DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/185.

Date of Institution   : 12.03.2018/29.11.2021.

Date of Decision    : 01.08.2022.

Narinder Kaur wife of Sh. Shivraj Singh Aulakh Age 60 years, resident of 17-B, Sandhu Avenue, G.T. Road, Chheherta, Amritsar.   

                …Complainant Versus

1.The Oriental Insurance Company Ltd., O/o Oriental House 7th Floor, 7 Jamsheji Tata Road, Churchgate, Mumbai 400020 India through its Manager/Principle Officer/Authorized Person. 

2.M.D. India, Health Care Service Pvt. Ltd. O/o Maxpro Park, D-38, 1st Floor, Industrial, Phase-1 Mohali through its Manager/Principle Officer/Incharge.

3.Nayyar Heart Institute and Super Specialty Hospital, Amritsar through its Administration Officer/Incharge.   

                 …Opposite Parties

 

Complaint Under Section 12 & 13 of the Consumer Protection Act, 1986. 

 

Present: Sh. B.S. Rajput Adv counsel for complainant.

Sh. Sandeep Khanna Adv counsel for opposite party No. 1.

Sh. Vipan Bhasin Adv counsel for opposite party No. 3.

Opposite party No. 2 exparte.

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Smt. Urmila Kumari : Member

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986,  against The Oriental Insurance Company Ltd., and others (hereinafter referred as opposite parties).

2. Brief facts of the case are that the complainant is a retired teacher from Government High School, Chawinda Kalan, Amritsar and the Punjab Government contract with the Oriental Insurance Company Limited i.e. opposite party No. 1 alongwith M.D. India Health Care Services Pvt. Ltd., the opposite party No. 2 for the medical insurance policy for the employee of the Punjab Government and dependent of the employee and the said policy was valid from 1.1.2016 to 31.12.2016. It is further alleged that Punjab Government employee and Pensioners health insurance scheme (PGEPHIS) issued I.D. Card to the complainant vide I.D. Card No. MDIS 09781300739 and GPF No. 60 by the opposite party No. 1. It is further alleged that the complainant was suffering from heart decease and the complainant got the treatment from Nayyar Heart Institute & Super Specialty Hospital, Amritsar as a case of CAD/SVD/ANT WALL MI/LVDF for the period from 4.10.2016 to 6.10.2016 and on her treatment the complainant spent Rs. 2,20,004.44/- and the complainant herself paid the entire amount to the hospital. On 18.10.2016 the complainant submitted the medical bill duly verified by the doctor concerned of Nayyar Heart Institute and Super Specialty Hospital, Amritsar through speed post to the M.D. India, Health Care Service Pvt. Ltd, Maxpro Park, D-38, 1st Floor, Industrial Area, Phase-1, Mohali. The complainant had paid all the expenses during hospitalization for the period of 4.10.2016 to 6.10.2016. The complainant visited the office of opposite parties No. 1 & 2 many times and requested them regarding settlement of claim but the opposite party No. 2 did not pay any heed to the genuine requests of the complainant and always gave answer  “your claim is under process” and the complainant also registered a complaint No. 564368 with the opposite parties. But the opposite parties every time demanded documents from the complainant which the complainant had already given to them. Due to the above said act of the opposite parties the complainant suffered mental agony and harassment which amounts to deficiency in service and unfair trade practice on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay the amount of Rs. 2,20,004.44/- as expenses incurred by the complainant during hospitalization as per medical bills.  

ii)To pay Rs. 70,000/- on account of compensation and Rs. 9,500/- as litigation expenses.  

3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version by taking preliminary objections interalia on the ground that the present claim has been settled in the light of Notification No. 21/28/12-5HB5/268 dated 20.10.2015 and as per Para No. 4 of the said notification “The treatment can be taken by any enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). No reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. However, reimbursement can be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances. In such circumstances, the insurance company will reimburse the bill of the employee up to Rs. 3.00 lacs as per the package rates defined under the scheme”. It is further alleged that the claim in question was approved by the competent authority of the opposite party No. 1 as per the terms and conditions of the policy and in accordance with approved schedule of rates for an amount of Rs. 1,61,254/- (PTCA-CODE 992 and CAG-CODE 974) and the said amount was duly credited in the account of the complainant on 30.1.2017 vide UTR No. 4441U17030428721, as such the present complaint has become infructuous on account of payment of the approved amount qua the claim in question. The complainant has not approached the Forum/Commission with clean hands. On merits, the opposite party No. 1 denied the case of the complainant and prayed for the dismissal of complaint. 

4. Notice was sent to the opposite party No. 2 but none has appeared on behalf of opposite party No. 2, as such vide order dated 9.5.2018 the opposite party No. 2 was proceeded against exparte.

