Punjab

Faridkot

CC/16/285

Sukhwinder Singh - Complainant(s)

Versus

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

Ashu Mittal

12 Jun 2017

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :      285

Date of Institution:  5.10.2016

Date of Decision :   12.06.2017

 

1. Sukhwinder Singh aged about 46 years, s/o Gurnam Singh
2. Mandeep Kaur aged about 23 years d/o Sukhwinder Singh

Both residents of Devi Wala Road, Street No. 6, Kotkapura, District Faridkot.                      

 ...Complainants

Versus

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

                     ....OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

                Sh P Singla, Member.

 

Present: Sh Ashu Mittal, Ld Counsel for complainant,

              Sh Deep Chand Goyal, Ld Counsel for OP-1 and 2,

              OP-3 Exparte.

 

 

ORDER

(Ajit Aggarwal, President)

                                                          Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to reimburse Rs.81,400/- the expenses incurred on treatment of complainant no. 2 on account of mediclaim insurance scheme and for further directing OPs to pay Rs 18,000/- as compensation for harassment, inconvenience, mental agony and litigation expenses.

2                                            Briefly stated, the case of the complainant is that being a government employee, complainant and his dependent family members are insured with Ops and are entitled to cashless health facilities under the Punjab Government Employees and Pensioners Health Insurance Scheme vide ID Card No. MD 15-B09878115534 and this policy was valid from 1.01.2016 to 31.12.2016 and premium regarding it was paid to Ops by government on behalf of complainants. It is further submitted that during the subsistence of insurance policy of Ops, complainant no. 2, who is daughter of complainant no. 1 suffered abdomen pain and diagnosed as having stone in her kidney. On 28.07.2016, complainant approached approved Fortis Hospital, Mohali and informed them about insurance and hospital informed Ops, but  thereafter, hospital did not diagnose the disease as Ops denied their liability as complainant no. 2 is not the card holder. Complainant showed them original card issued by Ops in which complainant no. 2 was also a member but hospital authorities did not listen their genuine request. They also approached OP-2 and 3, but to no effect and then, complainant contacted the helpline number 104 of Ops, but that also bore no fruit. It is further submitted that it was impossible for complainant to wait any more for treatment and thus, complainant no. 2 was diagnosed at RG Stone Urological Research Institute, Ludhiana and spent Rs.81,400/-on her treatment and after that complainant submitted all medical bills and requested Ops to reimburse the medical expenses of insured, but they declined his genuine request, rather OP-2 and 3 told complainant that rules and regulations have been changed and he is not entitled for any relief of reimbursement. Complainant made several requests to Ops to make payment of insurance claim, but all in vain. All this amounts to deficiency in service and trade mal practice on the part of OPs and has caused harassment and mental agony to complainants. Prayer for accepting the complaint is made alongwith compensation and litigation expenses.

3                                             The counsel for complainant was heard with regard to admission of the complaint and vide order dated 10.10.2016, complaint was admitted and notice was ordered to be issued to the opposite party.

4                                            On receipt of the notice, OP-1 and 2 appeared in the Forum Counsel and filed written statement taking preliminary objections that complainant is not the consumer of answering Ops as they are not service providers to complainants. Complaint is bad for non joinder of party as Punjab State and Department of Health and Family Welfare is necessary party in present case, which is insured with OP and therefore, it is liable to be dismissed on this ground. Moreover, complainants have not got the treatment from the hospital, which are on the panel of Ops and as such, they are not entitled for any claim. It is averred that as per Clause IV of notification dated 20.10.2015, government employees and their beneficiaries are entitled for treatment only under empanelled hospitals in Punjab and no reimbursement is available in Punjab where cashless treatment is available and thus, complainants are not entitled for any reimbursement. As per clause III of said notification, the scheme will ensure cashless indoor medical treatment, pre and post hospitalization as specified under State Services (Medical Attendant Rules) ( CS (MA) ) Rules 1940, but complainant no. 2 has not got treatment as per rules and therefore not entitled for any medical claim. It is further averred that even if the complainants prove to be their consumer, even then, the maximum liability of Ops is for Rs.13,941/-as per policy. However, on merits Ops have denied all the allegations of complainant being wrong and incorrect and taken same pleadings as in preliminary objections and asserted that Government of Punjab, Department of Health and Family Welfare had obtained the policy from the answering Ops, but complainants have not personally obtained the policy from them and they are not their consumers. All the other allegations levelled by complainant are denied being wrong and incorrect and reiterated that there is no deficiency in service on their part. Prayer for dismissal of complaint is made.

