Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  :  09 of 2018

Date of Institution                      : 01.02.2018

Date of Decision               : 14.03.2019

1. Tarlochan Singh son of Fateh Singh resident of H. No. 379/11 Guru Nanak Colony, Patti, Tehsil and District Tarn Taran
2. Manjit Kaur w/o Tarlochan Singh s/o Fateh Singh r/o H.No. 379/11, Guru Nanak Colony Patti, Tehsil and District Tarn Taran.

                                                ...Complainants

Versus

1. Oriental Insurance Company Ltd. Office at above SBI Bank, Amritsar Road, near Amritsar Bypass, Tarn Taran Tehsil and District Tarn Taran through its branch Manager,
2. Oriental Insurance Company Ltd. Office at First Floor, SCO 48-49, Sector 17A, Chandigarh through its authorized officer/ Branch Manager,
3. M.D. India Health Care Services (T.P.A), Pvt. Ltd. Plot No. 539 F, Industrial Area, Face 8-B , Mohali Tower, Air Port Road, Mohali, Punjab.

…Opposite Parties.

Complaint Under Section 11, 12 and 13  of the Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

                             Sh. Jatinder Singh Pannu, Member

For Complainant                     Sh. M.P. Arora Advocate

For Opposite Parties               Sh. Nitin Sharma Advocate

ORDERS:

Charanjit Singh, President;

1        The complainant Tarlochan Singh has filed the present complaint under Section 11, 12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against the Oriental Insurance Company Ltd. Office at above SBI Bank, Amritsar Road, near Amritsar Bypass, Tarn Taran, Tehsil and District Tarn Taran and others (Opposite Parties) on the allegations of deficiency in service and negligence in service on the part of opposite parties with prayer to direct the opposite parties to reimburse the expenses of Rs. 3,00,000/- i.e. the amount of insurance out of the total expenditure of Rs. 3,74,546/- as incurred by the complainants on the treatment, besides this the complainant requests for damages and compensation of Rs. 20,000/- and Rs. 10,000/- as costs of litigation and pendent-elite interest @ 12% per annum from the date of filing of the complaint.

2        The case of the complainants in brief is that the Government of Punjab has introduced a cashless Health Insurance Scheme herein referred as Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses. The said scheme covers OPD medical expenses relating to chronic disease up to a sum of Rs.3.00 Lacs per family per year on floater basis. All pre-existing diseases will be covered. The State Govt. through tendering process has selected Oriental Insurance Company for the insurance purpose. The benefits under the scheme will start from 1.1.2016 and will be available up to 31.12.2016. As per the directions/ as per orders passed by the Punjab Govt., all the medical expenses incurred by the Govt. employees on their specific relatives during the period of year 2016, will be reimburse by the Oriental Insurance Company and further the Oriental Insurance Company has also issued health insurance card in favour of the Govt. employees in collaboration with the Punjab Govt. The opposite party No. 3 is TPA (Third party Administrator) holding license from IRDA to process insurance claims and is under obligation to redeem the claim for the complainants. The complainant Tarlochan Singh is retired Head teacher at Government Elementary School Shaheed Block Patti, District Tarn Taran and he is having P.P.O. No. 177835. The complainant Manjit Kaur is wife of Tarlochan Singh and was also Government employee and both the complainants have been issued a health insurance scheme by the Punjab Govt. through Health Insurance Scheme Card issued by the Oriental Insurance Company Limited. The complainant Manjit Kaur suffered with knee joint pain, as such, she remained admitted in the hospital namely Fortis Escort Hospital Majitha, Verka Bypass Road, Amritsar from 12.10.2016 up to 18.10.2016, where her treatment with regard to knees was done by the concerned doctors of the hospital and the complainants have incurred the total expenditure of Rs. 3,74,546/- on her treatment and the same were paid by the complainants to the hospital and the intimation with regard to the treatment and expenditure were given by them to the concerned department, office of Oriental Insurance Company as well as to M.D. India as the Oriental Insurance Company is under obligation to reimburse Rs. 3,00,000/- i.e. amount of insurance out of the total expenditure. Afterwards, as per the direction of the concerned officials, the complainant has sent all relevant demanded documents to the office vide receipt No. 37113 dated 1.11.2016. All the other documents i.e. Investigation Report, Discharge Report and X-Ray etc. were sent to the company vide registered parcel No. CP149538124IN. Further the complainant has also fulfilled all other documentary formalities as directed by the officials of the company. The complainant has visited the offices of Oriental Insurance Company for several times and further has contacted concerned officials for so many times but no positive response has been given by the concerned  officials and further the company and the M.D. India have done nothing favourable in this respect in order to settle the claim of the complainant. As per the directions and orders passed by the Punjab Govt. all   the medical expenses incurred by the Govt. employees or their specific relatives during the period of year 2016 will be reimbursed by the Oriental Insurance company and further the Oriental Insurance Company has also issued health insurance card in favour of the Govt. employees in collaboration with the Punjab Govt. As such, the Oriental Insurance Company is under the obligation to reimburse the medical claim in favour of the complainant. The complainant Tarlochan Singh has also served a legal notice bearing reference No. L-40/2017 dated 4.12.2017 upon the Oriental Insurance Company and M.D. India Health Care Services Pvt. Ltd. The M.D. India has replied to the notice by citing that “the claim could not be settled for want of documents necessary for settling the claim”. The complainants are having receipt with them vide which they have deposited all the required documents. The complainants have again shown all the receipts vide which they have deposited documents to Oriental Insurance Company as well as to M.D. India. The officials are time and again lingered on the matter on one pretext or the other and finally repudiated the genuine claim of the complainants in an arbitrary manner.  This act of the opposite parties constitute deficiency in services, unfair trade practice. Feeling dissatisfied by the act and conduct of the opposite parties, the complainant perforce has filed this complaint against the opposite parties.

