Punjab

Sangrur

CC/591/2017

Rajvir Singh Saini - Complainant(s)

Versus

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

Sh.Sumir Fatta

05 Apr 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

 

                                                               

                                                Complaint No.  591

                                                Instituted on:    06.11.2017

                                                Decided on:       05.04.2018

 

 

 

Rajvir Singh Saini son of Tara Singh aged 54 years, resident of Krishan Pura Basti, Outside Nabha Gate, Sangrur.

                                                        …Complainant

 

                                Versus

 

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

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

3.             M.D. India Health Insurance TPA Private Limited, Regional Office, D-38, Max Pro Info Park, Industrial Area, Phase 1, Mohali-160056 through its Regional Manager.

4.             Executive Officer, Zila Parishad, 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          :       Shri SS Ratol, Adv.

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

 

Quorum:   Sarita Garg, Presiding Member

                Vinod Kumar Gulati, Member

 

Order by : Sarita Garg, Presiding Member.

 

1.             Shri Rajvir Singh Saini, 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 is working in Zila Parishad as a car driver and as such is 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, in the month of June suffered some health problem, as such was admitted at Rajindra Hospital Patiala on 2.7.2016 from where he was referred to PGI Chandigarh, where he remained admitted from 5.7.2016 to 12.7.2016, where he spent an amount of Rs.101490/- plus Rs.14628/- total Rs.1,16,118/- on the treatment and after discharge from the hospital, the complainant submitted all the bills to the Ops for reimbursement, but the grievance of the complainant is that the Ops repudiated the claim of the complainant vide letters dated 28.1.2017 and 29.3.2017 on the ground that the complainant has been treated for alcoholic hepatitis condition with complication. 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.1,16,118/- along with interest @ 9% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 to 3, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable. On merits, 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 further admitted that the complainant remained admitted in Rajindra Hospital Patiala from 2.7.2016 to 5.7.2016 due to alcoholic liver disease with cirrosis and submitted the billa for Rs.14,628/- and further again remained admitted in PGI Hospital Chandigarh for the period from 5.7.2016 to 12.7.2016 due to alcoholic liver disease with cirrosis and submitted the bills for Rs.1,01,409/- to the OPs for reimbursement.  It is further averred that since the claim arose out of use of alcohol abuse/drug, as such, it was found that the claim is not payable, as such it was rejected in view of notification number 21/28/12-5HB5/268 dated 30.10.2015. 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, it is admitted that the complainant is working as driver with the OP and the insurance was got done as per the terms and conditions of the policy. It is also admitted that the complainant spent an amount of Rs.1,16,118/- on the treatment.  It is admitted that the complainant submitted the bills to the OP number 4 and thereafter the same were taken back for submission to the insurance company.  The other allegations levelled in the complaint have been denied in toto.

 

4.             In reply to the complaint filed by Ops number 5 and 6, legal objections are taken up on the grounds that the 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 complainant being a government employee was insured under the insurance policy in question. 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-114 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.OP1to 3/5 copies of documents and affidavits and closed evidence. The learned counsel for OP number  4 has produced Ex.OP4/1 to Ex.OP4/7 copies of documents and affidavits and closed evidence. The learned counsel for OP 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 was insured with the OPs number 1 and 2 under the medical insurance 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 was admitted in Rajindra Hospital Patiala as well as PGI Hospital, Chandigarh for the period from 2.7.2016 to 12.7.2016  and spent an amount of Rs.1,01,490/- plus Rs.14,628/- on his treatment, but the grievance of the complainant is that the OPs number 1  to 3 have wrongly and illegally repudiated the rightful claim of the complainant on the ground that the complainant has been treated for alcoholic hepatitic condition with complications.  On the other hand, the learned counsel for Ops number 1 to 3 has contended vehemently that since the complainant was an alcoholic, as such the claim is not payable under exclusion clause ‘influence of intoxicating drugs or alcohol’ of the insurance policy.  But, we are unable to go with this contention of the learned counsel for the Ops number  1 to 3 as the policy in question was purchased by the Government of Punjab and no where the complainant was ever asked that whether he is alcoholic or not nor there is any cogent, reliable and trustworthy evidence produced by the Ops number 1 to 3 that the claim is not payable under the policy, if the complainant is a regular alcoholic.  In the present case, there is nothing on record produced by the OPs that the complainant submitted any wrong information at the time of getting the insurance policy, as the policy in question was purchased by the government of Punjab for insuring its employees.  Similar view was also taken by the Hon’ble Punjab State Commission in case titled as Bajaj Allianz Life Insurance Company Limited versus Balbir Kaur, First Appeal No.1249 of 2009 decided on 3.4.2013. In the circumstances, we feel that ends of justice would be met if the Ops number 1 to 3 are directed to pay to the complainant the claim amount so payable in view of the regulations.

 

8.             Accordingly, in view of our above discussion, we  allow the complaint partly and direct  Ops number 1 to 3 to settle the claim and pay the due amount to the complainant in view of the regulations. The Ops number 1 to 3  are further directed to pay to the complainant an amount of Rs.5,000/- in lieu of litigation expenses.  This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        April 5, 2018.

 

                                                                                             

                                                                (Sarita Garg)

                                                            Presiding Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member