DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  177

                                                Instituted on:    02.05.2017

                                                Decided on:       13.10.2017

Amrik Singh son of Tirath Singh R/O Kali Dass Basti, Sunam, District Sangrur.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Co. Ltd. through its Divisional Manager, CBO-III, SCO No.37, Sector 30-C, Chandigarh.

2.             The Oriental Insurance Company Ltd. through its MD, registered and head office , A-25/27, Asaf Ali Road, New Delhi.

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

4.             District Education Office through District Education Officer, Magazine Street, Near Dr. Rampuli Wala, Sangrur.

5.             State of Punjab through Deputy Commissioner, District Administrative Complex, Opposite Bus Stand, Sangrur.

                                                        ..Opposite parties.

For the complainant  :       Shri Vinay Jindal, Adv.

For Opp.Party No.1to3:    Shri Ashish Garg, Adv.

For Opp.Party No.4&5:     None.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

Order by : Sukhpal Singh Gill, President.

1.             Shri Amrik Singh, 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 being a government employee retired as PTI teacher from Punjab Education Department and as such he was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09417911891 for the period from 1.1.2016 to 30.12.2016.   The case of the complainant is that during the subsistence of the insurance policy on 23.5.2016, he suffered severe pain in his stomach and chest, as such he was immediately brought to Vinayak Hospital, Sunam, where the treating doctor referred him to Dayanand Medical College and Hospital Ludhiana being an emergency case, as such he was got admitted there and the doctors diagnosed the complainant as case of STATUS POST LAP CHOLE 9DONE OUTSIDE0 WITH BILIOMA WITH CYSTIC DUCT BLOW OUT.  The complainant was also operated by the doctors of DMCH at Ludhiana and the complainant was also treated for jaundice. The grievance of the complainant is that despite the cash less policy issued by the Ops, the hospital authorities charged an amount of Rs.91,373/- from the complainant.  Further case of the complainant is that after discharge from the DMC Hospital, Ludhiana, the complainant submitted all the bills to the OPs number 1 to 3 for reimbursement, but the OPs number 3 repudiated the claim of the complainant vide letter dated 21.3.2017.  As such, the complainant has averred in the complaint that the Ops have wrongly repudiated the claim without assigning any reason. Thus, 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.91,373/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1 to 3, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable. 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 stated that as per the schedule, the liability of the company 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 that the complainant was admitted in Dayanand Medical College and Hospital, Ludhiana on 23.5.2016 for treatment of Status Post Lap Chole (Done outside) with Billoma with Cystic Duct Blow out and the complainant submitted the bill for Rs.91,373/- for reimbursement, but the claim was not payable being admission in non empanelled hospital in Punjab and Chandigarh in non emergency case, as such according to clause 4 of the Gazette notification dated 20.10.2015, the claim of the complainant was rightly repudiated. 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.

3.             In reply filed by Ops number 4 and 5, legal objections are taken up on the grounds that the present complaint is not maintainable and that the complainant has no cause of action to file the present complaint and that the complainant has got no locus standi to file the present complaint.  On merits, it is stated that the OP has no liability to reimburse the medical claim/bills as alleged by the complainant. It is stated that as per the policy, the liability to pay the claim is of the insurance company.  The other allegations levelled in the complaint have been denied in toto.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-61 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 to 3  has produced Ex.OP1to3/1 to Ex.OP1to3/6 copies of documents and affidavits 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 retired Punjab government employee was insured with the OPs under the medical 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 suffered from Status Post Lap Chole (Done outside) with Billoma with Cystic Duct Blow out problem and as such he was admitted in the Dayanand Medical College and Hospital Ludhiana on 23.5.2016 being an emergency case as referred by Vinayaka Hospital, Sunam.  It is also an admitted fact between the parties that the complainant spent an amount of Rs.91,373/- on his treatment at DMC Hospital Ludhiana.  Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 1 to 3 for reimbursement, but the claim of the complainant was repudiated vide letter dated 21.3.2017 on the ground that the claim is not payable being the treatment taken from non empanelled hospital. The complainant has produced on record the copies of the bills Ex.C-4 to Ex.C-60, as such it is contended by the learned counsel for the complainant that the claim has wrongly been withheld/rejected by the OPs.  On the other hand, the stand of the OPs number 1 to 3  is that the claim is not payable as the complainant has not got any treatment from the empanelled hospital of the Ops nor the case of the complainant was an emergency one and has further contended that the claim has rightly been repudiated. 

7.             It is worth mentioning here that the learned counsel for the OPs has contended vehemently that the complainant has not produced any documentary evidence on record to show that the Ops are liable to pay the claim of the complainant, if the treatment has been received other than the empanelled hospital. The complainant has also produced on record the copy of bill Ex.C-13  submitted by the complainant to the Ops for reimbursement of the amount of Rs.91,373/- being spent by the complainant on his treatment at Dayanand Medical College and Hospital Ludhiana.  We have also perused the copy of prescription/referral slip Ex.C-10 dated 23.5.2016, which clearly reveals that  Dr. Shimpi Jindal of Vinayak Hospital, Sunam referred the complainant to DMCH Ludhiana being an emergency case and further  to corroborate this contention, she has also produced her sworn affidavit Ex.C-61 that the case of the complainant was an emergency one.

8.             We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1to3/3, 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 Hepatico Jelunostomy for Stricture Repair Bile Duct Stricutre/Excision and as per serial number 1292, the  complainant is entitled to get an amount of Rs.23,124/- plus Rs.4874/- under serial number 1289 i.e. total Rs.27,998/-.  Further it is worth mentioning here that there is nothing mentioned by the Ops  number 1 to 3 in their written reply that why the claim is not payable as the complainant has taken treatment and has spent the huge amount on the treatment as mentioned above. It is worth mentioning here that there is no explanation from the side of the Ops that why the claim of the complainant was repudiated/rejected, when it is proved case that the complainant took treatment from Dayanand Medical College and Hospital, Ludhiana in an emergency case.  The same view has also been taken by the Hon’ble Punjab State Commission in Sukhdev Singh Nagpal versus New Karian Pehalwal Cooperative Agriculture Service Society and others 2017(3) CLT 120 (Punjab State Commission)  and has further held that when there is an emergency, one cannot wait to find empanelled hospital and loss his life by the time, when he is not in a position to find the said hospital nearby. As such, we are of the considered opinion that the ends of justice would be met if the OPs number 1 to 3 are directed to pay to the complainant an amount of Rs.27,998/- on account of the claim, as discussed above.

9.             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.

10.           Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1 to 3  to pay to the complainant an amount of Rs.27,998/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 02.05.2017 till realisation.  We further order the OPs number 1 to 3 to pay to the complainant an amount of Rs.10,000/- in lieu of consolidated amount of compensation and further an amount of Rs.5000/- on account of litigation expenses.

11.           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.

                        October 13, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member

                                                        (Vinod Kumar Gulati)

                                                                    Member