Punjab

Faridkot

CC/16/357

Krishna Devi - Complainant(s)

Versus

Secretary to Govt. of Punjab Department of Health and family Welfare - Opp.Party(s)

Naresh Kumar Gupta

18 Aug 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     357

Date of Institution: 8.12.2016

Date of Decision :  18.08.2017

 

Krishna Devi aged about 69 years, Retd JBT Teacher, Govt Primary School, Ward No. 9, Kotkapura Tehsil Kotkapura District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1.  Secretary to Government of Punjab, Department of Health and Family Welfare Punjab, Chandigarh.
2. M D India, Health Care Services (TPA) Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali (Pb).
3. Oriental Insurance, M D India, Health Care Services (TPA) Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali (Pb).
4. District Co-ordinator, Oriental Insurance Co. Civil Hospital, Faridkot.
5. Block Primary Education Officer, Block Kotkapura, District Faridkot.
6. District Education Officer (Primary), Faridkot.
7. District Education Officer (Secondary), Faridkot.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Sh P Singla, Member.

 

Present: Sh N K Gupta, Ld Counsel for Complainant,

              Sh Kashmiri Lal, Ld Counsel for OP-1,

              Sh Vinod Monga, Ld Counsel for OP-2 to 4

              Representatives on behalf of OP-5, 6 and 7.

(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.2,54,070/- more as insurance claim with interest and for further directing OPs to pay Rs.1,50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.15,000/-.

2                  Briefly stated, the case of the complainant is that complainant retired as JBT Teacher from Govt Primary School, Kotkapura on 30.06.2015 and is having Pension Payment Order bearing 183959Pb issued by AG, Punjab and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme. 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 reimbursement of more than Rs. 03 lacs. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant It is further submitted that complainant suffered a severe heart problem and she got her treatment from DMC Hero Heart Hospital, Ludhiana from 4.04.2016 to 15.04.2016 and spent an amount of Rs.3,58,785/-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. Complainant submitted her claim for medical reimbursement to BPEO, Kotkapura, who forwarded the case to Civil Surgeon, Faridkot and Civil Surgeon verbally directed complainant to submit the claim directly to Oriental Insurance Company. Complainant lodged her claim for medical reimbursement with OPs on 6.05.2016, but was shocked to see  that OPs reimbursed only an amount of Rs.1,04,715/-in the account of complainant and withheld the remaining amount for no reason. Vide letter dt 8.06.2016 and 22.06.2016, complainant requested OPs for making remaining payment of reimbursement, but they did not give any reply. Complainant also served legal notice dated 26.09.2016 to OPs, but that also bore no fruit. Complainant made several requests to OPs for making payment of remaining amount of Rs.2,54,070/-, but they kept delaying the matter on one pretext or the other without disclosing any reason. 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 19.12.2016, complaint was admitted and notice was ordered to be issued to the OPs.

4                                                         On receipt of the notice, the OP-1 filed reply taking preliminary objections that as per notification of  Cashless Health Insurance Scheme launched by Punjab Government, Oriental Insurance Company has been selected as insurer for implementing the scheme and Insurance Company has appointed M D India Third Party Administrator to deal with the approval of claims and State Government is not liable to make payment of medical claims. However, on merits, OP-1 has denied all the allegations levelled by complainant being wrong and incorrect and asserted that Government of Punjab is not liable to pay any medical claim for the expenses incurred by complainant on her treatment and payment is to be made by OP-2 and 3 on account of reimbursement of medical claim lodged by complainant. It is reiterated that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

5                                                 Ld counsel for OP-2 to 4 filed reply wherein averred that no cause of action arises against them as claim of complainant has already been considered. It is averred that there is no deficiency in service on the part of OP-2 to 4 as after considering and processing the claim of complainant, they have already made payment of Rs.1,04,715/-to complainant. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to her as reimbursement of expenses incurred by her on her heart treatment. It is admitted by OPs that complainant was covered the policy in question. She is not entitled for more amount as sought by her. It is reiterated that there is no deficiency in service on the part of OP-2 to 4. All the other allegations and allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

6                                                  Representative of OP-5 and 6 appeared in the Forum and filed reply wherein they have denied all the allegations levelled by complainant being wrong and incorrect and asserted that complainant is not their consumer and no cause of action arises against answering OPs. It is averred that this Forum has no jurisdiction to hear and try the present complaint and for obtaining medical benefits, complainant should institute a suit or file her claim before concerned tribunal. It is further averred that complainant has concealed the material fact from this Forum that she never approached answering OPs regarding reimbursement of her claim. It is asserted that only OP-3 is liable to make payment of remaining amount of medical expenses incurred by complainant on her treatment. However, it is admitted by them that complainant submitted her claim with BPEO, Kotkapura on 2.05.2016 and they duly forwarded her claim case to Civil Surgeon, Faridkot. All the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

