Punjab

Fatehgarh Sahib

CC/53/2019

Gurdeep Singh - Complainant(s)

Versus

Oriental Insurance Co. Ld. - Opp.Party(s)

Sh. M.L Sharma

14 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL

                                  COMMISSION

                            FATEHGARH SAHIB

 

Complaint No.	:	CC/53/of 2019
Date of Institution	:	30/08/2019
Date of Decision	:	14/03/2023

                  

 

Gurdeep Singh son of Sh. Balvinder Singh, aged about 30 years resident of Village Dodra, Tehsil Budhlada, District Mansa.

 

                                                                                                                     …………....Complainant

 

                                                Versus

 

1.  Oriental Insurance Company, Regional Office , SCO 109-110-111, Surindera Building, Sector-17-D Chandigarh.

 

2. MD India Health  Insurance TPA Private Limited, D-38 Max-Pro info Park, Industrial Area, Phase-1, SAS Nagar Mohali.

 

3. Senior Superintendent of Police, Fatehgarh Sahib.

 

4. Civil Surgeon, Fatehgarh Sahib.

 

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

 

                                                                              ..………....... Opposite Parties

 

 

Complaint under Section  11-14 of Consumer Protection Act 1986(Old)

Quorum

Sh. S.K.Aggarwal, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

Present: Sh.MadanLal Sharma, counsel  for complainant.

     Sh.Amit Gupta, counsel for OP. No.1.

     Sh. K.G.Sharma, counsel for OPs no.4 and 5.

     OP no.2 Ex-Parte vide order dated 29.10.2019.

     OP no.3 Ex-Parte vide order dated 4.02.2021

 

Order By

 

MS. SHIVANI  BHARGAVA, MEMBER

 

 The  complaint has been filed against the OPs (opposite parties)  under Section 12 of Consumer Protection Act-1986(old) alleging deficiency in service with the prayer to give directions to the OPs to make the reimbursement of Rs.26,126/-  alongwith  interest @ 9% P.A,  Rs.50,000/- as compensation  for mental and physical harassment  and Rs.11,000 as  litigation  expenses to the complainant .

1.   The complainant is employee of Punjab Police as Head Constable . The Punjab Government  through Department  of Health & family welfare  (Health-V Branch) vide its notification no.21/28/12-5HB5/268  dated 20/10/2015 introduced a Cashless Health Insurance Scheme PGEPHIS-2016 i.e  Punjab Govt. Employees & Pensioners health  Insurance  Scheme (PGEPHIS)  to  cover indoor medical treatment expenses specified day care procedures and treatment of chronic disease as specified by the State Government in  tie-up with OP no.1 i.e Oriental Insurance Company.  The scheme was applicable to all the Punjab Government Employees including the pensioners on  compulsory basis.  This scheme covered medical expenses up to a sum of Rs.3 Lac for every employee/pensioner for the period from 1.1.2016 to 31.12.2016. Being  employee of Punjab Government, complainant was insured by  Oriental Insurance Company  and was issued  MD ID No.MD15-09914822799 under insurance policy No.231102/48/2016/769 for the period from 1.1.2016 to 31.12.2016. The complainant got treatment of his left side ear from Simran ENT Centre, 240-D, Chhoti Baradari, Patiala  from 2/12/2016 to 4/12/2016. Complainant submitted the bill of  Rs.26126/-  on 23.01.2017 to MD India Health Insurance TPA Private Limited, SAS Nagar Mohali  i.e OP no.2 for reimbursement. The MD India Health Insurance TPA Private Limited i.e OP no.2 vide its letter dated 27.3.2017 repudiated the claim on the ground that  claim was not submitted with in 30 days from the date of discharge from the hospital . Then the complainant submitted his bills  in the office of Senior Superintendent of Police Fatehgarh Sahib for reimbursement. The  Senior Superintendent of Police, Fatehgarh Sahib vide letter  no.51281 dated 20.11.2017 forwarded the bills along with all relevant documents to Civil Surgeon, Fatehgarh Sahib. But Civil Surgeon, Fatehgarh Sahib vide  letter no.358 dated 23.03.2018 returned the bills  with remarks  that bills were to be reimbursed by the insurance Company  as it relates to PGEPHIS-216.  Insurance Company had already repudiated the claim on the ground of delay. Hence this complaint.
2.        Notice of the complaint was given to the OPs through registered Post. OPs no.1,4 and 5 appeared through their Counsels  and OP no.3 appeared through his representative  Sanjeev Kumar, Executive Clerk and filed  written version. On later stage, OP no.3 was proceeded against Ex-Parte vide order dated 4.2.2021. OP no.2 did not appear despite service of summons as such OP no.2 was proceeded against Ex-Parte for non appearance vide order dated 29.10.2019.
3.  The complaint has been contested by the OP no.1 and filed written version. Complainant being the  employee of Punjab Government  was covered under the Punjab Government Employees &  Pensioners Health Insurance Scheme (PGEPHIS). The  Health insurance policy commenced from 1.1.2016 to 31.12.2016 subject to the terms and conditions  of the Policy and PGEPHIS Scheme.  The rates applicable shall be PGEPHIS schedule of rates and for the treatments where no rates have been mentioned the rates shall be CGHS rates or negotiated rates with the hospital whichever are less which is  with regard to private hospital in Punjab, Chandigharh and Panchkula.  While for Govt. Hospital in Punjab & Chandigarh , the rates applicable will be PGEPHIS schedule of rates fixed  by  the Nodal Department and the treatments which have not been mentioned,  shall be internal rates of the Govt. Hospital.  It was also clarified that for PGIMER, GMCH 32 and State Medical College, internal rates of hospital shall be applicable and likewise everything is specified within the rules.  The complainant  had lodged  claim taken from Simran ENT Centre w.e.f 2.12.2016 to 4.12.2016 for a sum of Rs.26,126/- and had submitted the said claim  on  23.1.2017  The  claim of the complainant was repudiated on ground of delay i.e.

