DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 155
Instituted on: 12.04.2017
Decided on: 11.09.2017
Pawan Kumar son of Mohan Lal, resident of H.No.57/2, Ward No.9A, Dhuri, Tehsil Dhuri, Distt. Sangrur.
…Complainant
Versus
1. The Oriental Insurance Company Limited, CBO-III, SCO NO.37, Sector 30-C, Chandigarh through its Branch Manager.
2. M.D.India Health Care Services Pvt. Limited, Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director.
3. Director, Health and Family Welfare, Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.
4. Deputy Commissioner, District Administrative Complex, Opposite Bus Stand, Sangrur.
..Opposite parties.
For the complainant : Shri G.S.Shergill, Adv.
For Opp.party No.1to2: Shri Ashish Garg, Adv.
For Opp.Party No.3&4: Ms.Amandeep Kaur, Adv.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Vinod Kumar Gulati, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Pawan Kumar, 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 as he is working as Pharmacist at Civil Hospital Dhuri and as such he was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme and the OP number 2 is a TPA. The case of the complainant is that during the subsistence of the insurance period, on 14.12.2016, the complainant suddenly fell ill and was immediately taken to Walia Hospital, Dhuri, where he was diagnosed with heart disease and was referred to Hero DMC Heart Institute Ludhiana, where he remained admitted from 14.12.2016 to 18.12.2016 and spent an amount of Rs.160,405/-. Thereafter the complainant lodged the claim with the OPs, but the Ops paid only an amount of Rs.1,09,254/- and withheld the amount of Rs.51,151/- without any basis. 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.51,151/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply filed by Ops number 1 and 2, 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 complainnnt 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 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 complainant was admitted in Hero DMC Heart Institute, Ludhiana on 14.12.2016 and remained admitted upto 18.12.2016, where he spent an amount of Rs.160405/-. The Op number 2 approved the claim amount of Rs.1,09,254/- (Rs.105624/- as per package code 992PTCA plus Rs.3630/- as per package code number 974 CAG including 10% extra being private ward) and the same was paid to the complainant on 14.3.2017. 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 to Ex.C-14 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/7 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 3 and 4 has produced Ex.OP3&4/1 to Ex.OP3&4/4 copies of documents and affidavit 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 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 complainant suffered heart disease and further remained admitted in the Hero DMC Heart Institute, Ludhiana for the period from 14.12.2016 to 18.12.2016, where he spent an amount of Rs.1,60,405/- only and submitted the bills thereof to the Ops after discharging from the hospital. In the present case, the grievance of the complainant is that the Ops paid only an amount of Rs.1,09,254/- out of the claim amount and withheld the remaining amount of Rs.51,151/- without assigning any reason. On the other hand, the stand of the Ops is that the claim amount has rightly been paid as per the instructions and schedule of rates of PGEPHIS.
6. We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1&2/3, 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, the complainant is entitled to get coronary angiography to the tune of Rs.7260/-, whereas the OPs have paid only an amount of Rs.3630/- and further as per the code number 961 i.e. amount of 2D echo cardiograph, the complainant is entitled to get an amount of Rs.550/- and further the complainant is entitled to get an amount of Rs.4259/- on account of medicine charges, as such, we are of the considered opinion that the complainant is entitled to get an amount of Rs.8439/- more from the OPs. As such, we feel that the ends of justice would be met if the OPs number 1 and 2 are directed to pay to the complainant an amount of Rs.8439/-.
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 1 and 2 to pay to the complainant an amount of Rs.8439/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 12.04.2017 till realisation. We further order the OP number 1 and 2 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.
September 11, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
(Vinod Kumar Gulati)
Member