5                                              Parties were given proper opportunities to prove their respective case. The ld counsel for complainant tendered in evidence affidavit of complainant no. 1 as Ex.C-1, affidavit of complainant no. 2 as Ex C-2 and documents Ex C-3 to C-8 and then, closed his evidence.

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

7                                              We have heard the arguments addressed by all the parties and have also gone through the evidence and documents led by the parties.

8                                          Ld Counsel for complainant argued that being a government employee, complainant no.1 and his dependent family members are insured with Ops and are entitled to cashless health facilities under the Punjab Government Employees and Pensioners Health Insurance Scheme vide ID Card No. MD 15-B09878115534 and this policy was valid from 1.01.2016 to 31.12.2016 and premium regarding it was paid to Ops by government on behalf of complainants. It is further submitted that during the subsistence of insurance policy of Ops, complainant no. 2, who is daughter of complainant no. 1 suffered abdomen pain and diagnosed as having stone in her kidney. On 28.07.2016, complainant approached approved Fortis Hospital, Mohali and informed them about insurance and hospital informed Ops, but  thereafter, hospital did not diagnose the disease as Ops denied their liability as complainant no. 2 is not the card holder. Complainant showed them original card issued by Ops in which complainant no. 2 was also a member but hospital authorities did not listen their genuine request. They also approached OP-2 and 3, but to no effect and then, complainant contacted the helpline number 104 of Ops, but that also bore no fruit. It is further submitted that it was impossible for complainant to wait any more for treatment and thus, complainant no. 2 was diagnosed at RG Stone Urological Research Institute, Ludhiana and spent Rs.81,400/-on her treatment and after that complainant submitted all medical bills and requested Ops to reimburse the medical expenses of insured, but they declined his genuine request, rather OP-2 and 3 told complainant that rules and regulations have been changed and he is not entitled for any relief of reimbursement. Complainant made several requests to Ops to make payment of insurance claim, but all in vain, which amounts to deficiency in service and has caused harassment and mental agony to complainants. Prayer for accepting the complaint is made alongwith compensation and litigation expenses. Ld counsel for complainant has stressed on documents Ex C-1 to 8.

9                                         To controvert the  arguments of complainant counsel, ld counsel for OP-1 and 2 argued that complainant is not the consumer of answering Ops as they are not the service providers to complainants. Present complaint is bad for non joinder of necessary party i.e  Punjab State and Department of Health and Family Welfare as necessary OP in present case, which is insured with OP and therefore, it is liable to be dismissed on this ground. Moreover, complainants have not got the treatment from the hospital, which are on the panel of Ops and as such, they are not entitled for any claim. It is averred that as per Clause IV of notification dated 20.10.2015, government employees and their beneficiaries are entitled for treatment only under empanelled hospitals in Punjab and no reimbursement is available in Punjab where cashless treatment is available and thus, complainants are not entitled for any reimbursement. As per clause III of said notification, the scheme will ensure cashless indoor medical treatment, pre and post hospitalization as specified under State Services (Medical Attendant Rules) ( CS (MA) ) Rules 1940, but complainant no. 2 has not got treatment as per rules and therefore is not entitled for any medical claim. It is further averred that even if the complainants prove to be their consumer, even then, the maximum liability of Ops is for Rs.13,941/-as per policy. Ops have denied all the allegations of complainant being wrong and incorrect and asserted that Government of Punjab, Department of Health and Family Welfare had obtained the policy from the answering Ops, but complainants have not personally obtained the policy from them and they are not their consumers. Prayer for dismissal of complaint is made.

