BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

                                                                   Complaint No.144 of 2018

                                                                   Date of Inst. 09.04.2018

                                                                   Date of Decision: 12.11.2021

1.       Gurdeep Singh (deceased) Son of Sh. Mehanga Singh R/o 30-MMS Colony, Village Colony, PO Jalandhar Cantt., Jalandhar Cantt. through his Legal       Heirs.

a)       Smt. Kulwant Kaur Wd/o Sh. Gurdeep Singh

b)      Sh. Gurinder Singh S/o Sh. Gurdeep Singh

c)       Sh. Supreet Kaur D/o Sh. Gurdeep Singh

..........Complainants

Versus

1.       Oriental Insurance Company Ltd., Orient House, A-25/27, Asaf        Ali Road, New Delhi-110002, through its Claims Incharge- Mediclaim.

2.       Oriental Insurance Company Ltd., SCO-50, PUDA Complex, Jalandhar, through its Branch Head.

3.       MD India Health Care Services (TPA) Pvt. Ltd.  Maxpro Info Park, D-38 Industrial Area, Phase-1, Mohali, Punjab Through its Authorized Representative.

4.       Executive Officer, Provincial Division, Public Works Department (Building & Roads), Jalandhar Cantt.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:         Smt. Harveen Bhardwaj           (President)

         Smt. Jyotsna                           (Member)                                  

            Sh. Jaswant Singh Dhillon       (Member)

Present:        Sh. Chandandeep Singh, Adv. Counsel for Complainants.              

                    Sh. A. K. Arora, Adv. Counsel for the OPs No.1 and 2.

                   OPs No.3 & 4 exparte.

Order

Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein alleged that Punjab Government notified health insurance scheme for its employees and pensioners to cover indoor medical treatment expenses, day care procedures and treatment of chronic diseases. The said scheme by the name of “Punjab Government Employees and Pensioners Health Insurance Scheme” (PGEPHIS), was outsourced to Oriental Insurance Company Ltd./OP No.1 and 2. Public Works Department (Building & Roads) is a department of Punjab Government and its employees/pensioners were covered under said insurance. That complainant was regular employee of Public Works Department and retired from the office of OP No.4 as Sub Divisional Engineer on 31.10.2010 and now complainant is drawing pension from office of OP No.4. The complainant was insured with OPs No.1 and 2, under the aforesaid scheme (supra) by virtue of his employment with Punjab Government vide Health Card No.MD15-09779939452 issued by OPs from the period of 01.01.2016 to 31.12.2016. That OPs issued only health card to the insured person/complainant. The policy documents/schedule/exclusion clause/guide book/list of hospitals were never issued and delivered by OPs to the insured person during the whole period of policy. It was mandatory and obligatory on OPs to have issued policy documents/schedule/exclusion clause/guide book/list of hospitals, which expresses the terms of contract between the insurer and insured. There is no ground or reason for not issuing the policy documents/schedule/exclusion/guide book/list of hospitals. As such terms and conditions including exclusion clause were never communicated, made known and explained to the insured as such not the part of the contract of insurance.

