Punjab

Moga

CC/17/48

Rajpal Gupta - Complainant(s)

Versus

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

Sh. Rajiv Kumar

11 Oct 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 48 of 2017

                                                                                      Instituted on: 17.05.2017

                                                                                      Decided on: 11.10.2017

 

Rajpal Gupta aged 72 years s/o Sita Ram r/o House no.28, Bank Colony, Ward no.4, Moga.

                                                                                ……… Complainant

 

Versus

1.       Oriental Insurance Company Limited through its Branch Manager, Amlok Bhawan, G.T. Road, Moga.

 

2.       M.D. India Health Care Service TPA Private Limited Maxpro Info Park-D 38, 1^st Floor, Industrial Area Phase-I, Mohali, Punjab through its Manager. (E-mail ID authorization_pgephis@mdindia.com) (1800 233 1166)

 

3.       Punjab Government Employee and Pensioners Health Insurance Scheme through its Secretary, Health Punjab, Chandigarh.

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Rajiv Kumar, Advocate Cl. for complainant.

                   Sh. Jasvinder Singh, Advocate Cl. for opposite party no.1.

                   Opposite party no.2 ex-parte.

                   Sh. Raj Kumar Goyal, Advocate Cl. for opposite party no.3.

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against Oriental Insurance Company Limited through its Branch Manager, Amlok Bhawan, G.T. Road, Moga and others (hereinafter referred to as the opposite parties) directing them to pay a sum of Rs.73,754/- (Rs.87,683 – Rs.13,929) the amount of claim on the basis of insurance policy of the complainant with interest @ 12% per annum from the date of claim till its realization. Further opposite parties may be directed to pay Rs.10,000/- as compensation for causing him mental tension, harassment and agony to complainant and to pay Rs.10,000/- as litigation expenses to the complainant and to grant any other relief to which this Forum deems fit and proper in the circumstances of the case.

2.                Briefly stated the facts of the case are that the complainant was doing the service in PWD Department as AE. Now, the complainant is retired from the service and receiving the pension from the Government. Being Punjab Government employee complainant was insured with opposite parties during the period of 2016. Punjab Government Employee and Pensioners Health Insurance Scheme (PGEHIS) issued ID card no.MD15-09592458042 to complainant by opposite parties. As per guidelines of health insurance bills of 7 days pre hospitalization and 30 past days hospitalization got covered. As per guidelines opposite parties covered the health of the complainant and his wife. The wife of the complainant namely Raksha Gupta is not feeling well and caught by some chronic disease, for which, she admitted in DMC Hospital, Ludhiana a number of times, where she got treated said disease and the complainant every times get the claim by deducting the some minor charges by the opposite parties. The wife of the complainant was again admitted in DMC Hospital, Ludhaina on 29.08.2016 and got discharged on 01.09.2016 and the complainant had bears expenses on the treatment of her wife is about Rs.87,683/-. When the complainant claimed the said amount from the opposite parties to reimburse the said amount, then the opposite parties approved the claim of the complainant only for an amount of Rs.13,929/- in spite of the total amount Rs.87,683/- without giving any satisfactory reason. The complainant approached the opposite parties for clarification, but the opposite parties did not give any satisfactory reply to the complainant, rather excuse the matter on one pretext or the other. Due to the aforesaid illegal and unwarranted acts of the opposite parties, the complainant has suffered huge mental tension, agony and harassment. The opposite parties were asked many times to pay the amount of claim, but they have refused to do. Hence this complaint.

3.                Upon notice, opposite party nos.1 & 3 appeared through their counsel and filed their separate written reply.