3        After formal admission of the complaint, notice was issued to Opposite Parties and Opposite Parties appeared through counsel. The opposite parties No. 1, 2 filed written version contesting the complaint on the preliminary objections that the complainant has filed a baseless, frivolous and an imaginary claim with an ulterior motive. The same is bad in law and cannot be entertained. The complainant has fabricated a false story with ulterior objectives to extract unlawful gains to which he is otherwise not entitled. The complainant is estopped by his own act and conduct to file the present complaint and the present complaint is not maintainable under law. The complainant does not fall within the ambit of consumer under Section 2 of CP Act. No cause of action has been arisen to the complainant to file the present complaint as the averments of present complaint do not depict any consumer dispute between the parties. The complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum. The present complaint is a fit case, where the Forum shall take stringent action against the complainant as envisaged under Section 26 of Consumer Protection Act 1986, as amended up to date as the same is frivolous qua Opposite party. The matter in dispute require lengthy and detailed evidence/ detailed trial to prove either way, the present matter cannot be disposed off in summery trial under ‘Act’ ibid as the allegations are of complex and complicated nature. This matter can only be tried by the Civil Court. Since the complainant has not produced complete record with the complaint, opposite parties reserves the right to rebut the allegations or documents, if any, produced in subsequent period.  The present complaint is bad for non joinder of necessary parties. The complaint contains the averments with regard to treatment taken from Forties Escort Hospital Amritsar by the complainant, however, the said Hospital  has not been impleaded as party in the present complaint. Keeping in view the terms and conditions of the policy, this  Forum has no jurisdiction to deal with present case.  It is further submitted that opposite parties No. 1, 2 have issued policy subject to terms and conditions of envisaged in the Punjab Govt. employees and Pensioner’s Health Scheme and by which all the parties i.e. Punjab Govt., beneficiary, health care provider, T.P.A and Insurance company are bound to obey the terms and conditions of the said scheme. As per the condition No. 21 of the Scheme, the mechanism with regard to dispute resolution and grievance redressal has been set up by providing grievance Redressal Committee in each District, which will constitute following members:-

          (i)      Deputy Commissioner;

          (ii)     Civil Surgeon;

          (iii)    Deputy Medical Commissioner;

