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

Complaint Case No : RBT/CC/2018/101

Date of Institution   : 12.02.2018/29.11.2021

Date of Decision    : 16.08.2022

 

Mr. Subhash Chander son of Sh. Sat Pal resident of H.No. 284, New Ranjitpura, Chhearta, 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.

Opposite party No. 1 exparte.

Sh. P.N. Khanna Adv counsel for O.P-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 himself and his wife Kanta Devi from the opposite parties by virtue of the Punjab Government employee and pensioner health insurance scheme. It is alleged that the complainant unfortunately fell ill and was to be hospitalized at Civil Hospital, Tarntaran and on the treatment of complainant the cost came to Rs. 18,501/- 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. It is further alleged that later on his wife Kanta Devi also fell ill and was also hospitalized at Civil Hospital, Tarantaran and on the treatment of complainant's wife the cost came to Rs. 12,237/- 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. It is further alleged that the sum insured for the medical benefit is for Rs. 5 lacs. But till today the opposite parties have failed to settle the genuine claim of the complainant despite several visits and requests, 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. 18,501/- and Rs. 12,237/- 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. None appeared on behalf of opposite party No. 1, as such the opposite party No. 1 was proceeded against exparte vide order dated 10.4.2018. 

4. Upon notice of this complaint, the opposite party No. 2 appeared and filed written statement by taking preliminary objections interalia on the grounds of maintainability, complaint is bad  in law, act and conduct, complaint is frivolous and baseless, suppressed of material facts, jurisdiction, the complaint is bad for mis-joinder of parties etc. It is further alleged that the complainant was admitted in hospital on 28.10.2016 and discharged on 28.12.2016, whereas the claim file was submitted with TPA on 29.5.2017. In fact, as per scheme of the insurance the beneficiary shall be eligible for the reimbursement subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital but in the present case the beneficiary has submitted the papers about five months later from the date of discharge, as such the claim was not eligible for reimbursement as per the scheme and the claim was returned by the TPA to Punjab State Health System Corporation, Phase-VI, Mohali to decide the claim after the expiry of the stipulated period. 

5. On merits, it is submitted that no claim was ever lodged with the replying opposite party at any time and only the claim file was received by the TPA but the same was submitted after five months from the date of discharge from the hospital, whereas as per the terms of the PGEPHIS policy, the complainant was bound to submit the claim within the period of 30 days from the date of discharge from the hospital. All other allegations of the complainant are denied and prayed for the dismissal of complaint. 

6. In order to prove the case the complainant tendered into evidence his own affidavit Ex.C-1, copy of prescription cards Ex.C-2 & Ex.C-3, copy of the insurance card Ex.C-4, copy of medical bills Ex.C-5 & Ex.C-6, copy of courier receipt Ex.C-7, copy of letter to Commissioner of Police Ex.C-8 and closed the evidence.  

7. To rebut the case of complainant the opposite party No. 2 tendered into evidence affidavit of Sh. O.P. Dhawan, Divisional Manager Ex.O.P2/1, copy of policy schedule Ex.O.P2/2, copy of terms and conditions Ex.O.P2/3, copy of e-mail Ex.O.P2/4, copy of e-mail Ex.O.P2/5, copy of the list Ex.O.P2/6 and closed the evidence. 

8. 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.

9. Ld. Counsel for complainant argued that the complainant got Health Benefit mediclaim insurance for himself and his wife Kanta Devi from the opposite parties by virtue of the Punjab Government employee and pensioner health insurance scheme i.e. Ex.C-4. It is further argued that the complainant unfortunately fell ill and was to be hospitalized at Civil Hospital, Tarntaran and on the treatment of complainant the cost came to Rs. 18,501/- Ex.C-6 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. It is further argued that later on his wife Kanta Devi also fell ill and was also hospitalized at Civil Hospital, Tarantaran and on the treatment of complainant's wife the cost came to Rs. 12,237/- Ex.C-5 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. It is also argued that the sum insured for the medical benefit is for Rs. 5 lacs but till today the opposite parties have failed to settle the genuine claim of the complainant despite several visits and requests. 

10. On the other hand, Ld. Counsel for the opposite party No. 2 argued that the complainant was admitted in hospital on 28.10.2016 and discharged on 28.12.2016, whereas the claim file was submitted with TPA on 29.5.2017. It is further argued that as per scheme of the insurance the beneficiary shall be eligible for the reimbursement subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital but in the present case the beneficiary has submitted the papers about five months later from the date of discharge, as such the claim was not eligible for reimbursement as per the scheme and the claim was returned by the TPA to Punjab State Health System Corporation, Phase-VI, Mohali to decide the claim after the expiry of the stipulated period i.e. Ex.O.P2/4 & Ex.O.P2/5. It is also argued that no claim was ever lodged with the opposite party No. 2 at any time and only the claim file was received by the TPA but the same was submitted after five months from the date of discharge from the hospital, whereas as per the terms of the PGEPHIS policy, the complainant was bound to submit the claim within the period of 30 days from the date of discharge from the hospital.

11. The contention of the opposite party No. 2 is that complainant is not eligible for the reimbursement subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital because the complainant has discharged from the hospital on 28.12.2016, whereas the claim file was submitted with TPA on 29.5.2017 and the claim was repudiated on the ground of non submission of claim within stipulated period of 30 days. On the other hand, Ld. Counsel for complainant argued that Ex.O.P2/4 & Ex.O.P2/5 shows that the said emails were sent by the TPA to Punjab State Health System Corporation, Phase-VI, Mohali, but the TPA has no authority to reject the claim as only the Insurance companies after making investigations can decide the claim. To prove his case the Ld. Counsel for complainant has relied upon the judgment of Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperative Agriculture Service Society & others in First Appeal No. 1105 of 2014 decided on 25.4.2017 of Hon’ble State Consumer Disputes Redressal Commission, Chandigarh, wherein it has been held that;- 

“The TPAs have no authority to reject the claim – Such power lies, exclusively with the Insurance Companies – The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance company is to decide about the same -The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA”. 

12. Ld. Counsel for complainant further argued that no terms and conditions were ever provided to the complainant by the opposite parties. Ld. Counsel for complainant also relied upon the judgment of the Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305, wherein it has been held that;-

  “the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company”.

However, on the perusal of the file it is clear that the insurance company has failed to prove on record that they have supplied the terms and conditions of the policy to the complainant/insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. 

13. In view of the above discussion and law laid down by the Hon'ble National Commission and the Hon'ble State Consumer Commission, Chandigarh, the present complaint is partly allowed and the opposite parties are directed to pay the amount of Rs. 18,501/- and Rs. 12,237/- alongwith interest @ 6% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation and Rs. 3,300/- on account of litigation expenses to the complainant. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of order will be supplied to the parties by District Consumer Commission, Amritsar as per rules. File be sent back to District Consumer Disputes Redressal Commission, Amritsar.  

ANNOUNCED IN THE OPEN COMMISSION:

       16th Day of August, 2022 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member