                   Opposite party no.1 filed written reply taking certain preliminary objections that the complaint is not maintainable; that the complainant has no locus-standi; that no deficiency in service has been attributed to answering opposite party and from the allegations in the complaint no deficiency in service is made out; that the claim of the complainant is barred by limitation and by the terms and conditions of the insurance policy; that the complainant is not consumer of opposite party no.1 and there is no privity of contract between the complainant and opposite party no.1. Therefore, the application qua the opposite party no.1 is liable to be dismissed. The opposite party no.1 has not received any premium for the insurance from the complainant; that the complainant has concealed the material facts from this Forum. There is an elaborate grievance redressal mechanism formulated by the State Govt. Of Punjab for this policy. But the complainant has not lodged his grievance there; that the complaint is absolutely false and frivolous. Complicated questions of law and facts are involved in the present complaint. Moreover lengthy examination-in-chief and cross examination of the parties/witnesses are required in the complaint. So, the complaint is required to be decided by the Civil Court and this Forum has got no jurisdiction to entertain, try and dispose of the complaint; that the complainant has not approached this Forum with clean hands rather he has wilfully concealed the material and patent facts from this Forum while filing the present complaint which ipso-facto disentitles the complainant to seek any relief against opposite party. Further submitted that the claim of the complainant has already been settled and a payment of Rs.13,929/- has already been made to him as per PGEPHIS Tender rates. On receipt of the claim papers the matter was referred to TPA i.e. opposite party no.2 and the claim of the complainant has been rightly settled by the opposite party no.2 and the payment of Rs.13,929/- was made to the complainant only after the standard deductions. Therefore, the claim was rightly settled by the MD India Health Insurance TPA Pvt. Ltd. The complaint is false, frivolous, baseless, vague and malicious, therefore, in the event of dismissal of the complaint, the opposite parties are entitled to special costs as per provided under Consumer Protection Act. On merits, it is submitted that all claims are paid subject to the terms and conditions of the policy and the guidelines of PGEHIS. The claim has been paid in accordance with the rules and regulations. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.

4.                Opposite party no.3 filed written reply taking certain preliminary objections that the complaint is not maintainable; that this Forum has got no jurisdiction to try and decide the instant complaint; that the complainant is stopped to file the present complaint by his own act and conduct. On merits, it is admitted correct to the extent that there is a policy of Punjab Government regarding Health Insurance Scheme. Further submitted that the complainant never informed to the answering opposite party about the alleged problem of his wife Raksha Gupta and never informed about her alleged treatment from DMC, Ludhiana. But said DMC Hospital, Ludhiana was not on the panel of opposite party no.3 regarding PGEPHIS. No information is available about any problem of said Raksha Gupta and regarding her admission and treatment in DMC Hospital, Ludhiana. It is admitted that opposite party no.1 has approved the amount of Rs.13,929/- to the complainant. Further submitted that as per rules and regulation of opposite party no.3 the complainant should approach the State Grievance Redressal Committee constituted at District Level as well as at State Level and the aggrieved party/employee is to make representation to the said committee. As per rules and regulations of opposite party no.3 no suit, prosecution or other legal proceedings shall lie against any officer or servant of the Corporation for any act or purporting to be done under this Act or any Regulation made thereunder without previous sanction of the Corporation. But the complainant has not followed proper procedure before filing this false complaint. Whatever the amount by the insurance company has been paid is legally paid. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint has been made.

5.                Registered notice issued for the service of opposite party no.2 was not received back either served or un-served. As such, after expiry of statutory period of 30 days, opposite party no.2 was proceeded against ex-parte.

6.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit as Ex.C-1 and copies of documents Ex.C-2 to Ex.C-19 and copy of cash receipt of Rs.600 dated 24.08.2016 as Ex.C-20 and closed the evidence. 

7.                On the other hand, opposite party no.1 tendered in evidence affidavit of Sh.Jasvinder Singh, Senior Divisional Manager, Oriental India Insurance Company Ltd. as Ex.OP-1/1 and copies of documents Ex.OP-1/2 to Ex.OP-1/5 and closed the evidence. Whereas, opposite party no.3 tendered in evidence affidavit of Dr.Surinder Kumar Setia, Deputy Medical Commissioner as Ex.OP-3/1 and copies of documents Ex.OP-3/2 to Ex.OP-3/4 and closed the evidence.

