PER:

Nidhi Verma, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 against the opposite parties on the allegations that the complainant was enrolled in to the Food, Civil Supplies and Consumer Affairs, Punjab on 27.1.1974 and retired from service on 28.2.2009 as an Assistant Food Supply Officer and purchased membership of Punjab Govt. Employees and Pensioners Health Insurance Scheme Card No MD15-09915082359, hence, the complainant is a consumer of OPs. According this scheme, he himself and his wife Rattan Kaur are authorized to avail medical treatment on cash less scheme. Mrs. Rattan Kaur has availed medical treatment and the complainant has sent medical reimbursement claim to OP No.1, which has been rejected by OP No. 2. Rattan Kaur has been undergone medical treatment due to the ailment related to heart. She had been admitted in the Hospital for the period from 21.12.2016 to 30.12.2016. An expenditure of Rs. 2,60,000/- has been borne by the complainant against the treatment of his legally wedded wife Rattan Kaur. To get the medical reimbursement the complainant has made efforts. On 10.3.2017, the complainant submitted requisite bills and other documents to the opposite party No. 1. On 29.4.2017, the complainant made request to opposite party No. 1 with copy of others to pass the claim at an early date. On 21.7.2017 Director Food, Civil Supplies and Consumer Affairs, Department Punjab, Chandigarh wrote letter to OP No. 1 to pass the claim and make payment of Rs 260,000- to the complainant. In the month of May 2017, M.D. India Health Insurance TPA Pvt Ltd. ie. OP No. 2 rejected the claim of the complainant on hyper-technical grounds stating that the claim case was required to be submitted within 30 days from the date of discharge of the patient from the hospital. On 20.5.2017, the complainant represented his request vide photocopy of Representation dated 20/05/2017 to OP No 1 and others to pass the claim stating that the claim of another beneficiary Shri Gurmej Singh holder of Punjab Govt Employees and Pensioners Health Insurance Scheme Card No MD15- 09814030605, who had submitted his claim against the treatment of his wife after a period of 96 days, has been passed and he has been issued with the medical claim i.e. his expenditure has been reimbursed. Thus, the complainant requested to reimburse his money in the same tone as reimbursed to above said Gurmej Singh. On 9.10.2017, the complainant made another representation vide photocopy of Representation dated 9.10.2017 to OP No. 2 and others to get reimbursement. On 9.11.2017, Director Food, Civil Supplies and Consumer Affairs Punjab, Chandigarh approached OP No. 1 to pass the claim and reimburse the money. On 7.5.2018, the complainant submitted representation to OP No. 1 & others to reimburse the money. On 4.10.2018, Director Food and Civil Supply Punjab, Chandigarh, has approached opposite party No. 1 to reimburse the money.  After availing all the possible measures and making correspondence given above to get reimbursement of medical claim from the OPs, the complainant appointed advocate through whom Legal Notice Ref No. 83 dated 5.6.2019 has been sent registered post on 6.6.2019. The OPs have ignored the legal notice too and had not given reply/response to the complainant till today.  The complainant has submitted the claim for reimbursement to OP No. 1 on 10.3.2017, i.e. after 69 days from the date of discharge of his wife Rattan Kaur, whereas, the other beneficiary Gurmej Singh above said has submitted his claim after 96 days. In the eyes of justice and legal process, no one should be made to suffer discrimination. The reimbursement in respect of the complainant, the delay might had been condoned on the same tone made applicable to other beneficiary Gurmej Singh above said.  The complainant has prayed that the following reliefs:

(a)     The OPs be directed to pay Rs. 2,60,000/- alongwith interest @ 18% per annum i.e. Rs. 1,20,770/- for the period from 10.3.2017 to 7.10.2019, the total amount claimed comes to Rs 3,80,770/-.

(b)     The OPs be directed to pay a sum of Rs. 3,00,000/- as compensation to the deponent.

(c)      The OPs be directed to pay a litigation fee at the tone of Rs 30,000/- to make irreparable loss to the deponent.

(d)     The OPs be directed to pay interest @ 18% per annum on amount Rs. 7,10,770/- (i.e. Rs. 2,60,000+1,20,770+3,00,000+30,000) for the further period from 8.10.2019 to the date of actual realsiation of claimed amount of reimbursement of medical claim.

Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, photocopy of rejection letter of OP2 Ex. C-2, Phototat cpy of scheme No. 09915082359 Ex. C-3, Photostat copy of Emergency certificate issued by EMC Super-specialty Hospitals Pvt. Ltd. Amritsar Ex. C-4, Photostat copy of Discharge Slip Ex. C-5, Photostat copy of claim form for Punjab Govt. Employees and Pensioners Health Insurance Scheme  Ex. C-6,  Photocopy of D.H.S.-47 signed by EMC Super Specialty Hospital, Amritsar Exhibit C-7, Photocopy of Case Summary/Discharge Slip -Exhibit C-8,  Photocopy of Bill No. 11556 dated 30.12.2016- Exhibit C-9,  Photocopy of Representation dated 10/03/2017- Exhibit C-10, Photocopy of Representation dated 29/04/2017 - Exhibit C-11, Photocopy of Director Food, Civil Supplies and Consumer Affair Department Punjab, Chandigarh - Exhibit C-12., Photocopy of Representation dated 20/05/2017 - Exhibit C-13,  Photocopy of claim of Shri Gurmej Singh holder of Punjab Govt Employee and Pensioners Health Insurance Scheme Card No MD15-09814030605 Exhibit C-14, Photocopy of Representation dated 09/10/2017 - Exhibit C-15 , Photocopy of Director Food, Civil Supplies and Consumer Affairs Punjab Chandigarh Exhibit C-16. Photocopy of Representation dated 07/05/2018- Exhibit C-17, Photocopy of Director Food and Civil Supply Punjab, Chandigarh -Exhibit C-18,  Photocopy of Legal Notice Ref No. 83 dated 05/06/2019- Exhibit C-19,  Photocopy of Orders of The Hon'ble Punjab and Haryana High Court Chandigarh in CWP No. 13494 of 2016 decided on 03 December 2018- Exhibit C-20, Photocopy of Pass Book of Account for Rs 1,60,000.00 Exhibit C-21,  Photocopy of Pass Book of Account for Rs 1,00,000.00 - Exhibit C-22, Calculation sheet of amount claimed - Exhibit C-23.

2        Notice of this complaint was sent to the opposite parties and opposite parties No. 1 and 2 appeared through counsel and filed written version by interalia pleadings that the present complaint is not legally maintainable because as per the admitted case of the complainant in para No.2 of the complaint itself that wife of the complainant was admitted in the hospital on 21.12.2016 and she was discharged on 31.12.2016 as per document Ex. C-4 and Ex.C-5 and as per admitted case of the complainant in Para no.7 of the complaint that the claim was repudiated by the opposite party No.2 in the month of May 2017 vide document Ex.C-2 whereas the present complaint has been filed by the complainant on 9.10.2019 i.e. after more than 2 years period and as such the present complaint is not filed within the period of limitation of 2 years as prescribed in the Consumer Protection Act, 1986 and as such, the present complaint is time barred by limitation and even otherwise the complainant cannot extend the period of limitation just by representations and legal notice. So far as medi-claim is concerned, the same are governed and followed by the independent MD India Health Insurance T.P.A. Private Limited appointed under the Insurance Regulatory & Development Authority (IRDA) and in the present case the opposite party No.2 had been appointed as Third Party Administrator to deal with the claim. However as per the comments of the said TPA, it has been stated as under:-

"As per medi-claim policies obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) vide clause 10.2 "The treatment provided shall be essentially on cashless basis, however in cases where cashless services has not been rendered by the hospital, due to any reasons whatsoever; the beneficiary shall be eligible for 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 complainant has not submitted the requisite documents with the opposite parties within the mandatory period of 30 days from the date of discharge from the hospital though he was under obligation to do so and as per the admitted case of the complainant in Para No.4 of the complaint that on 10.03.2017, he submitted the documents to opposite party No.1 as per document Ex.C-10 as such the complainant is not entitled to relief as claimed for and as such the present complaint merits dismissal on this simple score only.

