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

 

Complaint Case No : RBT/CC/2018/280

Date of Institution   : 10.04.2018/29.11.2021

Date of Decision    : 04.07.2022

1.Swarnjit Kaur wife of Sh. Jatinder Singh age 65 years resident of V.P.O. Nizampura, Tehsil and District Amritsar.

2.Jatinder Singh son of Sh. Ghasita Singh age 66 years resident of V.P.O. Nizampura, Tehsil and District Amritsar. (Mob. 9888645844).

               …Complainants Versus

1.The Oriental Insurance Company Limited, O/o Oriental House 7th Floor, 7 Jamshedji Tata Road, Churchgate, Mumbai 400020 India through its Manager/Principal Officer/ Authorized person.

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

3.Amandeep Hospital at Model Town, G.T.Road, Amritsar through its Administrative Officer/Incharge. 

              …Opposite Parties

Complaint Under Section 12 & 13 of Consumer Protection Act, 1986. As Amended Upto Date.

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

Sh. Subodh Salwan Adv counsel for O.Ps-1 & 2.

Sh. Vipan Bhasin Adv counsel for O.P-3.

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : 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 Dedressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against the Oriental Insurance Company Limited & others (hereinafter referred as opposite parties).

2. Brief facts of the case are that the complainant No. 1 is the wife of complainant No. 2 and the complainant No. 1 is retired from education department. It is alleged that the Punjab Government contract with the Oriental Insurance Company Limited alongwith MD India Health Care Service Pvt. Limited for the medical insurance policy for the pensioner of the Punjab Government and dependent of the pensioners and (PGEPHIS) issued I.D. Card to the complainant No. 1 Swarnjit Kaur vide I.D. Card No. MDIS 09463447993 G.P.F/PPO No. 252111 PB. Type Pensioner District Amritsar which cover the dependent Jatinder Singh (Spouse) and Gursimran Kaur (Daughter). It is alleged that the complainant is suffering from Pain over left knee and difficulty in walking and the complainant got the treatment from Amandeep Hospital, Model Town G.T. Road, Amritsar for Knee Joint replacement from 12.10.2016 to 19.10.2016. The total expenditure of the complainant in the Hospital is approximately Rs. 1,79,366/- and the complainant No. 1 paid the entire amount to the Hospital and received bill. It is further alleged that the complainant No. 2 again suffered pain in Left Knee and admitted in the Amandeep Hospital on 17.11.2016 and discharged on 29.11.2016 and the complainant No. 1 again paid the entire bill of Rs. 43,788/- on 3.1.2017 to the Hospital and complainant No. 1 submitted the same to the office of M.D. India Health Care Services Pvt. Ltd. vide receipt No. 29248 dated 3.1.2017 (two files i.e. Rs. 1,79,366/- & Rs. 43,788/-). The complainant had paid all the expenses during hospitalization for the period from 12.10.2016 to 19.10.2016 and 17.11.2016 to 29.11.2016. The complainant visited the opposite parties No. 1 & 2 time and again for the settlement of claim, but the opposite parties did not pay any heed to the genuine request of the complainant and always gave answer “yours claim is under process”. The complainant received a letter dated 25.1.2017 from the Oriental Insurance Company that your claim of Rs. 1,79,366/- & Rs. 43,788/- is repudiated. As such, the conduct of the opposite parties amounts to deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.- 

i)To pay a sum of Rs. 1,79,366/- & Rs. 43,788/- as expenses incurred by the complainant.

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

4. Upon notice of this complaint, the opposite party No. 1 appeared and filed written statement taking preliminary objections interalia on the grounds of maintainability, complaint is bad  in law, act and conduct, complaint is frivolous and baseless, suppressed of material facts, jurisdiction etc. 

5. On merits, it is submitted that the complainant No. 2 has lodged two claims i.e. CCN-MDI0099967 and CCN-MDI0099947 for the medical treatment taken by him twice a time. The complainant did not supply the required documents i.e. invoice and sticker of the implant, pre and post surgical X-ray and reason for not availing the cashless treatment in Hospital and Investigating report done in hospital but these documents not supplied by the complainant to the company. As per Clause-4 of notification no reimbursement will be available to employee/pensioner in the Punjab, Chandigarh and Punchkula where cashless treatment is available. However, reimbursement can be taken by the employee/pensioner for medical treatment taken in any other state in India in exceptional circumstances. Therefore, keeping in view the aforesaid clause of the Punjab Government Notification, the claim of the complainant is rightly repudiated. All other allegations of the complainant are denied and prayed for the dismissal of complaint. 

6. The opposite party No. 2 has failed to file written version despite taking number of opportunities and the right of the opposite party No. 2 for filing written version stands forfeited vide order dated 22.6.2018. 

7. In reply the opposite party No. 3 submitted that the present complaint is not maintainable and there is no cause of action to file the present complaint. On merits, it is admitted to the extent that the complainant remained admitted in the hospital from 12.10.2016 to 19.10.2016 and 17.11.2016 to 29.11.2016. The complainant paid the hospital bills is also admitted. It is further submitted that the opposite party No. 3 has no role for the recovery of insurance claim from the opposite parties No. 1 & 2. As such, they prayed for the dismissal of complaint against the opposite party No. 3. 

