DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No. 14 of 9.1.2018

                                      Decided on:   20.9.2019

Harbans Kaur , wife of Sh. Bant Singh, resident of H.No.607, Harinder Nagar, Sirhind Road, Patiala.

                                                                   …………...Complainant

                                      Versus

1. Oriental Insurance Company , S.C.O. No.109 to 111, Surendra Building 17-D, Chandigarh-1600017, through its Incharge/manager.
2. Oriental Insurance Company, Divisional Office, Sai Market, Patiala, through its Incharge/Manager.
3. The Manager Incharge, MD India Health Insurance TPA Private Ltd. Maxpro, Info Park, D-38, 1^st Floor, Industrial Area, Phase-1,Mohali, (Pb.)160056.
4. State of Punjab Health and Family Welfare Department, Chandigarh through Deputy Commissioner, Patiala (being insured/Principal of Opposite Parties No.1to3 and they being Insurer/Service providers for and on behalf of State of Punjab for the purpose of P.G.E.P.H.I.S.)

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. M.P.Singh Pahwa, President

                                      Smt. Inderjeet Kaur,    Member

                                      Sh.B.S.Dhaliwal,         Member       

ARGUED BY

                                       Sh.Manmohan Singh, Advocate, counsel for

                                      complainant.

                                      Sh.D.P.S.Anand, Advocate, counsel for OPs No.1to3.

                                      Sh.Rubal Sharma, representative for OP No.4.  

