DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  170

                                                Instituted on:    24.04.2017

                                                Decided on:       15.09.2017

Gurdev Singh aged 85 years son of S. Jawala Singh R/O Sant Atar Singh Nagar, Barnala Road, Sangrur.

                                                        …Complainant

                                Versus

1.             Oriental Insurance Co. Ltd. Branch Office, Nabha Gate, Sangrur through its Branch Manager.

2.             Oriental Insurance Co. Ltd. Registered and Head Office, A-25/27, Asaf Ali Road, New Delhi through its M.D.

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

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

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

6.             Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Divisional Manager.

                                                        ..Opposite parties.

For the complainant  :       Shri S.S.Ratol, Adv.

For Opp.party No.1to3&6:        Shri Ashish Garg, Adv.

For Opp.Party No.4&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 Gurdev 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 ASI from Punjab Police, Sangrur and as such he was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-08558824438.   The case of the complainant is that the wife of the complainant Smt. Harbhajan Kaur had already got transplanted her both knees and suddenly she felt pain in her left knee and  as such she was got admitted in Max Care Health Hospital, Mohali and it was disclosed that there was puss in the knee as such she remained admitted there from 10.3.2016 to 12.3.2016 for removing/treating the puss, but it was advised that the knee requires replacement from the same institution from it was originally replaced, however the TPA paid an amount of Rs.19,387/- for the treatment.  Further case of the complainant is that on the advice of the doctors of Max Health Care, Harbhajan Kaur was got admitted in Satyam Hospital, Jalandhar on 16.3.2016 and was discharged on 19.3.2016, where she spent an amount of Rs.37,007/- which was reimbursed by the Ops.  Further case of the complainant is that on the advice of the doctors, the left knee of Harbhajan Kaur was replace don 31.5.2016 and was discharged on 4.6.2016 and spent an amount of Rs.2,28,590/- during the treatment of the wife of the complainant, as such, the complainant submitted all the bills to the Ops, but the same were not reimbursed on flimsy grounds.  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.2,28,590/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1 to 3 and 6, 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, 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 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 wife of the complainant was admitted in Satyam Hospital, Jalandhar on 31.5.2016 and remained admitted upto 4.6.2016 due to internal derangements of knee and the complainant also submitted bill for Rs.2,28,590/- for payment, but the OP number 3 rejected the claim of the complainant under para 4 of notification number 21/28/12-5HB5/268 dated 30.10.2015 as it has been specifically mentioned that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available on PGEPHIS rates only. It is further stated that the claim was not payable being admission was 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.

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.  It is stated that the matter is between the insurance company and the complainant and the Ops number 4 and 5 have nothing to do.  The other allegations levelled in the complaint have been denied.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-28 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 to 3 and 6 has produced Ex.OP1to3&6/1 to Ex.OP1to3&6/6 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 Punjab government employee his entire family 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 wife of the complainant suffered knee problem and as such she got the same replaced from Satyam Hospital, Jalandhar.  It is further not in dispute that thereafter some problem arose in the knees and due to puss, she was got admitted in Max Care Health Hospital , Mohali on 10.3.2016 and was discharged on 12.3.2016 and spent an amount o Rs.19,387/- which was duly reimbursed by the Ops and further she spent an amount of Rs.37,007/-, which was also reimbursed to the complainant.  Now, the case of the complainant is that the wife of the complainant further remained admitted in Satyam Hospital, Jalandhar, where knee was replaced and the complainant spent an amount of Rs.2,28,590/-, but the same was not paid by the OPs on the ground that the same was not an empanelled hospital, the copy of the bill on record is Ex.C-4 and Ex.C-5, as such it is contended that the claim has wrongly been withheld/rejected by the OPs.  On the other hand, the stand of the OPs is that the claim is not payable as the wife of the complainant has not got any treatment from the empanelled hospital of the Ops. 

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 duly submitted to the Ops for Rs.2,28,590/- as Ex.C-5 to Ex.C-16 are the copies of the bills and reports duly submitted to the Ops.

8.             We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1to3&6/3, 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 wife of the complainant took treatment of knee replacement and as per serial number 1131, the  complainant is entitled to get an amount of Rs.1,00,393/- plus 10% i.e. Rs.10,039/- total Rs.1,10,432/-.  Further it is worth mentioning here that there is nothing mentioned by the Ops  number 1 to 3 & 6 in their written reply that why the claim is not payable as she has took treatment and has spent the huge amount on the knee replacement. It is worth mentioning here that the Ops have already paid the amount of Rs.19,387/- and Rs.37,007/- to the complainant as she took treatment from the non empanelled hospital in Punjab, but at this stage there is no explanation from the side of the Ops that why the claim was repudiated/rejected, when the Ops have paid the claim earlier as the wife of the complainant took treatment from the non empanelled hospital, as discussed above.  As such, we are of the considered opinion that the ends of justice would be met if the OPs number 1 to 3 and 6 are directed to pay to the complainant an amount of Rs.1,10,432/- 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  and 6 to pay to the complainant an amount of Rs.1,10,432/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 24.04.2017 till realisation.  We further order the OPs number 1 to 3 and 6 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and 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.

                        September 15, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member

                                                        (Vinod Kumar Gulati)

                                                                    Member