8. In order to prove the case the complainant tendered into evidence her own affidavit Ex.CW1/A, copies of enrollment detail cum claim detail Ex.C-1, copy of the claim detail repudiation Ex.C-2, copy of acknowledgment receipt Ex.C-3, copy of the claim form Ex.C-4, copy of essentiality certificate Ex.C-5, copy of patient discharge summary Ex.C-6, copy of bill of Amandeep Hospital Ex.C-7, copy of insurance card Ex.C-8, copy of claim form Ex.C-9, copy of essentiality certificate Ex.C-10, copy of discharge summary Ex.C-11, copy of insurance card Ex.C-12 and closed the evidence. 

9. To rebut the case of complainant the opposite party No. 1 tendered into evidence documents Ex.O.P1/1 to Ex.O.P1/6.

10. The opposite party No. 3 tendered into evidence affidavit of Dr. Amandeep Kaur Ex.O.P3/1 and closed the evidence. 

11. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. Written arguments filed by opposite party No. 1.

12. Ld. Counsel for complainant argued that the complainant No. 1 is the wife of complainant No. 2 and the complainant No. 1 is retired from education department and she is pensioner of the Punjab Government. It is further argued by the Ld. Counsel for complainant  that the Punjab Government contract with the Oriental Insurance Company Limited alongwith MD India Health Care Service Pvt. Limited for the medical insurance policy for the pensioners of the Punjab Government and dependent of the pensioners and (PGEPHIS) issued I.D. Card to the complainant No. 1 Swarnjit Kaur vide I.D. Card No. MDIS 09463447993 G.P.F/PPO No. 252111 PB. Ex.C-4, which cover the dependent Jatinder Singh (Spouse) and Gursimran Kaur (Daughter). It is further argued by the Ld. Counsel for complainant that the complainant is suffering from Pain over left knee and difficulty in walking and the complainant got the treatment from Amandeep Hospital, Model Town G.T. Road, Amritsar, for Knee Joint replacement from 12.10.2016 to 19.10.2016 Ex.C-6. It is further argued by the Ld. Counsel for complainant that the total expenditure of the complainant in the Hospital is approximately Rs. 1,79,366/- and the complainant No. 1 paid the entire amount to the Hospital and received bill Ex.C-7. It is further alleged that the complainant No. 2 again suffered pain in Left Knee and admitted in the Amandeep Hospital on 17.11.2016 and discharged on 29.11.2016 Ex.C-11 and the complainant No. 1 again paid the entire bill of Rs. 43,788/- on 3.1.2017 to the Hospital and complainant No. 1 submitted the same to the office of M.D. India Health Care Services Pvt. Ltd. vide receipt No. 29248 dated 3.1.2017 (two files i.e. Rs. 1,79,366/- & Rs. 43,788/-). It is further argued by the Ld. Counsel for complainant that the complainant had paid all the expenses during hospitalization for the period from 12.10.2016 to 19.10.2016 and 17.11.2016 to 29.11.2016 and the complainant visited the opposite parties No. 1 & 2 time and again for the settlement of claim, but the opposite parties did not pay any heed to the genuine request of the complainant and always gave answer “yours claim is under process”. It is also argued by the Ld. Counsel for complainant that the complainant received a letter dated 25.1.2017 from the Oriental Insurance Company that your claim of Rs. 1,79,366/- & Rs. 43,788/- is repudiated. 

13. On the other hand, Ld. Counsel for opposite party No. 1 argued that the complainant No. 2 has lodged two claims i.e. CCN-MDI0099967 and CCN-MDI0099947 for the medical treatment taken by him twice a time but the complainant did not supply the required documents i.e. invoice and sticker of the implant, pre and post surgical X-ray and reasons for not availing the cashless treatment in Hospital and Investigating report done in hospital but these documents not supplied by the complainant to the company. It is further argued by the Ld. Counsel for opposite party No. 1 that as per the Government of Punjab department of health and family welfare Notification No. 21/28/12-5 HB 5-268 dated 20.10.2015 Ex.O.P1.1/1 the Government has introduced a cashless health insurance scheme to its employees to cover indoor medical treatment expenses and for this purpose the government has notified the hospitals as described in Clause 4 of the notification, which read as under;-

“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). Further, details of the scheme can be seen on website www.pbhealth.gov.in. 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 argued by the Ld. Counsel for opposite party No. 1 that keeping in view the aforesaid clause of the Punjab Government Notification, the claim of the complainant is rightly repudiated. 

14. Ld. Counsel for opposite party No. 3 also argued that the complainant remained admitted in the hospital from 12.10.2016 to 19.10.2016 and 17.11.2016 to 29.11.2016 and the complainant paid the hospital bills. It is further argued by the opposite party No. 3 that the opposite party No. 3 has no role for the recovery of insurance claim from the opposite parties No. 1 & 2. 

15. So, from the perusal of Notification No. 21/28/12-5 HB 5-268 dated 20.10.2015 Ex.O.P1.1/1 it is proved from the Clause No. 4 of the notification that treatment can be taken by enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi) and 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/pensioners for medical treatment taken in any other State in India in exceptional circumstances. Therefore, we are of the view that the complainant is not entitled to reimbursement of above said amounts from the opposite parties No. 1 & 2.

16. In view of the above discussion, there is no merit in the  present complaint and same is dismissed. However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.    

ANNOUNCED IN THE OPEN COMMISSION:

       4th Day of July, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member