 ORDER

                                     M.P.SINGH PAHWA,PRESIDENT

1. This is the complaint filed by Harbans Kaur   (here-in-after referred to as the complainant) against  Oriental Insurance Company  and ors. (here-in-after referred to as the OPs).
2. Briefly the case of the complainant is that she is employed in the office of Chief Electrical Inspector to Govt. of Punjab, Patiala. The Punjab Govt. vide notification dated 20.10.2015 introduced cashless health insurance scheme ( for short PGEPHIS) on compulsory basis for Punjab Govt. employees and pensioners. Complainant was issued ID card No.MD15-09779168575 under PGEPHIS. The scheme remained in operation till 31.12.2016.
3. Husband of the complainant namely Bant Singh had to be admitted in Patiala Heart Institute, Patiala on 31.12.2016 in emergency. He was treated by the institute for CAD/AC/AWMI/LVD/EF-30%/CAG  and discharged on 2.1.2017. He was advised to continue to take medicine with follow up treatment even after discharge and during post hospitalization treatment. The Senior consultant prescribed certain medicines on 23.1.2017 for further one month. Husband of the complainant again consulted the institute’s senior consultant cardiologist on 21.2.2017.During the post hospitalization treatment the doctor recorded on the prescription slip that there is no fresh complaint. Thereafter the complainant got the essentiality certificate signed from doctor and submitted the same to the OP No.3 on 28.2.2017.
4. It is alleged that OP No.3 had mechanically rejected the claim on the erroneous and unlawful plea that the claim has not been submitted within 30 days from the date of discharge. As per alleged tender clause No.11.6 this condition of OP No.3 is against the provisions of State Services(Medical Attendant Rules)(CSMA) Rules,1940. Vide notification dated 20.10.2015, it is clearly stated that the PGEPHIS will cover all the entitlements as specified under the rules of 1940 and these rules  have the overriding effect of provisions of PGEPHIS and the tendered clause 11.6. The PGEPHIS was made compulsory applicable in the case of complainant and her husband. The OPs cannot take away the pre existing right of the complainant or her husband to claim the reimburse charges.
5. It is also asserted that as per Govt. notification dated 20.10.2015, the reimbursement of medical expenses incurred by any employee or pensioner who is admitted in the hospital on or before 31.12.2016 and continues to receive treatment after 31.12.2016 are to be borne by OPs No.1to3. The complainant also got served legal notice to the OPs through her counsel but the response to the notice is not collected.
6. On this background of the facts, the complainant has alleged deficiency in service and unfair trade practice on the part of the OPs and prayed for direction to the OPs to reimburse medical expenses amounting to Rs.2,17,781/- with interest @15%, Rs.2 lac compensation  for mental agony, harassment, humiliation, Rs.20,000/- costs of the litigation. Hence this complaint.
7. Upon notice, OPs appeared through their respective counsel. OPs No.1to 3 filed joint written reply wherein they have raised preliminary objections that the complaint is not maintainable as claim has already been declined on the ground that the complainant has submitted claim after expiry of 30 days from the date of discharge. The complainant was discharged from the hospital on 2.1.2017 and submitted claim after expiry of 30 days. It was declined as per terms and conditions of the policy. The OPs floated the insurance scheme for public in general after prior approval of the Insurance Regulatory and Development Authority. All the terms and conditions of the policy are set by the IRDA under the IRDA Act,1999 and Insurance Act,1938.The insurance is a contract of indemnity . It has to be viewed as normal contract as per Indian Contract Act of insurance. Any violation of the contract by the parties to the contract of insurance becomes void. The company will not be able to answer the claim of the other party; that the complainant does not qualify the ingredients of a valid complaint as envisaged in Section 2(1)( c) of the Consumer Protection Act. There is no allegation of any deficiency of service or unfair trade practice and lastly the complainant has no cause of action or locus standi to file the complaint
8. On merits, the OPs No.1to3 have reiterated their stand as taken in the complaint and prayed for dismissal of the complaint.
9. OP No.4 in its reply also raised preliminary objections that the complaint is not maintainable; the scheme was for cashless claim. According to this notification the Govt. entered into an agreement with OP No.3 to provide cashless insurance scheme from 1.1.2016 to 31.12.2016.Bant Singh, husband of the complainant was admitted in Patiala Heart Institute on 31.12.2016. He took treatment there and finally  discharged on 2.1.2017. He was to get medical claim from OP No.3.The complainant was to submit bills within a period of 30 days from discharge but he had deposited her medical bills after 57 days. Therefore, the complaint is liable to be dismissed.
10. On merits also it is admitted that the complainant is regular employee. The scheme vide notification dated 20.10.2015 is also admitted. It is admitted that Bant Singh was admitted on 31.12.2016 and discharged on 2.1.2017 and he was eligible to get medical claim from OP No.3. All the other averments of the claim are denied. In the end, OP prayed for the dismissal of the complaint.
11. In support of her case, the complainant tendered into evidence her affidavit, Ex.CA, copy of notification, Ex.C1, copy of ID card, Ex.C2, copy of letter, Ex.C3, copy of discharge summary, Ex.C4, copy of medical reimbursement /treatment certificate, Ex.C5, copy of letter, Ex.C6, copy of certificate, Ex.C7, copy of scheme, Ex.C8, copy of legal notice, Ex.C9, copy of reply to legal notice, Ex.C10, copy of letter/circular , Ex.C11, copy of circular .C12, copy of news paper clipping, Ex.C13.
12. OPs No.1to3 tendered into evidence affidavit of Mukesh Malhotra, Ex.OPA, copy of discharge summary, Ex.OP1, copy of repudiation letter, Ex.OP2, copy of policy, Ex.OP3.
13. The OP No.4 tendered into evidence affidavit of Dr.Manjit Inder Singh, Ex.OPB and closed the evidence.
14. The complainant also submitted written arguments. We have heard the ld. counsel for the parties. They have reiterated their stand as taken in their respective pleadings. We have given careful consideration to their rival submissions.
15. The admitted facts are that the complainant being in service was covered under the scheme and Bant Singh, husband of the complainant took treatment from 31.12.2016 to 2.1.2017 as indoor patient and thereafter as OPD (outdoor patient). The complainant submitted the claim and the OP3 has repudiated the claim vide letter,Ex.C7 on the ground that the treatment was to be reimbursed subject to submission of the claim to the TPA within 30 days from the date of discharge and this claim was submitted in the office after 30 days from discharge.
16. Of course, as per scheme the insured was required to submit the claim within 30 days but the point for determination is whether the repudiation is justified in case the claim is submitted after 30 days.
17. Complainant has placed on record, copy of letter Ex.C11 issued by the Punjab State Power Corporation ,whereby the letter of the Punjab Govt. Health and Family Welfare Department dated 1.4.2011 was circulated. This letter  rather goes to show that the medical claim  submitted even after six months is not to be repudiated  but it should carry a certificate  by the controlling officer to the effect that he is satisfied with the reason of delay explained by the officer/official. The spirit of this letter leaves no room to infer that the claim submitted after 30 days was to be repudiated outrightly.
18. Even otherwise the matter can be examined from another angle also. The OP No.4 was under obligation to reimburse the claim. OPs No.1to3 were out sourced by OP no.4 only for the period from 1.1.2016 to 31.12.2016. The contract with OPs No.1 to 3 stands terminated after 31.12.2016.This fact is also not disputed. In these circumstances, the OP no.4 is liable to reimburse the claim of the complainant as per the rates decided by the State Govt.
19. For the reasons recorded above, the complaint is partly accepted with Rs.10,000/- as costs of the litigation. OP No.4 is also directed to reimburse the claim of the complainant as per scheme/rules and regulations of the State Govt.
20. The compliance of the order be made within 45 days from the date of the receipt of the certified copy of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.

ANNOUNCED

DATED:20.9.2019       

                               B.S.Dhaliwal           Inderjeet Kaur           M. P. Singh Pahwa

                                     Member                 Member             President