“ The treatment availed by the beneficiary shall be on reimbursement basis , subjectto submission of the claim to the TPA within 30 days from the date of discharge from the hospital”

Thus , the present complaint filed by the complainant is against the rules framed by the Govt. in this regard and as such the present complaint is liable to be dismissed.

4. Op no.3 appeared through  representative  Sanjeev Kumar, Executive Clerk  and stated in his reply that complainant is employee of Punjab Police and presently working  at SSP office, Fatehgarh Sahib.  Complainant got  treatment of his left ear from  Simran ENT Centre, SCO 240-D, Chotti Baradari, Patiala from 02.12.2016 to 4.12.2016.  Complainant claim  for reimbursement  was sent to Civil Surgeon , Fatehgarh Sahib vide letter no.51281/ Lekhakar dated 20.11.2017. Civil Surgeon returned medical bills with endorsement  no.358 dated 23.03.2018 with the  noting  that  claim  pertained to PGEPHIS-2016, claim will be settled by  Insurance Company.   Again Medical bills were sent to S.S.P, Sangrur  with endorsement no.30033/Lekhakar dated 8.6.2019 because complainant  got transferred to Sangrur. But S.S.P Sangrur sent it to I.G, Patiala range vide letter dated 24.6.2019, where complainant is presently posted. As such the present complaint is liable to be dismissed against OP no.3.
5.  The complaint has been contested by the OPs no.4 and 5 and filed joint written version. The  medical bills were to be paid by the Insurance Company not by the Department. Hence prayer for dismissal of complaint has been made.
6. The complainant in support of his complaint tendered in evidence his  affidavit Ex.C1 along with copies of  documents  i.e Ex.C2 notification no.21/28/12-5HB5/268 dated 20.10.2015 of Govt. Of Punjab , Department of Health and Family welfare (Health-V Branch), Ex.C3 MD ID number MD15-09914822799, Ex.C4 claim form for reimbursement dated 23.1.2017, Ex.C5 Repudiation letter by OP no.2 dated 27.03.2017,  Ex.C6 letter no.51281 dated 20.11.2017 sent to Civil Surgeon, Fatehgarh Sahib, Ex.C.7 Letter of Civil Surgeon no.358 dated 23.03.2018 ,Ex.C8 letter dated 24.6.2019 by  SSP Sangrur, Ex.C9 treatment certificate, Ex.C11 to Ex.C19 medical bills,  Ex.C20 discharge summary, Ex.C21  declaration, Ex.C22 notification.  In rebuttal the OP no.1 tendered Ex.OP/A affidavit of Sh.S.K.Sharma, Sr. Divisional Manager of OIC, Ex.OP/B affidavit of Md. Samiyodin Sr. Manager of OIC, Ex.OP1PGEPHIS schedule of Rates, Ex.OP2  notification issued by Government of Punjab, Department of Health and Family welfare. OPs no.4 and 5 tendered Ex.OP4/1 affidavit of Dr. Jagdish  Singh Nodal Officer, Deputy  Medical Commissioner, Civil Hospital, Fatehgarh Sahib and closed their evidence. 
7.  Heard. Entire record perused.
8.   Admittedly, Punjab Govt. launched a  scheme for cashless mediclaim  for their employees &  Pensioners  namely  PGEPHIS  i.e Punjab Govt. Employees & Pensioners Health  Insurance Scheme and made a contract  with OPs no.1 and 2. The premium was paid by  State Govt.. Being a employee of Punjab Govt. , complainant was beneficiary  under this Scheme. The Medical bills  are to be paid by the Insurance Company not by the  department.
9.  From the perusal of the record, we find that complainant had lodged his claim with  OP no.1 on 23.1.2017 vide Ex.C4. OP no.2 repudiated his claim on 27.3.2017 vide Ex.C5 on the ground  that the treatment availed  by beneficiary shall be on  reimbursement basis  subject  to the submission of the claim to the TPA within 30 days from the date of discharge from the  hospital . OP no.2 repudiated the claim as per instructions from OP no.1.
