Chandigarh

StateCommission

A/301/2018

Oriental Insurance Company Limited - Complainant(s)

Versus

Mohini Trivedi - Opp.Party(s)

Swatantar Kapoor, Adv.

25 Jun 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	301 of 2018
Date of Institution	17.10.2018
Date of Decision	25.06.2019

 

1. Oriental Insurance Company Limited, RO, SCO109-110-111, Sector 17, Chandigarh through Manager.
2. MD India Health Care Services Pvt. Limited,
   D-38, Industrial Area, Phase-I, Mohali.

....Appellants/Opposite Parties No.3 & 2

Versus

1. Mohini Trivedi, Retired from Office of Chief Auditor Coop Societies Punjab, now resident of H.No.3045, Sector 38-D, Chandigarh. 

                 ....Respondent/Complainant

2. State of Punjab through Secretary Department of Health and Family Welfare Punjab, Sector 34-A, Chandigarh.

                             ....Respondent/Opposite Party No.1

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:   JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER

                MR. RAJESH K. ARYA, MEMBER

 

 

Argued by:  Dr. Mrs. Swatantar Kapoor, Advocate for the appellants.

                  Sh. N.S. Jagdeva, Advocate for Respondent No.1.

                     Sh. Amarbir Dhaliwal, Advocate for Respondent No.2.

                  

PER PADMA PANDEY, MEMBER

              This appeal is directed against an order dated 31.8.2018, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter to be called as the District Forum only), vide which, it allowed complaint against the Opposite Parties
No.2 & 3 and dismissed qua Opposite Party No.1.  The Opposite Parties No.2 & 3 was directed as under:-

“13]      After careful analytical examination of facts & circumstances of the case, the present complaint hereby allowed against OPs No.2 & 3 with direction to pay to the complainant the balance amount of Rs.1,56,916/- (i.e. Rs.340006-183090/-) along with interest @9% per annum from the date of discharge i.e. 7.11.2016, along with litigation cost of Rs.10,000/-.

The OPs No.2 & 3 shall comply the order, within a period of 30 days from the date of receipt of copy of this order, failing which they shall also be liable to pay additional compensatory cost of Rs.50,000/- apart from the above relief.”

2.    The facts in brief, are that, the Complainant/Respondent No.1 is retired Punjab Govt. Employee and she had subscribed for Punjab Govt. Employees & Pensioners Health Insurance Scheme (PGEPHIS) from Opposite Parties for herself (Annexures C-1 & C-2).  It was stated that the complainant was entitled for cashless medical treatment of Rs.3.00 lacs under the said scheme.  It was further stated that the complainant suffered from Knee Joint Problem, and as such admitted in Max Hospital, Mohali on 01.11.2016, got the Knee Joint Replacement procedure done and was discharged on 07.11.2016. It was further stated that she incurred the expenses of Rs.3,63,692/- on the said treatment, against which the Opposite Parties No.2 & 3 paid only an amount of Rs.1,83,090/- and illegally denied the balance payment of Rs.1,80,602/-. It was further stated that the complainant filed a representation to the Opposite Parties No.2 & 3 for payment of the balance amount, but to no avail. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed.
3. Reply was not filed by the Opposite Party No.1 (State of Punjab).
4. The Opposite Party No.2 in its written version admitted the factual matrix of the case and stated that the claim of the complainant has been paid as per the terms & conditions of the Insurance Scheme.  It was further stated that the complainant was entitled to Rs.1,83,090/- only and the said amount had been paid to the Hospital against her bill, as per prescribed PGEPHIS rates.  It was further stated that PGEPHIS schedule of rates includes reimbursement of Pre & Post hospitalization benefits that includes pre & post investigation, medicines & consultation, Additional surgical procedure, medications & consumables used under special circumstances, blood transfusion, use of special equipment etc. procedures like strapping etc. and Implants Cost.  It was further stated that there is no deficiency in service on its part, and the answering Opposite Parties had prayed for dismissal of the complaint.
5. In its written statement, the Opposite Party No.3 reiterated the contentions as stated by Opposite Party No.2 and had prayed for dismissal of the complaint.
6.  The complainant, filed rejoinder to the written statement of the Opposite Parties No.2 & 3, wherein she reiterated all the averments, contained in the complaint, and refuted those, contained in the written version of the Opposite Parties. 
7. The Parties, led evidence, in support of their case.
8.       After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Forum, allowed the complaint, as stated above.
9.       Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties
   No.2 & 3.
10.       We have heard the Counsel for the parties, and have gone through the evidence, and record of the case, carefully.
11.       After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the Parties, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons, to be recorded hereinafter. 
12.             The Punjab Govt. Employees & Pensioners Health Insurance Scheme (PGEPHIS) (Annexure C-2), will cover the indoor/daycare entitlements as specified under the State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940 except for certain exclusions. Para No.6 of the said Punjab Govt. Employees & Pensioners Health Insurance Scheme reads as under:-

