Punjab

Faridkot

CC/19/171

Pritam Singh - Complainant(s)

Versus

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

Ashu Mittal

23 Aug 2021

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :              171 of 2019

Date of Institution:    12.07.2019

Date of Decision :      23.08.2021

 

1. Pritam Singh son of Ujjagar Singh aged about 70 years.
2. Sarabjit Kaur aged about 67 years, wife of Pritam Singh,

Both residents of Mohalla Bagiwana # BV/196-1, Faridkot, Tehsil and District Faridkot.

                                                                           .........Complainants

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 Pro Info Park, D-38, Industrial Area, Phase-I, Mohali.
3. M D India, Health Care Services TPA Pvt Ltd, Max Pro Info Park, D-38, Industrial Area, Phase-I, Mohali.
4. State of Punjab through Deputy Commissioner, Faridkot.

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5. Department of Health and Family Welfare through Health System Corporation, State Institute Health and Family Welfare Complex, Phase-6, Mohali through its Managing Director.

   .............O.P.s

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Amrinder Singh Sidhu, President,

               Smt. Param Pal Kaur, Member.

 

Present: Sh Ashu Mittal, Ld Counsel for Complainant,

              Sh Vinod Monga, Ld Counsel for OP-1 to 3,

   Sh Manpreet Singh, Ld Counsel for OP-4 and 5,

                                  

ORDER

(Smt. Param Pal Kaur, Member)

                                                  Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against O.P.s seeking directions to them to make payment of Rs.2,65,183/- on account of reimbursement of expenses spent by complainant on her treatment with interest and for further directing O.P.s to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses.

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2                                              Briefly stated, the case of the complainants is that both the complainants are government employees and as per Health Insurance Scheme for Pensioners, they are fully covered under Punjab Government Employees and Pensioners Health Insurance Scheme. The policy was valid from 1.02.2016 to 31.12.2016 and as per policy, complainants is entitled for cashless treatment and O.P.s 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. O.P.s neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that during the subsistence of said policy on 28.12.2016, complainant no.2 suffered pain in chest and was immediately rushed to Pragma Hospital, Bathinda where after angiography, she was found to be suffering from proximal and distal critical disease that relates to heard. As there was danger to the life of complainant no.2, therefore, operation was conducted upon her on 29.12.2016 and she was discharged therefrom on 04.01.2017. After operation, complainant no.2 was very weak and complainant no.1 was busy in looking after

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his wife/complainant no.2 and in February, he submitted all the bills and relevant documents required for processing the reimbursement of claim to District Education Officer, Faridkot, who returned the same to complainant vide letter dated 14.02.2017 for further submission of same to OP-2.  Thereafter, complainant contacted OP-2 and OP-3 several times, but they kept putting off the complainant on one pretext or the other and even after five months, neither gave any response nor reimbursed the expenses. Then, complainant approached OP-4 and OP-4 vide letter dated 22.12.2017, asked him to contact OP-5. Complainant approached OP-5 and submitted the bills, but till now, O.P.s have not reimbursed the expenses incurred by complainants. After that complainant filed RTI before OP-5 regarding reimbursement of medical bills to which OP-5 gave reply dated 04.04.2019 wherein it was disclosed that OP-2 and OP-3 have repudiated the genuine claim of the complainant due to late submission of documents. OP-2 and OP-3 took plea that claim file is submitted by complainant beyond the 30 days. Complainant again approached OP-3, but OP-3 returned the claim file of complainant vide rejection letter dated 19.06.2019, which is totally illegal.

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Repudiation of genuine claim of complainants by O.P.s amounts to deficiency in service and trade mal practice. Complainant has prayed for accepting the present complaint alongwith compensation for harassment and litigation expenses incurred by them besides the main relief. Hence, the present complaint.                         

3                                     The counsel for complainant was heard with regard to admission of the complaint and vide order dated 17.07.2019, complaint was admitted and notice was ordered to be issued to the O.P.s.

