BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.193 of 2017

      Date of Instt. 02.06.2017

      Date of Decision: 12.02.2020

Bahadur Singh S/O Late Shri Jagat Singh, Police Inspector (Retired) R/o Ghduwal Post Office Phull Ghuduwal, Sub-Tehsil Lohian, Tehsil Shahkot, District Jalandhar.

..........Complainant

Versus

1.       MD India Healthcare Service (TPA) Pvt. Ltd.  (Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), MD India Health Insurance TPA Private Limited Maxpro Information Park, D-38 Industrial Area,    Phase-1, Mohali, Punjab-160056 Through its Authorized Representative.

2.       The Oriental Insurance Company Ltd., Head Office, 25/27 Asaf Ali Road New Delhi-110001 Through its Chairman cum Managing Director.

3.       Shri Ram Carrdie Center, Kapurthala Chowk Jalandhar.

4.       State of Punjab Chandigarh through its Principal Secretary, Department of Health and Family Welfare, Punjab.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Karnail Singh           (President)

Smt. Jyotsna                   (Member)

Present:       Sh. K. C. Malhotra, Adv. Counsel for the Complainant.

Sh. Brijesh Bakshi, Adv. Counsel for the OPs No.1 & 2.

OP No.3 exparte.

Complaint against OP No.4 DAW.

Order

Karnail Singh (President)

1.                This complaint has been filed by the complainant, wherein alleged that        he is retired from Government Job, as Police Inspector and he was insured in a cashless Health Insurance Scheme (PGEPHS) introduced by Government of Punjab to cover indoor medical treatment expenses, specified day care procedures and treatment of chronic diseases as specified or to be specified by State Government. The beneficial PGEPHS floated by government was applicable to all government serving employees as well as pensioners. The premium as consideration of main members as well as dependents to cover risk under PGEPHS was to be paid by government under Policy bearing No.231102/48/2016/769. Master insurance policy for all insured was issued by OP No.2. The complainant claim ID number is MD10053875 and MD India ID No.MD15-09464015890. The OP No.2 is insurer and OP No.1 third party administrator (TPA) as per tie up arrangement between OP No.4 and OP No.2.

2.                That the complainant was clinically/physically examined and angioplasty tests were diagnosed malady HTN and CAD (Coronary Artery Disease) and Angina. The complainant was admitted on 08.09.2016 and discharged on 10.09.2016 for surgical treatments as in patient by OP No.3. The complainant was undergone surgical operation for Coronary Angiography followed by PTCA with stents. After discharge from hospital, the complainant referred medical claim through OP No.1 to OP No.2 for the reimbursement of expenses incurred and paid to OP No.3 for an amount of Rs.1,50,000/-. The complainant submitted original bills, receipts of payment, original reports, original discharge summary alongwith prescribed claim form duly signed and also completed and complied with all the formalities and requirements, which ever were asked for. The medical expenses of the complainant has neither been reimbursed nor did his mediclaim settle till date despite his repeated request, follow up and protestations with OPs No.1 and 2. The complainant has been put off on the pretext that settlement of mediclaim expenses amount is lying pending with OP No.1 and the complainant will get reimbursement of expenses is due course. The claim settlement status has not been made known to the complainant and as such, the complainant has been running pillar to post for the last over one year awaiting claim settlement and reimbursement of expenses, but all in vain. The OPs No.1 and 2 are required and duty bond to process, finalize and settle mediclaim expenses amount within 30 days from the receipts of prescribed claim forms with all supportive documents as per statutory and mandatory insurance regulatory and development authority of India. The delay in settlement of Mediclaim expenses per se is sufficient to settle with charge of deficiency in rendering service and negligence on the part of the OPs No.1, 2 and 4 and accordingly, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs No.1 and 2 be directed to reimburse Rs.1,50,000/- to the complainant alongwith interest @ 12% per annum from the date of payment to OP No.3 till actual realization since the complainant has been deprived of the beneficial use and advantage of this amount and further, OPs be directed to pay compensation of Rs.50,000/- to the complainant for causing mental torture and harassment and further, OPs be directed to pay litigation expenses of Rs.10,000/-.