          (iv)    Representative of Insurance Company:

          The said committee will resolve the grievance within 30 days from the date of application. However, the complainant has not filed the same prior to the filing the present complaint and therefore, this Forum is not a proper Fora for adjudicating the matter in question. On merits,  it was pleaded that the mediclaim in question has been lodged with the opposite parties No. 1 and 2 by the complainant and the opposite party No. 3 i.e. the T.P.A. who has to scrutinize and proceed the medi-claim of the complainant has sought some documents/ justifications from the complainant which are necessary for the processing of the claim of the complainant’s wife. However, till date the complainant has failed to provide those documents/ justifications to the opposite parties No. 1 and 2 or opposite party No. 3 i.e. TPA. The detail of the documents/ justifications sought from the complainant is reproduced here under for the kind perusal of this Forum.  (i) Kindly provide the original discharge card from the Hospital (ii) Kindly provide all original reports for investigations done during the hospitalization supporting the diagnosis. It was further pleaded that letter had been written to the complainant seeking aforesaid information/ justifications / documents from the complainant but till date, the complainant has failed to provide the relevant information/ documents as mentioned above against claim lodged by the complainant, which clearly manifests that the lapse is on the part of the complainant himself  for non-processing of the claims.  The contract of insurance is always subject to its terms and conditions which are having a legal binding force in the eyes of law and the claims arisen under the insurance policies are decided by the insurance companies accordingly. The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the complaint.   

4        The opposite party No. 3 appeared through counsel but has not filed written version.

5        In order to prove their case, the complainants have tendered in evidence affidavit of Tarlochan Singh Ex. C-1 alongwith documents Ex. C-2 to Ex. C-27 and closed the evidence.  To rebut the evidence of the complainant the opposite parties tendered in evidence affidavit of Naresh Singla Senior Divisional Manager OIC Ex.OPs/1 alongwith documents Ex. OPs/2 to Ex. OPs/9 and closed the evidence.

6        We have heard the Ld. Counsel for the parties and have gone through the evidence and documents placed on the file by the parties.

7        Ld. counsel for the complainant contended that the wife of the complainant namely Manjit Kaur suffered with knee joint pain as such, she remained admitted in Forties Escort Hospital, Majitha, Verka Bye-pass road, Amritsar from 12.10.2016 up to 18.10.2016 and spent Rs. 3,74,546/- on her treatment and the complainant contended that he incurred the total expenditure of Rs.3,74,546/- on her treatment. He further contended that the intimation with regard to the treatment and expenditure were given by them to the concerned department, office of Oriental Insurance Company as well as to M.D. India. Oriental Insurance Company is under obligation to reimburse Rs. 3,00,000/- i.e. amount of insurance out of the total expenditure. He further contended that afterwards, as per the direction of the concerned officials, the complainant has sent all relevant demanded documents to the office vide receipt No. 37113 dated 1.11.2016. All the other documents i.e. Investigation Report, Discharge Report and X-Ray etc. were sent to the company vide registered parcel No. CP149538124IN.  He further contended that the complainant has also fulfilled all other documentary formalities as directed by the officials of the company. He further contended that the complainant has visited the offices of Oriental Insurance Company for several times and further has contacted concerned officials for so many times but no positive response has been given by the concerned officials and further the company and the M.D. India have done nothing favourable in this respect in order to settle the claim of the complainant. As per the directions and orders passed by the Punjab Govt. all   the medical expenses incurred by the Govt. employees or their specific relatives during the period of year 2016 will be reimbursed by the Oriental Insurance company and further the Oriental Insurance Company has also issued health insurance card in favour of the Govt. employees in collaboration with the Punjab Govt. He further contended that the Oriental Insurance Company is under the obligation to reimburse the medical claim in favour of the complainant. He further contended that the complainant Tarlochan Singh has also served a legal notice bearing reference No. L-40/2017 dated 4.12.2017 upon the Oriental Insurance Company and M.D. India Health Care Services Pvt. Ltd. The M.D. India has replied to the notice by citing that “the claim could not be settled for want of documents necessary for settling the claim”. The complainants are having receipt with them vide which they have deposited all the required documents. He further contended that the complainants have again shown all the receipts vide which they have deposited documents to Oriental Insurance Company as well as to M.D. India. He further contended that the officials are time and again lingered on the matter on one pretext or the other and finally repudiated the genuine claim of the complainants in an arbitrary manner and prayed that the present complaint may be allowed.