4                                      On receipt of the notice, the O.P.s no.1, 2 & 3 filed reply taking preliminary objections that complainant has no cause of action to file the present complaint as he has violated the terms and conditions of the PGEPHIS. It is admitted by OP-1 to 3 that they have rejected the claim of complainant because as per clause 11.6 of PGEPHIS, treatment availed by beneficiary shall be on reimbursement basis subject to submission of claim to TPA within 30 days from the date of discharge from the hospital, but in present case, complainant failed to submit the claim within prescribed period and

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submitted the file much late after 30 days from discharge from the hospital and thus, his claim could not be entertained being in violation of terms and conditions of Insurance Policy in question launched by the government. Further averred that complaint filed by him is time barred as claim relates to health problem and its treatment taken on 29.12.2016 and complainant no.2 was discharged from hospital on 04.01.2017. Complainant submitted the claim file very late on 19.06.2019 though it was required to be submitted within 30 days from the date of discharge from the hospital. There is no illegality in rejection of claim of complainant. It is reiterated that there is no deficiency in service on the part of answering O.P.s and all the other allegations and the allegation with regard to relief sought too are denied being wrong and incorrect. Prayer for dismissal of complaint with costs is made.

5                                          OP-4 & 5 appeared in the Forum through counsel and filed written reply wherein asserted that as per Section 10 (3) of the Policy, if the grievance of the beneficiary is not satisfied, it was required to be approached by beneficiary to DGRC and DGRC

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was further required to take an appropriate decision within 30 days from the receipt of complaint, but in present case, complainant has not been registered with DGRC. Even if the beneficiary is not satisfied  with the decision of DGRC, he may appeal before SCRC, who would decide the matter within 30 days, but no complaint or appeal is received from complainant. it is further averred that they have never received any consideration from complainant and does not fall under the definition of consumer. However, on merits, they have denied all the allegations of complainant being wrong and incorrect and asserted that complainant has sought relief from Insurance Company and therefore, complaint is liable to be dismissed against answering O.P.s. It is further averred that bills for disputed period were required to be submitted as per clause 11.6 of the Company within 30 days for cashless treatment, but complainant has submitted the claim late before the Company and therefore, payment has not been made to complainant. Moreover, there is no relationship between complainant and answering O.P.s. It is further averred that there is no provision to submit the bills to OP-5, rather it was the company who rejected the claim due to late submission of claim

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beyond 30 days after discharge of the patient. Answering O.P.s are not liable to make payment of claim sought by complainant. There is no deficiency in service or trade mal practice on the part of O.P.s and prayer for dismissal of complaint with costs is made.

6                                    Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence affidavit of complainant no.1 and 2 as Ex.C-1 and Ex C-2, document Ex C-3 is copy of Card issued by Punjab Government Employees And Pensioners Health Insurance Scheme showing the photographs of both complainant no.1 and complainant no.2,  Discharge Summary Ex C-4, Essentiality Certificate Ex C-5, copy of letter no.102 dated 14.02.2017 Ex C-6, letter issued by Director, Health and Family Welfare, Punjab Ex C-7, copy of information sought under RTI Ex C-8 and Ex C-9 and then, closed the same vide statement dated 14.01.2020.

7                                        In order to rebut the evidence of the complainant, ld Counsel for OP-1 to 3 tendered in evidence affidavit of Vikas Kataria, Divisional Manager Oriental Insurance Company

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Ltd., Ferozepur as Ex OP-1 to 3/1 and document Ex OP-1 to 3/2 and then, closed the same on behalf of OP-1 to 3. Ld Counsel for OP-4 and OP-5 has tendered in evidence affidavit of Dr. Rohini Goyal, Deputy Medical Commissioner, Faridkot as Ex OP-4,5/1 and closed the evidence on behalf of OP-4 and OP-5.

8                                 We have heard the ld counsel for complainant as well as O.P.s and have carefully gone through evidence and documents placed on record by respective parties.                            

