DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 37
Instituted on: 02.02.2018
Decided on: 26.12.2018
Pawan Kumar aged about 65 years son of Sh. Khajanchi Ram, resident of H.No.18-P, Partap Nagar, Sangrur.
…Complainant
Versus
1. The Oriental Insurance Company Limited, CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Branch Manager.
2. M.D. India Health Care Services Pvt. Limited, 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. Deputy Registrar, Cooperative Societies, Sangrur.
5. State of Punjab through Deputy Commissioner, Sangrur.
..Opposite parties.
For the complainant : Shri Sanjeev Goyal, Adv.
For Opp.Party No.1&2: Shri Ashish Garg, Adv.
For Opp.Party No.3&5: Ms.Amandeep Kaur Bhangu, Adv.
For OP NO.4 : Shri Sukhwinder Singh, Adv.
Quorum: Inderjeet Kaur, Presiding Member
Vinod Kumar Gulati, Member
Order by : Inderjeet Kaur/Vinod Kumar Gulati,Members.
1. Shri Pawan 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 was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD15-09855603217, but no terms and conditions of the policy were supplied to the complainant. The case of the complainant is that in the month of March, 2016, he suffered an acute heart attack and as such was immediately taken to DMC Hero Heart Hospital, Ludhiana, where the doctors recommended for immediate bypass surgery and accordingly the bypass surgery was done and the complainant remained admitted in the hospital from 5.3.2016 to 31.3.2016, where the complainant spent an amount of Rs.5,76,575/- on his treatment. Thereafter the complainant spent an amount of Rs.5407/- as outdoor patient and by this way, the complainant spent an amount of Rs.5,81,982/- on his treatment. Thereafter the complainant submitted the claim with the OP number 2, but the OP number 2 released the amount of Rs.3,69,059/- only out of Rs.5,81,982/- and withheld an amount of Rs.2,07,516/-, which is said to be deficiency in service on the part of the OPs. As such, 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 remaining claim amount of Rs.2,07,516/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply filed by Ops number 1 to 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 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 remained admitted in DMC Hero Heart Hospital, Ludhiana for the period from 5.3.2016 to 31.3.2016 and submitted a bill for Rs.5,81,982/-, but the Ops have paid an amount of Rs.3,69,065/- as per PGEPHIS Schedule of rates and it is stated that the complainant is not entitled to get an amount of Rs.2,07,516/- from the Ops.
3. In reply filed by Ops number 3 and 5, legal objections are taken up on the grounds that the present complaint is premature, that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint. On merits, it is admitted that the complaint is correct to this extent that the complainant is a government employee and policy number MD15-09855603217 was issued. The other allegations levelled in the complaint have been denied.
4. In reply filed by OP number 4, preliminary objections are taken up on the grounds that this complaint is bad for non joinder of necessary party, that the complainant has not come to the Forum with clean hands and that the complaint is not maintainable. On merits, it is stated that the matter is between the insurance company and complainant only and the OP number 4 has to do nothing. Lastly, the OP number 4 has prayed for dismissal of complaint qua OP number 4.
5. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-26 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&2/9 and closed evidence. The learned counsel for OP number 4 has produced Ex.OP4/1 affidavit and closed evidence. The learned counsel for OP number 3&5 has produced Ex.OP3&5/1 to Ex.OP3&5/6 copies of documents and affidavit and closed evidence.
6. We have carefully gone through the record, heard the oral arguments, none of the parties submitted the written arguments.
7. It is admitted fact that the complainant was insured by the Op.No.1 and the OP.No.2 was the TPA of the said scheme. OPs.1&2 issued the card to the complainant and during the policy period in the month of March 2016, the complainant suffered heart attack and was taken to DMC Hospital Ludhiana and remained admitted in the hospital from 05.03.2016 to 31.03.2016 and spent an amount of Rs.5,81,982/- being as indoor/outdoor patient and the Op.No.2 released the amount of Rs.3,69,059/- out of the amount of Rs.5,81,982/- and the request of the complainant to pay the balance amount of Rs.2,07,516/- was denied and this amount is to be paid by the Ops.No.1&2 as submitted by the complainant. The complainant placed on record Ex.C-5. “Complicated Chronic Disease Certificate” valid from 10.09.2014 to 09.09.2019 issued by Rajindera Hospital Patiala and the copy of the tender notice of the Punjab Government Employees & pensioners health scheme, Govt of Punjab and as per serial No.4/d of this document, Coverage of Chronic Diseases ; Medical reimbursement of bills more than Rs.6000/- against chronic diseases, that are covered under the existing Punjab Medical attendance rules, shall be admissible as long as either the patient is treated as indoor patient or as out door patient having valid complicated chronic disease certificate. Treatment can be had from any Hospital/Nursing Home/Clinic anywhere in India. Complicated Chronic Disease Certificate has to be issued by State Govt. Medical Colleges/PGIMER Chandigarh, AIIMS Delhi and GMCH Chandigarh. Further as per serial No.7 it is mentioned that in an event the sum insured of Rs.3 lacs per family is exhausted, the coverage of the family shall be met through the Buffer sum insured of Rs.25/- crore available to each and every beneficiary of the group on group floater basis, to be maintained by the insurance company.
8. In view of our above discussion, we find the denial made by the OPs to release the balance payment to the complainant is neither legal nor sustainable under law and as such the complaint is allowed with the direction to OPs. No.1&2 to release the balance payment of Rs.2,07,516, the OPs are further directed to pay to the complainant an amount of Rs.2500/- as compensation for mental tension, agony as well as harassment and an amount of Rs.2500/- on account of litigation expenses to the complainant within one month from the receipt of copy of order, failing which the complainant shall be entitled to receive the awarded amount along with interest @ 9% per annum from the date of passing of the order until full and final payment is made. A copy of this order be sent to the parties free of cost and thereafter the file be indexed and consigned to records.
Pronounced.
December 26, 2018.
(Inderjeet Kaur)
Presiding Member
(Vinod Kumar Gulati)
Member