10                                      From the careful perusal of record and above discussion, it is observed that case of the complainant is that being permanent employee of government, complainant no. 1 alongwith his dependent family members was insured with Ops as per Cashless Health Scheme of Government valid from 1.01.2016 to 31.12.2016 and during tahe period of insurance contract with Ops, daughter of complainant no.1 suffered from some health problem and for this purpose, he approached Fortis Hospital, Mohali for treatment regarding his ailing daughter and informed them about his  being insured with Ops and also showed his health card issued by Ops to them, but after contacting with Ops, hospital authorities refused to provide treatment to his ailing daughter and under compelling circumstances, he got conducted the operation of removal of stone from the kidney of her daughter from RG Stone Urological Research Institute, Ludhiana and spent Rs.81,400/-on her  her treatment. Thereafter, complainant approached OPs for obtaining insurance claim from Ops, but till now, they have not paid anything to complainants. Despite repeated requests by complainant no.2 and her father, they have not made payment of claim amount, rather they assert that complainants are not their consumers. In reply, stand of OP-1 and 2 is that complainants are not their consumers and as the complainants have not got treatment from empanelled hospital, so, they are not entitled to any compensation as per terms and conditions of the Policy. Moreover, if it is proved that they are consumers of Ops, then in that case also, Ops are liable to pay on Rs.13,940/-in all for payment on account of expenditure incurred by complainant on treatment of his daughter as per specified rates of such type of treatment as per Policy conditions. They have sternly refuted all the allegations of complainant being wrong and incorrect and prayed from dismissal of complaint.

11                          Careful perusal of document Ex C-3, which is the Health Insurance Card issued by Ops, it is clear that complainants are consumers of Ops and premium on behalf of complainants is being paid to them by Government of Punjab. Ex C-4 copy of bill clearly reveals the fact that complainant paid Rs.81,400/-on account of treatment of his daughter, who was also the beneficiary under the said Cashless Health Scheme being dependent family member of complainant. Ex C-5 to 8 are copies of bills issued by Fortis Hospital, Mohali, which prove the pleading of complainant that earlier he approached them for treatment of his daughter, but they refused to give treatment as per scheme of government for grant of cashless health services. The submission of Ops that as per scheme, the employees of Punjab Government can take treatment only from the empanelled hospital in Punjab and no reimbursement is available to employees of Punjab government where cashless treatment is available  and as complainants have not got treatment from the empanelled hospital, so, they are entitled to any  compensation. In their support, they produced on record copy of letter dated 2.03.2016 issued by Secretary, Health cum Managing Director PHSC for implementation of Punjab Government Employees & Pensioners Health Insurance Scheme, wherein it is given in para no.1 that as per Para 4 of the notification, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available. However, it is clarified that the bills pertaining to Government hospitals like PGMIR, Chandigarh, GMCH Sector 32, General Hospital Sector 16, Chandigarh will be reimbursed to the employees on submission of their bills to the Insurance Company. From the perusal of this letter, it is clear that beneficiaries cannot claim reimbursement of medical bills for the treatment taken by them in the hospital where cashless treatment is available but there is no bar to take the treatment from any other hospital and claim reimbursement of bills of hospitals which are not empanelled for cashless treatment. So, these submissions of the Ops are not sustainable. The other objection of the Ops that as per their scheduled rates for the treatment taken by complainant no.2 is eligible only for payment of Rs13,940/-, but they have not proved how they calculated this amount. Whereas from copy of the bills and receipts of hospital produced by complainant, Ex C-4, it is clear that they paid Rs.81400/-for treatment of complainant no. 2. The Ops cannot fix their own rates for treatment and calculate the expenses on their own ignoring the actual expenses borne by complainant. All these acts of OPs amount to deficiency in service on their part.

12                                      From the careful observation of record and evidence put forward by complainant and in view of arguments advanced by respective parties, this Forum is of considered view that there is a deficiency in service on the part of OPs in not providing cashless health treatment to complainant for his daughter and further in refusing to reimburse the medical expenses incurred by complainant no. 1 for treatment of her daughter/complainant no.2 who is entirely dependent upon him and who is also the beneficiary under the Cashless Health Insurance Scheme Launched by Government through Ops. Complainant has succeeded in proving his case and hence, complaint in hand is hereby allowed against Ops. Ops are directed to reimburse the amount of Rs.81,400/-to complainant alongwith interest at the rate of 9% per anum from the date of filing the complaint till final realization. OPs are further directed to pay Rs.3000/-to complainant as compensation on account of harassment and mental agony suffered by complainant besides Rs.2000/-as litigation expenses. Compliance of this order be made within one month from the date of receipt of the 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 given to parties free of cost under rules. File be consigned to record room.

Announced in Open Forum

Dated : 12.06.2017       

 

  Member                            President

                                                  (P Singla)                      (Ajit Aggarwal)