Chandigarh

StateCommission

A/149/2018

The Oriental Insurance Company Ltd. - Complainant(s)

Versus

Sh. Dwarka Dass Vashisht - Opp.Party(s)

J.P.Nahar, Adv.

01 Jun 2018

ORDER

^{STATE CONSUMER DISPUTES REDRESSAL COMMISSION,}

^{UNION TERRITORY, CHANDIGARH}

 

First Appeal No.	149/2018
Date of Institution	30.05.2018
Date of Decision	01.06.2018

 

^{The Oriental Insurance Co. Limited, through its Incharge/Authorised Signatory, SCO 109-110-111, Sector 17-D, Chandigarh 160017 [Now through their Authorized Signatory Alka Bansal, Manager, The Oriental Insurance Co. Limited, Regional Office SCO 109-111, Sector 17-D, Chandigarh].}

^{….Appellant/Opposite Party No.4}

Vs.

 

^{1. Sh.Dwarka Dass Vashisht, Aged 75 years, Husband of Late Mrs.Pushpa Vahisht, R/o House No.1101, Sector 21-B, Chandigarh.}

^{…..Respondent/Complainant}

^{2] State of Punjab, through its Charge/Principal Secretary, Punjab Civil Secretariat, Capitol Complex, Sector 1, Chandigarh.}

^{3] The Department of Irrigation (Canals), Punjab, Sector 18-B, Madhya Marg, Chandigarh 160018}

^{4] The Department of health and Family Welfare, through its Principal Secretary/Authorised Signatory, Room No.313, 3rd Floor, Mini Secretariat, Punjab, Sector 9, Chandigarh 160009}

^{5] Ace Heart and Vascular Institute, Shivalik Hospital Premises, through its Director/Incharge/Authorised Signatory, Sector 69, Mohali 160062}

^{….Respondents/OPs No.1 to 3 and 5}

 

^{BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT}

^{SH.DEV RAJ, MEMBER}

^{SMT.PADMA PANDEY, MEMBER}

 

^{Argued by: Sh.J.P.Nahar, Adv. for the appellant.}

 

^{PER PADMA PANDEY, MEMBER}

^{This appeal is directed against the order dated 18.04.2018 rendered by the District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which it allowed the complaint filed by the complainant qua OP No.4 only and directed it as under:-}

^{“11] Keeping into consideration the facts in issue, obviously the OPs No.4 suffers from deficiency in service. The complaint as such is allowed with directions to the Opposite Party NO.4 (Oriental Insurance Company Ltd.) to reimburse Rs.2,78,152/- (Rs.3,86,860-1,08,708/-) to the complainant along with interest @12% p.a. w.e.f. 30.6.2016 till payment. The Opposite Party No.4 is further directed to pay compensation of Rs.50,000/- for causing mental torture and harassment to the complainant by way of their casual approach and undue delay in settlement of claim, also with litigation cost of Rs.10,000/-, within a period of 30 days from the date of receipt of copy of this order.}

^{12] However, the complaint qua Opposite Party No.1,2, 3 & 5 stands dismissed”.}

2. ^{In brief, the facts of the case, are that the complainant retired from post of Chief Engineer from Irrigation Department, Punjab at Chandigarh. It was averred that on 20.10.2015, the Opposite Party No.3 introduced a cashless Health Insurance Scheme referred as Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) made applicable to all the government serving employees and pensioners on compulsory basis. Accordingly, the complainant and his wife Smt.Pushpa Vashisht (now deceased) had cover of health insurance under cashless Health Insurance Scheme as notified by the Punjab Government on 20.10.2015. It was further submitted that on 26.6.2016, the wife of the complainant was got admitted in Ace Heart and Vascular Institute (OP No.5) at Mohali as an emergency case of facial and pedal edema and dyspnea on exertion class-III. It was further submitted that complainant’s wife was advised for Dual Chamber PPI by Opposite Party No.5 and accordingly, a pre-authorization have been sent by Opposite Party NO.5 to OPs No.1 to 4. It is also submitted that during the treatment, the Opposite Party No.5 carried out numerous tests of Mrs.Pushpa Vashisht, and discharged on 30.6.2016. However, at the time of discharge, the complainant had to make payment of the bill raised by Opposite Party No.5 to the tune of Rs.3,94,360/-. Thereafter, the complainant brought this matter to the notice of Opposite Parties No.1 to 4 and requested them to reimburse the said amount of Rs.3,94,360/-, but they did not settle the matter and kept on lingering it. It was further stated that the Opposite Parties were deficient, in rendering service, as also, indulged into unfair trade practice. When the grievance of the complainant was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the “Act” only), was filed.}