However the payable amount was to the tune of Rs.1,03,059/- instead of Rs.2,60,000/- as claimed subject to terms and conditions but though the complainant is not entitled to claim this amount also on account of time barred of the present complaint as well as on account of clause 10.2 of the notification as stated above and as such the present complaint merits dismissal on this simple score only. Even otherwise further claim documents were also required by the opposite party No.2 more particularly Investigation Report supporting Diagnosis (ECG, ECHO Report) and Invoice & Sticker of Pacemaker which was also not submitted by the complainant and as such the present complaint merits dismissal on this simple score only. The present complaint is an abuse of the process of forum as it is settled principle of law that process of Consumer Commission cannot become a tool in the hands of unscrupulous persons who file complaints merely with a view to extract money in the garb of compensation. It is settled as well as essential requirement of equity that one who alleges must prove the allegation and the complainant cannot make this commission reach the conclusion as he desires on the basis of distorted facts. The complainant has not come to the Commission with clean hands and has concealed material facts from this commission and as such the present complaint is liable to be dismissed. The present complaint is an abuse of process of court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the replying opposite parties and as such the present complaint merits dismissal on this simple score only. The complainant is not a consumer much less he is covered under the definition of consumer to maintain the present complaint and as such the present complaint is liable to be dismissed on this ground alone. The complainant has not obtained any insurance policy personally from the Insurance Company but the policy in question has been obtained by the Punjab Government under Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) but the complainant has not made the State of Punjab as well as concerned hospital i.e. EMC Super Specialty Hospital as party to the present complaint. In the absence of necessary parties i.e. State of Punjab and Hospital, the complainant alone has no cause of action to file the present complaint nor he is covered under the definition of Consumer.  The opposite parties have denied the contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Om Parkash Dhawan Ex. OP1, 2/1, PGEPHIS scheme Ex. OP1, 2/2, Letter dated 2.3.2016 Ex. OP1, 2/3, Notification dated 21.9.2016 Ex. OP1, 2/4, Notification dated 20.10.2015 Ex. OP1, 2/5, Claim status Ex. OP1, 2/6, Policy document Ex. OP1, 2/7, List of Hospital Ex. OP1, 2/8, Reimbursement Condition Ex. OP1, 2/9, PGEPHIS Schedule of Rates Ex. OP1, 2/10, PGEPHIS Code Ex. OP1, 2/11, Case law Ex. OP1, 2/12 Case Law Ex. OP1, 2/13, Case Law Ex. OP1, 2/14, Case lay Ex. OP1, 2/15, Case law Ex. OP1, 2/16, Case law Ex. OP1, 2/17.

3        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.

4        The opposite parties No. 1 and 2 have filed written version and have taken preliminary objection that the present complaint is not legally maintainable because as per the admitted case of the complainant in para No.2 of the complaint itself that wife of the complainant was admitted in the hospital on 21.12.2016 and she was discharged on 31.12.2016 as per document Ex. C-4 and Ex.C-5 and as per admitted case of the complainant in Para No.7 of the complaint stated that the claim was repudiated by the opposite party No.2 in the month of May 2017 vide document Ex.C-2 whereas the present complaint has been filed by the complainant on 9.10.2019 i.e. after more than 2 years period and as such the present complaint is not filed within the period of limitation of 2 years as prescribed in the Consumer Protection Act, 1986 and as such, the present complaint is time barred by limitation. Without touching the merits of the case, we have to decide the point as to whether the present complaint is well within limitation or not. As per pleadings of the complainant and document Ex. C-3 placed on record, the claim of the complainant has been rejected/repudiated in the month of May 2017 and the present complainant has been filed by the complainant on 9.10.2019. The complainant has placed on record representations and one legal notice dated 5.6.2019 addressed to the opposite parties but it does not help to the complainant for covering the present complaint within limitation.

5        Section 69 of the Consumer Protection Act, 2019 Limitation Period:- (1) The District Commission, the State Commission or the National Commission shall not admit a complaint unless it is filed within two years from the date on which the cause of action has arisen.

(2) Notwithstanding anything contained in sub-section (1), a complaint may be entertained after the period specified in sub-section (1), if the complainant satisfies the District Commission, the State Commission or the National Commission, as the case may be, that he had sufficient cause for not filing the complaint within such period:

Provided that no such complaint shall be entertained unless the District Commission or the State Commission or the National Commission, as the case may be, records its reasons for condoning such delay.

