Punjab

Faridkot

CC/17/207

Kailash Rani - Complainant(s)

Versus

ORIENTAL INSURANCE COMPANY - Opp.Party(s)

Ashu Mittal

19 Dec 2018

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     207

Date of Institution: 27.06.2017

Date of Decision :  19.12.2018

 

Kailash Rani aged about 65 years, w/o Suman Kumar s/o Ram Nath r/o Backside Swaran Palace, Sukhija Colony, Faridkot Tehsil and District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1. Oriental Insurance Company Ltd, Branch Office Near Old Grain Market, Kotkapura, Tehsil and District Faridkot through its Branch Manager.         
2. Oriental Insurance Company Ltd through its MD, c/o MD India, Health Care Services TPA Pvt Ltd, Max Info Park, D-38, Industrial Area, Phase-I, Mohali (Pb).
3.  M D India, Health Care Services TPA Pvt Ltd, Max 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,

               Ms Param Pal Kaur, Member.

 

Present: Sh Ashu Mittal, Ld Counsel for Complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

(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 make payment of Rs.1,86,534/- on account of reimbursement of expenses spent by complainant on her treatment with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses.

2                  Briefly stated, the case of the complainant is that complainant is a retired government employee and as per Health Insurance Scheme for Pensioners, complainant alongwith her husband  was fully covered under Punjab Government Employees and Pensioners Health Insurance Scheme. The policy was valid from 1.01.2016 to 31.12.2016 and as per policy, complainant is entitled for cashless treatment and OPs are liable to pay the cashless insurance claim upto Rs.3,00,000/- and also reimbursement upto Rs.3 lacs. Premium for enrolment under scheme was paid by Punjab Government. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that during subsistence of said policy complainant suffered a severe heart problem and she got her treatment from DMC Hero Heart Hospital, Ludhiana from 10.05.2016 to 15.05.2016 and spent an amount of Rs.1,86,534/-on her treatment and as per Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by her on her treatment. Son of complainant submitted her claim for medical reimbursement to OP-2 and 3 and made several requests to them to make reimbursement of the amount spent by them on treatment of complainant, but OPs kept putting off the matter on one pretext or the other and then, finally repudiated the claim of complainant on the ground that no reimbursement is admissible where cashless treatment is available. Complainant made several requests to OPs for making payment of amount of Rs.1,86,534/-, but they declined the genuine request of the complainant. All this amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                   The counsel for complainant was heard with regard to admission of the complaint and vide order dated 3.07.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                    On receipt of the notice, the OPs filed reply taking preliminary objections that complainant has no cause of action to file the present complaint. It is averred that as per notification of Health Insurance Scheme launched by Punjab Government, the treatment can be availed by any enrolled beneficiaries in government or in empanelled hospitals in Punjab, Chandigarh and NCR area. No reimbursement will be available to employees or pensioners in Punjab Chandigarh and Panchkula where cashless treatment is available. However, on merits, OPs have denied all the allegations levelled by complainant being wrong and incorrect and admitted that both complainant as well as her husband were insured under the said policy and were covered for upto the rate of Rs.3 lacs. It is also admitted by OPs that they received bills for reimbursement of medical treatment of complainant and it is also admitted by them that they rejected the said bills on the basis of para no. 4 of notification vide which no reimbursement of medical treatment is pursuable as complainant had not availed the cashless treatment which is available in Punjab and complainant was duly informed about this. It is reiterated that there is no deficiency in service on the part of OPs and they refuted all the other allegations alongwith allegations for relief sought by complainant and also prayed for dismissal of complaint with costs.

5                                    Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-12 and then, closed their evidence.

6                                        In order to rebut the evidence of the complainant, Counsel for OP-1 tendered in evidence affidavit of Ashwani Kumar as Ex OP-1, documents Ex OP-2 and OP-3 and then, closed the same on behalf of OPs.

 7                                       We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

8                                       The case of the complainant is that being a retired Government employee, complainant was insured under the policy in question. She got conducted her heart treatment at DMC, Hero Heart Hospital, Ludhiana and spent about Rs.1,86,534/-on her treatment. She lodged claim with Ops, but Ops repudiated the claim of complainant on the ground that where cashless treatment is available, there reimbursement on account of medical treatment is not admissible, which amounts to deficiency in service. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of claim amount to her which amounts to deficiency in service and trade mal practice. She has prayed for accepting the complaint. On  the other hand, OPs have stressed mainly on the point that as per rules, terms and conditions and package rate of policy reimbursement is not admissible where cashless treatment is available. In the hospital cashless treatment was available but she did not took cashless facility, as such, complainant is not entitled for any relief of claim amount as sought by her.  As per OPs, they rejected the medical bills of treatment of complainant on the basis of para no. 4 of notification vide which no reimbursement of medical treatment is pursuable as complainant had not availed the cashless treatment which is available in Punjab and complainant was duly informed about this. They have prayed for dismissal of complaint with costs.

