Order by:

Sh.Amrinder Singh Sidhu, President

1.       Smt.Krishna Devi, complainant  has filed the instant complaint under section 12 of  the Consumer Protection Act, 1986 (as amended upto date) on the allegations that  she is a senior citizen and is law abiding  person and was  doing the service in Education Department as Teacher. Now the complainant has been retired from the service and receiving the pensions from the government.  The Complainant alleges that being the Punjab Government Employee, she was insured with Opposite Parties during the period 01.01.2016 to 31.12.2016 and in this regard, Opposite Party No.1- Insurance Company also issued  Id Card No. MD15-09988322850 to the complainant i.e. Punjab Government Employee and Pensioners Health Insurance Scheme (PGEHIS), having PPO No.189940, Type Pensioner.  It is also pertinent to mention over here that during the issuance of the said card to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. Moreover, as per the guidelines of the Health Insurance, the bills of seven days pre-hospitalization and 30 days post hospitalization were covered in this scheme of the Opposite Parties. Unfortunately, on 8.5.2016 at about 5.30 PM  (on Sunday),  the complainant suffered with Severe Acute Panratites Attack with severe abdomen pain and vomiting  and the complainant became unconscious and she was immediately in emergency brought to the nearest hospital i.e. Sidhu Hospital, Dutt Road, Moga by her husband with the help of neighbors, where the doctors started  the treatment of the complainant, got some tests conducted and the treating doctors told that the complainant had suffered with  Acute Panratites Attack. The complainant remained in Sidhu Hospital, Moga from 08.05.2016 to 12.05.2016, where the complainant could not recover and thereafter, seeing the critical condition of the complainant, advised to admit the complainant in some specialty hospital. In this regard, the doctor of Sidhu Hospital, Moga also issued Emergency Certificate. In Sidhu Hospital, Duttt Road, Moga, an amount of  Rs.38,303/- has been charged from the complainant for the medical treatment and tests/ scans etc.for the period, the complainant remained admitted w.e.f. 08.05.2016 to 12.05.2016, the detail of which is enclosed herewith. She further alleges that thereafter, when the complainant could not recover then, in the emergency condition, the complainant was admitted in P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh on 13.5.2016, where the complainant remained admitted from 13.05.2016 to 17.5.2016 and in hospital at Chandigarh,  the complainant spent Rs.54,781/- from the complainant. Said hospital also issued the complainant, the emergency certificate, copy of which is also enclosed herewith. When the complainant could not recover from Panratites Attack problem, at last on 29.6.2016, she was again admitted in P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh  where said hospital conducted the operation upon the complainant and  removed the Gall Bladder of the complainant and the complainant was discharged on 30.06.2016, where again the P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh   charged Rs.50,651/- from the complainant, the detail of which is enclosed herewith.

That after discharge from the hospital, the complainant submitted the claim  of her reimbursement of expenditure spent by her on the treatment alongwith copies of bills and essentiality certificate and completed all the formalities, with Opposite Party No. 2-MD India through Suvidha Centre, Counter No. 13, Moga well within time. It is very shocked to mention over here  that Opposite Party No. 2 returned the claim of the complainant  on 29.9.2016 and 18.10.2016 without any reasonable cause mentioning that the complainant should take the treatment from some cashless hospital, photo copy of the repudiation letter is enclosed herewith. Not only this, after the rejection of the claim of the complainant by Opposite Parties No.1 and 2, the complainant also submitted her medical claim with her parent department i.e. Opposite Party  No.4-DEO on 30.01.2017, but Opposite Party  No.4 refused to reimburse  the claim of the complainant vide letter No. 2518 dated 10.3.2017 stating that during the period 1.1.2016 to 31.1.2016, there was cashless scheme issued by Opposite Parties No.1 and 2 to the Punjab Government Employees and Pensioners, copy of the said letter is also enclosed herewith.  The Complainant further alleges that  she was got admitted in unconscious condition in nearest hospital when she was suffering with Severe Acute Panratites Attack with severe pain abdomen and vomiting and the complainant was immediately in emergency brought to the nearest hospital i.e. Sidhu Hospital, Dutt Road, Moga by her husband with the help of neighbors where due to emergency and threat of her life, the doctors advised immediate care of the complainant to save here life and attendants of the complainant were not aware about the insurance in question and in emergency, they done as per the advice of the doctors to save only the life of the complainant. But after the treatment when the complainant lodged the claim for reimbursement with the Opposite Parties, now the Opposite Parties are denying the genuine claim on the basis of certain terms and conditions, where were never explained or supplied to her at the time of inception of insurance policy by any of the Opposite Parties.  Moreover, from the medical record of the complainant, it is clear that she was admitted in hospital in emergency conditions and in emergency, the treating doctors gave her treatment best available at that time to save her life. It is quite natural in the time of emergency where there is threat to the life of patient, the patient or her attendants immediately will approach to the nearest hospital or doctors and will take treatment as per the advise of doctors to save the life of the patient and not supposed to find the hospital or go for the treatment as per alleged terms and conditions of insurance company, which can be fatal for patient. Even as per notification date 20.10.2015 regarding said insurance scheme at clause no.4, it is clear that reimbursement can be taken by any employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances. In view of the above, the insurance companies can not deny the reimbursement of his medical bills to patient or hospital. Further,  the repudiation of the genuine claim of the complainant was made by Opposite Party No. 2-MD India Health Insurance TPA Private Limited, copy of which is enclosed herewith, but said TPA has no authority to reject the claim- such power lies, exclusively with the Insurance Companies. Thereafter, the complainant approached the Opposite Parties time and again for the reimbursement of her  genuine medical claim and  initially, the Opposite Parties have been lingering on the matter on one pretext but at last, Opposite Party No. 2 repudiated the claim of the complainant vide letter dated 10.01.2018 and flatly refused to reimburse the claim of the complainant, as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