 7                                               OP-7 himself appeared in the Forum and filed reply wherein admitted the pleadings of complainant that she retired as government teacher from Government Primary School, Kotkapura and she got treatment regarding her heart problem from aforementioned hospital and spent about Rs.3,58,785/-on her treatment but asserted before the Forum that complaint has sought relief from Op-2 and 3 and they have nothing to do in making payment of reimbursement. Answering OP acts just like a proforma party and has no role to play in redressal of grievance of complainant. he has prayed for dismissal of complaint against them.

8                                                        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-13 and then, closed their evidence.

9                         In order to rebut the evidence of the complainant, Counsel for OP-1 tendered in evidence affidavit of Dr Jai Singh as Ex Op-1/1 and closed the same on behalf of OP-1.Counsel for OPs-2 to 4 tendered in evidence affidavit of Ashwani Kumar Ex OP-2 to 4 /1 and document Ex OP-2 to 4/2 and then, closed the evidence on behalf of OP-2 to 4. Representative of OP-5 and 6 tendered in evidence affidavit of Mohinder Kaur as Ex OP-5,6/1  and Op-5, 6/3 and document Ex OP-5, 6/2 and then closed the same. Representative of OP-7 tendered in evidence his affidavit Ex OP-7/1 and closed the evidence.

10                    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.

11              Ld Counsel for complainant vehementally argued that complainant retired as JBT Teacher from Govt Primary School, Kotkapura on 30.06.2015 and is having Pension Payment Order issued by AG, Punjab and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme. As per policy, she is entitled for cashless treatment and OPs are liable to pay the cashless insurance claim upto Rs.3,00,000/- and reimbursement of more than 03 lacs. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant Complainant suffered a severe heart problem and she got her treatment from DMC Hero Heart Hospital, Ludhiana from 4.04.2016 to 15.04.2016 and spent an amount of Rs.3,58,785/-on her treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, she is entitled for reimbursement of expenditure spent by her on her treatment. Complainant submitted her claim for medical reimbursement to BPEO, Kotkapura, who forwarded the case to Civil Surgeon, Faridkot and Civil Surgeon verbally directed complainant to submit the claim directly to Oriental Insurance Company. Complainant lodged her claim for medical reimbursement with OPs on 6.05.2016, but was shocked to see  that OPs reimbursed only an amount of Rs.1,04,715/-in the account of complainant and withheld the remaining amount for no reason. Vide letter dt 8.06.2016 and 22.06.2016, complainant requested OPs for making remaining payment of reimbursement, but they did not give any reply. Legal notice dated 26.09.2016 issued to OPs, also bore no fruit. Complainant made several requests to OPs for making payment of remaining amount of Rs.2,54,070/-, but they did not pay any heed to her requests. All this amounts to deficiency in service. Complainant has prayed for accepting the complaint and for directing the OPs to pay compensation alongwith litigation expenses besides the main relief.

12                                                      To controvert the allegations of complainant, ld counsel for OP-1 asserted that as per notification of  Cashless Health Insurance Scheme launched by Punjab Government, Oriental Insurance Company has been selected as insurer for implementing the scheme and Insurance Company has appointed M D India Third Party Administrator to deal with the approval of claims and State Government is not liable to make payment of medical claims. However, on merits, OP-1 has denied all the allegations levelled by complainant being wrong and incorrect and asserted that Government of Punjab is not liable to pay any medical claim for the expenses incurred by complainant on her treatment and payment is to be made by OP-2 and 3 on account of reimbursement of medical claim lodged by complainant. It is reiterated that there is no deficiency in service on the part of OP-1 and prayed for dismissal of complaint with costs.

13                                            Ld counsel for OP-2 to 4 averred that no cause of action arises against them as claim of complainant has already been considered. It is averred that there is no deficiency in service on the part of OP-2 to 4 as after considering and processing the claim of complainant, they have already made payment of Rs.1,04,715/-to complainant. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to her as reimbursement of expenses incurred by her on her heart treatment. It is admitted by OPs that complainant was covered the policy in question. She is not entitled for more amount as sought by her. It is reiterated that there is no deficiency in service on the part of OP-2 to 4. All the other allegations are refuted with a prayer to dismissed the complaint with costs.