“6.       SUM INSURED AND BUFFER/CORPORATE SUM   INSURED

A.      BASE SUM INSURED

The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs.3,00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to prescribed rates on cashless basis through Photo ID Cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total cover of Rs.3.00 lakh can be availed by one individual or collectively by all members of the family. In an event the sum insured of Rs.3 lacs per family is exhausted, the coverage of the family shall be met through the Buffer Sum Insured of Rs.25 Crore available to each and every beneficiary of the group, on group floater basis, to be maintained by the Insurance Company. In an event the Buffer Sum Insured of Rs.25 crores gets completely exhausted, the cashless reimbursement more than Rs.3.00 lacs will not be available to any employee/ pensioner and the over and above expenses shall be met by the State Government as per the extent of the medical reimbursement policy and procedures. In such circumstances, the Insurance Company will inform the employee/pensioner that further treatment shall not be available on cashless but reimbursement basis as per existing pattern at PGI/ AIIMS rates and the employee/pensioner will seek the reimbursement over and above Rs.3.00 lacs as per existing pattern to the extent of the medical reimbursement policy and procedures. The concerned DDO will seek the reimbursement from concerned Civil Surgeon/Directorate of Health & Family Welfare who will examine the bill as per the entitlement of the claimant as per State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940. If that particular bill(s) as per the entitlement(s) is less than Rs.3.00 lacs then no amount will be reimbursed to the employee and if the bill(s) is more than Rs.3.00 lacs then additional amount will be reimbursed to the employee through Treasury Route.”

13.       In the present case, we find that the Max Hospital, Mohali is an empanelled hospital by Oriental Insurance Company i.e. Appellant No.1 and as such the Insurance Company is liable to bear the medical expenses for cashless treatment by paying Rs.3.00 lac, but they misrepresented the terms and conditions of MoU between the Govt. of Punjab and the Oriental Insurance Company and paid only an amount of Rs.1,83,000/- to the Complainant/Respondent No.1. The Respondent No.1 is however entitled for reimbursement of Rs.3,40,006/- during her admission from 1.11.2016 to 7.11.2016, at the said hospital.
14.        As earlier pointed out, Clause No.6 of Punjab Govt. Employees & Pensioners Health Insurance Scheme (PGEPHIS) reads as Sum insured and Buffer/Corporate sum insured and through the said clause, in an event the sum insured of Rs.3.00 lacs per family is exhausted, the coverage of the family shall be met through the Buffer Sum Insured of Rs.25.00 Crore available to each and every beneficiary of the group, on group floater basis, to be maintained by the Insurance Company. In this case, the expenditure incurred was Rs.3,40,006/- which could be made out from Buffer Scheme, whereas, the Respondents paid only Rs.1,83,090/- and therefore, we find that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
15.         For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Forum is upheld. Accordingly.
16.       Certified Copies of this order be sent to the parties, free of charge.
17.        The file be consigned to Record Room, after completion.

 

Pronounced.

25.06.2019

 

                                         Sd/-                           [JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

                     

                                                                                       Sd/-                     

[PADMA PANDEY]

MEMBER

                                    

                                                                                        Sd/-      

[RAJESH K. ARYA]

 MEMBER

 

Gp

 

                                STATE COMMISSION

APPEAL No.301 of 2018

(Oriental Insurance Company Ltd. & Anr. Vs. Mohini Trivedi & Anr.)

 

Argued by:

Dr. Mrs. Swatantar Kapoor, Advocate for the appellants.

Sh. N.S. Jagdeva, Advocate for Respondent No.1.

Sh. Amarbir Dhaliwal, Advocate for Respondent No.2.

 

 

Dated    the  25^th  day of  June, 2019

               

            Vide our detailed order of the even date, recorded separately, the appeal filed by the appellants/Opposite Parties No.2 & 3 has been dismissed, with no order as to cost and the order passed by the District Forum has been upheld.

 

Sd/-                       Sd/-                         Sd/-

(PADMA PANDEY) MEMBER	(JUSTICE JASBIR SINGH (RETD.)) PRESIDENT	(RAJESH K. ARYA) MEMBER

Gp