2.                That in the months of May to August 2016, the complainant undergone four day care chemotherapies after the interval of one month each for treatment of Chronic Lymphocytic Lukemia (CLL). Complainant paid an amount of Rs.2,39,009/- towards the hospital bills, medicine bills, test for investigation etc. The complainant is still under the treatment of his disease, taking medicine and follow up examinations/medical test etc. That complainant lodged/submitted his claim with OP No.3 for his mediclaim as per the requirement of OP No.1 and 2 coupled with all original documents, prescription slips of doctors, medical, hospital bills, complicated chronic disease certificate for reimbursement thereon. Above said documents/bills were given against each chemotherapy separately to OP No.3 vide registered post dated 08.07.2016, 18.07.2016, 19.08.2016 and 22.09.2016, as per instructions of OP No.1 & 2. OPs No.1 and 2 have engaged and made tendered into evidence-up arrangement with OP No.3 as their agent to process and settle the mediclaim of insured person as per their mutual interse arrangement worked out themselves in accordance to their whims and fancies. That despite protracted follow-ups, letters, enquiries and protestations, the OPs failed to settle the genuine claim of the complainant. The insurance company at the time of selling policies chases people/consumer and literally promise everything but once the question of liability arises, the companies prefer to sit over the claim or resort to one technical objection and other. That exasperated by the delay, deficiency in rendering and negligence on the part of OPs and their failure to pay claim to the complainant, the humble complainant seeks the redress from this Forum. The complainant has been running from pillar to post to get the genuine and rightful claim but the OPs attitude have been callous and remorseful. The enormous delay of one year and nine months, on the part of the OPs is unpardonable and deficiency is inexcusable since approach of the OPs was indifferent and cavalier to the need of the complainant. That as per the provisions of Insurance Regulatory and Development Authority (Protection of Policy Holders Interest Regulation 2002), it is mandatory on OPs to settle the claim of the insured with in a period of 30 days on the receipt of information but OPs acting in gross contravention to the rules, have sent/submitted no communication as to the fate of settlement of claim. That not to resolve/settle insurance claim without any reason and rhyme whimsically and without any valid justification is sufficient to saddle OPs with the charge of deficiency in rendering service apart from unfair and deceptive trade practice. In action and lethargic attitude approach in dealing with the insurance claim is casual, callous and leisurely manner on the part of the OPs shakes faith of insured in insurance. The OPs are guilty of rendering deficient services, negligent and unfair trade practice as envisaged under the Act and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay claim of Rs.2,39,009/- to the complainant with interest @ 18% per annum from the date of  lodging of claim, upto the date of actual payment and further OPs be directed to pay Rs.25,000/- as compensation and Rs.10,000/- as litigation expenses.

3.                Notice of the complaint was given to the OPs, but OP No.3 despite service did not appear and ultimately, OP No.3 was proceeded against exparte, whereas OPs No.1 and 2 appeared through their counsel and filed written reply, whereby contested the complaint by taking preliminary objections that the the complainant is estopped by his own act and conduct from filing the present complaint. The complainant submitted four claims with the Claim Settling Agency of opposite parties nos. 1 & 2 i.e. opposite party no.3, the detail of which are as under:-

 a)      Claim of Rs.54176/- for the treatment taken by the complainant         from 07.06.2016 to 17.06.2016 from Patel Hospital, Jalandhar.

b)      Claim of Rs.69371/- for the treatment taken by the complainant         from 09.05.2016 10.05.2016 from Patel Hospital, Jalandhar.

c)       Claim of Rs.56037/- for the treatment taken by the complainant         on 14.07.2016 from Patel Hospital, Jalandhar.

d)      Claim of Rs.59435/- for the treatment taken by the complainant         on 12.08.2016 from Patel Hospital, Jalandhar.        

          Claim of Rs.54176/- was repudiated by the Claim Settling Agency of the opposite party as per para no. 4 of the notification, wherein it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where the cashless treatment is available. Claim of Rs.69361/- was closed by the Claim Settling Agency of the opposite party because the complainant failed to submit the additional information i.e. Original Discharge Card from the Hospital despite letter dated 06.12.2016 written to the complainant. The claim of Rs.56037/- was processed by the Claim Settling Agency of the opposite party and a sum of Rs.44511/- was paid to the complainant on 22.11.2016 by credit to his account bearing no. 233000105479918 with Punjab National Bank, Church Road, Jalandhar Cantt. The said payment of Rs.44511/- was paid to the complainant after deducting an amount of Rs.11526/- as per PGEPHIS i.e. PUNJAB GOVERNMENT EMPLOYEES AND PENSIONERS HEALTH INSURANCE SCHEME.          Claim of Rs.59435/- submitted by the complainant for the treatment of complainant on 12.08.2016 has been paid on 08.11.2016 through NEFT by credit to his account no. 233000105479918 Punjab National Bank Church Road, Jalandhar Cantt. That being so, the complaint filed by the complainant is liable to be dismissed with special costs being not maintainable. It is further averred that there is no deficiency of service over or unfair trade practices on the part of the answering opposite parties and that being so, the present complaint dismissed. On merits, it is admitted that an insurance policy was issued to the complainant from the period 01.01.2016 to 31.12.2016. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.     

