Punjab

Sangrur

CC/101/2017

Jagatpreet Singh - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sh.G.S.Shergill

09 Aug 2017

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    101

                                                Instituted on:      16.03.2017

                                                Decided on:       09.08.2017

 

 

Jagatpreet Singh, Superintendent of Police (Investigation), Amritsar, resident of S.P. Investigation Niwas, Lawerence Road, Police Lines, Amritsar.

                                                        …Complainant

                                Versus

1.             Oriental Insurance Company Limited, Branch Office: Nabha Gate, Sangrur through its Branch Manager.

2.             Oriental Insurance Company Limited, Registered & Head Office: A-25/27, Asaf Ali Road, New Delhi through its Managing Director.

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

4.             Oriental Insurance Company Limited, CBO-III, SCO No.37, Sector 30-C, Chandigarh through its authorised signatory.

5.             State of Punjab through Deputy Commissioner Sangrur.

                                                        ..Opposite parties.

 

For the complainant    :       Shri G.S.Shergill, Adv.

For Opp.party No.1to4:       Shri Ashish Garg, Adv.

For Opp.Party No.5    :       Ms.Amandeep Kaur Bhangu, Adv.

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Jagatpreet 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 is a government employee and as such he is insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme and the OP number 3 is a TPA.  The case of the complainant is that during the subsistence of the insurance period, in the month of April 2016, the son of the complainant, namely, Pritham Singh suffered from RECURRENT RIGH SIDES SPONTANEOUS PNEUMOTHORAX WITH APICAL BLEBS and as such took treatment from Sir Ganga Ram Hospital, New Delhi, where he remained admitted for the period from 14.4.2016 to 20.4.2016 and spent an amount of Rs.3,51,955/- on the treatment of his son.  Thereafter the complainant immediately lodged the claim with the Ops and submitted all the relevant documents, but the Ops paid only an amount of Rs.47,945/- and withheld the remaining amount of Rs.3,04,010/- and the same was not paid despite the fact that the complainant approached the Ops a number of times. 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 remaining claim amount of Rs.3,04,010/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 to 4, legal objections are taken up on the grounds that the complainant has no cause of action to file the present complaint, that the complainant has dragged the Ops into unwanted litigation, that complicated questions of law and facts are involved in the present case and that the complainant is not a consumer, that the policy was not issued by Ops number 1 and 2 rather the same was issued by Chandigarh branch of the Oriental Insurance Co. Ltd.  On merits, it has been admitted that the policy in question was issued by Chandigarh branch office of the OPs for the period from 1.1.2016 to 31.12.2016 under which sum of Rs.3,00,000/- was insured per family on floater basis under which he was entitled under the general ward and the liability of the company was liable to pay the rates as per the Annexure XX.   It is further admitted that son of the complainant Pritham Singh remained admitted in Sir Ganga Ram Hospital New Delhi for the period from 14.4.2016 to 20.4.2016 for treatment of PNEUMOTHORAX WITH APICAL BLEBS and the TPA approved Rs.26,124/- as per package code number 1098 and Rs.16500/- as per code number 571 and thus paid Rs.47,945/- to the complainant.  It is stated further that the claim has rightly been paid to the complainant as per the terms and conditions of the policy.  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.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-11 copies of documents and closed evidence. On the other hand, the learned counsel for the OPs number 1 to 4 has produced Ex.OP1to4/1 to Ex.OP1to4/7 copies of documents and affidavits and closed evidence.

 

4.             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.

 

5.             It is an admitted fact between the parties that the complainant being a government employee was insured with the Ops number 1 and 2 under the medical policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 1.1.2016 to 20.4.2016.  It is also not in dispute that during the subsistence of the insurance period, the son of the complainant namely Pritham Singh suffered from RECURRENT RIGHT SIDES SPONTANEOUS PNEUMOTHORAX WITH APICAL BLEBS and as such took treatment from Sir Ganga Ram Hospital, New Delhi, where he remained admitted for the period from 14.4.2016 to 20.4.2016 and spent an amount of Rs.3,51,955/- on the treatment of his son. Now, the grievance of the complainant is that the Ops have paid only an amount of Rs.47,945/- out of the above said amount and further retained the amount of Rs.3,04,010/- without assigning any conclusive reason.  

 

6.             We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1to4/3, wherein in para 3 it is mentioned that “cost of implants is reimbursable in addition to package rates to the provider Hospitals. Medicines/Investigations/consumables outside the purview of the package but required/utilized in special circumstances/complications related to the treatment of the disease for which authorisation has been sought from the TPA by the provider hospital, are also reimbursable in addition to package rates to the provider hospital.  In the present case, it is worth mentioning here that as per the medical bill Ex.C-10, the complainant has spent an amount of Rs.62,384/- on the purchase of the medicines for the treatment and further has spent an amount of 19,124/- spent on anesthesia, which we feel are payable by the   Ops   to the complainant   in   view  of   the   Annexure-XX OP1 to 4/3, as both of these includes in the rates (for general Ward).  There is no explanation from the side of the Ops that why they did not pay the amount of Rs.62,384/- spent by the complainant on the medicines and further an amount of Rs.19,124/- spent on conducting the Anaesthesia.  It is made clear that Anaesthesia itself is nothing, but it is required at a special occasion when any special treatment such like operation/surgery of the patient is conducted.  In the circumstances, we feel that ends of justice would be met if the OP number 2 to 4 are directed to pay to the complainant the amount of Rs.62,384/- plus Rs.19,124/- as discussed above. It is made clear that the other charges as claimed by the complainant includes in the package as per the terms and conditions of the policy.

 

7.             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.

 

8.             Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 2 to 4 to pay to the complainant an amount of Rs.81,508/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 16.03.2017 till realisation.  We further order the OP number 2 to 4 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

 

9.             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.

                        August 9, 2017.

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member