Complainant Amrik Singh through the present complaint U/S 12 of the Consumer Protection Act 1986 (hereinafter for short the Act.) has prayed for issuance of necessary directions to the opposite parties (the OP insurers) to make the payments of Rs.2,52,707/- spent by him on his treatment in terms of the Insurance Policy alongwith interest @ 18% P.A. from the due date  till actual realization.  Opposite parties be further directed to pay Rs.50,000/- as compensation for harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as costs of litigation, in the interest of justice..

2.       The case of the complainant in brief is that he is member of Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) as per policy of the Punjab Govt. and he was insured with the opposite party no.1 Insurance company for the period from 01.01.2016 to 31.12.2016. He as well as his dependent family members was entitled for free treatment as per policy. The opposite party no.2 is Third party Administrator (TPA) as service provider and is responsible for providing the services to the insured as per the terms and conditions of the Insurance policy and standing as the Privity of contract for both the parties. He has further pleaded that on 05.01.2016, he suffered from disease of Ca Pancreas Gall bladder. He remained under treatment from Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar where he treated from 05.01.2016 to 27.01.2016 and thereafter as outdoor patient till date. An amount of Rs.2,52,707/- was spent by him on his treatment which includes Hospital bills, Medicine bills and Lab tests etc. He is entitled for the refund of abovementioned amount from the opposite parties as per policy of the Govt.  Thereafter he submitted his claim to the opposite parties supported with medical bills, documents and reports etc. but till today the opposite parties have not reimbursed the above mentioned amount.  He also made representations to the opposite parties with a request to make payment of the amount spent by him on his treatment, but the opposite parties repudiated his claim on false and fake observations whereas, he has supplied entire documents to the opposite parties. On account of this illegal act of the opposite parties, he is suffering physically, mentally as well as financially for no fault on his part.  Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.      Upon notice, the opposite party no.1 appeared through its counsel and filed its written reply taking the preliminary objections that the complaint filed by the complainant is not legally maintainable against opposite party and is liable to be dismissed and no cause of action has ever arisen in favour of the complainant against the opposite party to file the present complaint, the complaint under reply is an abuse of the process of law and as such the same is liable to be dismissed, with exemplary cost.   On merits, it was submitted that as per record of opposite party no.2 NO CLAIM WAS LODGED WITH THE OPPOSITE PARTY NO.2 MD INDIA HEALTH INSURANCE TPA PVT. LTD. MOHALI by the complainant regarding his treatment. The opposite party no.1 was informed by the opposite party no.2  MD India Health Insurance TPA Pvt. Ltd. Mohali that BENEFICIARY NOT SUBMITTED CLAIM FOLDER TO TPA which means no claim was lodged by the complainant with opposite party no.2. It was further submitted that the jurisdiction of Hon'ble Commission is disputed. This Hon'ble Commission has no jurisdiction to entertain or try the present complaint as it neither amounts to deficiency of service nor amounts to unfair trade practice.  There is no insurance contract exist between beneficiaries/complainant and opposite party no.1, hence there is no point of any contractual liability or otherwise for the complaints filed by beneficiaries/complainant under Consumer Commission. There is no consideration taken from the beneficiaries/complainant by opposite party no.1. Therefore, the consumer complaints are not tenable under COPA and should be summarily rejected by the Commission. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.      Notice issued to opposite parties no.2 and 3 had not been received back. Period of 30 days had already been elapsed. Presumption could be drawn that opposite parties no.2 and 3 had been served but it was intentionally evading the service of the notice. Case called several times, but none had appeared on behalf of opposite parties no.2 and 3. Hence, opposite parties no.2 and 3 was ordered to be proceeded against exparte vide order 29.1.2019. On 12.2.2019, opposite party no.3 had moved an application for joining the proceedings in the complaint at this stage.  In the interest of justice application of opposite party no.3 was hereby allowed and opposite party no.3 was permitted to join the proceedings of this case.

5.      After obtaining the permission to join procedings, the opposite party no.3 appeared through its counsel and filed its written reply taking the preliminary objections that the complaint is not maintainable against opposite party no.3. On merits, it was submitted that as per the Punjab Govt. Instruction, the opposite party no.2 i.e. MD India Health Insurance TPA Private Ltd. MAXPRO Info Park 38-D, Mohali is responsible to release the re-imbursement bill of the complainant under the said notification.  It was next submitted that all the treatment bills of the complainant he should submitted directly to the opposite party no.2 under notification and he should paid the amount of the re-imbursement to the complainant.  The opposite party no.2 is fully responsible to release the amount of re-imbursement under the AIIMS RULE OF DELHI. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed.

6.      Rejoinders filed on behalf of complainant.

7.       Alongwith the complaint the complainant has filed his own affidavit Ex.C-1/A alongwith other documents exhibited as: Ex.C1 to Ex.C-46 and Ex.C-3A.

8.     Alongwith the written statement ld.counsel for the opposite party no.1 has filed Ex.OP-1/1.

9.       Alongwith the written statement ld.counsel for the opposite party no.3 has filed Annexure D-1.

10.      Written arguments have been filed on behalf of complainant, opposite party no.1 and 3.

11.       We have carefully gone through the pleadings of counsel for the parties; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the parties for the purposes of adjudication of the present complaint.

12.     As detailed above, the present complaint was filed by the complainant (who has retired as Head Master of Govt. High School Naniokot) regarding non reimbursement of medical claim amounting to Rs.2,52,707/- by the opposite parties. The complainant placed on record the medical bills for his treatment from Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar from 05.01.2016 to 27.01.2016. It was further pleaded by the complainant that as per Ex.C-1 he was insured by his department under Punjab Government Employees and Pensioner Health Insurance Scheme (PGEPHIS) valid upto 31.12.2016. This document was issued by opposite party no.1. As per Ex.C-2, the pension payments order also shows that the complainant was retired Punjab Government Employee.

13.     As per written reply of opposite party no.3 it has been stated that opposite party no.2 is responsible for release of reimbursement of the bills of the complainant as per notification placed at annexure D-1.

14.     As mentioned in above details opposite party no.2 was proceeded against exparte.

15.     Opposite party no.1 in their written reply stated that opposite party no.2 has informed them that the complainant has not submitted any claim to them yet. As per their copy of e-mail placed at Ex.OP-1/1 it is clearly mentioned that "we have not received any claim filed from the abovesaid beneficiary". It has also been pointed out by opposite party no.1 that there is no insurance contract between complainant and opposite party no.1 but it is towards Punjab Government only.

16.    As per document placed by complainant on record the complainant deserve the reimbursement of medical claim as the complainant was registered by his department under PGEPHIS (Health Insurance Scheme) but opposite party no.1 and 2 could not decide it due to non submission of the claim by the complainant.

17.     In view of the above, we are of the considered view that the present complaint is premature and it can be best disposed off by giving directions to both the parties.

         Hence, the complainant is directed to submit the medical claim documents to opposite party no.1 & 2 within 30 days from the date of receipt of copy of orders and opposite party no.1 & 2 are directed to decide and settle the medical claim of the complainant within 45 days of the submission of the documents by the complainant as per terms and conditions of the said policy.

          The present complaint is disposed of accordingly with no order as to costs.

  18.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and non sitting of this Commission due to pandemic of Covid-19.

19 .   Copy of the order be communicated to the parties free of charges. File be consigned.                                                                                                                                                   

         (Kiranjit Kaur Arora)

                                                                           President  

Announced:                                                           (B.S.Matharu)

April 19, 2023                                                            Member

*MK*