Complainant Gurwinder Singh through the present complaint

filed U/s 12 of the Consumer Protection Act, 1986 (hereinafter called the Act)

has prayed for issuance of the necessary directions to the titled opposite parties

to pay Rs.75,770.51 on account of reimbursement of medical bills of his wife

and pay Rs.20,000/- on account of compensation for harassment and mental

agony alongwiith Rs.10,000/- as litigation expenses to him, in the interest of

justice, equity and fair play.

2.       The case of the complainant in brief is that he is a Punjab Govt. employee and is serving in Punjab Police as PHC No.1111/Gsp under the kind control of opposite party no.3. He being a Punjab Govt. employee was a member of Punjab Government Employees and Pensioners Health Insurance Scheme vide PPO No.41594 with ID card No.MD15-07508910709 which was valid from 01.01.2016 to 31.12.2016. He availed the services of opposite parties no.1 and 2, hence he is consumer of the opposite parties. In November 2016, Smt.Paramjit Kaur, his wife was suffering from Cholelithiasis c Choledocholithiasis c Acute Pancreatitis c Septicemiaa disease and she was admitted at Arora Hospital, B.S.F. Road, Near Railway Station, Gurdaspur on 24.11.2016 and he got the treatment of his wife from there from 24.11.2016 to 27.11.2016 and and he spent Rs.75,770.51 on his wife treatment from his own pocket. He applied to the opposite party no.1 on 15.3.2017 alongwith all the documents, medical bills of the said hospital and completed all the required formalities for the reimbursement of the amount of Rs.75,770.51 but the same has been returned to him by making the objection by the opposite party that the reimbursement of the medical bills should be submitted in their office within 30 days from the discharge from the hospital. He had requested the opposite parties so many times to make the reimbursement of his medical bills as he is the only bread earner of his family but they refused to do so. By not admitting his claim, it is clear cut deficiency in service on the part of the opposite parties. Hence this complaint.

3.       Upon notice the opposite party no. 1 appeared and filed its written reply through its counsel taking the preliminary objection that the complaint of the complainant against opposite party is not maintainable; the present complaint is bad for non-joinder and mis-joinder of necessary parties. On merits, it was admitted that the complainant had applied to the opposite party on 15.3.2017 alongwith documents and medical bills etc. for the reimbursement of the amount of Rs.75,770-51p. The claim of the complainant was not admitted by opposite party with the objection that the reimbursement of the medical bills should be submitted in the office of the opposite party within 30 days from the  date of discharge from the hospital, which is the mandatory condition under the terms and conditions of the Punjab Govt. Employees and Pensioners Health insurance Scheme (PGEHIS). Hence the MD India Health Insurance TPA Pvt.Lld. has rightly not entertained the claim under the terms and conditions of the PHEHIS. Hence, the opposite party is not liable to pay the claim under the provisions of the scheme. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.      Upon notice the opposite party no. 2 appeared and filed its written reply through its counsel taking the preliminary objection that the complaint of the complainant is not maintainable. On merits, it was admitted that the wife of the complainant was admitted in Arora Hospital from 24.11.2016 to 27.11.2016. The complainant spent Rs.75,770.51 on the treatment of his wife namely Paramjit Kaur who was suffering from Cholelithiasis c Choledocholithiasis c Acute Pancreatitis c Septicemiaa disease and she  remained  admitted  with opposite party as per the record of the opposite party. To this effect the original bills of Arora Clinic Laboratory, Arora Diagnostic  Centre, Arora Hospital and medicine bills of Arora Hospital Dispensary were given to the complainant. All other averments made in the complaint have been vehemently denied and lastly prayed that the complaint may be dismissed with costs.  alongwith the Discharge Card i.e. on  27.11.2016.

5.        Notice issued to the opposite party no.3 had not been received back. Case called several times, but none had come present on its behalf, therefore, it was proceeded against exparte vide order dated 23.10.2017

6.       Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 alongwith other documents Ex.C2 to Ex.C18 and closed the evidence.

7.       Counsel for the opposite party no.1 tendered into evidence affidavit of Mr.Md Samiyoddin Patel, Sr.Legal Manager Ex.OP1/1 and closed the evidence.

8.       Counsel for the opposite party no.2 tendered into evidence affidavit of Dr.Payal Arora, Doctor Incharge Ex.OP2/1 and closed the evidence.

9.     We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for the respective contestants. We find that the present dispute has arisen at the admitted but impugned ‘claim-refusal’ amounting to ‘repudiation’ Ex.C18 by the OP1 TPA (Third Party Administrator) for reimbursement of hospitalization expenses of the insured-patient wife of the complainant pertaining to the PGEPHIS Med-claim Policy (facilitating cash-less medical-aid and treatment to the Punjab Govt. Employees at the Govt. Hospitals/Network Hospitals and reimbursement @ Govt./Network Hospital Rates of medical expenses incurred at other than Govt./ Network Hospitals) on the arbitrary grounds of delayed submission of the same I.e., not within 30 days of the date of discharge from the treating hospital.

10.     We find that the titled opposite party TPA insurers (hereinafter for short ‘the OP1 TPA insurers’) have duly admitted the receipt-refusal/ repudiation through their written statement and accompanying lone affidavit (Ex.OP1/1) on the grounds as mentioned out above as per the paragraph ‘1’ of the written statement being allegedly in contravention of the terms of the Policy etc with no other independent/cogent evidence of the same; and that surely indicates that the ‘claim’ has been repudiated on flimsy grounds for collateral reasons. Firstly, the TPA cannot legally repudiate/settle a mediclaim on its own; it can simply put forth its recommendatory opinion for consideration by the OP insurers while deciding the same. The OP insurers are desired to settle the claim per the overall evidence available on cogent grounds and not on the hearsay conjectures and presumptions. The requisite documents are duly available on the records of the present proceedings and could also have been easily procured by the OP1 TPA from the OP2 Hospital that has not been on its network Hospitals List.    

11.     We observe that the complainant has sufficiently and satisfactorily proved the contents of his allegation-contented complaint vide his deposition (affidavit Ex.C1) and other evidentiary documents exhibited here as: Ex.C2 to Ex.C18. The OP1 TPA Insurers/service providers have somehow admitted the principal facts and have deposed its other contentions vide its lone Affidavit Ex.OP1/1 but have somehow not produced any other cogent evidence in support of the bald rebuttals that however fail to prove/establish the main pleading of delayed submission of the requisitioned documents. The OP’s other plea of non-existence of an ‘insurance contract’ with the complainant does not hold water, either. We find that the OP1 TPA requisitioned documents have been available on the present proceedings records but the OP insurers did not opt to settle the impugned claim even during the pendency of the complaint to prove its bonafide whereas the complainant being a ‘beneficiary’ to the insurance cover (qua the applicable policy) shall be held to be the statutory consumer even in absence of an express insurance contract.        

12.     We find that the instant impugned claim receipt-refusal/repudiation has not been in resonance with the contracted terms of the Policy that have not even been proved to have been dispatched by OP1 TPA and/or received by present complainant and as such he shall be entitled to statutory relief. Lastly, we set aside the impugned closure/repudiation in favor of the complainant for a fresher settlement.                                                   

13.     Finally, we partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ in full pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.                                

14.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                                                                       (Naveen Puri)

    President.      

ANNOUNCED:                                    (Jagdeep Kaur)

July 25, 2018.                                         Member.                                  

*MK*