Punjab

Faridkot

CC/17/376

Inderjit Singh - Complainant(s)

Versus

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

Jaswant Singh

29 Apr 2019

ORDER

      DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :        376 of 2017

Date of Institution:     21.11.2017

Date of Decision :      29.04.2019

 

Inderjit Singh aged about 47 years, s/o Ajit Singh r/o H No. 81, Kirat Nagar, Old Cantt Road, Faridkot, District Faridkot State Punjab.

...Complainant

Versus

1. Oriental Insurance Company Ltd, Branch Office near Old Grain Market, Kotkapura, Tehsil and District Faridkot through its Branch Manager.
2. Oriental Insurance Company Ltd, through its M D c/o M D India, Health Care Services, TPA Pvt Ltd, Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali.
3. M D India, Health Care Services, TPA Pvt Ltd, Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali.

.....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

Present: Sh Jaswant Singh, Ld Counsel for complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

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                               Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to reimburse mediclaim amount of Rs.46,711.88 on account of expenses incurred by complainant on his treatment and for further directing OPs to pay Rs.50,000/- as compensation for harassment, inconvenience, mental agony besides litigation expenses.

2                               Briefly stated, the case of the complainant is that complainant is a lecturer in Government Senior Secondary School, Golewala, Faridkot and was insured under the Punjab Government Employees and Pensioners Health Insurance Scheme launched by Government. His ID No. Was 9501300655 and insurance policy of government was valid from 1.01.2016 to 31.12.2016. It is submitted that during the subsistence of insurance policy in question, complainant suffered from Esophageal Varies and for treatment of same, he was admitted in Dayanand Medical College and Hospital, Ludhiana on 4.07.2016 and was discharged therefrom on 7.07.2016. Thereafter, complainant submitted all the bills and relevant documents to OPs for reimbursement of amount incurred by him on his treatment, but OPs kept putting off the complainant on one pretext or the other and failed to finalize his genuine claim. Complainant also wrote letters dated 24.04.2017 and 18.09.2017 to complainant wherein requested OPs to pass his claim, but all in vain. Act of OPs in not clearing the claim of complainant, amounts to deficiency in service. Due to non payment of insurance claim by OPs, complainant has been suffering great economic

cc no. -376 of 2017

loss and hardships. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to him for which he has prayed for accepting the complaint alongwith compensation and litigation expenses. Hence, the present complaint.

3                                                        The counsel for complainant was heard with regard to admission of the complaint and vide order dated 28.11.2017, complaint was admitted and notice was ordered to be issued to the opposite parties.

4                                              On receipt of the notice, OPs filed written statement taking legal objections that there is no deficiency in service on their part and complaint filed by complainant is liable to be dismissed. it is averred that claim of complainant arose due to use of alcohol/drug abuse and as per Punjab Government Employees and Pensioners’ Health Insurance Scheme, claim of complainant was rejected and it was duly conveyed to complainant. complainant has breached the terms and conditions of the PGEPHIS and therefore, he is not entitled for any reimbursement.  On merits, OPs denied all the allegations of complainant being wrong and incorrect but admitted that complainant was insured with OPs under said scheme. It is also admitted that complainant lodged his claim alongwith treatment record but denied that they ever put off the claim under any pretext. It is averred that claim of complainant is rejected by them as it is not permissible under the rules

 

cc no. -376 of 2017

and it is reiterated that there is no deficiency in service on the part of Ops and prayed for dismissal of complaint with costs.

5                                        Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-1 and documents Ex C-2 to 47 and then, closed his evidence.

6                                                        In order to rebut the evidence given by complainant, the ld Counsel for OPs tendered in evidence, affidavit of Ashwani Kumar as Ex OP-1 and documents Ex OP-2 to Ex OP-4 and then, closed the same on behalf of OPs.

7                                                        We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                                                                 The case of complainant is that he  was insured under the Policy in question and during the period of insurance, complainant got conducted his treatment for esophageal varies from Dayanand Medical College and Hospital, Ludhiana and spent Rs.46,711.88/-on his treatment. He lodged the claim with Ops, but they did not pass the claim of complainant on false pretexts. Grievance of complainant is that despite repeated requests and even issuance of letters dated 24.04.2017 and 18.09.2017 to OPs, they did not pass his genuine  claim of Rs.46,711.88/-, which amounts to deficiency in service

cc no. -376 of 2017

and has caused great harassment and mental agony to him for which he has prayed for accepting the present complaint alongwith compensation and litigation expenses besides the main relief. On the other hand, plea taken by Ops is that as per terms and conditions of the police in question, claim of the complainant is not permissible and they have rightly rejected the same and complainant was duly informed regarding it. Treatment documents furnished by complainant reveal that claim lodged by complainant arose out of use of alcohol and for drug abuse and it is not covered under policy in question. Claim sought by complainant for reimbursement of expenses is not permissible. There is no deficiency in service on the part of Ops and have prayed for dismissal of complaint with costs.

