Complainant Mohan Dass has filed the present complaint U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the opposite party to make the payment of amount spent by him on his treatment in terms of the Insurance Policy alongwith interest @ 18% P.A. from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation on account of mental agony, physical harassment and deficiency in service on their part alongwith Rs.5,000/- as litigation expenses, 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 were entitled for free treatment as per above mentioned policy. The opposite party no.2 is third party Administrator (TPA) as service provider and are 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 opposite parties. On 15.10.2016, he suffered grievous head and facial injuries in an accident. He was rushed to Amandeep Hospital, Amritsar where he remained admitted from 15.10.2016 to 24.10.2016. An amount of Rs.2,58,749/- was spent by him  on his treatment which includes Hospital bills, Medicine bills and Lab test etc. He is entitled for the refund as per policy of the Govt. He submitted his claim to the opposite parties supported with medical bills, documents and reports etc but till today they have not reimburse the abovementioned 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 till today no action has been taken by the opposite parties. On account of this illegal act, he is suffering physically, mentally as well as financially for no fault on his part. A legal notice dated 14.7.2017 was served upon the opposite party no.1 but the opposite party has not taken any action into the matter till today. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.           Upon notice, the opposite party no.1 and 2 appeared through its counsel and filed its written version taking the preliminary objections that the complaint filed by the complainant against the opposite party is hopelessly pre-mature and the complaint is not maintainable. On merits, it was submitted that the complainant had lodged his claim for reimbursement of the amount on his medical treatment, but due to non-supplying the requisite documents to the abovesaid TPA, he is not in a position to settle the claim under the terms and conditions of the PHEHIS. Hence, till the date, the claim is closed for want of requisite documents. There is no deficiency in service on the part of the opposite parties. 

4.      The opposite party no.3 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable. On merits, it was submitted that the complainant submitted re-imbursement bill of their treatment before the opposite party no.1 and 2. As per notification issued by the Punjab Govt. Director Health and Family Welfare, Punjab Chandigarh dated 20.10.2015 stated therein that the scheme will be applicable to all the Govt. Serving Employees and pensioners and all the amount of re-imbursement will be paid to the complainant by opposite partyno.1 and 2. Thus, the opposite party no.3 is not liable to pay any amount under this notification.  All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs. 

5.      Complainant tendered into evidence his own affidavit Ex.C-W-I, along with the other documents exhibited as Ex. C1 to Ex.C26 and closed the evidence.

6.        On the other hand, counsel for the opposite party no.1 and 2 tendered into evidence affidavit of Karam Singh S.D.M. Oriental Insurance Company Ex.OP-1,2/1 and closed the evidence.

7.       Sh. Parminder Singh Junior Assistant tendered into evidence affidavit of Dr.Sunita Bhalla, Assistant Civil Surgeon Ex.OP-3/1 and closed the evidence.

8.        We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for the respective contestants. We find that the present dispute has arisen at the admitted but impugned closure amounting to ‘repudiation’ by the OP2 TPA (Third Party Administrator) of hospitalization-treatment expenses reimbursement claim pertaining to the PGEPHIS Med-claim Policy (facilitating cash-less medical-aid and treatment to the Punjab Govt. Employees at the Govt. Hospitals/ Network Hospitals and reimbursement @ Govt./ Network Hospital Rates of medical expenses incurred at other than Govt./ Network Hospitals) on the flimsy grounds of non-submission of the OP2 TPA  requisitioned documents comprising of Hospital Admission and Discharge Cards.             

9.       We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the closure/repudiation through their written statement and accompanying lone affidavit (Ex.OP1,2/1) on the grounds as mentioned out above as per the paragraph ‘1’ of the written statement being allegedly in contravention of the terms of the Policy etc with no other independent/ cogent evidence of the same; and that surely indicates that the ‘claim’ has been repudiated on flimsy grounds for collateral reasons. Firstly, the TPA cannot legally repudiate/ settle a mediclaim on its own; it can simply put forth its recommendatory opinion for consideration by the OP insurers while deciding the same. The OP insurers are desired to settle the claim per the overall evidence available on cogent grounds and not on the hearsay conjectures and presumptions. The OP requisitioned documents are duly available on the records of the present proceedings and could also have been easily procured by the OP2 TPA from Hospital that has been on its network Hospitals List.   

10.     We observe that the complainant has sufficiently and satisfactorily proved the contents of his allegation-contented complaint vide his deposition (affidavit Ex.Cw-1) and other evidentiary documents exhibited here as: Ex.C1 to Ex.C26. The OP Insurers/service providers have somehow admitted the principal facts and have deposed its other contentions vide its lone Affidavit Ex.OP1,2/1 but have somehow not produced any other cogent evidence in support of the bald rebuttals that however fail to prove/ establish the main pleading of non-submission of requisitioned documents. The OP’s other pleas of ‘pre-mature’ complaint and non-existence of an ‘insurance contract’ with the complainant does not hold water, either. We find that the OP2 TPA requisitioned documents have been available on the present proceedings records but the OP insurers did not opt to settle the impugned claim even during the pendency of the complaint to prove its bonafide whereas the complainant being a ‘beneficiary’ to the insurance cover (qua the applicable policy) shall be held to be the statutory consumer even in absence of an express insurance contract.        

11.     We find that the instant impugned claim-closure/repudiation has not been in resonance with the contracted terms of the Policy and the present complainant shall be entitled to statutory relief. Lastly, we set aside the impugned closure/repudiation in favor of the complainant for a fresher settlement.                                                        

12.     Finally, we partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ in full pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.                                

13.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                                                                           (Naveen Puri)

                                                                                   President.                                                                                               

ANNOUNCED:                                               (Jagdeep Kaur)

July 20, 2018                                                                    Member.

*MK*