Punjab

StateCommission

A/625/2017

Oriental Insurance Company Ltd. - Complainant(s)

Versus

Puran Chand - Opp.Party(s)

Satpal Dhamija

20 Nov 2017

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,    PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

 

                   First Appeal No.625 of 2017

 

 

                                                          Date of Institution:  31.08.2017

                                                          Order Reserved on : 15.11.2017                              

                                                         Date of Decision   : 20.11.2017

 

Oriental Insurance Company Limited, through its Senior Divisional Manager, Hoshiarpur City, Tehsil and District Hoshiarpur, through its authorized Signatory, Shri B.S. Ahuja, Deputy Manager, Oriental Insurance Company Limited, Regional Office, Surendra Building 109-111, Sector 17-D, Chandigarh.

 

                                                                Appellant/Opposite party no.1         

                   Versus

 

1.      Puran Chand son of Sh. Piara Lal , resident of Mohalla New   Hari Nagar near Kamal Palace, Hoshiarpur City, Tehsil and    District Hoshiarpur.

                                                          Respondent no.1/Complainant

 

2.      M.D India Health Care Services Scheme (TDA) Private Limited, Max Information Park, D-38, Industrial Area, Phase-1,     Mohali.

 

                  

                                                Respondent no.2/Opposite party no.2

 

First Appeal against order dated 27.07.2017 passed by the District Consumer Disputes Redressal Forum,  Hoshiarpur

 

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

            Smt.Surinder Pal Kaur, Member

 

Present:-

 

          For appellant                   : Sh.Satpal Dhamija, Advocate

          For respondent no.1      : Sh. Arnav Sood, Advocate

          For respondent no.2      : Ex-parte

……………………………………………………………………………..

 

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

          Challenge in this appeal by the appellant is to order dated 27.07.2017 of District Consumer Disputes Redressal Forum, Hoshiarpur, directing the appellant to pay Rs.1,17,402/- to respondent no.1 of this appeal with interest @ 9% per annum from the date of submitting of claim i.e. 13.07.2016 till realization, besides litigation expenses of Rs.5000/-. Respondent no.1 of this appeal is complainant in the complaint and appellant of this appeal is OP no.1 in the complaint and respondent no.2 of this appeal is opposite party no.2 therein before District Forum Hoshiarpur and they be referred as such hereinafter, for the sake of convenience, as arrayed in the complaint.

2.      The complainant has filed complaint U/s 12 of Consumer Protection Act, 1986 (in short, "the Act") against OPs on the averments that he retired from the services of Punjab Government working as Reader from District & Sessions Court Hoshiarpur on 31.03.2005. He was member of Cashless Medical Reimbursement Scheme floated by Government of Punjab for its retired employees with OP no.1. His wife Tripta Rani is beneficiary for this scheme duly covered under the above Cashless Scheme floated by Punjab Government. The complainant and his wife were insured and cashless identity card was issued to them by OP no.1. His wife Tripta Rani was attacked with an ailment and was hospitalized at DMC Hospital at Ludhiana and he had to pay Rs. 1,17,402/- for her treatment. The complainant lodged claim with OP through registered post on 13.07.2016 on specified proforma, supported with documents, but no payment was made by OP to complainant despite reminder sent by the complainant on 19.10.2016. OP neither repudiated the claim nor made the payment to complainant. The complainant has, thus, filed complaint directing OP to pay the amount of Rs.1,17,402/- with interest for their deficient act.

3.      Upon notice, OP no.1 appeared and filed written reply raising preliminary objections that complainant is not consumer of OP no.1. DMC Ludhiana is not empanelled hospital under network of the hospitals. The beneficiaries of policy are entitled to take treatment in Government or in empanelled hospitals only.  No reimbursement is permissible for treatment from any hospital outside the empanelled hospitals. The complainant failed to submit the claim within stipulated period and there is no contract between the complainant and OP no.1. On merits, OP no.1 contested the complaint on the ground that DMC Hospital is not an empanelled hospital under the network of hospitals under PGEPHIS and reimbursement of the complainant is thus not permissible. Wife of the complainant suffered from Hernia, which is not covered under the Scheme. The treatment was received from 03.05.2016 to 11.05.2016, whereas complaint was filed after 13.07.2016 beyond the period prescribed from filing it and it is barred by time. OP no.1 prayed for dismissal of the complaint.

4.      OP no.2 was set exparte before District Forum, vide order dated 04.05.2017.

5.      The complainant tendered in evidence his affidavit Ex.C-1 , supplementary affidavit Ex.C-2 along with copies of documents Mark C-3 to Mark C-70.. As against it; OP  No.1 tendered in evidence affidavit of Satbir Singh Bal Assistant Manager Oriental Insurance Company Ex.OP1/1 along with copies of documents Mark OP1/2 to Mark OP1/3 and closed the evidence. On conclusion of evidence and arguments, District Forum Hoshiarpur accepted the complaint of the complainant by virtue of order dated 27.07.2017. Dissatisfied with the order of the District Forum Hoshiarpur, opposite party no.1 now appellant, carried this appeal against the same.

