DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                Complaint No.  17

                                                Instituted on:    16.01.2018

                                                Decided on:       21.05.2018

Inderjeet Garg son of Kaur Sain resident of Thalesh Bagh, Street No.1, Opp. BSNL Park, Sangrur.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Company Ltd. Regional Office SCO 109, 110, 111, Sector 17-B, Chandigarh through its Regional Manager.

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

3.             M.D. India Health Insurance TPA Pvt. Ltd. Regional Office, D-38, Maxpro Info Park, Industrial Area, Phase I, Mohali-160056 through its Regional Manager.

4.             XEN, PWD B&R (Construction Department) Sangrur.

5.             Department of Health and Family Welfare through Health Systems Corporation, SIHFW Complex, Phase-6, Mohali through its Managing Director.

6.             State of Punjab through Deputy Commissioner, Sangrur.

                                                        ..Opposite parties.

For the complainant  :       Shri Sumir Fatta, Adv.

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

For Opp.Party No.4  :       Exparte.

For Opp.Party No.5&6:     Ms.Amandeep Kaur Bhangu, Adv.

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

Order by : Sukhpal Singh Gill, President.

1.             Shri Inderjeet Garg, 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 retired as Assistant Engineer from the OP number 4 and as such he along with his family members were  insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under policy number 231102/48/2016 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 complainant underwent Cataract Surgery in the right eye at PGI Chandigarh in the month of May, 2016 and remained admitted at PGI Chandigarh from 19.5.2016 to 21.5.2016 and 19.6.2016 and spent an amount of Rs.15,886/- on the treatment and thereafter submit all the documents to the OPs for payment of the claim amount, but the Ops paid only an amount of Rs.6000/- on 12.11.2016 and withheld the remaining amount of Rs.9886/- without assigning any reason. 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.9886/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by Ops number 1 to 3, 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.  Further it is admitted that the complainant remained admitted in PGI Chandigarh and under went cataract surgery in right eye at PGI Chandigarh for the period from 19.5.2016 to 21.5.2016 and the complainant submitted the bills for an amount of Rs.15,886/- for reimbursement and it is further admitted that the amount of Rs.6000/- has been paid as per package rates, package code 79 (Cataract), as such, it is stated that the complainant is not entitled to get more claim of Rs.9886/- as claimed. 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 OP number 4, legal objections are taken up on the grounds that there are complicated questions of law and facts involved in the present case and that the complaint is not maintainable. On merits, it is stated that the complainant retired from the service on 31.10.2003 and the remaining allegations levelled in the complaint have been denied being not relevant.

4.             In reply filed by Ops number 5 and 6, 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.

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-20 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.OP1to3/4 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 5 and 6 has produced Ex.OP5&6/1 to Ex.OP5&6/6 copies of documents and affidavit 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 complainant being a Punjab Government employee retired as Assistant Engineer from the PWD B&R Department, Punjab, 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 policy in question 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 the complainant suffered the problem of Cataract Surgery in his right eye and as such he remained admitted in PGI Hospital Chandigarh for the period from 19.5.2016 to 21.5.2016, where he spent an amount of Rs.15,886/- on his treatment and thereafter he submitted the bills for Rs15,886/- for payment, but the OPs paid an amount of Rs.6000/- only on 12.11.2016 and withheld the remaining amount of Rs.9886/-, as such, the learned counsel for the complainant has contended vehemently that the remaining amount of Rs.9886/- may kindly be ordered for payment to the complainant. On the other hand, the learned counsel for the Ops number 1 to 3 has contended vehemently that the amount of Rs.6000/- has already been paid in view of package code 79 (Cataract). We have also perused the copy of PGEPHIS Schedule of Rates, Ex.OP1to 3/3, which clearly reveals that the amount of Rs.6000/- has rightly been paid to the complainant and find further that nothing more is required to be paid to the complainant.  However, we feel that if the complainant is still unsatisfied, then he is free to move to the District Level Grievance Redressal Committee.

8.             Accordingly, in view of our above discussion, we find no merit in the complaint. However, the complainant is at liberty to approach to the  District Level Grievance Redressal Committee for redressal of his grievance, if he so desired. 

9.             A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 21, 2018.

                                                        (Sukhpal Singh Gill)

                                                                President

                                                                (Sarita Garg)

                                                                    Member