6        The provisions of Section 24A of the C.P. Act 1986 and now Section 69 of C.P. Act 2019, were interpreted by the Hon’ble Supreme in the judgment reported as “State Bank of India v. B.S. Agricultural Industries (I)” 2009 CTJ 481 (Supreme Court) (CP) in which it has been observed as under:-

“8. It would be seen from the aforesaid provision that it is peremptory in nature and requires consumer forum to see before it admits the complaint that it has been filed within two years from the date of accrual of Consumer cause of action. The consumer forum, however, for the reasons to be recorded in writing may condone the delay in filing the complaint if sufficient cause is shown. The expression, ‘shall not admit a complaint’ occurring in Section 24A is sort of a legislative command to the consumer forum to examine on its own whether the complaint has been filed within limitation period prescribed thereunder. As a matter of law, the consumer forum must deal with the complaint on merits only if the complaint has been filed within two years from the date of accrual of cause of action and if beyond the said period, the sufficient cause has been shown and delay condoned for the reasons recorded in writing. In other words, it is the duty of the consumer forum to take notice of Section 24A and give effect to it. If the complaint is barred by time and yet, the consumer forum decides the complaint on merits, the forum would be committing an illegality and, therefore, the aggrieved party would be entitled to have such order set aside.”

7        This view of law was reiterated by the Hon’ble Supreme Court in its judgment reported as “V.N. Shrikhande (Dr.) v. Anita Sena Consumer Fernandes” 2011 CTJ 1 (SUPREME COURT) (CP). It was held by the Hon’ble Supreme Court as under:-

“Section 24A(1) contains a negative legislative mandate against admission of a complaint which has been filed after 2 years from the date of accrual of cause of action. In other words, the consumer forums do not have the jurisdiction to entertain a complaint if the same is not filed within 2 years from the date on which the cause of action has arisen. This power is required to be exercised after giving opportunity of hearing to the complainant, who can seek condonation of delay under Section 24A(2) by showing that there was sufficient cause for not filing the complaint within the period prescribed under Section 24A(1). If the complaint is per se barred by time and the complainant does not seek condonation of delay under Section 24A(2), the consumer forums will have no option but to dismiss the same. Reference in this connection can usefully be made to the recent judgments in State Bank of India v. B.S. Agricultural Industries (I), 2009 CTJ 481 (SC)(CP)=(2009) 5 SCC 121 and Kandimalla Raghavaiah and Company v. National Insurance Company and  another, 2009 CTJ 951 (SC)(CP)=(2009) 7 SCC 768.”

8        So far as the averments of the complaint that the complainant sent legal notice dated 5.6.2019, Ex.C-19, is concerned, it is now well settled that the sending of such notice does not extend the period of limitation for filing the complaint. In this context reference can be made to the law laid down by the Hon’ble Supreme Court in the judgment reported as ‘Kandimalla Raghavaiah & Co. Versus National Insurance Co. Ltd. and another” 2009 CTJ 951 (Supreme Court) (CP)’ wherein it was held by the Hon’ble Supreme Court as under:-

“By no stretch of imagination, it can be said that Insurance Company’s reply dated 21st March, 1996 to the legal notice dated 4th January, 1996, declining to issue the forms for preferring a claim after a lapse of more than four years of the date of fire, resulted in extending the period of limitation for the purpose of Section 24A of the Act. We have no hesitation in holding that the complaint filed on 24th October, 1997 and that too without an application for condonation of delay was manifestly barred by limitation and the Commission was justified in dismissing it on that short ground.”

9        In the present, the cause of action, if any, had accrued to the complainant in the month of May 2017 and the complaint should have been filed within two years. However, the complainant has filed this complaint only on 9.10.2019 and that too without filing any application for condonation of delay explaining cause for such delay. It appears that the complainant has suddenly woken up and has filed this complaint without any justified reasons and even without filing application for condonation of delay explaining cause for such delay. It is, therefore, held that certainly this complaint has been filed beyond the period of limitation of two years as provided in Section 69 (old 24A) of the C.P. Act.

10      In view of the ratio of the law laid down in the above noted authorities and the discussion held above, the present complaint is not filed within limitation and same is hereby dismissed being barred by limitation. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copy of order be supplied to the parties as per rules. File be consigned to record room.

Announced in Open Commission

10.05.2023