3.                At the time of admission of the complaint, OP No.4 was not summoned by this Forum. OP No.3 was duly served, but despite service OP No.3 did not bother to appear and ultimately, OP No.3 was proceeded against exparte.

4.                OPs No.1 and 2 appeared through its counsel and filed a joint written reply, whereby contested the complaint by taking preliminary objections that the above noted complaint is not maintainable under the law against the answering respondents and further averred that the complainant has got no cause of action to file the present complaint qua answering respondent because there has been no default or undue delay, on the part of the answering respondent in processing the claim of the complainant and even otherwise, the claim was neither been received nor yet processed by the respondent No.1. The fact of the matter is that the respondent No.1 had received cashless request for the case of the complainant from the respondent No.3 and as per the policy terms and conditions, the respondent No.1 had given the initial approval for Rs.7260/- for such like cases in the case of the complainant as well. However, thereafter the respondent No.3 hospital did not submit the requisite documents and did not give any further information about any operation/surgery performed or not. Thus, the respondent No.1 on account of non-submission of further documents was constrained to close the case file in cashless. It is further alleged that the complainant is barred by his own act, conduct, laches and negligence from filing the present complaint and even the complainant has concealed the material facts from the Forum. On merits, it is admitted that the complainant is retired employee as per record and he got the said insurance policy floated by the government and further submitted that the entitlement to lodge claim has vested with the complainant, but firstly he has to file a claim and papers thereof to respondent No.1 for verification and claim settlement procedure to be adopted by OPs No.1 and 2 as per law and policy terms and conditions. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

5.                Replication not filed.

6.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence two affidavits of the complainant Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-14 and closed the evidence.

7.                Similarly, counsel for the OPs No.1 and 2 tendered into evidence two affidavits Ex.OA and Ex.OB alongwith some documents Ex.O-1 and Ex.O-2 and closed the evidence.

8.                We have heard the learned counsel for the respective parties and also gone through the written arguments submitted by both the counsel for the parties as well as case file very minutely.

9.                Before imparting with the main issue in dispute, we constrained to take the legal plea taken by the OPs in its written reply that the complainant is entitled to lodge insurance claim and it is the vested right with the complainant, but       firstly he has to file the insurance claim paper alongwith other relevant documents and in the instant complaint, the complainant has never filed insurance claim. So, in the absence of insurance claim, the OP No.1 is not in position to process the claim of the complainant or settle the same as per terms and conditions. This plea has been taken by the OPs numerous times in the preliminary objections No.2 as well as in Para No.3 on merits. But no reply in the shape of rejoinder has been filed by the complainant to rebut the written statement of the OP and even the complainant has not brought on the file any documentary evidence to disprove the plea of the OP that the claim alongwith other relevant document has been submitted. No doubt, the complainant has brought on the file claim form Ex.C-3, but it has not been acknowledged by any of the official of the OP No.1. If the insurance claim has not been filed by the complainant, then how he can say there is any negligence, unfair trade practice on the part of the OPs No.1 and 2. So, accordingly, we find that the complaint of the complainant is premature and accordingly, the complainant is directed to file insurance claim alongwith all the relevant documents and also fulfill the requisite formalities and thereafter, the OPs No.1 and 2 will settle the claim of the complainant according to terms and conditions. The complainant will submit the claim form and other documents as well as fulfill the formalities and thereafter, the OPs No.1 and 2 will take 30 days to settle the claim of the complainant on either side and after that, if the complainant will not satisfy with the settlement of the claim by OPs No.1 and 2, then the complainant has liberty to file a fresh complaint and accordingly, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.

10.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                       Jyotsna                           Karnail Singh

12.02.2020                                        Member                          President