Order by:

Sh.Amrinder Singh Sidhu, President

1.       The complainant  has filed the instant complaint under section 35 of Consumer Protection Act, 2019 on the allegations that the Complainant purchased Happy Family Floater-2015, Silver Plan Policy bearing No.233904/48/2020/422 in continuation of previous policy bearing No.233904/48/2019/507 from the Opposite Parties which was valid for the period w.e.f. 14.01.2020 to Midnight of 13.01.2021 for himself as well as  for her wife Smt.Rashmi Singhal  having sum insured of Rs. 3 lakhs against the payment of premium of Rs.18846/-. This is the continuous policy of previous policy bearing No.233904/48/2019/507 as mentioned above  and the Complainant has been purchasing this policy from the Opposite Parties since 14.01.2016  continuously and paid a hefty amount to the Opposite Parties on account of premiums till date.  Further alleges that  during the continuation of the previous policy, Sh.Avnish Gulati, Development Officer of the Opposite Parties approached the Complainant and advised that that there is some other best policy which also covers Corona namely Corona Kavach Policy and on the allurement of the official of the Opposite Parties, the Complainant also purchased Corona Kavach Policy-Oriental Insurance Family Floater Plan bearing No.233904/48/2021/284 valid for the period w.e.f. 28.07.2020 to 08.05.2021 for himself as well as  for her wife Smt.Rashmi Singhal  having sum insured of Rs. 5 lakhs against the additional payment of premium of Rs.3089/-. In this policy, the treatment of Corona Disease was also included. Unfortunately, during the policy period, the Complainant  fell ill  due to Viral Pneumonia and was diagnosed with diseases of Covid-19 Positive and admitted in Garg Hospital, Moga on 16.09.2020 where he remained admitted upto 17.09.2020, but the Complainant did not improve and thereafter shifted to SPS Hospital, Ludhiana where he remained admitted in that hospital from 17.09.2020 to 28.09.2020 and the Complainant was discharged on 28.09.2020. In both the hospitals, the Complainant spent Rs.3,55,934/- besides other expenses.   After discharge from the hospital, the Complainant lodged the claim with the Opposite Parties under the policy in question for the reimbursement of his claim on 23.10.2020 and also completed all the formalities and submitted the requisite documents to the Opposite Parties as per their requirement and at that time, the officials of the Opposite Parties also took the bank account of the Complainant for making the claim amount. The Opposite Parties thoroughly gone through the claim of the Complainant and admitted the claim of the Complainant. Out of this, amount, the Opposite Parties directly paid Rs.1,19,480/- to  hospitals and an amount of Rs.56,661/- has been directly credited in the account of the Complainant  against the balance amount of Rs.1,79,793/- without the consent of the Complainant. Thereafter, the Complainant approached the office of the Opposite Parties to know the reason for retaining the remaining amount of the claim amount, but the officials of the Opposite Parties kept mum and did not disclose any reason for retaining the remaining genuine claim of the Complainant.  In this way, said conduct of the Opposite Parties clearly amounts to deficiency in service and as such, the Complainant is left with no other alternative but to file the present complaint.  Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to reimburse the remaining medical claim of the complainant amounting to Rs.1,79,793/- bill alongwith future interest  @ 18 % per annum from the date of discharge from the hospitals till its actual realization.

 b)     The amount of Rs.2 lakhs be allowed to be paid by the opposite parties on account of compensation for mental tension and harassment caused by the complainant.

c)       The cost of complaint amounting to Rs.31,000/- may please be allowed.

d)      And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Parties No.1 and 2   appeared through counsel and contested the complaint by filing  the written version  on the ground inter alia that the complaint is not maintainable; that there is no deficiency in service on the part of the Opposite Party and that the complaint is absolutely false and frivolous.  It is submitted that both the claims of the complainant  i.e. claim No.OICCH1/27110 and Claim No.OICCH1/27587 under the policy in question  were fully settled as per the order of Government of Punjab, Department of Health & Family Welfare (Health-IV Branch) vide No.COVID-19/NHM/2020/4HB4/205 dated 16.07.2020. Admittedly, the complainant has lodged two claims i.e. Claim No.OICCH1/27110 and claimed Rs.2,51,759/- and out of which, the amount of Rs.1,32,279/- has been disallowed  which was over and above the packages rates as per Punjab Government for Covid-19. The detail of which is the grant amount of Rs.1,19,480/- and payable amount is Rs.1,10,519/- (After 7.5% TDS=8961/- and said amount was transferred to the account of the hospital. Similarly, the complainant lodged another claim No.OICCJ1/27587/- vide which the complainant claimed the amount of Rs.2,36,454/- and as per the Punjab Government instructions, the  amount of Rs.1,79,793/- has been disallowed (i.e. Rs.2500/- one day excess daily cash benefit+ Rs.1,32,278/- over and above Covid package paid at the time of discharge in cashless + Rs.950/- Instami Inhaler + Rs.44,065/- over and above Punjab Government Covid Package).  In this way, the grant amount  was Rs.56,661/-  and said amount was transferred to the account of the complainant through NEFT and in this way, both the claims were settled as per the orders of Government of Punjab. Hence, there is no deficiency in service on the part of the Opposite Parties.   On merits, Opposite Parties No.1 and 2 took up almost the same and similar pleas as taken up by them in the preliminary objections.  Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint was made.

