DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  657

                                                Instituted on:    11.12.2017

                                                Decided on:       08.05.2018

Alka Rani Wife of Shri Sanjeev Kumar, resident of House No.2048, Magazine Street, Sangrur.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Co. Ltd., Nabha Gate, through its Branch Manager, Sangrur.

2.             The Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh  through its Manager.

3.             M.D. India Health Care Services (TPA) Pvt. Ltd. through its Managing Director, PGEPHIS, Claim Department,  Maxpro Info Park, D-38, Industrial Area, Phase-I, Chandigarh.

4.             State of Punjab through District Collector, Sangrur.

5.             Department of Health and Family Welfare Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh through its Director.

                                                        ..Opposite parties.

For the complainant  :       Shri Sanjeev Garg, Adv.

For Opp.Party No.1to3:    Shri Ashish Garg, Adv.

For Opp.Party No.4&5:     Ms. Amandeep Kaur, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

Order by : Sukhpal Singh Gill, President.

1.             Smt. Alka Rani, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant being a government employee is working as Mistress in Govt. Senior Secondary School, Bhaini Mehraj and as such she along with his family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09872298752 for the period from 1.1.2016 to 30.12.2016.   The case of the complainant is that during the subsistence of the insurance policy, the mother in law of the complainant suffered problem in her gall bladder on 13.8.2016 and as such being a case of emergency, she was immediately taken to Patiala Surgical Centre, Patiala, where she was operated upon and an amount of Rs.15,654/- was spent and thereafter she submitted the bills for reimbursement, but no amount was paid, despite her best efforts.  Further on 2.11.2016, the mother in law of the complainant suffered fever on 2.11.2016, as such she was immediately admitted in  Bansal Hospital and Heart Centre, Sangrur, where she remained admitted in the hospital for the period from 2.11.2016 to 7.11.2016, where she spent an amount of Rs.15,669/- from her own pocket and the claim was submitted to the OP number 3, but the same was not paid.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.31,323/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1 to 3, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable. On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis.   It is further stated that as per the schedule, the liability of the company is to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room.  It is admitted that mother in law of the complainant Smt. Shanta Rani remained admitted in Patiala Surgical Centre, Patiala for the period from 13.8.2016 to 14.8.2016 and submitted bill for Rs.15654/- for reimbursement and further it is admitted that she again remained admitted in Bansal Hospital and Heart Centre, Sangrur for the period from 2.11.2016 to 7.11.2016 and spent an amount of Rs.15669/- for the treatment of dengue. Further case of the Ops is that the claim of the complainant was rejected as the claim was submitted after the period of thirty days from the discharge of the hospital. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee.

3.             In reply filed by Ops number 4 and 5, legal objections are taken up on the grounds that the present complaint is premature and that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint and that the complainant has got no locus standi to file the present complaint.  On merits, it is stated that the OP has no liability to reimburse the medical claim/bills as alleged by the complainant. It is stated that as per the policy, the liability to pay the claim is of the insurance company.  The other allegations levelled in the complaint have been denied in toto.

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-47 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 to 3  has produced Ex.OP1to3/1 to Ex.OP1to3/5 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 4 and 5 has produced Ex.OP4&5/1 to Ex.OP4&5/6 and closed evidence.   

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

6.             It is an admitted fact between the parties that the complainant being a Punjab Government employee is working as Mistress in Govt. Senior Secondary School, Bhaini Mehraj and as such she along with her family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09872298752 for the period from 1.1.2016 to 30.12.2016.  It is also not in dispute that during the subsistence of the insurance policy on 13.8.2016, the mother in law of the complainant Smt. Shanta Rani suffered problem in her gall bladder on 13.8.2016 and as such being a case of emergency, she was immediately taken to Patiala Surgical Centre, Patiala, where she was operated upon and an amount of Rs.15,654/- was spent and thereafter she submitted the bills for reimbursement, but no amount was paid, despite her best efforts.  Further on 2.11.2016, the mother in law of the complainant suffered fever on 2.11.2016, as such she was immediately admitted in the Bansal Hospital and Heart Centre, Sangrur, where she remained admitted in the hospital for the period from 2.11.2016 to 7.11.2016, where she spent an amount of Rs.15,669/- from her own pocket and the claim was submitted to the OPs, but the same was not paid. It is also an admitted fact between the parties that the complainant spent an amount of Rs.31,323/- on her treatment on both the occasions. Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 1 to 3 for reimbursement, but the claim of the complainant was not paid without assigning any reason thereof. The complainant has produced on record the medical record including the copies of the bills as Ex.C-6 to Ex.C-45, as such it is contended by the learned counsel for the complainant that the claim has wrongly been withheld/rejected by the OPs.  On the other hand, the stand of the OPs number 1 to 3  is that the claim is not payable as the complainant has submitted the bills beyond the stipulated period of thirty days for getting the claim amount from the OPs. But, we are unable to accept such a contention of the learned counsel for the OPs as there is nothing in the rules that the complainant is bound to submit the claim within a period of thirty days from the discharge from the hospital. It is worth mentioning here that the OPs number 1 to 3 chose to sit over the claim for such a long period without assigning any reason.

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1 to 3  to pay to the complainant an amount of Rs.31,323/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 11.12.2017 till realisation.  We further order the OPs number 1 to 3 to pay to the complainant an amount of Rs.5,000/- in lieu of consolidated amount of compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses.

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 8, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member