3. ^{Opposite Party No.1 did not turn up despite service of notice, hence it was ordered to be proceeded exparte vide order dated 9.11.2017.}

4. ^{OP No.2 (Irrigation works, Punjab) in its reply stated that Opposite Party No.3 notified the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover the indoor medical treatment expenses for the period from 1.1.2016 to 31.11.2016 and selected Oriental Insurance Company, Chandigarh for insuring and providing cashless health insurance scheme to employees & pensioners of Punjab vide notification dated 20.5.2015 (Annexure C-2). It was further stated that the complainant had filed Medical Reimbursement Bill with Opposite Party NO.4, which were returned on 7.2.2017 (Ann.C-2) with remarks that as per PGEPHIS notified by Punjab Government, he may take up the matter with insurance company and as such, the claim of the complainant cannot be settled by Opposite Party No.4. Pleading no deficiency in service and denying other allegations, Opposite Party No.2 prayed for dismissal of the complaint qua it.}

5. ^{Opposite Party No.3, in its written version has stated that the complainant being pensioner of Punjab Government was covered under the Punjab Government Employees & Pensioners Health Insurance Scheme formulated by the Govt. of Punjab vide notification dated 20.10.2015 (Ann.R-3/1). It was stated that the claim for Medical Reimbursement for the employees/ pensioners was to be settled by the Insurance company i.e. Oriental Insurance Company and the policy started from 1.1.2016 ended on 31.12.2016. It was further submitted that Opposite Party No.3 never received any communication or representation about his claim from the complainant nor it gave any assurance to the complainant. Other allegations have been denied for want of knowledge with a prayer to dismiss the complaint qua Opposite Party No.3.}

6. ^{In its written statement, OP No.4 (Oriental Insurance Company) while admitting the factual matrix of the case, stated that no claim was ever been received from the complainant and even from pleading, it appears that the so called beneficiary was not enrolled himself in the scheme. It was further submitted that the complainant did not follow the procedure under the policy nor applied to M/s MD India TPA Limited in this regard. It was also stated that no enrolment proof or e-card was placed along with the complaint so as to enable the OPs to look into the matter and in the absence of the same, as well as no claim form etc. submitted along with requisite information and document, the Opposite Party was not in a position to either look into the matter or get the claim processed as per the procedure in terms of Memorandum of Understanding/policy of insurance. It was further stated that if at all any claim was found payable by the Forum on merit, it would be strictly as per terms, conditions and exceptions of MOU/Policy of Insurance, but it denied its liability. Pleading no deficiency in service and denying rest of the allegations, Opposite Party No.4 prayed for dismissal of the complaint.}

7. ^{Opposite Party No.5 (Ace Heart and Vascular Institute) also filed reply and admitted the factual matrix of the case about giving treatment to the wife of complainant and payment so made by the complainant for the said treatment. It was submitted that the request for pre-authorization was sent by Opposite Party No.5 to MD India Health Insurance TPA Private Limited about the said treatment. It was also stated that the wife of the complainant was discharged from the Hospital on 30.6.2016 in an absolutely normal condition. Other allegations have been denied being not related and it was prayed that the complaint qua Opposite Party No.5 be dismissed.}

8. ^{The complainant filed replication thereby reiterating the averments made in the complaint.}

9. ^{The parties led evidence, in support of their case.}

10. ^{After hearing the Counsel for the parties and, on going through the evidence and record of the case, the District Forum, allowed the complaint, as stated above.}

11. ^{Feeling aggrieved, the instant appeal, has been filed by the appellant/OP No.4-Insurance Company for setting aside the order passed by the District Forum.}

12. ^{We have heard the learned Counsel for the appellant and have gone through the evidence and record of the case, carefully.}

