Punjab

Sangrur

CC/530/2017

Sushil Devi - Complainant(s)

Versus

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

Sh.Naveen Shrivastav

12 Mar 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    530

                                                Instituted on:      09.10.2017

                                                Decided on:       12.03.2018

 

 

Sushil Devi aged about 66 years wife of Late Sh. Ramesh Chander, resident of Dashmesh Avenue, Street No.5, H.No.69, Opposite Nam Dev Gurudwara, Sangrur.

                                                        …Complainant

                                Versus

1.             The Oriental Insurance Co. Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Manager.

2.             M.D. India Health Insurance TPA Private Limited, Tower 1^st Floor, Plot No. F-539, Phase-8-B, Industrial Area, Airport Road, Mohali through its Managing Director.

3.             Director, Health & Family Welfare, Punjab,  Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.

4.             Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, Near Civil Hospital, Sahibzada Ajit Singh Nagar, Mohali through its Secretary, Health cum Managing Director.

                                                        ..Opposite parties.

 

 

For the complainant            :       Shri Naveen Srivastava, Adv.

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

For Opp.Party No.3&4       :       Ms.Amandeep Bhangu, Adv.

 

 

 

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

 

Order by : Sukhpal Singh Gill, President.

 

1.             Smt. Sushil Devi, 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 husband of the complainant, namely, Shri Ramesh Chander being a government employee was working in Punjab Health Department, Sangrur and died during his service on 16.5.2001 and as such thereafter the complainant became pensioner being his legal heir and the complainant was insured with the OPs under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD-15-09464512144 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 May, 2016 she suffered some health problem and she got herself checked from the doctor of Singla Surgical and Maternity Hospital, Sangrur, who advised the complainant an operation.  Further case of the complainant is that she admitted in the hospital on 1.6.2016, where PFR     was done under SA and was further discharged from the hospital on 3.6.2016, where she spent an amount of Rs.21,434/- on her treatment. Further case of the complainant is that after the treatment, she lodged the claim and  submitted all the bills to the OP number 2 for release of the payment, but the Ops repudiated the claim of the complainant. The complainant has further averred that though she approached the Ops on various occasion for reimbursement of the claim amount, but all in vain. 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.21,464/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by Ops number 1 and 2, 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 Singla Surgical and Maternity Hospital, Sangrur from 1.6.2016 to 3.6.2016, where PFR done SA (diagnosis for Rectocele) and the complainant submitted the bills of Rs.21,434/- for reimbursement, but the claim was found not payable being admission in non empanelled hospital in Punjab and Chandigarh in non emergency case, as such according to clause 4 of the Gazette notification dated 20.10.2015, the claim of the complainant was rightly repudiated. 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 to the complaint filed by Ops number 3 and 4, 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, insurance card in question was issued. The other allegations levelled in the complaint are denied as the matter is between the complainant and the insurance company.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-9 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 4 has produced Ex.OP3&4/1 to Ex.OP3&4/5 copies of documents and affidavits and closed evidence.  

 

5.             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 dismissal, for these reasons.

 

6.             It is an admitted fact between the parties that the complainant being a Punjab government pensioner, she was insured with the OPs number 1 and 2 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 was admitted in Singla Surgical and Maternity Hospital Sangrur and the doctor advised her operation which was done on 1.6.2016 and the complainant remained admitted there upto 3.6.2016, where she spent an amount of Rs.21,434/-, but the grievance of the complainant is that the OP number 1 and 2 has wrongly and illegally repudiated the rightful claim of the complainant.  On the other hand, the learned counsel for Ops number 1 and 2 has contended vehemently that it is not an emergency case, whereas it is the own case of the complainant that in the month of May, 2016, the complainant suffered from health problem and got herself checked from the doctor of Singla Surgical and Maternity Hospital, Sangrur, where she was advised for operation.  The complainant got conducted operation on 1.6.2016 by spending an amount of Rs.21,434/-.  But, we may mention that there is not even a single document on record to show that it was a case of emergency, where the operation was required immediately.  The complainant should go for getting the operation in the empanelled hospital or in any government hospital. There is no explanation from the side of the complainant that why she did not do so, as it was not a case of emergency one.  Since the complainant has miserably failed to prove her to be a case of emergency one, we feel that the complaint of the complainant deserves dismissal on this score alone as first she should go to the empanelled hospital for her treatment.

 

7.             Accordingly, in view of our above discussion, we  dismiss the complaint of the complainant. However, the parties are left to bear their own costs. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        March 12, 2018.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member