3.       None has come present on behalf of Opposite Party No.3 and hence, Opposite Party No.3 was proceeded against exparte.

4.       In order to  prove  his  case, the complainant has tendered into evidence his affidavit Ex.C1  alongwith copies of documents Ex.C2 to Ex.C85, additional affidavit of the complainant Ex.C86 and closed his evidence.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties No.1 and 2  tendered into evidence affidavit of Sh.Sukhwinder Singh Ex.OP1,2/1 alongwith copies of documents Ex.OP1,2/2 to Ex.OP1,2/111 and closed the evidence on behalf of Opposite Parties No.1 and 2.

6.       We have heard the ld.counsel for the parties and  gone through the documents placed  on record.

7.       During the course of arguments, ld.counsel for the Complainant as well as Opposite Parties have mainly reiterated the facts as narrated in the complaint as well as in the written statements respectively. We have perused the rival contentions of  the parties and also gone through the record on file. The main contention of the ld.counsel for the complainant is that after discharge from the hospital, the complainant lodged the claim with the Opposite Parties under the policy for the reimbursement of the medical expenses, but the Opposite Parties paid part payment and retained the balance amount without any reason and in this way, there is deficiency in service on the part of the Opposite Parties. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that both the claims of the complainant  i.e. claim No.OICCH1/27110 and Claim No.OICCH1/27587 under the policy in question  were fully settled as per the order of Government of Punjab, Department of Health & Family Welfare (Health-IV Branch) vide No.COVID-19/NHM/2020/4HB4/205 dated 16.07.2020. Admittedly, the complainant has lodged two claims i.e. Claim No.OICCH1/27110 and claimed Rs.2,51,759/- and out of which, the amount of Rs.1,32,279/- has been disallowed  which was over and above the packages rates as per Punjab Government for Covid-19. The detail of which is the grant amount of Rs.1,19,480/- and payable amount is Rs.1,10,519/- (After 7.5% TDS=8961/- and said amount was transferred to the account of the hospital. Similarly, the complainant lodged another claim No.OICCJ1/27587/- vide which the complainant claimed the amount of Rs.2,36,454/- and as per the Punjab Government instructions, the  amount of Rs.1,79,793/- has been disallowed (i.e. Rs.2500/- one day excess daily cash benefit+ Rs.1,32,278/- over and above Covid package paid at the time of discharge in cashless + Rs.950/- Instami Inhaler + Rs.44,065/- over and above Punjab Government Covid Package).  In this way, the grant amount  was Rs.56,661/-  and said amount was transferred to the account of the complainant through NEFT and in this way, both the claims were settled as per the orders of Government of Punjab and  hence there is no deficiency in service on the part of the Opposite Parties. Admittedly, the complainant was insured with the Opposite Parties for sum assured of Rs.5 lakhs and the said policy was Corona Kavach Policy-Oriental Insurance Family Floater Plan, copy of which is placed on record as Ex.OP1,2/2. It is also not disputed that the complainant lodged two claims i.e.  Claim No.OICCH1/27110 claiming Rs.2,51,759/- and  another claim No.OICCJ1/27587/- vide which the complainant claimed the amount of Rs.2,36,454/- and both the claims have been settled by the Opposite Parties by deducting the amount as per the Punjab Government Instructions. As per Government of Punjab, Department of Health & Family Welfare (Health –IV Branch) vide order No. COVID-19/MHM/2020/4HB4/205 dated 16.07.20120, the copy of which is placed on record as Ex.OP1,2/3 the complainant has duly been paid the amount as per the Treatment charges for Covid-19 Patients’ availing treatment at Private Hospitals/ Nursing Home/ Clinics and accordingly,  out of the first claim, amount of Rs.1,32,279/- has been disallowed  which was over and above the packages rates as per Punjab Government for Covid-19. The detail of which is the grant amount of Rs.1,19,480/- and payable amount is Rs.1,10,519/- (After 7.5% TDS=8961/- and said amount was transferred to the account of the hospital. Similarly, the complainant lodged another claim No.OICCJ1/27587/- vide which the complainant claimed the amount of Rs.2,36,454/- and as per the Punjab Government instructions, the  amount of Rs.1,79,793/- has been disallowed (i.e. Rs.2500/- one day excess daily cash benefit+ Rs.1,32,278/- over and above Covid package paid at the time of discharge in cashless + Rs.950/- Instami Inhaler + Rs.44,065/- over and above Punjab Government Covid Package).  In this way, the grant amount  was Rs.56,661/-  and said amount was transferred to the account of the complainant.  On the other hand, the complainant has neither denied these payments of the medical expenses made to him by the Opposite Parties under the policy, nor  ever challenged or rebutted the  calculation made by the Opposite Parties  with regard to payment as per the Punjab Government Order. As such, we hold that there is no deficiency in service on the part of the Opposite Parties and the Opposite Parties have rightly made the payment to the complainant as per the instructions of Government of Punjab, Department of Health & Family Welfare (Health –IV Branch) vide order No. COVID-19/MHM/2020/4HB4/205 dated 16.07.20120 (Ex.OP1,2/3). 

8.       In view of the aforesaid facts and circumstances of the case, we found no deficiency in service on the part of the Opposite Parties and hence, the instant complaint stands dismissed.  Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

Announced in Open Commission.