Punjab

Sangrur

CC/44/2017

Virender Kumar - Complainant(s)

Versus

M/s MDINDIA Healthcare Service (TPA) Pvt. Ltd. - Opp.Party(s)

Sh.Yogesh Gupta

27 Jul 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    44

                                                Instituted on:      02.02.2017 

                                                Decided on:       27.07.2017

 

 

Virendar Kumar son of Shri T.R.Gupta R/O Street  No.2, Mubarak Mehal Colony, Sangrur.

                                                        …Complainant

                                Versus

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

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

3.     State of Punjab through District Collector, Sangrur.

4.     Oriental Insurance Company Limited, CBO-III, SCO No.37, Sector 30-C, Chandigarh.

5.     Mayo Health Care Super Speciality Hospital, Sector 69, Mohali (OP No.5 given up vide order dated 13.6.2017).

                                                        ..Opposite parties

 

 

For the complainant    :       Shri Yogesh Gupta, Adv.

For OP No.1,2&4       :       Shri Ashish Kumar, Adv.

For OP NO.3.            :       Exparte.

 

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Virendar Kumar, 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 was insured under Punjab Government Employees and Pensioner Health Insurance Scheme (PGEPHIS) vide card number MD15-09417090007 and GPF/PPO number 15893/PB for the period from 1.1.2016 to 31.12.2016 as the policy in question was obtained by the Punjab Government for the employees of the Punjab Government from the Oriental Insurance Company Limited.  The grievance of the complainant is that he took treatment from MAYO Health Care Super Speciality Hospital, Mohali for the period from 11.5.2016 to 12.5.2016 and spent an amount of Rs.51,150/-, as the amount was not paid by the OPs to the hospital despite requests. Thereafter the complainant submitted the bills to the OP number 1 on 4.6.2016 and reminder was also sent on 16.11.2016, but despite that no reply was sent 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 insurance claim amount of Rs.51,150/- along with interest and further claimed compensation and litigation expenses.

 

2.             In reply of the complaint filed by the OPs number 1 and 2, legal objections are taken up on the grounds that the complainant has no cause of action, that the complicated questions of law and facts are involved in the present complaint, that the complainant is not a consumer and that there is an agreement amongst insurer, TPA, MAYO Health care Super Speciality Hospital and Punjab Government, but the complainant has not impleaded the said hospital as OP.  On merits, it is admitted that the complainant was insured under the policy in question for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions for Rs.3,00,000/- per family on floater basis.  It is stated further that the complainant was entitled to charge the room charges on twin sharing basis as per the Annexure XX and the liability of the company was 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.  Further it is stated that the liability of the company was 10% higher than the rates applicable to general ward category contained in the above said annexure and as regards private category of room the liability of the company will be 10% higher than the rates applicable to semi private category of room.  It is further averred that the complainant admitted in the hospital on 11.5.2016 for treatment of right PCNL and discharged on 12.5.2016 and he submitted the bill for Rs.51,150/- and the Op number 1 approved the amount of Rs.13,941/- as per the terms and conditions of the policy and the same was paid to the complainant on 1.2.2016. It is stated further that the complainant is not entitled to get claim Rs.6000/- regarding room rent per day as he was not entitled for more than Rs.500/- per day on twin sharing basis.  It is stated further that the amount of the claim has rightly been paid to the complainant. The other allegations levelled in the complaint have been denied.

 

3.             In reply filed by OP number 4, legal objections are taken up on the grounds that the complainant is not a consumer and that complicated questions of law and facts are involved in the present case and as such has prayed for dismissal of the complaint. On merits, similar reply has been filed as stated by Op number 1 and 2.  However, it is stated that the complaint is not maintainable as if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provision of the scheme, it will be settled by the District Level Grievance Redressal Committee consisting of Deputy Commissioner, Civil Surgeon, Deputy Medical Commissioner, Representative of Insurance Company and Representative of TPA and has stated further that this Forum has got no jurisdiction to hear and try the present complaint.  It is stated further that the claim amount has already been paid to the complainant and nothing remains to be paid and prayed for dismissal of the complaint.

 

4.             Record shows that the Op number 3 was proceeded against exparte.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-19 affidavit and copies of documents and closed evidence. On the other hand, the learned counsel for OPs number 1, 2 and 4 has produced Ex.OP1,2&4/1 to Ex.OP1,2&4/9 copies of documents and affidavit and closed evidence.

 

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

 

 

7.             It is an admitted fact that the complainant being the employee of the Punjab Government was insured with the OP number 4 and the Op number 4 issued card bearing number MD15-09417090007 for the period from 1.1.2016 to 31.12.2016.  It is also not in dispute between the parties that the complainant took treatment from Mayo Health Care Super Speciality Hospital, Mohali and remained admitted there for the period from 11.5.2016 to 12.5.2016.  Now, the grievance of the complainant is that the Ops did not settle the claim of the complainant as he had spent an amount of Rs.51,150/- on his treatment.  On the other hand, the stand of Ops number 1 and 2 is that the amount of Rs.13,941/- has already been paid to the complainant on 1.2.2017 as per the entitlement of the complainant as the complainant was entitled to get the room charges at the rate of Rs.500/- plus 10% twice as per Annexure XX.  But, the complainant has disputed that the amount has not been paid despite approaching the Ops again and again.  It is worth mentioning here that the present complaint has been filed on 2.2.2017 and the Ops has paid the amount as settled by the Ops on 1.2.2017 by transferring the same in account of the complainant.  We have also perused the copy of the insurance policy document Ex.OP1,2&4/6, which shows that the same was taken by the Government of Punjab, Department of Health and Family Welfare Mohali from the OP number 4, but it is worth mentioning here that the complainant never gave any legal notice either to the Government of Punjab, Department of Health and Family Welfare Mohali or to the OP number 4, as is evident from the copy of legal notice Ex.C-16, as the notice has been given to the Oriental Insurance Co. Ltd. Sangrur and District Collector Sangrur, as both these parties had to do nothing with the case of the complainant.  Further it is worth mentioning here that the OPs have already paid the amount to the complainant as per the terms and conditions of the policy, as such, we feel that nothing remains to be paid to the complainant as claimed by the complainant nor there is any proved deficiency in service on the part of the OPs. However, if the complainant still remains unsatisfied, then the complainant can approach the District Level Grievance Redressal Committee formed by the Ops for the redressal of the grievances of the complainant/insured.

 

 

8.             In view of our above discussion, we dismiss the complaint of the complainant. In the peculiar circumstances of the case, the parties are left to bear their own costs. However, it is open for the complainant to approach the District Level Grievance Redressal Committee formed by the Ops for the redressal of the grievances of the complainant/insured, if he so desired.  A  copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        July 27, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

 

                                                              (Sarita Garg)

                                                                   Member

 

 

                                                        (Vinod Kumar Gulati)

                                                                   Member