10.  We are of the considered opinion that  denial of claim by OPs no.1 and 2 is not  sustainable. Rejection of claim purely on  technical grounds will  result in Policy  holder’ loosing confidence in Insurance Companies and giving  rise to excessive litigation. Insurance  Companies  should  not  repudiate the claims  unless they are convinced that claim would not  have been admissible even if  reported within specific time  frame .  It  is also necessary to mention  that it would not be fair and reasonable to reject genuine  claims. As per circular issued by Insurance Regulatory Development Authority IRDA/HLTH/MISC/CIR/216/09/2011,  a genuine claim  can not be  outrightly rejected on ground of delay. The  insurer is required to enquire from the claimant as to what was the reason for the delay in  submission of the claim.

According to notificationissued by Punjab Govt. , Departmentof Health &Family Welfare dated 20.10.2015,clause 5,there are certain treatment which are not covered under Health Insurance as per the IRDA. If treatment is given under the guidelines laid down by IRDA as mentioned in notificationthen one cannot escape from its liability toreimbursethe claim because IRDA under Section 34(I) of Insurance Act, 1938 vide no.IRDA/NL/MISC/CIR/214/10/2016 dated 28.10.2016 clarifying that circular dated 20.9.2011 is binding upon theInsurer. The OPs have not furnished any list showing the payment after deduction as per rules. Therefore the amount submitted by the complainant is to be taken as correct.

11.  There is no averment against OPs no.3,4 and 5. They are just proforma        opposite parties.
12.   As  a corollary of our above discussion, the present complaint is partly allowed.  OP no.1 is held liable for deficiency in service. The liability to reimburse the  incurred Medical expenses  is of the insurer  i.e OP no.1 and not of the agent i.e  OP no.2 who is just to process the claim  at the asking  of the insurer . So OP no.1 is liable to pay the claim. The OP no.1, directed:-

[a] Toreimburse the amount of Rs.26,126/- paid by the complainant on his treatment along with interest@ 6% P.A from the date of filing of complaint within 30 days, failing which interest @ 9% P.A. shall be payable.

        [b]To payRs.10,000/- compensation for harassmentand litigation charges to the complainant.

Compliance of the order be made by the OP no.1 within 30 days from the date of receipt of certified copy of this order. Failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within the statutory period due to pandemic of Covid-19. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record room.

Pronounced 14 March 2023

                                                           

                                                                      (S.K. Aggarwal)

                                                                              President

                                                                    

    

                                                                             (Shivani Bhargava)

                                                                              Member

 

                                                                             ( Manjit Singh Bhinder )

                                                                             Member