8        On the other hands, Ld. counsel for the opposite party contended that  the complainant is estopped by his own act and conduct to file the present complaint and the present complaint is not maintainable under law. He further contended that the complainant does not fall within the ambit of consumer under Section 2 of CP Act. No cause of action has been arisen to the complainant to file the present complaint as the averments of present complaint do not depict any consumer dispute between the parties. He further contended that the complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum. He further contended that the matter in dispute requires lengthy and detailed evidence/ detailed trial to prove either way, the present matter cannot be disposed off in summery trial under ‘Act’ ibid as the allegations are of complex and complicated nature and this matter can only be tried by the Civil Court. He further contended that the complainant has not produced complete record with the complaint as such, opposite parties reserves the right to rebut the allegations or documents, if any, produced in subsequent period. He further contended that the present complaint is bad for non-joinder of necessary parties. The complaint contains the averments with regard to treatment taken from Forties Escort Hospital Amritsar by the complainant, however, the said Hospital has not been impleaded as party in the present complaint. Keeping in view the terms and conditions of the policy, this  Forum has no jurisdiction to deal with present case.  He further contended that opposite parties No. 1, 2 have issued policy subject to terms and conditions of envisaged in the Punjab Govt. employees and Pensioner’s Health Scheme and by which all the parties i.e. Punjab Govt., beneficiary, health care provider, T.P.A and Insurance company are bound to obey the terms and conditions of the said scheme. He further contended that the condition No. 21 of the Scheme, the mechanism with regard to dispute resolution and grievance redressal has been set up by providing grievance Redressal Committee in each District, which will constitute following members:-

          (i)      Deputy Commissioner;

          (ii)     Civil Surgeon;

          (iii)    Deputy Medical Commissioner;

          (iv)    Representative of Insurance Company:

          The said committee will resolve the grievance within 30 days from the date of application. He further contended that, the complainant has not filed the same prior to the filing the present complaint and therefore, this Forum is not a proper Fora for adjudicating the matter in question. He contended that the medi-claim in question has been lodged with the opposite parties No. 1 and 2 by the complainant and the opposite party No. 3 i.e. the T.P.A. who has to scrutinize and proceed the medi-claim of the complainant has sought some documents/ justifications from the complainant which are necessary for the processing of the claim of the complainant’s wife. However, till date, the complainant has failed to provide those documents/ justifications to the opposite parties No. 1 and 2 or opposite party No. 3 i.e. TPA. The detail of the documents/ justifications sought from the complainant is reproduced here under for the kind perusal of this Forum.  (i) Kindly provide the original discharge card from the Hospital (ii) Kindly provide all original reports for investigations done during the hospitalization supporting the diagnosis. It was further pleaded that letter had been written to the complainant seeking aforesaid information/ justifications / documents from the complainant but till date, the complainant has failed to provide the relevant information/ documents as mentioned above against claim lodged by the complainant, which clearly manifests that the lapse is on the part of the complainant himself  for non-processing of the claims and prayed for dismissal of the complaint.

