Complainant Manohar Lal has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to make payment of the amount of Rs.1,80,507/-, spent by him on the treatment of his wife in terms of the Insurance Policy alongwith interest @ 18% P.A. from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation and above mentioned expenses being incurred by him on his wife besides the amount in question on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he was serving as Game Boy in Punjab School Education Board and retired from service on 31.03.2015. He was member of Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) as per policy of the Punjab Govt. and he was insured with the opposite party no.1. He as well as his wife namely Smt.Shanti Devi were entitled for free treatment as per the above mentioned policy. He has further pleaded that his wife Smt.Shanti Devi all of sudden fell ill due to heart disease on 30.12.2016. She was rushed to EMC Super Specialty Hospital Amritsar where she remained admitted from 30.12.2016 to 05.01.2017. An amount of Rs.1,80,507/- was spent by the complainant on treatment of his wife which includes Hospital bills, medicine bills and Lab tests etc. He is entitled for the refund of abovesaid amount from the opposite parties as per policy of the Government. Thereafter he submitted his claim to the opposite parties, supported with medical bills, documents and reports etc. within time through his department, but the opposite parties did not make the payment on one or the other excuse.  He made various representations to the opposite parties with a request to make payment of the amount spent by him on his wife's treatment but all in vain. Thus, there is deficiency in service on the part of the opposite parties who did not pay insured amount to him. He has next pleaded that he also filed CWP No.30172 of 2018 titled as Manohar Lal Vs. State of Punjab and others before the Hon'ble High Court for the states of Punjab  & Haryana at Chandigarh which was disposed off vide order dated 29.11.2018 by Ms.Justice Harsimran Singh Sethi, Judge P & H.  Thereafter, he made several requests to the opposite parties to make payment of the amount claimed by him, but of no use. Hence, this complaint.

 3.        Notice of the complaint was issued to the opposite parties.  Opposite party no.1 and 2 appeared through their counsel and filed their written reply taking the preliminary objections that the present complaint of the complainant is not maintainable as the same is hopelessly PRE-MATURE. Neither the complainant, nor the opposite party no.3 ever lodged the claim of the complainant with the opposite party Insurance Company alongwith the requisite documents under the terms and conditions of the company. Hence, the question of settlement of the claim under the provisions of law does not arise. Hence, the present complaint of the complainant is liable to be dismissed on this score only. However, if the Hon'ble Commission passes the order for the reimbursement of the expenses of medical treatment of wife of the complainant, that should be determined as per the list of tender rates determined in accordance with PGEPHIS. As per the list of tender rates, the final liability of the opposite party would be only Rs.63,057/- and the present complaint is not maintainable against the opposite parties as there is no insurance contract exits between the complainant and opposite parties, hence there is not any contractual liability of the opposite parties against the complainant under the Consumer Protection Act. On merits, it was denied that the complainant is not insured with the Insurance Company under the scheme, however, if the complainant is insured, then he is covered under the scheme only subject to the terms and conditions of the scheme.  It was admitted that the opposite party no.2 i.e. M.D.India Health Insurance TPA Pvt.Ltd. is the claim settling authority, which settles the claim under the terms and conditions of the policy as per the documents provided by the complainant. It was submitted that the complainant has not lodged his claim with the opposite parties, hence the question of settlement of the claim of the complainant does not arise.  It was denied that all of sudden wife of the complainant Smt.Shanti Devi fell ill due to heart disease on 30.12.2016. She was rushed to EMC Super Specialty Hospital, Amritsar, where she allegedly remained admitted from 30.12.2016 to 05.01.2017. It was also denied that Rs.1,80,507/- was spent by the complainant on treatment of his wife. The alleged medical bills, lab bills etc. are forged and fabricated documents, which have been manipulated by the complainant with the connivance of the Hospital Staff etc. Hence, opposite parties are not bound to pay the claim. Thus, there is no deficiency in service on the part of the opposite parties. Further submitted that the complainant has not supplied the copy of order dated 29.11.2018 passed by Justice Harsimran Singh Sethi, Judge of Punjab and Haryana High Court, Chandigrh. Hence, the opposite parties cannot give the complete and proper reply.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.          Opposite party no.3 appeared through its counsel and filed its reply taking the preliminary objections that complaint is not maintainable against the opposite party no.3 as the complainant had to take sanction first from the Corporation before initiating any legal proceeding against opposite party no.3 as per Section 15 of Punjab Health System Corporation Act, 1996 and no cause of action even arose to complainant for filing the present complaint. On merits, it was submitted that the claim of the complainant is matter between insurer and the insured therefore the complainant is not entitled for any claim from answering opposite party. Earlier complainant moved his complaint to the opposite party that the medical reimbursement agency is opposite party no.1 therefore on 5.9.2018 he withdrew his claim from the opposite party and this fact was also informed to the Divisional Manager of opposite party no.1 vide letter dated 03.07.2019 and opposite party also recommended the case of the complainant to opposite party no.1 for taking into consideration as per their policy.  It was next submitted that the opposite party is not liable to pay any claim to the complainant because it is matter between the insurer and insured and opposite party has already fulfilled his duty by recommending the case of the complainant.  Actually after 5.9.2018, the complainant never approached the opposite party. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.          Alongwith the complaint, complainant has filed his own affidavit  and copies of documents Ex.C-1 to Ex.C-12.

6.          Alongwith the written statement ld.counsel for the opposite party no.1 and 2 filed affidavit of Sh.Harbans Lal, Divisional Manager, O.I.C. Ltd. Pathankot Ex.OP-1,2/A.

7.          Alongwith the written statement, ld.counsel for the opposite party no.3 filed affidavit of Dr.Parveen Kumar, Deputy Medical Commissioner, PHSC, Gurdaspur Ex.OP-3/A and documents Ex.OP-1.

8.            Written arguments have been filed by complainant and opposite party no.3.

9.          We have carefully gone through the pleadings of counsel for the both parties; written arguments as well as oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the complainant for the purposes of adjudication of the present complaint.

10.       After hearing both the parties, we find merit in the case. Opposite parties no.1 and had wrongfully withheld the genuine claim of the complainant.

11.     The complainant had duly submitted the claim. Opposite party was bound to settle the claim as per terms and conditions laid down in the service conditions of the parent department of the complainant and also read in conjunction with the memorandum agreed upon with Oriental Insurance Co. Ltd. and M.D. Health Insurance TPA Pvt.Ltd..

12.    It is wrong on the part of opposite party no.1and 2 to object on the ground of non submission of rightful claim even when the final liability on this account has been assessed by opposite party Rs.63,057/- in accordance with tender rates of PGEPHIS.

13.     In view of the above observation, facts and circumstances, this complaint is partly allowed and opposite party no.1 and 2 is directed to pay Rs.63,057/- to the complainant alongwith interest @ 7%p.a. from the date of submission of bill Ex.C10 and Ex.C-11 till the actual realization of this award. Opposite party no.1 and 2 are further directed to pay Rs.10,000/- to the complainant on account of litigation expenses and mental harassment.  Compliance of the order be made within 45 days from the date of receipt of the order.

14.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

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

             (Naveen Puri)

                                                                            President   

Announced:                                                   (R.S.Sukhija)

May 19, 2022                                                       Member

*MK*