8.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

9.                Ld Counsel for complainant vehementally argued that complainant retired from PWD Department as AE and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme under which he and his wife was covered. As per policy, he is entitled for cashless treatment and opposite parties are liable to pay the cashless insurance claim upto Rs.3,00,000/- and reimbursement of more than 3 lacs. Opposite parties neither submitted any document nor explained any terms and conditions of policy in question to complainant. Wife of the complainant suffered some chronic disease for the treatment of which she admitted in DMC Hospital, Ludhiana a number of times. However, the complainant every time gets the claim amount by deducting some minor amount. The wife of the complainant again admitted in DMC Hospital, Ludhiana on 29.08.2016 and discharged on 01.09.2016, where complainant spent an amount of Rs.87,683/- on the treatment of her wife and as per Cashless Health Insurance Scheme launched by Government of Punjab, he is entitled for reimbursement of expenditure spent by him on the treatment of her wife. Complainant submitted her claim for medical reimbursement with opposite party no.1, but was shocked to see  that it reimbursed only an amount of Rs.13,929/- in the account of complainant and withheld the remaining amount for no reason. The complainant requested the opposite parties for making remaining payment of reimbursement, but they did not give any satisfactory reply. The complainant made several requests to opposite parties for making payment of remaining amount of Rs.73,754/-, but they did not pay any heed to his requests. All this amounts to deficiency in service. Complainant has prayed for accepting the complaint and for directing the opposite parties to pay compensation alongwith litigation expenses besides the main relief.

10.              To controvert the allegations of complainant, ld counsel for opposite party no.1 averred that no cause of action arises against them as claim of complainant has already been considered. It is averred that there is no deficiency in service on the part of opposite party no.1 as after considering and processing the claim of complainant, the same has been settled and a payment of Rs.13,929/- has already been made to him as per PGEPHIS Tender rates and as per terms and conditions of the policy As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to him as reimbursement of expenses incurred by him on the treatment of his wife. It is reiterated that there is no deficiency in service on the part of opposite party no.1.

11.              Whereas, ld. Counsel for opposite party no.3 asserted that as per notification of  Cashless Health Insurance Scheme launched by Punjab Government, Oriental Insurance Company has been selected as insurer for implementing the scheme and Insurance Company has appointed M D India Third Party Administrator to deal with the approval of claims and State Government is not liable to make payment of medical claims. They denied all the allegations levelled by complainant being wrong and incorrect and asserted that complainant never informed to the answering opposite party about the alleged problem of his wife Raksha Gupta and never informed about her alleged treatment from DMC, Ludhiana. Moreove, the said DMC Hospital, Ludhiana was not on the panel of opposite party no.3 regarding PGEPHIS. They admitted that opposite party no.1 has approved the amount of Rs.13,929/- to the complainant. Further submitted that as per rules and regulation of opposite party no.3 the complainant should approach the State Grievance Redressal Committee constituted at District Level as well as at State Level and the aggrieved party/employee is to make representation to the said committee. The complainant has not followed proper procedure. Whatever the amount has been paid by the insurance company.

12.              The case of the complainant is that being a retiree as AE From PWD Department. He and his wife were duly insured under the policy in question. The wife of the complainant got her treatment at DMC Hospital, Ludhiana and where he spent Rs.87,683/-on the treatment of her wife. After discharge, the complainant lodged claim with opposite parties, but they made payment of Rs.13,929/- only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, opposite parties refused to make payment of remaining claim amount to him, which amounts to deficiency in service. He prayed for accepting the complaint. In reply,

13.              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 and his wife with opposite parties. The opposite parties have themselves admitted that wife of the was insured with them as per Cashless Health Insurance Scheme launched by Punjab Government. 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 Rs.13,929/- as reimbursement for her treatment at DMC Hospital, Ludhiana. As per scheduled  rate she is not entitled for any other amount than this and this amount has already been paid to complainant and now, the complainant is not entitled for anything else. Opposite parties have made payment of Rs.13,929/- to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. Admittedly, the complainant spent Rs.87,683/- for the treatment of his wife and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

14.              Ld Counsel for complainant argued that the opposite parties cannot deduct the amount in dispute out of claim of complainant 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.

15.               From the above discussion and case law produced by the complainant, we are of considered opinion that opposite party nos.1 & 2 have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted against opposite party nos.1 & 2 and stands dismissed against opposite parties no.3. The opposite party nos.1 & 2 are directed to pay Rs.72,784/-to complainant, which was wrongly deducted by them out of amount spent by complainant on the treatment of his wife alongwith interest at the rate of 9 % per annum from 17.05.2017 i.e. from the filing of present complaint till final realization. They are further directed to pay Rs.5,000/- (Five thousand only) to complainant as compensation for harassment and mental agony suffered by him besides Rs.3000/-(three thousand only) as litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated: 11.10.2017

                                                   (Bhupinder Kaur)                      (Ajit Aggarwal)                         
                                                        Member                                    President