4.                OP No.4 filed its separate written reply and contested the complaint by simply stating that the Complainant is a pensioner of Punjab Government who had retired as Sub Divisional Engineer from the office of opposite party no.4. That during 2015 the Punjab Government had enrolled all his employees/Pensioners under Punjab Govt. Employees and Pensioners Health Insurance Scheme. Under this scheme the Punjab Govt. Employees and Pensioners were entitled to take cashless medical treatment w.e.f 1-1-2016 to 31-12-2016 in the empaneled hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). That during the period w.e.f 1-1-2016 to 31-12-2016 the Oriental Insurance Co. Ltd. was liable to Pay/Reimburse all the medical bills of employees and pensioners of the Punjab Government enrolled under the scheme. That the complainant had sent his medical bills directly to the said Insurance Company for which the opposite party no. 4 has no knowledge/Information and further stated that the claim of the complainant is to be settled by the opposite parties no. 1 to 3 under the policy instructions of Punjab Government, Department of Health and Family Welfare issued vide no. 21/28/12-5HB5/268 dated 20-10-2015. After filing the written reply, the OP No.4 was proceeded against exparte for non-appearance in the Forum (now Commission).

5.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant as Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-7 and closed the evidence.

6.                In order to rebut the evidence of the complainant, the counsel for the OPs No.1 and 2 tendered into evidence affidavit of Sh. Yash Pal as Ex.OP1&2/A alongwith some documents Ex.OP1&2/1 to Ex.OP1&2/6 and closed the evidence.

7.                We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

8.                It is admitted and proved by the complainant that the complainant was employee of Public Works Department and retired from the office of OP No.4 as Sub Divisional Engineer on 31.10.2010. It is also admitted and proved that he was insured with OPs No.1 and 2 under the “Punjab Government Employees and Pensioners Health Insurance Scheme” (PGEPHIS), vide Health Card No.MD15-09779939452 issued by the OPs. It is also admitted that the complainant filed four claims before the OPs No.1 and 2, out of which two claims were paid and one was repudiated and the other was closed. As per the case of the OPs No.1 and 2, the claim of Rs.54,176/- was repudiated by Claim Settling Agency of the OP, whereas the claim of Rs.69,361/- was closed by Claim Settling Agency of the OP. With regard to third claim of Rs.56,037/-, the complainant was paid Rs.44,511/- out of Rs.56,037/- after deducting an amount of Rs.11,526/- as per PGEPHIS and the last claim of Rs.59,435/- was paid to the complainant.

9.                As per the documents produced on record by the complainant, he was treated in the Patel Hospital from 06.05.2016 to 25.05.2016 and spent Rs.69,361/- and again was treated from the same hospital from 07.06.2016 to 17.06.2016 and spent Rs.54,176/- for his treatment as per Ex.C-1 and Ex.C-2. The contention of the OPs No.1 and 2 is that the complainant has not given any detail regarding his treatment taken by him. The contention of the OPs No.1 and 2 is that two claims of the complainant were repudiated and closed as were recommended by Claim Settling Agency on the ground that the complainant had not filed discharge card issued by the hospital to the OP. The Ld. Counsel for the OPs No.1 and 2 has relied upon the notification Ex.OP1&2/1 wherein it has been mentioned that no reimbursement will be available to employees/pensioners in Punjab, Chandigarh and Panchkula, where cashless treatment is available. On this ground only, the claim of the complainant was rejected. Ex.OP1& 2/5 is the detail given by the TPA regarding all the four claims submitted by the complainant and as per Ex.OP1&2/6, the Assistant Manager of PGEPHIS had demanded the documents on the basis of which the deduction of Rs.11,526/- was made and the copy of the letter written to the insured/complainant for submission of additional information called by the insurance company.

