Punjab

Sangrur

CC/276/2017

Bharpur Singh - Complainant(s)

Versus

M/s MDINDIA Health Care Servuce (TPA) Pvt. Ltd. - Opp.Party(s)

Sh. Rajan Kapil

27 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  276

                                                Instituted on:    12.06.2017

                                                Decided on:       27.11.2017

 

 

Bharpur Singh son of Jang Singh R/O Village Dhandiwal, Tehsil Dhuri, Distt. Sangrur.

                                                        …Complainant

                                Versus

1.             M.D. India Health Care Services (TPA) Pvt. Ltd. through Managing Director, PGEPHIS, Claim Department Maxpro Info Park, D-38, First Floor, Phase-I, Industrial Area, Mohali.

2.             The Oriental Insurance Co. Ltd. through District Manager, Sangrur.

3.             State of Punjab through District Collector, Sangrur.

4.             The Oriental Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh.

5.             Department of Health and Family Welfare Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh through its Director.

                                                        ..Opposite parties.

For the complainant      :   Shri Rajan Kapil, Adv.

For Opp.party No.1,2&4:  Shri Ashish Garg, Adv.

For Opp.Party No.3&5  :   Ms.Amandeep Kaur Bhangu, Adv.

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Bharpur Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a government employee, as such, he was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09417715106 and having PPO number 244967/Punjab for the period from 1.1.2016 to 31.12.2016. The case of the complainant is that during the subsistence of the insurance policy, he took treatment from Arora Neuro Centre, Ludhiana for the period from 9.12.2016 to 16.12.2016, where he spent an amount of Rs.55,723/-. The grievance of the complainant is that despite the fact he gave intimation to the OPs, but the OP did not pay the amount to the hospital directly nor the same was paid to the complainant. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.55,723/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1, 2 and 4, legal objections are taken up on the grounds that the OPs have been dragged into unwanted litigation, that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable, that the policy was issued in favour of the Govt. of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Punjab, Mohali, but the complainant has not impleaded it as a party.  On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis.  It is further averred that the Govt. of Punjab framed a policy for cashless treatment in Government or in empanelled hospitals in Punjab, Chandigarh and NCR area and no reimbursement will be available, where cashless treatment is available.  It is further stated that as per the schedule, the liability of the company is to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room.  It is admitted that the complainant was admitted in Arora Neuro Centre, Ludhiana on 9.12.2016 and discharged on 16.12.2016.  But, the claim of the complainant was rejected as he submitted the claim after a period of thirty days of discharge from the hospital. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the insurance policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee. Lastly, the OPs have prayed for dismissal of the complaint with special costs.

 

3.             In reply filed by OP number 3, legal objections are taken up on the grounds that the complaint is premature, that the present complaint is not maintainable and that the complainant has no cause of action to file the present complaint. On merits, is admitted that the complainant being a government employee the insurance card was issued.  It is stated that the matter is between the insurance company and the complainant and the OP number 3 has nothing to do.  The other allegations levelled in the complaint have been denied.

 

4.             In reply filed by OP number 5, legal objections are taken up on the grounds that the complaint is pre mature and that the complaint is  not maintainable and that the complainant has no cause of action to file the present complaint. On merits, it is admitted that the complainant is a government employee and was insured under card number MD-1509417715106. However, any deficiency in service on its part has been denied.   Lastly, the OP has prayed for dismissal of the complaint with special costs.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-6 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1,2  and 4 has produced Ex.OP1,2&4/1 to Ex.OP1,2&4/5 copies of documents and affidavits and closed evidence. The learned counsel for OP number 3 and 5 has produced Ex.OP3&5/1 to Ex.OP3&5/4 documents and affidavit and closed evidence.  

 

6.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

7.             It is an admitted fact between the parties that the complainant being a Punjab Government employee/pensioner, his entire family was insured with the OPs under the medical insurance policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 1.1.2016 to 31.12.2016.  It is also not in dispute that during the subsistence of the insurance period, the complainant was admitted in Arora Neuro Centre, Ludhiana and remained there admitted from 9.12.2016 to 16.12.2016, where he spent an amount of Rs.55723/- on the treatment. Now, the case of the complainant is that despite submission of the bills for Rs.55723/- to the OPs for reimbursement being the amount spent by the complainant on his treatment, but the claim of the complainant has been rejected by the OPs on the ground that the claim has been submitted by the complainant after a period of thirty days, whereas as per the provisions contained in the scheme of insurance, the complainant was bound to submit the claim within a period of thirty days of the discharge from the hospital.

 

8.             It is worth mentioning here that the learned counsel for the OPs number 1, 2 and 4 has contended vehemently that the complainant has not produced any documentary evidence on record to show that the Ops are liable to pay the claim of the complainant, if the claim is submitted even after a period of thirty days of discharge from the hospital.

9.             It is true that as per the clause 11.6 of tender notice Ex.OP1&2/1, the complainant was required to submit the claim to the Ops within a period of thirty days, if the treatment is taken in private hospitals in Punjab and Chandigarh, Govt. hospitals in Punjab and Chandigarh, For PGIMER, GMCH and State Medical Colleges, For private hospitals in NCR region and for Govt. Hospitals in NCR Region.  But, it is worth mentioning here that the complainant took treatment at Arora Neuro Centre, Ludhiana, which does not come under the above said hospitals as detailed above.  The clause i) of 11.6 of tender notice Ex.Op1,2&4/1 does not provide any time limit for submitting the claim.  The clause i) is also reproduced as “For Private Hospitals in Punjab & Chandigarh: Rates shall be determined in accordance with the PGEPHIS rates, fixed by the Nodal Department/State Government. For treatments that have not been mentioned in the PGEPHIS rates, the rates shall be as may be negotiated by the TPA with the Network Hospital. The treatment provided shall be mandatorily on cashless basis.”    As such, we are of the considered opinion that the OPs have wrongly and illegally not entertained the claim of the complainant even after a period of thirty days of discharge from the hospital.  It is worth mentioning here that even after filing of the complaint by the complainant, the Ops did not take such necessary steps to entertain the claim of the complainant.  As such, we find it to be a case of clear cut deficiency in service on the part of the Ops number 1,  2 and 4.   

 

10.           The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

11.           Accordingly, in view of our above discussion, we allow the complaint partly and direct the complainant to submit the bills to the OPs number 1,2 and 4  under proper receipt within a period of 15 days and thereafter the OPs number 1,  2 and 4 shall pay to the complainant the amount so settled within a period of thirty days of the submission of the bills by the complainant.  In the circumstances of the case, the parties are left to bear their own costs.

 

12.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        November 27, 2017.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member