PER:

Charanjit Singh, President;

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section  11 and 12 against the opposite parties on the allegations that the complainant is a retired pensioner from the Punjab Govt. having GPF/PPO No. 219035 PB. The opposite party No.1 floated a scheme as Punjab Govt. Employee and Pensioners Health Insurance Scheme and under the said scheme the complainant obtained health insurance policy under which the complainant and his wife were insured with the opposite party No. 1 under policy valid from 1.1.2016 to 31.12.2016 and in this regard ID Card NO. MD15-09814840920 was issued to the complainant. During the currency period of the said insurance policy, Smt. Pushpa Kumari wife of complainant fell ill due to cancer disease and she remained under treatment at Nayyar Hospital, Amritsar as well as Rajiv Gandhi Cancer and Research Institute, Rohni, New Delhi and ultimately, she died due to her cancer disease on 9.9.2016. In this regard, the complainant submitted bills of Rs. 6,18,090/-, Rs. 1,05,738/- and Rs. 87,400/- respectively total Rs. 8,11,228/- on 23.12.2016 vide receipt No. 45941 and the same were submitted to the opposite party No. 2 being TPA. The complainant was assured that the amount of bills will be settled and reimbursed to his bank account very soon, however, the complainant in the month of March 2017, checked his bank account from where it came to notice of complainant that only a payment of Rs. 1,60,564/- was transferred to the account of complainant on 6.1.2017 and further payments of Rs. 20,369/- and Rs. 38,248/- were transferred in the account of the complainant on 16.1.2017 total of which comes to Rs. 2,19,181/- only. After that the complainant approached the opposite parties time and again but no satisfactory reply was given and the balance payment of the bills has not been reimbursed to the complainant so far. Even the complainant sent the registered letter dated 13.3.2017 but no response was given and again the complainant wrote a letter dated 9.4.2017 which was duly received by the opposite party under their seal, but even then neither the payment of remaining amount of treatment bills of wife of the complainant is reimbursed to the complainant nor any reply to the said letters is given. Even the complainant through his counsel served a legal notice dated 30.8.2017 upon the opposite parties, but they have neither made any reply to the said notice nor complied with the said notice so far. As per the insurance policy, the complainant is entitled to full payment of the bills of treatment of his wife but the said amount is not released/ reimbursing the remaining amount of treatment bills of the complainant and withholding the said payment is wrong, illegal and unlawful. The complainant has prays as under:-

(i)      The opposite party may kindly be directed to immediately release the payment of balance amount of claim treatment bills of the wife of complainant to the tune of Rs. 5,92,047/- alongwith interest thereon @ 18% per annum from the date of submission of bills i.e. 23.12.2016 up to date of payment

(ii)     The opposite party may be directed to pay sum of Rs. 50,000/- as compensation to the complainant for the mental pain, agony, harassment and inconvenience and financial losses suffered by him at the hands of then opposite parties due to their said negligence, deficiency

(iii)    The complainant may also be awarded Rs. 5000/- as litigation expenses and Rs. 22000/- as counsel fee for the present litigation against the opposite parties.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not legally maintainable as the complainant has not placed on record any cogent and convincing material supported with documentary evidence in order to substantiate the pleas as alleged in the complaint much less the relief sought is available to the complainant on the basis of vague and ambiguous pleas without any basis and on the basis of false and frivolous documents and as such, the present complaint merits dismissal on this simple score only.  The complainant has not come to this commission with clean hands and has concealed the material facts from this commission and as such, the present complaint merits dismissal on this simple score only. Infact, the opposite party No. 2 has already settled the claim of the complainant as the payable amount was to the tune of Rs. 2,19,181/- which was paid under PGEPHIS Rates as per terms and as such, it cannot be attributed that there is any lapse shortcomings and any deficiency in service on the part of the replying opposite parties and even otherwise, the complainant and even the said scheme only ensures cashless all indoor medical treatment, pre and post hospitalization specified as defined, Day care procedures, (requiring less than 24 Hours hospitalization) and OPD medical expenses relating to chronic disease up to a sum of Rs. 3 Lacs per family per year. Even in such like controversy, the Hon’ble Punjab State Commission has already granted stay order in favour of opposite parties. The present complaint is an abuse of process of court and is simply filed just with a view to get wrongful gain and to cause wrongful loss to the opposite parties and as such, the present complaint merits dismissal on this simple score only.  No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant. The present complaint is bad for mis-joinder of necessary parties as the opposite parties have been unnecessarily impleaded without any cause of action and even otherwise keeping in view the facts and circumstances of the case, no liability can be fastened upon the replying opposite parties and as such, the present complaint merits dismissal on this simple score only. Infact, the complainant has not obtained any insurance policy personally from the insurance company but the policy in question has been obtained by the Punjab Govt. under Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) but the complainant has not made the State of Punjab as party to the present complaint. In the absence of necessary parties i.e. State of Punjab , the complainant alone has no cause of action to file the present complaint nor he is covered under the definition of Consumer. Even the Government of Punjab as per notification dated 21.9.2016 has constituted Grievance Committees as well as at State Level committee  to redress grievance of the beneficiaries and other stakeholders and from this notification, it is clear that the complainant has the legal remedy to approach the District Level as well as State Level Committee for redressal of his grievance and once he has not availed of this legal remedy, the present complaint is not maintainable and deserves outright dismissal. In the light of preliminary objections as stated above, it is apparent that there is no deficiency in service on the part of the opposite party No. 1 and as such, claim of compensation, claim amount as well as interest is not payable under the provisions of Consumer Protection Act and the opposite parties are liable to be deleted from the array of opposite parties and the opposite parties have denied the other contents of the complaint and prayed for dismissal of the same.