9                                     Ld Counsel for OPs argued that complainant does not fall under the definition of consumer and the present complaint is not maintainable. The policy in question was issued in favour of Government of Punjab, Department of Health and Family Welfare. As per terms and conditions of the policy and as per para no.4 of the notification dated 20.10.2015 Government of Punjab, Department of Health and Family Welfare, it is specified that no reimbursement will be available for the treatment in Punjab and Chandigarh, where cashless treatment is available. Only empanelled hospitals in Punjab, Chandigarh

and NCR are eligible for treatment of the enrolled beneficiaries. The complainant has not taken cashless treatment from empanelled hospital, so her claim is rightly repudiated. They argued that this Forum has no jurisdiction to try and decide this complaint, because as per contract with Punjab Government as per clause 24 of the tender, there are District Level Grievance Redressal Committees are constituted and every dispute is to be settled by these committees and complainant did not approach to these committees and filed this complaint before Forum. So, this Forum has no jurisdiction to try this complaint.

10                                          Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being the pensioner of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that the complainant took treatment from DMC Hero Heart Hospital, Ludhiana from 10.05.2016 to 15.05.2016 and spent an amount of Rs.1,86,534/-on her treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by her on her treatment. She lodged claim for the reimbursement of medical expenses borne by her with OPs, which was repudiated by them. Now, the first objection of opposite parties is that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and Grievance Redressal Committees are                                     constituted to settle the dispute, but the complainant did not approach to these committees and filed the present complaint before this Forum. It is settled principle of law that the remedy under Consumer Protection Act is an additional remedy other than available remedies. If there is any contract of arbitration or to settle any dispute by settlement committee under the scheme in that case also the complainant can approach to this Forum instead of arbitrator or dispute settlement committee. In that event the jurisdiction of this Forum is not barred and this Forum can entertain and decide the present complaint. Now, the second and main objection of OPs for non payment of medical expenses of complainant and for repudiation of the claim is that as per notification no reimbursement was available for the treatment in Punjab and Chandigarh, where cashless treatment is available and the beneficiary is entitled for the treatment under the scheme only from the hospitals which are empanelled under the scheme. The OPs argued that complainant did not claim cashless treatment, so she is not entitled for any relief and cannot claim reimbursement of  medical expenses and her claim is rightly repudiated.

11.                                     Ld counsel for complainant submitted that complainant had severe pain in her chest and her condition was very serious and when she was brought to doctor, concerned doctor advised her family to take her to DMC, Ludhiana and as her condition was very serious, therefore, she was brought to DMC Hospital, Ludhiana under compelling circumstances. As there was an emergency and due to threat to her life, doctors advised immediate operation of the complainant to save her life and attendants of the complainant was not aware about the insurance in question and in emergency they did as per the advice of doctors to save her life only. After the treatment when she lodged the claim with opposite parties, they denied her genuine claim on the basis of certain terms and conditions, which were never explained or supplied to her. From the medical record of the complainant, it is clear that she was admitted in hospital in emergency conditions and in emergency doctors gave her treatment best available at that time to save life. It is quite natural in the time of emergency when there is threat to the life of patient, the patient or his attendants immediately will approach to the nearest hospital or doctors and will take treatment as per the advice of doctors to save the life of the patient and not supposed to find the hospital or go for the treatment as per  alleged terms and conditions of insurance company, which can be fatal for patient. Even as per notification date 20.10.2015 regarding said insurance scheme copy of which is Ex.OP-2 at clause no.4, it is clear that reimbursement can be taken by any employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances. In view of the above, we are of the opinion that it is generally seen that insurance companies rejected pre authorization for cashless treatment on various grounds and do not allow cashless treatment to patient or hospital, then in that case only the resources left for insured is to reimburse the medical bills.

12                                            From the above discussion, we are of the considered opinion that the complainant took her treatment in emergency conditions and at that time she cannot be supposed to approach any empanelled hospital of opposite parties and to wait for pre-authorization of insurance company for her cashless treatment before starting treatment, which can be threat to her life. OPs wrongly and illegally repudiated the claim of the complainant for reimbursement of her medical bills, which amounts to deficiency in service on their part. Hence the present complaint is allowed against OPs. OPs are directed to make payment of insurance claim as per PGI rates alongwith interest @ 9% per annum from 9.12.2016, when they repudiated the claim of the complainant till realization. Further OPs are directed to pay Rs.5000/- (Five thousands only) consolidated as compensation and litigation expenses to the complainant. Compliance of the order be made within 30 days from the receipt of copy of this order, failing which, the complainant shall be entitled to  initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of order be sent to the parties free of costs. File be consigned to record room.

Announced in Open Forum

Announced in Open Forum

Dated : 19.12.2018

                                      Member                      President

                                                (Param Pal Kaur)         (Ajit Aggarwal)