Punjab

Sangrur

CC/499/2017

Darshan Singh - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Sh.Jaspreet Singh Ladda

06 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    499

                                                Instituted on:      25.09.2017

                                                Decided on:       06.02.2018

 

 

Darshan Singh son of Kartar Singh, resident of Punjab Prison Department, Quarter No.21, Jail Complex, Police Line, Sangrur.

                                                        …Complainant

                                Versus

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

2.             M.D. India Health Care Services Pvt. Ltd. Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director.

3.             Director, Health and Family Welfare, Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.

4.             Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-6, Near Civil Hospital, Sahibzada Ajit Singh Nagar, Mohali, through its M.D.

                                                        ..Opposite parties.

 

For the complainant    :       Shri J.S.Ladda, Adv.

For Opp.party No.1&2:       Shri Ashish Garg, Adv.

For Opp.Party No.3&4:       Ms.Amandeep Kaur Bhangu, Adv.

 

 

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Darshan Singh, 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 in District Jail, Sangrur and, as such, he along with his family members was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09465021590 which was valid for the period from 1.1.2015 to 31.12.2016.   The case of the complainant is that the mother of the complainant was suffering from chronic disease i.e. blood cancer and is getting treatment from Guru Gobind Singh Medical College, Faridkot.  The grievance of the complainant is that he submitted bills for Rs.8443/- and Rs.3525/- to the OPs for release of the payment, but the  payment was not made on the ground that the bills have not been submitted within the period of thirty days of discharge, whereas there is no requirement for admission being the case of the mother of the complainant is a cancer one.  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.11,968/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 and 2, legal objections are taken up on the grounds that the OPs have been dragged into unwanted litigation, 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 averred that the Govt. of Punjab framed a policy for cashless treatment in Government or in empanelled hospitals in Punjab, Chandigarh and NCR area and no reimbursement will be available, where cashless treatment is available.  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 the mother of the complainant took treatment from Guru Gobind Singh Medical College, Faridkot from 24.6.2016 to 12.12.2016 due to cancer and submitted the bills for Rs.8443/- and Rs.3525/- for reimbursement, but the claim was rejected as the complainant submitted the claim file after a period of thirty days of discharge. 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. Lastly, the OPs have prayed for dismissal of the complaint with special costs.

 

3.             In reply filed by Ops number 3 and 4, legal objections are taken up on the grounds that the complaint is premature, that the present complaint is not maintainable and that the complainant has no cause of action to file the present complaint.  It is stated that the matter is between the insurance company and the complainant and the Ops number 3 and 4 have nothing to do.  The other allegations levelled in the complaint have been denied.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-22 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1  and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/5 copies of documents and affidavits 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 pensioner, his entire family was insured with the OPs under the medical policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 1.1.2016 to 31.12.2016.  It is also not in dispute that during the subsistence of the insurance period, the mother of the complainant suffered cancer problem as she was a chronic patient. It is also not in dispute that the complainant submitted medical bills to the tune of Rs.8443/- and Rs.3525/- with the Ops for reimbursement of the same, but the case of the OPs number 1 and 2 that the claim has been rejected on the ground that the same was not submitted within a period of thirty days of discharge from the hospital. The learned counsel for the complainant has contended vehemently that the mother of the complainant remained an outdoor patient and was not admitted in the hospital, as such, the question of submission of the bills after a period of thirty days from the discharging of hospital does not arise at all.  Moreover, the bills are of very petty amount, but the same requires to be counter signed from the authorities from where the medical treatment was taken before submission to the OPs.   Ex.C-3 and Ex.C-14 are the copies of the medical bills submitted to the OPs on various dates.  Since the mother of the complainant was a case of chronic disease and the bills are of very petty amount, we feel that the OPs should not go to the technicalities in settling suck like claims.  

 

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 and 2 to pay to the complainant an amount of Rs.11,968/- only. In the circumstances of the case, the parties are left to bear their own costs.

 

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.

                        February 6, 2018.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member