4        To prove his case, the complainant has placed on record affidavit of complainant Ex. C-1 alongwith documents Ex. C-2 to Ex. C-120 and closed the evidence of the complainant. On the other hands, Ld. counsel for the opposite parties has tendered in evidence affidavit of Sh. R.K. Sharma Divisional manager Ex. OPs, 1,2/1, copy of notifications dated 20.10.2015 Ex. OPs 1,2/2, copies of Claim status Ex. OPs 1, 2/3, Copies of notifications dated 21.9.2016 Ex. OPs 1, 2/4, Ex. OPs. 1,2/5, copy of PGEPHIS schedule of rates Ex. OPs 1,2/6.

5        We have heard the Ld. counsel for the parties and have gone through the record on the file.

6        Ld. counsel for the parties have mainly reiterated the facts as narrated in the complaint as well as in written versions respectively and we have gone through the rival contentions of the parties. In the present case insurance is not disputed as after admitting the insurance the opposite parties have made the payment of Rs. 1,60,564/- on 6.1.2017, Rs. 20,369/- and Rs. 38,248/ on 16.1.2017 totaling Rs. 2,19,181/-.  Smt. Pushpa Kumari wife of complainant fell ill due to cancer disease and she remained under treatment at Nayyar Hospital, Amritsar as well as Rajiv Gandhi Cancer and Research Institute, Rohni, New Delhi and ultimately, she died due to cancer disease on 9.9.2016. In this regard, the complainant submitted bills of Rs. 6,18,090/-, Rs. 1,05,738/- and Rs. 87,400/- respectively total Rs. 8,11,228/- on 23.12.2016 vide receipt No. 45941 and the same were submitted to the opposite party No. 2 being TPA. It is case of the complainant that the opposite party has made the payment of Rs. 2,19,181/- however, the complainant is entitled to Rs. 8,11,228/-. On the other hands, the case of the opposite parties is that the opposite party No. 2 has already settled the claim of the complainant as the payable amount was to the tune of Rs. 2,19,181/- which was paid under PGEPHIS Rates as per terms.

7        In the present case, it is not disputed that the wife of the complainant namely Smt. Pushpa Kumari fell ill due to cancer disease and she remained under treatment at Nayyar Hospital Amritsar as well as Rajiv Gandhi Cancer and Research Institute, Rohini, New Delhi.  After admitting the insurance and the opposite parties have made the payment of Rs. 1,60,564/- on 6.1.2017, Rs. 20,369/- and Rs. 38,248/- on 16.1.2017 total of which comes to Rs. 2,19,181/-.  The case of the complainant is that he deposited the bill to the tune of Rs.8,11,228/- and opposite party has made the payment of Rs. 2,19,181/- only and the complainant is entitled to Rs. 5,92,047/- from the opposite parties.  Now question arises in this case that the complainant is entitled to Rs. 5,92,047/- from the opposite parties or not. The opposite party has placed on record notification dated 20.10.2015 in which it is clearly written that the scheme will ensure cashless all indoor medical, treatment Pre and Post hospitalization specified as defined. Day Care procedures (requiring less than 24 hours hospitalization) and OPD medical expenses relating to chronic disease up to a sum of Rs. 3.00 Lac per family per year on floater basis. As such, as per this notification insurance is up to Rs. 3.00 Lacs. The opposite parties have made the payment of Rs. 2,19,181/- as per PGEPHIS rates which are applicable as per the terms and conditions of the present policy and in this regard opposite parties No. 2 has placed on record PGEPHIS schedule of rates Ex.OP1,2/6. The opposite parties have made the payment to the complainant as per PGEPHIS rates. In this regard reliance has been placed upon MD India Vs. Sushil Dhawan in First Appeal No. 870 of 2017 of the Hon’ble State Commission, Punjab Chandigarh wherein it has been held that the opposite parties have already paid the amount of Rs. 61,137/- according to PGEPHIS rate, therefore, in case the complainant has spent more amount than the admissible rates then he is required to pay from his own pocket because the Government cannot pay more than the rates fixed under PGEPHIS rates.

8        Further both the parties are bound by the terms and conditions of the policy. The terms and conditions of the Insurance Policy have to be strictly construed. Hon’ble Supreme Court in the case of Export Credit Guarantee Corporation of India vs. Garg Sons International 2013 (1) SCALE 410 (SC) held in Para Nos.8 to 11 as under:

“8.  It is a settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567). 

9.  The insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829). 

10.   In Vikram Greentech (I) Ltd. & Anr. v. New India   Assurance Co. Ltd. AIR 2009 SC 2493, it was held:  “An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. (See also: Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).” 

11.  Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.” 

9        The opposite parties have made the payment of Rs. 2,19,181/- as per PGEPHIS Schedule of Rates and there is no deficiency and unfair trade practice on the part of the opposite party.

10      In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. However, the complainant is at liberty to approach the District Level as well as State level Committee for redressal of his grievance, if any, as per law. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.

 Announced in Open Commission

14.07.2022