Punjab

Sangrur

CC/405/2018

Ghumand Singh - Complainant(s)

Versus

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

Sh.Nem Kumar

06 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No. 405

 Instituted on:   26.09.2018

                                                                        Decided on:     06.07.2023

 

Ghumand Singh @ Ghammand Singh aged 83 years son of Sh. Harchand Singh, R/O H.No.675, W.No.6, Dohla Road, Lashami Bhag, Dhuri, Tehsil Dhuri and Distt. Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             The Oriental Insurance Company Ltd. through its Manager, Basement, SCO 99-100, 17-B, Bank Square, Chandigarh 160017.

2.             M.D. India Insurance TPA Pvt. Ltd. through its Manager, Mohali Towers, First Floor, Plot No.F-539, Phase-8, Industrial Area, Air Port Road, Mohali 160071.

3.             State of Punjab through Deputy Commissioner, Sangrur.

4.             Fortis Hospital through its Manager, Sector 62, Phase 8, Mohali 160062.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Nem Kumar, Adv.

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

For Opp.Party No.3            Shri Vinay Kumar Jindal, Adv.

For Opp.Party No.4            Shri Udit Goyal, Adv.

 

Quorum                                           

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

 

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that complainant being a retired government employee was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09417159967 which was valid for the period from 1.1.2016 to 31.12.2016.   The case of the complainant is that he felt physical ailment, regular pain etc in his body at his home at Dhuri and even sustained difficulty in household activities due to his knee problem as such the complainant was advised total left knee replacement. Thus, the complainant got himself admitted at OP number 4 on 8.8.2016 for total knee replacement under said cashless scheme and the complainant was discharged on 16.8.2016.  Further case of complainant is that the total bill dated 16.8.2016 for said treatment was to the tune of Rs.2,12,374/-, but  OPs 1 & 2 sanctioned only an amount of Rs.1,78,850/- and the remaining amount of Rs.33,524/- was paid by the complainant to OP number 4 i.e. hospital authorities under compelled circumstances.  Thereafter the complainant requested OP number 1 and 2 to pay the remaining claim amount of Rs.33,524/-, but nothing was 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.33,524/- along with interest @ 12% 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 averred that the complainant was insured under the above said scheme and room entitlement was twin sharing. As per PGEPHIS/CGHS, schedule of rates, the liability of the company 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 complainant was admitted in Fortis Hospital Mohali on 8.8.2016 for total knee replacement and discharged on 16.8.2016 and submitted the bill to the tune of Rs.2,12,374/- for reimbursement and the Ops paid a sum of Rs.1,78,550/- on 10.11.2016 inclusive of medicines, investigation charges as per package code number 1198. The complainant again submitted the bill of Rs.33,524/- regarding balance of Rs.2,12,374/-, as such, it is stated that the complainant is not entitled for remaining amount of Rs.33,524/-. 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 Op number 3,  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.  It is stated that the matter is between the insurance company and the complainant and the Op number 3 has nothing to do.  The other allegations levelled in the complaint have been denied.

4.             In reply filed by OP number 4, legal objections are taken up on the grounds that the complaint is false, frivolous and vexatious in nature and that the complainant is not entitled to any claim from OP number 4.  On merits, it is admitted that the complainant was advised for left knee replacement and the complainant agreed to pay Rs.2,12,374/- out of which the OP number 2 sanctioned an amount of Rs.1,78,850/- and the remaining amount of Rs.33,524/- was paid by the complainant.  The other allegations levelled in the complaint have been denied.

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-13 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&2/7 copies of documents and affidavits and closed evidence. The learned counsel for OP number 3 tendered affidavit Ex.OP3/1 and closed evidence.  The learned counsel for OP number 4 has produced Ex.OP4/1 to Ex.OP4/6 copies of documents and affidavits and closed evidence.

6.             We have gone through the pleadings put in by  the parties along with their supporting documents with their valuable assistance.  

7.             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 complainant remained admitted in the Fortis Hospital for left knee replacement and spent an amount of Rs.2,12,374/- out of which an amount of Rs.1,78,850/- was paid to the complainant as reimbursement and the remaining amount of Rs.33,524/- was withheld by OPs number 1 and 2 on the ground that the same is not payable as per the rules/guidelines. The learned counsel for the complainant has contended vehemently that since the complainant was insured for the amount of Rs.3,00,000/- and the hospital authorities charged Rs.2,12,374/-, as is evident from the copy of the bill Ex.C-6 issued by the OP number 4,  but the OPs paid only an amount of Rs.1,78,850/- and the OPs are still liable to reimburse the remaining amount of Rs.33,524/-.  After perusal of the record we find that there is no reason for the OPs number 1 and 2 to withheld the remaining claim amount of Rs.33,524/- as the complainant has spent an amount of Rs.2,12,374/- on the replacement of the left knee from the authorised/empanelled hospital of the OPs and the OPs number 1 and 2 have no option to deduct any amount from the bill issued by OP number 4.

 

8.             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.

 

9.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs number 1 and 2 to pay to the complainant remaining claim amount of Rs.33,524/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 26.09.2018 till realisation. Further the OPs number 1 and 2 are directed to pay to the complainant an amount of Rs.2500/- as compensation for mental tension, agony and harassment and further an amount of Rs.2500/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

 

10.            The complaint could not be decided within the statutory time period due to heavy pendency of cases.

 

11.            Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                        Pronounced.

 

                       July 6, 2023.