6.      We have heard learned counsel for the parties, as respondent no.2 in this appeal is exparte and also examined the record of the case. Sh. Satpal Dhamija, Advocate counsel for appellant contended that the terms and conditions of the policy document have been not appreciated by learned District Forum below. No premium was paid by the complainant to OP no.1, now appellant and hence there is no relationship of consumer and service provider between them. The argument of counsel for the appellant is noted to be rejected by us, being without any substance. Punjab Government floated cashless scheme for the benefit of serving employees, retired employees and persons dependent upon them. The wife of the complainant was dependent upon him as she is covered under this cashless policy being dependant. The identity card of this cashless policy was issued by OP no.1 in this regard to complainant, which is not a disputed fact in this case, vide Ex.C-2 on the record. There is no dispute of this fact that Tripta Rani wife of the complainant was dependent upon him and she has also been covered as his dependent under this cashless scheme floated for the benefit of serving government and retired employees. Affidavits of complainant is Ex.C-1 and Ex.C-2 on the record. Copy of the cashless identity card issued to complainant is Ex.C-4. The complainant lodged medical reimbursement claim with OPs vide Ex.C-5 on the record supported with other documents Ex.C-3 to Ex.C-70 on the file. These documents have proved that Tripta Rani was hospitalized under cashless treatment at DMC Ludhiana. It is the basic right of the employee to be medically reimbursed, as per Article 21 of the Constitution of India, which cannot be denied to him. Instead of providing reimbursement claim to him, Punjab Government floated cashless scheme by entering into agreement with OP no.1. OP no.1 received premium from Punjab Government on behalf of the complainant and the complainant and his wife are beneficiaries of the scheme with express approval of Punjab Government and as such they are consumer. The contention of counsel for the appellant that there is no privity of contract between the complainant and OP no.1 is without merit and is rejected by us.

7.      Next submission of counsel for the appellant is that complainant took treatment for his wife from un-empanelled hospital and as such, OP no.1 is not bound to pay the insurance claim to him. Punjab Government Employees and Pensioners Health Insurance Scheme has been examined by us. Clause 12(A) deals with Pre-authorization for Cashless Access in case of Emergency/Planned Hospitalization for Listed /Non Listed Packaged Procedures. The wife of the complainant was attacked with Hernia disorder and it led to her hospitalization abruptly in DMC Ludhiana. Had Punjab Government not taken this scheme, then it was obligation of the Punjab Government to reimburse the claim to the complainant  for the treatment of his wife as mandated by law. OP no.1 cannot deny this claim to complainant that he has not received the claim from an empanelled hospital as it would be direct infringement of basic right of the complainant flowing from article 21 of Constitution of India, as Punjab Government is passing buck to insurance company and insurance company is denying the claim to complainant. The claim documents submitted by complainant were not honoured by OP no.1 who took over the responsibility on the basis of agreement entered into with Punjab Government Cashless Scheme for Reimbursement of the treatment expenses of retired employees and their dependants after taking premium from Punjab Government on behalf of them. The claim cannot be denied to complainant on this hyper- technical matters only, when it is fundamental right of the complainant enshrined in Article 21 of the Constitution of India for reimbursement for the treatment of his health from the State Government. OP no.1 has taken the premium from State Government and it cannot deny the claim to complainant being beneficiary of this scheme on this technical point.

8.      The next submission of counsel for the appellant is that the policy contained terms and conditions, which have not been complied with in this case. We find no force in it. It is duty of the State Government , which has been delegated to OP no.1 by giving premium to take this responsibility of this reimbursement of the claim to its retired employees and serving employees. We also find no force in the submission of counsel for the appellant that Hernia falls in the category of non-emergency cases, because condition of the  wife of the complainant became so grave due to swelling of Hernia that she had to be hospitalized forthwith. Had she not been properly taken care in DMC Hospital Ludhiana, it would have further caused serious complications to her. This contention of counsel for the  appellant is also not accepted by us.

9.      From perusal of entire evidence on the record and pleadings of the parties and order of District Forum under challenge in this case, we do not find any ground to interfere with the order of the District Forum in this appeal and same is affirmed in this appeal. Finding no merit in the appeal, same is hereby dismissed.

10.    The appellant had deposited the amount of Rs.25,000/-with this Commission at the time of filing the appeal and further deposited Rs.76874/-. Both these amounts with interest, which accrued thereon, if any, be remitted by the registry to respondent no.1/complainant of this appeal by way of a crossed cheque / demand draft   after the expiry of 45 days. Remaining amount as per order of the District Forum, if any due, shall be paid by the appellants/OPs to the complainant within 45 days from receipt of copy of this order, subject to  stay order if any.

11.    Arguments in this appeal were heard on 15.11.2017 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

12.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                    

 

                                                               (SURINDER PAL KAUR)

                                                                               MEMBER

November, 20  2017                                                           

(ravi)