9                                              To prove his case complainant has relied upon document Ex C-3 that is copy of acknowledgment vide which he lodged his claim with OP-3 that fully proves the pleading of complainant that he submitted all the documents with OPs. Ex C-5 is copy of Discharge Summary that reveals the fact that complainant was admitted in DMC, Ludhiana on 4.07.2016 and remained there till 7.07.2016, it also shows the treatment undertaken by complainant. Documents Ex C-11 to Ex C-47 are copies of bills that clear the point complainant paid Rs.46,711.88 to hospital authorities on account of his treatment for esophageal varies. Through his affidavit Ex C-1, complainant has reiterated his grievance.

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10                                              There is no iota of doubt that during the subsistence of mediclaim insurance policy in question, complainant suffered from some problem and being insured under the said policy, he was entitled to get insurance claim on account of expenses incurred by him on his treatment.

11                                                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. Ops have themselves admitted that he was insured with them as per Punjab Government Employees and Pensioners Health Insurance Scheme. OPs admitted that complainant remained hospitalized from 4.07.2016 to 7.07.2016 in DMC Hospital, Ludhiana. It is also admitted by the opposite parties that the complainant lodged claim for reimbursement of Rs.46,711.88/- on account of his treatment charges regarding his hospitalization in DMC, Ludhiana from 4.07.2016 to 7.07.2016 with opposite parties. He argued that on receipt of claim, it was duly processed and investigated by them and during the course of investigation, it was found that the patient was admitted in DMC Hospital, Ludhiana on 4.07.2016 for alcoholic liver disease and it is observed that the claim arose out of use of alcohol abuse/drug abuse as PGEPHIS is public health scheme, hence, the claim is not admissible within the standard  exclusions. So, the claim of complainants was repudiated and denied on justified grounds. There is no dispute regarding the Insurance Scheme and the fact that complainant was covered under

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the said scheme. Further, there is no dispute regarding the hospitalization of complainant and lodging of claim by complainant for reimbursement of his treatment expenses. The only point of opposite parties is that in their investigation, it is found that the claim arose out of alcohol abuse/drug abuse. So, under the scheme, the claim is not admissible and  covered under the exclusion clause. So, the claim has rightly been repudiated. Ld. Counsel for complainant argued that it is wrong that complainant was suffering from any disease due to alcoholic abuse. Even if, it is presumed that the disease of complainant was due to alcohol abuse, then in that case also, the opposite parties cannot repudiate the claim on this ground. Under the scheme, there was no such exclusion clause, under which, the disease due to alcohol or drug abuse, claim is not payable. Under this scheme all the pre-existing diseases are covered and there is no such exclusion clause. The opposite parties themselves produced the terms & conditions of Punjab Govt. Employees & Pensioners Health Insurance Scheme as Ex.OP-4, in which, at serial No.3 under the head of Insurance Coverage at point b, it is clear that all the diseases under the scheme shall be covered from the day one. A person suffering from any disease prior to the inception of the Policy, shall also be covered. Further at serial No.19 under the head of Exclusions, some diseases and expenses for treatment which are not covered under the scheme are mentioned but there is nowhere the disease due to alcohol or drug abuse is mentioned. As such, the diseases arose due to alcohol or drug abuse, are covered under the scheme

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whereas the disease due to alcohol or drug abuse is not excluded under the scheme and covered under it. Thus, opposite parties cannot deny the claim of complainants on the ground that the claim arose out of use of alcoholic abuse is not admissible.

12                                From the above discussion, we are of considered opinion that the opposite parties have wrongly and illegally repudiated  the claim of complainant on false grounds which amounts to deficiency in service and trade malpractice on their part. Hence, the present complaint is allowed. The opposite parties are directed to settle and pay the claim of complainant for his treatment for the period from 4.07.2016 to 7.07.2016 in DMC Hospital, Ludhiana as per PGI rates alongwith interest at the rate of 9% per annum from the date of filing the present complaint till final realization. OPs are further directed to pay Rs.5000/- to complainant as consolidated compensation for harassment and litigation expenses etc. Compliance of this order be made within one month from date of receipt of copy of the order, failing which, complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 29.04.2019         

          (Param Pal Kaur)              (Ajit Aggarwal)

                                         Member                              President