Punjab

Sangrur

CC/48/2018

Harbhajan Kaur - Complainant(s)

Versus

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

Sh.Sanjeev Goyal

27 May 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  48

                                                Instituted on:    07.02.2018

                                                Decided on:       27.05.2019

 

 

Harbhajan Kaur aged about 68 years wife of Sh. Mangat Rai, resident of Village Sohian, Tehsil Payal, District Ludhiana.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Branch 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.             Irrigation Department, Opposite Govt. College, Vegetable Market Road, Malerkotla, Tehsil Malerkotla District Sangrur through its Divisional Engineer.

5.             State of Punjab through Deputy Commissioner, Sangrur.

                                                        ..Opposite parties.

 

For the complainant  :       Shri Udit Goyal, Adv.

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

For Opp.Party No.3&5:     Ms.Amandeep Kaur Bhangu, Adv.

For Opp.Party No.4  :       Shri Ramesh Chander

 

 

 

Quorum:   Vinod Kumar Gulati, Presiding Member

                Mrs.Manisha, Member

Order by : Vinod Kumar Gulati, Presiding Member.

 

1.             Smt. Harbhajan Kaur, 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 husband of the complainant Shri Mangat Rai, being a government employee retired from the office of OP number 4, as such he being the pensioner along with his family members was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09417073133 which was valid for the period from 1.2.2016 to 31.12.2016.   The case of the complainant is that during the subsistence of the insurance policy, the husband of the complainant fell ill on 17.9.2016 and was immediately taken to DMC Hospital Ludhiana, where he was diagnosed as a case of Cirrhosis liver and ultimately died on 22.9.2016, where an amount of Rs.1,21,067/- was spent on his treatment.  The complainant was under shock, as such after recovering from trauma in the month of January, 2017, the complainant came to know about the medical health scheme as such she approached OP number 4 and submitted all the bills for release of the claim, who assured that the claim would be released shortly. Thereafter, the complainant approached the OP number 4, who put off the matter on one pretext or the other. Thereafter the OP number 4 forwarded the documents to OP number 1 and 2, but the OP number 1 and 2 repudiated the claim of the complainant on the ground that the claim was not submitted within thirty days from the date of discharge from the hospital.    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.1,21,067/- 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 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 complainant took treatment from DMC Hospital Ludhiana and submitted the bills for Rs.1,21,067/- 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 5, 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 5 have 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 complainant is not a consumer and that the complainant has not impleaded the necessary and proper parties.  It is admitted that the husband of the complainant Mangat Rai retired from the OP number 4 and being the pensioner he was insured under the said scheme.  It is denied that the OP number 4 is liable to pay the insurance claim.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-6 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. The learned counsel for OP number 3 and 5 has tendered documents Ex.OP3&5/1 to Ex.OP3&5/6 copies of documents and closed evidence.  The learned counsel for OP number 4 has produced Ex.Op4/1 to Ex.OP4/3 copies of documents and closed evidence.   

 

6.             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.

 

7.             It is an admitted fact between the parties that the husband of the complainant, Shri Mangat Rai was a retired employee and as such was insured with the OPs number 1 and 2 under the scheme of the  Govt.  It is also admitted fact that the complainant lodged the claim with the OPs number 1 and 2 for payment of Rs.1,21,067/- in respect of her husband, who remained admitted in DMC Hospital Ludhiana and ultimately died there in the hospital, but the claim of the complainant was rejected by the Ops on the ground that the claim was lodged after the period of thirty days, as such no claim was payable according to the terms and conditions of the policy.  But, at this stage, it is agreed that the OPs number 1 and 2 are ready to reconsider the claim of the complainant.  In the circumstances, we feel that ends of justice would be met, if the OPs number 1 and 2 are directed to reconsider the claim of the complainant.

 

8.             Accordingly, in view of our above discussion, we allow the complaint partly and direct the OPs number 1 and 2 to reconsider the claim of the complainant and intimate their decision to the complainant within a period of 30 days from the receipt of copy of this order. Further OP number 4 is directed to pay the complainant an amount of Rs.10,000/- on account of inordinate delay in processing the claim of the complainant as the claim of the complainant was received by OP number 4 on 26.1.2017 and OP number 4 forwarded the claim to the Civil Surgeon Sangrur on 14.7.2017 after the period of about six months.  The OP number 4 shall pay the above ordered amount to the complainant within a period of 30 days from the date of receipt of copy of this order. It is made clear that if the complainant still remains unsatisfied, then it is open for her to again approach this Forum, if she so desired. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 27, 2019.

                                               

 

                                                        (Vinod Kumar Gulati)

                                                            Presiding  Member

 

 

 

                                                                (Manisha)

                                                                  Member