Punjab

Sangrur

CC/337/2017

Amandeep Kansal - Complainant(s)

Versus

Oriental Insurance Company Limited - Opp.Party(s)

Sh.Ramit Pathak

13 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  337

                                                Instituted on:    17.07.2017

                                                Decided on:       13.11.2017

 

 

Amandeep Kansal son of Shri Krishan Kumar Kansal R/O H.No.437, Street No.3, Prem Basti, Sangrur.

                                                        …Complainant

                                Versus

1.             Oriental Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Branch Head/Authorised signatory.

2.             M.D.India Health Care Services Pvt. Ltd. Maxpro Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director.

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

4.             District Education Officer, Near Ram Pulli Wala, Magazine Mohalla, Sangrur through its authorised signatory.

5.             Deputy Commissioner, District Administrative Complex, Opposite Bus Stand, Sangrur.

                                                        ..Opposite parties.

For the complainant  :       Shri Ramit Pathak, Adv.

For Opp.party No.1&2:     Shri Ashish Garg, Adv.

For Opp.Party No.4  :       Smt. Sunita Rani.

For OP No.3&5         :      Ms.Amandeep Kaur, Adv.

 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Amandeep Kansal, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is working as an ETT teacher at Govt. Primary School, Bijalpur, District Sangrur and as such he  was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09855610224.  The OP number 2 is the TPA of the OPs.  The case of the complainant is that he was some ear problem and has been taking treatment from Dr. Harsimran Singh at Simran ENT Centre, Patiala, as no such efficient and experienced ENT centre was here at Sangrur.  Further case of the complainant is that in the month of August, 2016 the complainant felt severe infection in his right ear due to the ongoing problem in his ear and as such, he was immediately rushed to Simran ENT Centre, Patiala and the doctor suggested that there is an infection in the ear, which can damage the hearing power of the complainant and can further effect the brain, as such the complainant got admitted himself at the hospital and was operated for ‘Right Ear CSM AAO’ on 13.8.2016 and remained admitted in the hospital upto 15.8.2016 and spent an amount of Rs.31,737/-.  Further case of the complainant is that he submitted all the documents to OP number 2 vide receipt number 39294 dated 4.10.2016 with the request to reimburse the same, but the Ops repudiated the claim of the complainant, despite serving of legal notice  upon the OPs.  As such, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.31,737/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 and 2, legal objections are taken up on the grounds that the OPs have been dragged into unwanted litigation, that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable, that the policy was issued in favour of the Govt. of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Punjab, Mohali, but the complainant has not impleaded it as a party.  On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis.  It is further averred that the Govt. of Punjab framed a policy for cashless treatment in Government or in empanelled hospitals in Punjab, Chandigarh and NCR area and no reimbursement will be available, where cashless treatment is available.  It is further stated that as per the schedule, the liability of the company is to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room.  It is admitted fact that the complainant was admitted in Simran ENT Centre, Patiala on 13.8.2016 and remained there admitting upto 15.8.2016 due to treatment of acute otitis media and submitted the bill for Rs.31,737/-. But, the claim of the complainant was rejected on the ground that no reimbursement is available for the treatment in Punjab and Chandigarh, where cashless treatment is available on PGEPHIS rates only except in emergency cases.  It is further averred that the claim was not payable being admission in non empanelled hospital in Punjab and Chandigarh. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee. Lastly, the OPs have prayed for dismissal of the complaint with special costs.

 

3.             In reply filed by Ops number 4 and 5, legal objections are taken up on the grounds that the complaint is not maintainable, that the complainant has dragged the Ops into unwanted litigation, that the complainant has no locus standi to file the present complaint and that the claim has been repudiated for the reason that the complainant has got his treatment from non empanelled hospital.  It is stated that the medical bills were never submitted by the complainant to  and that the complainant has no cause of action to file the present complaint. On merits, is admitted that the complainant is not entitled to get the claim as he has got treatment from the non empanelled hospital. Lastly, the OPs have prayed for dismissal of the complaint with special costs.

 

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-15 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1  and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/7 copies of documents and affidavits and closed evidence. The learned counsel for OP number 4 has produced Ex.OP4/1 affidavit and closed evidence. The learned counsel for OP number 5 has produced Ex.OP5/1 to Ex.OP5/6 copies of documents and affidavit and closed evidence.   

 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact between the parties that the complainant being a Punjab government employee, his entire family was insured with the OPs under the medical insurance policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 1.1.2016 to 31.12.2016.  It is also not in dispute that during the subsistence of the insurance period, the complainant in the month of August, 2016 suffered severe infection in his right ear due to the ongoing problem in his ear as such the complainant was immediately rushed to Simran ENT Centre, Patiala and there he remained admitted there from 13.08.2016 to 15.08.2016, where he spent an amount of Rs.31,737/- on his treatment. Now, the case of the complainant is that despite submission of the bills for Rs.31,737/- to the OPs for reimbursement being the amount spent by the complainant on his treatment, but the claim of the complainant has been repudiated by the Ops on the ground that the complainant has got treatment from the non empanelled hospital, as such no claim is payable.

 

7.             We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1&2/1, wherein in para 3 it is mentioned that “package rate shall mean and include lump sum cost of in-patient treatment/ daycare/diagnosis procedure for which a beneficiary has been authorised by the TPA to have cashless treatment at provider hospital from the time of admission to the time of discharge including patient’s diet, operation charges, injection charges, dressing charges, doctor/consultation visit charge, ICU/ICCU charges, monitoring charges etc….”  In the present case, it is worth mentioning here that as per the PGEPHIS schedule of rates, the complainant took treatment of Mastoidectomy(P) as per serial number 28 under ENT, the  complainant is entitled to get an amount of Rs.13,624/- plus 10% i.e. Rs.1362/- total Rs.14,986/-.  Further it is worth mentioning here that there is nothing mentioned by the Ops  number 1 and 2 in their written reply that why the claim is not payable as he has took treatment in emergency as the ear is a very sophisticated part of the body and has spent the huge amount on the treatment.  In the circumstances, we feel that at this stage there is no explanation from the side of the Ops that why the claim was repudiated/rejected by the OPs.  As such, we are of the considered opinion that the ends of justice would be met if the OPs number 1 and 2 are directed to pay to the complainant an amount of Rs.14,986/- on account of the claim, as discussed above.

 

8.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

9.             Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1  and 2 to pay to the complainant an amount of Rs.14,986/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 17.07.2017 till realisation.  We further direct the OPs number 1 and 2 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

10.           This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

 

                        Pronounced.

                        November 13, 2017.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member