10.              Perusal of the documents Ex.C-1 to Ex.C-4 shows that the same documents have been supplied by the Patel Hospital and the information mentioned in these documents i.e. Claim Form of Punjab Govt. is the same in all the four claims. The OPs No.1 and 2 has not produced on record any documents to show that they have ever written a letter to the complainant to provide the additional information regarding the two claims, which have been denied to the complainant. The document Ex.OP1&2/2 produced on record, no where shows that it was ever received by the complainant. The document Ex.OP1&2/5 shows that in this document against the column ‘Final Status’ claim of Rs.54,176/- and Rs.69,361/- have been repudiated and closed respectively and regarding the other two claims payment has been made. The OPs No.1 and 2 have not produced any documents to show that the complainant had furnished the information sought by them in other two claims and have not given the detail and rule as to why they have deducted Rs.11,526/- out of Rs.56,037/- nor any information was ever supplied to the PGEPHIS as sought as per Ex.OP1&2/6. The contention of the OPs No.1 and 2 is that the claims have been repudiated and closed by TPA. It has been held by the Hon’ble State Consumer Disputes Redressal Commission, in FA No.179 of 2017, titled as ”Dr. Sudarshan Jindal Vs. the United India Insurance Co. Ltd. etc.”, decided on 13.10.2017 that “the TPA had no right to repudiate the claim of the complainant. The competent authority of Insurance Company is only competent to pass orders, accepting or rejecting the insurance claim.” In the present case also the insurance company has not passed any order accepting or rejecting the claim and the Claim Settling Agency/TPA is not competent to pass any order. The TPA can only process the claim and forward the same to the insurance company.

11.              Even if for the sake of arguments, it is admitted that the complainant had not furnished the discharge card from the hospital, the insurance company was having knowledge of duration of treatment and hospital from which the complainant took the treatment as is clear from the detailed claim filed by the complainant, the insurance company could collect the medical record from the hospital. It has been held by Hon’ble State Consumer Disputes Redressal Commission, in FA No.43 of 2014, decided on 01.04.2014, titled as “Avneet G. Singh Vs. ICICI Lombard Gen. Insu. Co. Ltd. & Ors.”, that “where the insurance company is having knowledge of duration of treatment and hospital where patient was admitted, than they could collect the medical record from the hospital”. The claim cannot be denied on the ground that relevant treatment record was not supplied by the complainant. The complainant has placed on record the bills. The payment has been made from his own pocket as per the bills attached with    Ex.C-1 to Ex.C-3 which relate to treatment and medicines purchased by the complainant during the time he was admitted in the hospital.

12.              In view of the above detailed discussion, the complainant is entitled to the total amount of two claims as per Ex.C-1 and Ex.C-2 i.e. Rs.69,361/- and Rs.54,176/- along with interest @ 6%. OPs No.1 and 2 have failed to produce on record the rules or the scheme under which the amount of Rs.11,526/- was deducted while settling the claim of Rs.56,037/-. Thus, the complainant is entitled to Rs.11,526/- also alongwith Rs.69,361/- and Rs.54,176/- with interest @ 6% per annum from the date of bill paid in hospital, till its realization against OPs No.1 to 3. Further OPs No.1 to 3 are directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.7000/- as litigation expenses. The compliance of the order be made within 45 days from receipt of copy of this order. This complaint could not be decided within stipulated time frame due to rush of work.

13.               Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.

Dated             Jaswant Singh Dhillon      Jyotsna     Harveen Bhardwaj     

12.11.2021     Member                          Member     President