14                                                  Representative of OP-5 and 6 have argued and denied all the allegations levelled by complainant being wrong and incorrect and asserted that complainant is not their consumer and no cause of action arises against answering OPs. It is averred that this Forum has no jurisdiction to hear and try the present complaint and for obtaining medical benefits, complainant should institute a suit or file her claim before concerned tribunal. It is further averred that complainant has concealed the material fact from this Forum that she never approached answering OPs regarding reimbursement of her claim. It is asserted that only OP-3 is liable to make payment of remaining amount of medical expenses incurred by complainant on her treatment. However, it is admitted by them that complainant submitted her claim with BPEO, Kotkapura on 2.05.2016 and they duly forwarded her claim case to Civil Surgeon, Faridkot. All the other allegations are also denied being wrong and incorrect and prayed for dismissal of complaint.

15                              OP-7 argued that and admitted the pleadings of complainant that she retired as government teacher from Government Primary School, Kotkapura and she got treatment regarding her heart problem from aforementioned hospital and spent about Rs.3,58,785/-on her treatment but asserted before the Forum that complaint has sought relief from Op-2 and 3 and they have nothing to do in making payment of reimbursement. Answering OP acts just like a proforma party and has no role to play in redressal of grievance of complainant. he has prayed for dismissal of complaint against them.

16                                             The case of the complainant is that being a retiree as JBT Teacher from Government Primary School, Kotkapura complainant was insured under the policy in question. She got conducted her heart treatment at DMC, Hero Heart Hospital, Ludhiana and spent about Rs.3,58,785/-on her treatment. She lodged claim with Ops, but Ops made payment of Rs.1,04,715/-only and withheld the reimbursement of remaining amount. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to her which amounts to deficiency in service. She has prayed for accepting the complaint. In reply, OP-2 to 4 have stressed mainly on the point that they have already paid the amount admissible as per rules, terms and conditions and package rate of policy and nothing is due towards them. Complainant is not entitled for further relief of claim amount as sought by her. Remaining Ops i.e Op-1, OP-5, OP-6 and OP-7 have asserted that there is no deficiency in service on their part and liability for making reimbursement of insurance claim lies only with OP-2 to 4.

17                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that she was insured with them as per Cashless Health Insurance Scheme launched by Punjab Government. OP-2 to 4 argued that as per policy terms and conditions and scheduled rate for the treatment under policy in question, the complainant is entitled only for Rs.1,04,715/-as reimbursement for her treatment at DMC Hero Heart Hospital, Ludhiana. As per scheduled  rate she is not entitled for any other amount than this and this amount has already been paid to complainant and now, she are not entitled for anything else. OP-2 to 4 have made payment of Rs.1,04,715/-to complainant, but no plausible reason is put forward by them to justify that why they have not made payment of entire claim amount. They have not placed on record any documentary evidence or statement that how they calculated this amount on their own. Admittedly, the complainant spent Rs.3,58,785/- for her treatment and paid this amount to hospital authorities, the Insurance Companies cannot fix their own rates at their own will than the actual expenses borne by the persons.

18                                                            Ld Counsel for complainant argued that the OPs cannot deduct the amount in dispute out of claim of complainant on the ground of alleged terms and conditions, which are never supplied or explained to them at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy. He further put reliance upon citation 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein our Hon’ble Punjab and Haryana High Court held that Contract act, 1872-Insurance Act, 1938-contract among unequal – Validity – Mediclaim Policy - Exclusion Clause – Pre Existing Disease - Exclusion Clause is standard form of contracts – when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power.

19                                                    From the above discussion and case law produced by the complainant, we are of considered opinion that OP-2 to 4 have wrongly and illegally deducted this amount, on false grounds of terms and conditions of policy out of entire amount, spent on treatment by complainant, which was covered under the Mediclaim insurance policy. The present complaint is hereby accepted against OP-2 to OP-4 and stands dismissed against remaining opposite parties i.e OP-1, OP-5 to 7. OP-2 to OP-4 are directed to pay Rs.2,54,070/-to complainant, which was wrongly deducted by them out of amount spent by her on her treatment alongwith interest at the rate of 9 % per anum from 4.06.2016 when they made less payment till final realization. They are further directed to pay Rs.5,000/-to complainant as compensation for harassment and mental agony suffered by him besides Rs.3000/- as litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 18.08.2017

                                                Member                   President

                                                          (P Singla)              (Ajit Aggarwal)