Punjab

Faridkot

CC/17/75

SUSHIL DHAWAN - Complainant(s)

Versus

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

HARLOK NATH MUTHREJA

31 Aug 2017

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     75

Date of Institution: 14.03.2017

Date of Decision :  31.08.2017

 

Sushil Dhawan aged about 64 years, Retd Junior Assistant (Govt College of Education, Faridkot) r/o House No.C-36, New Cantt Road, St No.5 -L, Faridkot 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. Principal, Govt College of Education 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 Vinod Monga, Ld Counsel for OP-2 to 4

              Representative on behalf of OP-5,

              OP-1 Exparte.

(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.75,000/- more as insurance claim with interest and for further directing OPs to pay Rs.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 Junior Assistant from Govt College of Education, Faridkot on 31.07.2011 and is having Pension Payment Order bearing no. 251138/Pb issued by AG, Punjab and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme. As per policy, complainant alongwith dependent members of his family 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 wife of complainant suffered from Type-2 Diabetes Mellitus, hypertension, Progressive Dementia with delirim Urinary Tract Infection Hypothyroidism, Hypocalcaemia, Hyponatremia and Central Pontine Myelinoysis and she got her treatment from S P S Hospital, Ludhiana from 1.08.2016 to 11.08.2016 and complainant spent an amount of Rs.1,36,137/- on her treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by him on treatment of his wife. Complainant submitted claim for medical reimbursement to Oriental Insurance Company on 1.09.2016. Complainant lodged the claim for medical reimbursement with OPs on 1.09.2016, but was shocked to see that OPs reimbursed only an amount of Rs.61,137/-in the account of complainant on 28.11.2016 and withheld the remaining amount for no reason. Vide letter dt 3.12.2016, complainant requested OPs for making remaining payment of reimbursement, but they did not give any reply. Complainant also served legal notice dated 2.02.2017 to OPs, but that also bore no fruit. Complainant made several requests to OPs for making payment of remaining amount of Rs.75,000/-, 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 21.03.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                    On receipt of the notice, the OP-1 appeared in the Forum through representative, but despite having sufficient notice of complaint and availing many opportunities, OP-1 neither filed reply either himself or through counsel nor appeared in the Forum. Therefore, vide order dated 30.06.2017 Op-1 was proceeded against exparte.

5                                      Ld counsel for OP-2 to 4 filed reply wherein asserted that present complaint is without any cause of action and there is no privity of contract between complainant and answering Ops. It is further 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.61,137/-to complainant. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to him as reimbursement on account of expenses incurred by him on treatment of his wife. It is admitted by OPs that complainant and dependent members of his family were covered under the policy in question. He is not entitled for more amount as sought by him. 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 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 has not come to the Forum with clean hands 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 present complaint is beyond the limitation. It is further averred that wife of complainant has no concern with OP-5 and complainant neither submitted his bill for reimbursement of medical expenses on account of treatment of his wife to them nor do they have any intimation regarding treatment of his wife in said hospital. All the other allegations are denied being wrong and incorrect and prayed for dismissal of complaint with costs.

7                                              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-10 and then, closed their evidence.

8                                            In order to rebut the evidence of the complainant, 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 tendered in evidence affidavit of Jaswant Singh as Ex OP-5/1 and then also closed the same..

9                                               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.

10                                                Ld Counsel for complainant vehementally argued that complainant retired as Junior Assistant from Govt College of Education, Faridkot on 31.07.2011 and is having Pension Payment Order bearing no. 251138/Pb issued by AG, Punjab and was covered under Punjab Government Employees and Pensioners Health Insurance Scheme. As per policy, complainant alongwith dependent members of his family 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 wife of complainant suffered from Type-2 Diabetes Mellitus, hypertension, Progressive Dementia with delirim Urinary Tract Infection Hypothyroidism, Hypocalcaemia, Hyponatremia and Central Pontine Myelinoysis and she got her treatment from S P S Hospital, Ludhiana from 1.08.2016 to 11.08.2016 and complainant spent an amount of Rs.1,36,137/- on her treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by him on treatment of his wife. Complainant submitted claim for medical reimbursement to Oriental Insurance Company on 1.09.2016, but OPs reimbursed only an amount of Rs.61,137/-in the account of complainant on 28.11.2016 and withheld the remaining amount for no reason. Vide letter dt 3.12.2016, complainant requested OPs for making remaining payment of reimbursement, but they did not give any reply. Complainant also served legal notice dated 2.02.2017 to OPs, but that also bore no fruit. Complainant made several requests to OPs for making payment of remaining amount of Rs.75,000/-, but they kept delaying the matter on one pretext or the other without disclosing any reason. 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.

11                                                      To controvert the allegations of complainant, ld counsel for OP-2 to 4 averred that no cause of action arises against them as claim of complainant has already been considered and paid and nothing is due on account of reimbursement charges. 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.61,137/- to complainant. As per terms and conditions and package rate of policy, complainant has been paid the amount admissible to him as reimbursement of expenses incurred by him on treatment of his wife. It is admitted by OPs that complainant  alongwith dependent members of his family was covered under the policy in question. He is not entitled for more amount as sought by him. 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.

12                                               Representative of OP-5 have argued and denied all the allegations levelled by complainant being wrong and incorrect and asserted that wife of complainant has no concern with them and no cause of action arises against OP-5. 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 he never approached answering OPs regarding reimbursement of claim. It is further argued that complainant neither submitted his bill for reimbursement of medical expenses on account of treatment of his wife to them nor do they have any intimation regarding treatment of his wife in said hospital. All the other allegations are also denied being wrong and incorrect and prayed for dismissal of complaint.

13                                             The case of the complainant is that being a retiree from Government Education College, Faridkot complainant was insured with Ops under the policy in question. He got conducted treatment of his wife regarding Type-2 Diabetes Mellitus, hypertension, Progressive Dementia with delirim Urinary Tract Infection Hypothyroidism, Hypocalcaemia, Hyponatremia and Central Pontine Myelinoysis and she got her treatment from S P S Hospital, Ludhiana from 1.08.2016 to 11.08.2016 and complainant spent an amount of Rs.1,36,137/-on her treatment. Complainant lodged claim with Ops, but Ops made payment of Rs.61,137/-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 him which amounts to deficiency in service. He 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 him. OP-5 has asserted that there is no deficiency in service on their part and they have no concern with the wife of complainant  and even complainant did not submit his claim for reimbursement of medical expenses spent by him on treatment of his wife with them.

14                                                          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 wife of complainant 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.61,137/-as reimbursement for treatment of his wife at Ludhiana. As per scheduled  rate complainant is not entitled for any other amount than this and this amount has already been paid to complainant and now, he is not entitled for anything else. OP-2 to 4 have made payment of Rs.61,137/-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.1,36,137/- 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.

15                                      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.

16                                                    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 of wife of 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 and  OP-5. OP-2 to OP-4 are directed to pay Rs.75,000/-to complainant, which was wrongly deducted by them out of amount spent by him on treatment of his wife alongwith interest at the rate of 9 % per anum from 28.11.2016 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 : 31.08.2017

                                                Member                   President

                                                          (P Singla)              (Ajit Aggarwal)