1.2/3, copy of silent features of insurance scheme Ex.O.P1.2/4 and closed the evidence.  

7. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. Written arguments filed by the opposite party No. 2.

8. Ld. Counsel for complainant argued that the complainant got Health Benefit mediclaim insurance for her deceased husband and herself from the opposite parties by virtue of the Punjab Government employee and pensioner health insurance scheme. It is argued that the husband of the complainant unfortunately fell ill and was to be hospitalized at FORTIS ESCORT HOSPITAL, AMRITSAR from 21.1.2016 till his demise 22.1.2016 and on the treatment the cost came to Rs. 1,14,780/- and the opposite parties were immediately informed about the above said hospitalization and all the treatment record alongwith medical bills were furnished to the opposite parties and the sum insured for the medical benefit is for Rs. 3 lacs. It is further argued that unfortunately husband of the complainant expired on 22.1.2016 and thereafter the complainant visited the office of the opposite parties till filing the present complaint but the opposite parties have failed to settle the genuine claim of the complainant. 

9. On the other hand, Ld. Counsel for opposite parties argued that the complaint contains the averments with regard to treatment taken from the Fortis Escort Hospital, Amritsar by the complainant, however, the said Hospital has not impleaded as party in the present complaint. It is argued that any policy holder who had opted for the medical treatment from any private hospital, the treatment provided shall be mandatory on cashless basis as per the clause 11.6(i) and if the policy holder had taken the medical treatment from a Government Hospitals in Punjab and Chandigarh the reimbursement has to be claimed within 30 days from the discharge of hospital i.e. Ex.O.P1.2/4. It is further argued that in case where the claim has been lodged within a stipulated period as per the condition No. 21 of the scheme, the mechanism with regard to dispute resolution and grievance Redressal has been setup by providing grievance Redressal committee in each district and the said committee will resolve the grievance within 30 days from the date of application, however, the complainant has not filed the same prior to the filing of present complaint. It is further argued that the present complaint is hopelessly time barred and there is no documentary evidence in the shape of copy of claim form or any other document, which proves that the complainant has ever lodged claim in question with the opposite party No. 2. 

10. On the perusal of the file it is established that the complainant has filed the present complaint on 16.2.2018 and the cause of action has arisen to the complainant on 22.1.2016 which is after a gap of two years. Ld. Counsel for opposite parties also relied upon the judgment of the Hon'ble National Consumer Disputes Redressal Commission, New Delhi in Consumer Complaint No. 89 of 2014 decided on 1.5.2014 in case titled Niloba Ghanshyam Naik & Anr. Vs Lodha Pranik Developers Pvt. Ltd. & Others in which the Hon'ble National Commission held that the complaint should be filed within two years from the cause of action and it is well settled that the correspondence, representations and legal notice do not extend the time of limitation. Moreover, the complainant has failed to place on record any document to prove that the complainant has lodged her claim with the opposite parties till today. Further, to prove her case the complainant has placed on record a letter dated 1.6.2016 Ex.C-2 which is written to the Executive Engineer, U.B.D.C, Punjab Irrigation Department, but the complainant has failed to implead the above said department as party in the present complaint. Therefore, the present complaint is bad due to non-joinder of necessary parties. Ld. Counsel for the opposite parties also argued that the complainant has failed to comply the clause No. 23 of the scheme Ex.O.P1.2/4 which is as under;-

Operational Terms and Conditions Applicable To The Reimbursement Claims; “All hospitals of the Punjab Health System Corporation (PHSC), Civil Hospitals, Government Hospitals and Government Medical Colleges/Research Institutes located in the State of Punjab and Chandigarh and Govt. Hospitals in New Delhi shall be automatically included in the list of Provider Hospitals where the beneficiaries can avail medical services as covered under the terms and conditions of the scheme. In an event, the aforesaid hospitals fail to provide cashless treatment beneficiary shall be entitled to avail reimbursement of his/her claim subject to the submission of claim within 30 days from the date of discharge from the hospital”.

11. As per Section 24-A of The Consumer Protection Act 1986 the limitation period for filing a complaint before the District Commission is as under.-

“ 24-A. Limitation period

(1) The District Forum, the State Commission or the National Commission shall not admit a complaint unless it is filed within two years from the date on which the cause of action has arisen.

(2) Notwithstanding anything contained in sub-section (1), a complaint may be entertained after the period specified in sub-section (1), if the complainant satisfies the District Forum, the State Commission or the National Commission, as the case may be, that he had sufficient cause for not filing the complaint within such period. 

Provided that no such complaint shall be entertained unless the National Commission, the State Commission or the District Forum, as the case may be, records its reasons for condoning such delay.”

The complainant has not filed any application for condonation of delay in the present complaint or mentioned any reasons for delay in filing the present complaint. Therefore, in view of the above mentioned facts and circumstances and as per Section 24-A of the Consumer Protection Act 1986 present complaint is barred by limitation.

12. In view of the above discussion and evidence produced by opposite party the present complaint is dismissed being time barred.  However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.  

ANNOUNCED IN THE OPEN COMMISSION:

       16th Day of August, 2022 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member