9        In the instant case insurance is not disputed. The complainant has produced on record Card Ex. C-8 issued by Punjab Government Employee and Pensioners health Insurance Scheme (PGEPHIS) in which the policy period has been written as 1.1.2016 to 31.12.2016 and during the period of policy i.e. on 12.10.2016 the wife of the complainant namely Manjit Kaur remained admitted in Forties Escort Hospital and she discharged on 18.10.2016 which is very much clear from the document Ex. C-14 issued by Forties Escort Hospital. The complainant has also placed on record Bill dated 18.10.2016 Ex. C-14 which shows that total amount of Rs. 3,74,546/- has been incurred on the treatment of Manjit Kaur. The opposite party has taken the objection that the present complaint is pre matured as the complainant has not submitted requisite documents to the opposite parties. But the complainant has placed on record Ex. C-4 on which the M.D. India acknowledged one file. The complainant has also served an application dated 20.6.2017 addressed to Insurance Company c/o M.D. India Health Care Services (TPA) Pvt. Ltd. Plot No. 539 F. Industrial Area Phase 8 B, Mohali Tower, Air Port road, Mohali (Punjab) in which the complainant has enclosed two receipts, claim form, I.D. Card, Investigation Report, Discharge Card and postal receipt of the same is Ex. C-21 placed on the file. Vide application Ex. C-20 the complainant has also submitted to the insurance company that he has already submitted the requisite documents demanded by the opposite parties through parcel No. CP149538124 In receipt of the same is Ex. C-4. As such, the complainant has proved on record that he has submitted the requisite documents to the opposite parties. Secondly the opposite parties have stated that the present complaint is pre mature as the complainant has not submitted the requisite documents, therefore, the claim has not been settled so far. But the complainant has placed on record one document Ex. C-5 in which claim detail has been mentioned and the name of the claimant has been written Manjit Kaur, date of admission is mentioned as 12.10.2016, date of discharge is mentioned as 18.10.2016 and date of lodging the claim is 5.12.2016, Lodge amount is mentioned as Rs. 3,00,000/- paid amount N/A and Claim status is written ‘Repudiated’ . During the course of arguments, the counsel for the complainant contended that this documents was placed on record by the complainant alongwith the complaint but the document Ex. C-5 is not rebutted by the opposite parties, therefore, as per claim detail Ex. C-5 the claim of the complainant has been repudiated. 

10      On the other hand, ld. counsel for opposite parties argued that complainant does not fall under the definition of consumer and the present complaint is not maintainable. The policy in question was issued in favour of Government of Punjab, Department of Health and Family Welfare. However, it is also admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being the employee of Punjab Government, the complainant was beneficiary under this scheme. The wife of the complainant took treatment during the policy period. The complainant lodged claim for the reimbursement of medical expenses borne by him with opposite parties.

11      The other objection of opposite parties is that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and Grievance Redressal Committees are constituted to settle the dispute, but the complainant did not approach to these committees and filed the present complaint before this Forum. It is settled principle of law that the remedy under Consumer Protection Act is an additional remedy other than available remedies. If there is any contract of arbitration or to settle any dispute by settlement committee under the scheme in that case also the complainant can approach to this Forum instead of arbitrator or dispute settlement committee. In that event the jurisdiction of this Forum is not barred and this Forum can entertain the present complaint.

12      In the written arguments, the opposite parties have pleaded that keeping in view the prevailing PGEPHIS Schedule of Rates a sum of Rs. 1,98,148 is payable additional documents are supplied by the complainant to the opposite party instead of Rs. 3,00,000/- as claimed by the complainant. But the opposite parties have not placed on record any document which supporting the calculation of Rs. 1,98,148. From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. The opposite parties argued that as per policy terms and conditions and scheduled rate for the treatment under policy in question, the complainant is entitled only for Rs1,98,148 only as reimbursement for her treatment. The opposite parties have not exhibited any document showing that how they calculated this amount.

13      Ld Counsel for complainant argued that the opposite parties are liable to make the payment of Rs. 3,00,000/- and they cannot deduct any amount from the complainant out of claimed amount on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.  So deficiency stand proved and the opposite party Nos.1 & 2 have incorrectly refused the payment of the claim.

14      In view of the above discussion, the present complaint is allowed and the opposite parties No. 1 and 2 are directed to make the payment of Rs. 3,00,000/-  (Rs. three lacs only) to the complainant. Complainant is also entitled to Rs.7,000/- ( Rs. Seven Thousand only) as compensation on account of harassment and mental agony and Rs 5,000/- (Rupees Five Thousand only) as litigation expenses. Opposite Parties No. 1 and 2 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.