Punjab

Sangrur

CC/232/2018

Ganesh Kumar - Complainant(s)

Versus

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

Sh.Naveen Shrivastava

06 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

       

                                                       

                                                Complaint No.    232

                                                Instituted on:      09.05.2018

                                                Decided on:       06.05.2019

 

 

 

Ganesh Kumar aged about 35 years son of Late Sh. Ramesh Chander, resident of Dashmesh Avenue, Street No.5, H.No.69, Opposite Nam Dev Gurudwara, Sangrur.

                                                        …Complainant

                                Versus

 

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

2.             M.D. India Health Insurance TPA Pvt. Ltd. Tower First Floor, Plot No.F-539, Phase-8-B, Industrial Area, Airport Road, 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 Secretary Health cum Managing Director.

                                                        ..Opposite parties.

For the complainant    :       Shri Naveen Shrivastava, Adv.

For Opp.Party No.1&2:       Shri AshishGArg, Adv.

For Opp.Party No.3    :       Exparte.

For OP No.4              :       Shri Vinay Jindal, Adv.

 

Quorum:    Vinod Kumar Gulati, Presiding Member

                 Manisha, Member

 

Order by : Vinod Kumar Gulati, Presiding Member.

 

1.             Shri Ganesh Kumar, 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 is a government employee and is working in Punjab Health Department, 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 MD15-09417488899 for the period from 1.1.2016 to 31.12.2016.   The case of the complainant is that during the subsistence of the insurance policy, the wife of the complainant felt severe labour pain on 8.12.2016 and in emergency she got admitted in Singla Surgical and Maternity Hospital Sangrur for the delivery of child, where she gave a birth to a male child and she remained admitted in the hospital upto 12.12.2016, where she spent an amount of Rs.36,320/-on her treatment and thereafter he submitted all the documents to the Ops, but the claim was not paid, despite his best efforts. 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.36,320/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 and 2, 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 the wife of the complainant was admitted in Singla Surgical and Maternity Hospital, Sangrur on 8.12.2016 for the delivery of child and discharged on 12.12.2016 and submitted the bills for Rs.36,320/- for reimbursement, but the claim was rejected as complainant submitted the claim file after 30 days of discharge/consuming medicine.  As per tender notice, the treatment availed by the beneficiary shall be on reimbursement basis subject to submission of the claim to the TPA within 30 days from the date of discharge/death from the hospital.  As such, any deficiency in service on the part of the Ops has been denied.  It is further averred that as per clause 24 of the tender this Forum has got no jurisdiction to try and decide the present complaint as there is specific provision regarding dispute between beneficiary and Health care provider/care provider and the TPA/insurance company shall be referred to the District Level Grievance Redressal Committee. 

 

3.             In reply filed by Ops number 4, legal objections are taken up on the grounds 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, that the complainant has not come to the Forum with clean hands.    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-17 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1& 2  has produced Ex.OP1&2/1 to Ex.OP1&2/4 copies of documents and affidavits and closed evidence. The learned counsel for OP number 4 has produced Ex.OP4/1 affidavit 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 part acceptance, for these reasons.

 

6.             It is admitted fact between the parties that the complainant is a Government Employee and is working in the Punjab Health Department Sangrur and is insured with the Ops vide card number MD15-09417488899 valid for the period from 01.01.2016 to 31.12.2016. Further that on 08.12.2016, the wife of the complainant felt severe labour pain and was got admitted in Singla Surgical and Maternity Hospital Sangrur for the delivery of the child and was discharged from the Hospital on 12.12.2016 and paid a bill of Rs.36,320/- to the hospital. The complainant lodged the claim for the reimbursement of the above amount with the TPA i.e. Op number 2 on 20.02.2017 and the TPA repudiated the claim of the complainant as per guidelines under Punjab Government Employee Scheme tender clause 11.6 as per which,  said claim has been submitted in their office after 30 days from the discharge. The complainant has submitted that the repudiation has been done on vague ground and has relied upon the circular dated 20.09.2011 issued by IRDA addressed to All Life Insurers and Non-Life Insurers etc., as per which, the current contractual obligation imposing the condition that the claim shall be intimated to the insurer with the prescribed documents within the specified number of days is necessary for insurers for effecting various activities like investigation, loss assessment etc and this condition should not prevent genuine claims, particularly when there is a delay in intimation or in submission of documents due to unavoidable circumstances. Further the insurer’s decision to reject a claim shall be based on the sound logic and valid grounds. As such, repudiation of the claim made by the OPs is illegal and not justified.

 

7.             In sequel of the above discussion we allow the complaint and direct the Ops to settle the claim of the complainant as per the terms and conditions contained in the tender notice of Punjab Government Employees and Pensioners Health Insurance Scheme and PGEPHIS schedule of rates within 60 days from the receipt of the order. If the complainant is not satisfied with the decision of the Ops then he can approach the Forum again for the redressal of his grievance, if he so desires. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 6, 2019.                                                             

                                               

                                                        (Vinod Kumar Gulati)

                                                          Presiding Member

 

                                                       

 

                                                                (Manisha)

                                                                  Member