5. In reply the opposite party No. 3 has raised preliminary objections on the grounds of maintainability, no cause of action etc. On merits, it is admitted to the extent that the bill raised by the answering opposite party and verifying the same on account of expenditure incurred by complainant. All other allegations are denied by the opposite party No. 3 and prayed for the dismissal of complaint.

6. In order to prove her case the complainant tendered into evidence her own affidavit Ex.CW1/A, copy of pension payment order Ex.C-1, copy of discharge summary Ex.C-2, copy of the bill Ex.C-3, copy of the patient discharge bill Ex.C-4, copy of the claim form Ex.C-5, copy of the essentiality certificate Ex.C-6, copy of the health insurance card Ex.C-7 and closed the evidence. 

7. To rebut the case of the complainant the opposite party No. 1 tendered into evidence affidavit of Sh. O.P. Dhawan, Divisional Manager Ex.O.P1/1, attested copy of insurance policy Ex.O.P1/2, attested copy of notification Ex.O.P1/3, attested copy of PGEPHIS schedule of rates of containing 4 pages Ex.O.P1/4, copy of recommendation of TPA Ex.O.P1/5 and closed the evidence. 

8. To rebut the case of the complainant the opposite party No. 3 filed an affidavit of Dr. Shashi Nayyer Ex.O.P3/A. 

9. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. 

10. Ld. Counsel for the complainant argued that the complainant is a retired teacher from Government High School, Chawinda Kalan, Amritsar and the Punjab Government contract with the Oriental Insurance Company Limited i.e. opposite party No. 1 alongwith M.D. India Health Care Services Pvt. Ltd., the opposite party No. 2 for the medical insurance policy for the employee of the Punjab Government and dependent of the employee and the said policy was valid from 1.1.2016 to 31.12.2016. It is further argued that Punjab Government issued I.D. Card to the complainant No. MDIS 09781300739 Ex.C-5. Ld. Counsel for complainant further argued that the complainant was suffering from heart decease and got the treatment from Nayyar Heart Institute & Super Specialty Hospital, Amritsar as a case of CAD/SVD/ANT WALL MI/LVDF for the period from 4.10.2016 to 6.10.2016 Ex.C-2 and on her treatment the complainant spent Rs. 2,20,004.44/- Ex.C-4 and the complainant herself paid the entire amount to the hospital. It is further argued that on 18.10.2016 the complainant submitted the medical bill duly verified by the doctor concerned of Nayyar Heart Institute and Super Specialty Hospital, Amritsar through speed post to the M.D. India, Health Care Service Pvt. Ltd, Maxpro Park, D-38, 1st Floor, Industrial Area, Phase-1, Mohali and the complainant visited the office of opposite parties No. 1 & 2 many times and requested them regarding settlement of claim but the opposite party No. 2 did not pay any heed to the genuine requests of the complainant. 

11. On the other hand, Ld. Counsel for opposite party No. 1 argued that the claim has been settled in the light of Notification No. 21/28/12-5HB5/268 dated 20.10.2015 Ex.O.P1/3 and as per Clause No. 4 of the said notification. However, reimbursement can be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances and in such circumstances, the insurance company will reimburse the bill of the employee up to Rs. 3.00 lacs as per the package rates defined under the scheme. It is further argued that the claim in question was approved by the competent authority of the opposite party No. 1 as per the terms and conditions of the policy and in accordance with approved schedule of rates for an amount of Rs. 1,61,254/- (PTCA-CODE 992 and CAG-CODE 974) and the said amount was duly credited in the account of the complainant on 30.1.2017 vide UTR No. 4441U17030428721 Ex.O.P1/5 and as such the present complaint has become infructuous on account of payment of the approved amount qua the claim in question.

12. On the perusal of copy of the recommendation of TPA  (Claim File-Non Cashless) Ex.O.P1/5 it is proved that the insurance company has credited an amount of Rs. 1,61,254/- (i.e. 2nd Stent Rs. 52,000/- + PTCA (Code 992) Rs. 1,05624/- + CAG (Code 974) 50% of 2nd Package Rs. 3,630/-)  in the account of the complainant on 30.1.2017 vide UTR No. 4441U17030428721. The opposite party No. 1 in support of its version has also produced copy of PGEPHIS schedule of rates containing 4 pages Ex.O.P1/4. But the complainant has failed to rebut the above said documents Ex.O.P1/4 and Ex.O.P1/5 by bringing on record any cogent evidence. The complainant has also failed to prove on record that the above said amount of Rs. 1,61,254/- has not been credited in the account of complainant as alleged by the opposite party No. 1 vide Ex.O.P1/5. Therefore, the complainant has failed to prove any deficiency in service on the part of opposite parties. 

13. In view of the above discussion, the present complaint is dismissed. Copy of the order will be supplied to the parties free of costs by the District Consumer Commission, Amritsar as per rules.  File be sent back to District Consumer Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

       1st Day of August, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Urmila Kumari)

Member