9                                    The case of the complainant is that being a  Government employee, complainant was insured under the policy in question. She got conducted the treatment of her heart disease from Pragma Hospital at Bathinda and spent Rs.2,65,183/-on her treatment. She lodged claim with O.P.s, but O.P.s did not clear the bill. Repeated requests made by complainant to consider her case for clearing the claim amount, but it bore no fruit. In reply to RTI filed by complainant before OP-5 regarding non clearance of her bill, complainant came to know that genuine claim of complainant no.2 was repudiated by OP-2 and OP-3 on the ground that claim was

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submitted by complainant beyond 30 days. Requests made by complainant before O.P.s went futile, which amounts to deficiency in service. Grievance of complainant is that despite repeated requests, O.P.s 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, O.P.s no.1 to 3 have stressed mainly on the point that they have rightly rejected the claim as per clause 11.6 of PGEPHIS. Complainant was required to submit the claim to TPA within 30 days from the date of discharge from hospital, but complainant failed to submit claim within prescribed period and submitted the file very late after 30 days after discharge from the hospital and thus, his claim is time barred as claim relates to health problem and its treatment taken on 29.12.2016 and complainant no.2 was discharged from hospital on 04.01.2017. Claim file was submitted very late on 19.06.2019 though it was required to be submitted within 30 days from the date of discharge from the hospital. There is no deficiency in service on their part. Plea taken by OP-4 and OP-5 is that as per Section 10 (3) of the Policy, beneficiary was required to approach DGRC and DGRC was to take an

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appropriate decision within 30 days from the receipt of complaint, but complainant has not been registered with DGRC. Even if the beneficiary is not satisfied  with the decision of DGRC, he could appeal before SCRC, but no complaint or appeal is received from complainant. It is also argued that complainant is not their consumer as they have not received any consideration from him. Claim of complainant is rejected by Insurance Company and only Insurance Company is liable to make payment on account of treatment undertaken by complainant no. 2.They have prayed for dismissal of complaint with costs.

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 employee of Punjab Government, the complainant no.2 was beneficiary under this scheme. It is further admitted that the complainant no.2 took treatment from Pragma Hospital, Bathinda and spent an amount of Rs.2,65,183/-on her treatment and as per Cashless Health Insurance

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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 O.P.s, but they did not pay expenditure amount incurred by her on her treatment. The O.P.s argued that claim of complainant is not permissible under the terms and conditions and rules of policy in question as complainant did not submit the documents in time. So, she is not entitled for any relief and cannot claim reimbursement of medical expenses and her claim cannot be reviewed. There is no dispute that complainant got her treatment from hospital and spent Rs.2,65,183/-, which is duly proved from the bills. She lodged claim for reimbursement of this amount from O.P.s but the version of the O.P.s is that claim file was submitted very late, but O.P.s failed to prove on record any documentary evidence to prove their version. They wrongly repudiated the claim for expenses of Rs.2,65,183/- spent by her on her  treatment. This act of O.P.s amounts to deficiency in service and trade mal practice on their part. Moreover, in the light of judgment given by Hon’ble Punjab and Haryana High Court in CWP No.17694 of 2017 titled as Maninder Singh Patwari Vs

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State of Punjab and others as per Article 226 of Constitution of India, 1950, Medical claim of petitioner rejected for reason that bills were not submitted within 30 days- Petitioner had duly applied for reimbursement to deputy Commissioner alongwith original bills – Deputy Commissioner instead of forwarding same returned bills with direction to send claim to Insurance Company – It was actually the duty of State to ensure that medical bills of their employees were reimbursed taking into account agreement between State and Insurance Company – Premium paid by State – Respondents under no circumstances could deny medical reimbursement on ground of delay – Medical reimbursement was right of petitioner, which should have been granted immediately on receipt of medical bills – Petition allowed – Insurance Company to reimburse medical bills to petitioner as per policy. It is generally seen that Insurance Companies are interested only in earning the premiums and at the time of settlement, they find excuses to deny the genuine claim of consumers.

11                                            From the above discussion, we are of the considered opinion that being a government employee, complainant was fully insured under the Punjab Government

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Employees Pensioner Health Insurance Scheme and is fully entitled to expenses incurred by her on her treatment. O.P.s No. 2 and 3 wrongly and illegally repudiated the genuine 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 OP No. 2 to 3 and they are directed to settle the claim of complainant as per PGI rates alongwith interest @ 9% per annum from the date of filing the present complaint till final realization. Further O.P.s No. 2 to 3 are directed to pay Rs.5,000/- (Five thousands only) as consolidated compensation for harassment and litigation expenses to the complainant. Complaint against OP-1,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  4 and OP-5 stands dismissed. 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 71 and 72 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 Commission

Dated : 23.08.2021

 

 

                    (Param Pal Kaur)              (Amrinder Singh Sidhu)

                    Member                        President (Addl. Charge)