13. ^{The Counsel for the appellant/OP No.4 has submitted that the Forum has not even referred to the notification dated 20.10.2015 issued by the Punjab Government under which the complainant made the claim. It was further submitted that it was mentioned in para 3 of the said notification that the PGEPHIS will ensure cashless all indoor medical treatment upto a sum of Rs.3 lacs per family per year on floater basis. It was further submitted that the charges on account of attendant room were not payable as per the terms and conditions of the Policy. It was submitted that they have paid the admissible amount of Rs.1,07,708/- as per the PHEPHIS schedule of rates. It was further submitted that the order of the Learned District Forum is liable to be set aside.}

14. ^{Keeping in view the submissions of the counsel for the appellant/OP No.4, the only question to be determined in this case is as to whether the District Forum has rightly allowed the complaint by directing the insurance company to reimburse Rs.2,78,152/- (Rs.3,86,860-1,08,708/-) to the complainant along with interest @12% p.a. w.e.f. 30.6.2016 till payment and to pay compensation of Rs.50,000/- on account of the mental torture and harassment to the complainant by way of their casual approach and undue delay in settlement of claim besides Rs.10,000/- as litigation expenses. The answer to this question is in the affirmative. The perusal of the record shows that the wife of the complainant Smt.Pushpa Vashisht, who was covered under the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) (supra), fell sick on 26.6.2016 and admitted in Ace Heart and Vascular Institute, Sector 69, Mohali, with disease facial and pedal edema and dyspnea on exertion class-III and after treatment, she was discharged on 30.6.2016 (Ann.C-3). The complainant incurred a sum of Rs.3,94,360/- on the treatment of his wife in the Ace Heart and Vascular Institute, Sector 69, Mohali, the detail of which was given in para 9 of the order under appeal. The scheme of Cashless Health Insurance for indoor treatment as notified by Government of Punjab is applicable to all the government serving employees and pensioners on compulsory basis. This scheme envisages Cashless Health Insurance over & above the fixed medical allowance payable to pensioners to meet out the day-to-day OPD expenses. As per the Notification No.21/28/12-5HB5/268, dated 20th October, 2015 (Ann.R-4/A) an agreement by way of Memorandum of Understanding (Ann.R-4/C) was executed between Ace Heart & Vascular Institute, Oriental Insurance Company Ltd and MD India Healthcare & Services TPA Pvt. Limited. The District Forum was right in observing that the terms & conditions of MOU between the Oriental Insurance Company and Ace Heart & Vascular Institute, clearly stipulate the coverage of medical expenses to the pensioners of Punjab Government for the treatment in Ace Heart & Vascular Institute.}

15. ^{As per the bill submitted by Ace Heart & Vascular Institute towards the treatment of Smt.Pushpa Vashisht for net payable amount of Rs.3,94,360/-, a sum of Rs.7500/- towards the attendant room charges were not payable as per the terms and conditions of the policy and rest of the amount i.e. Rs.3,86,860/- is legally permissible for payment under the policy. The District Forum has further rightly observed that the Oriental Insurance Company/OP No.4 initially in its reply refused to make any payment to the complainant, but during the pendency of this complaint, Opposite Party No.4 considered the claim and made the payment of Rs.1,08,708/- only to the complainant on 16.3.2018, which is not the end of the storey. Keeping in view the facts and circumstances of the case, we are of the considered view that the District Forum was right in concluding that the Oriental Insurance Company is bound under Memorandum of Understanding (Ann.R-4/C) to stand the bill for Rs.3,86,860/- of Ace Heart & Vascular Institute, regarding treatment of Smt.Pushpa Vashisht and accordingly it (OP No.4) was rightly held liable to pay the balance amount of Rs.2,78,152/- (Rs.3,86,860-1,08,708/- already paid on 16.3.2018) to the complainant along with interest @12% p.a. w.e.f. 30.6.2016 till payment. The District Forum has rightly awarded the compensation of Rs.50,000/- on account of the mental torture and harassment suffered by the complainant and Rs.10,000/- as litigation expenses.}

16. ^{In view of the reasoning given above by the District Forum, we do not find any force in the submissions made in the grounds of appeal and it is held that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any perversity, warranting the interference of this Commission.}

17. ^{For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.}

18. ^{Certified Copies of this order be sent to the parties, free of charge.}

19. ^{The file be consigned to Record Room, after compliance.}

^Pronounced.

^01.06.2018

^Sd/-

[JUSTICE JASBIR SINGH [RETD.]

PRESIDENT

sd/-

[DEV RAJ]

MEMBER

 

sd/-

^{[PADMA PANDEY]}

^MEMBER