1. The Opposite Parties may be directed to reimburse the medical claim of the complainant amounting to Rs.1,43,735/- as detailed above alongwith future interest  @ 12 % per annum from the date of payment to the respective hospitals till its actual realization.

 b)     The amount of Rs.2,00,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant.

c)       The cost of complaint amounting to Rs.20,000/- may please be allowed.

d)      And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Parties  No.1 and 2 appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that there is complicated question of law and facts involved and the same can not be adjudicated in summary proceedings, therefore this Commission has got no jurisdiction to try and decide the present complaint; that from the allegations of the complaint, the Complainant does not fall under the definition of Consumer Protection Act. The claim of the Complainant was repudiated under para No.4 of the Notification  No.21/28/12-5HB5/268 dated 20.10.2015 of the Department of Health & Family Welfare as well as letter dated 18.10.2016 and 19.01.2017 of MD India Health Insurance TPA Private Limited and intimation to this effect was sent to the Complainant. On merits, it is alleged that as per the tender of Punjab Government, the insurance company issued a insurance policy namely Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) w.e.f. 01.01.2016 to 31.12.2016 as per terms and conditions framed and implemented by Punjab State Government and detail of scheme was made available by State Government in public domain W.W.W.pbhealth.govt.in and hence the claim of the complainant was repudiated under para No.4 of the Notification dated 20.10.2015 of Government of Punjab, Department of Health & Family Welfare. As per para 4 of the notification, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available. However, it is clarified that the bills pertaining to government hospitals like, PGIMER Chandigarh and General Hospital, Chandigarh will be reimbursed to the employees on submission of their bills to the Insurance Company. Hence, there is no deficiency in service on the part of the answering Opposite Parties. Hence, it is prayed that the complaint against Opposite Parties No.1 and 2 may be dismissed with costs.        

3.       Initially, Sh.Harvinder Singh, Legal Assistant appeared on behalf of  Opposite Party No. 3, but lateron none has come present on behalf of  Opposite Party No. 3 nor filed the written reply and as such, Opposite Party No. 3 was proceeded against exparte vide order dated 17.01.2019. Similarly, none has come present on behalf of Opposite Party No.4 despite service, accordingly Opposite Party No.4 was also proceeded against exparte vide order dated 17.01.2019  of this District Commission.

4.       In order to  prove  her  case, the complainant has tendered into evidence, her affidavit Ex.C1 alongwith documents i.e. Ex.C2 self attested copy of identify card, Ex.C3 to Ex.C7 self attested copy of repudiation letters, Ex.C8 self attested copy of claim form, Ex.C9 self attested copy of reply by DEP Moga, Ex.C10, self attested copy of letter to MD India, Ex.C11 self attested copy of Essentiality Certificate, Ex.C12 to Ex.C1,   self attested copy of bills, Ex.C16 to Ex.C18  self attested copy of Investigations/ Diagnosis, Ex.C19 self attested copy of Certificate and Authority letter Ex.C47 and closed her evidence.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties  No.1 and 2 also tendered into evidence  the affidavit of Sh.Muneesh Nagpal Ex.OPsW/1,  copy of letter of TPA Ex.OP1,2/1 to Ex.OP1,2/4, copy of repudiation letter Ex.OP1,2/5 to  Ex.OP1,2/7,  copy of letter Ex.OP1,2/8.

6.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

7.       During the course of arguments, Ld.counsel for the Complainant has mainly reiterated the facts as narrated in the complaint and contended that the complainant has been retired from the service and now receiving the pension from the government. Further contended that  being the Punjab Government Employee, the Complainant was insured with Opposite Parties during the period 01.01.2016 to 31.12.2016 and in this regard, Opposite Party No.1- Insurance Company also issued  Id Card No. MD15-09988322850 to the complainant i.e. Punjab Government Employee and Pensioners Health Insurance Scheme (PGEHIS), having PPO No.189940, Type Pensioner.  It is the case of the Complainant that at the time of  issuance of the said card to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. Moreover, as per the guidelines of the Health Insurance, the bills of seven days pre-hospitalization and 30 days post hospitalization were covered in this scheme of the Opposite Parties. Further contended that on 8.5.2016 at about 5.30 PM  (on Sunday),  the complainant suffered with Severe Acute Panratites Attack with severe abdomen pain and vomiting  and the complainant became unconscious and she was immediately in emergency brought to the nearest hospital i.e. Sidhu Hospital, Dutt Road, Moga by her husband with the help of neighbors, where the doctors started  the treatment of the complainant, got some tests conducted and the treating doctors told that the complainant had suffered with  Acute Panratites Attack. The complainant remained in Sidhu Hospital, Moga from 08.05.2016 to 12.05.2016, where the complainant could not recover and thereafter, seeing the critical condition of the complainant, advised to admit the complainant in some specialty hospital. In this regard, the doctor of Sidhu Hospital, Moga also issued Emergency Certificate. In Sidhu Hospital, Duttt Road, Moga, an amount of  Rs.38,303/- has been charged from the complainant for the medical treatment and tests/ scans etc.for the period, the complainant remained admitted w.e.f. 08.05.2016 to 12.05.2016, the detail of which is enclosed herewith. Ld.counsel for the Complainant further contended that  thereafter, when the complainant could not recover then, in the emergency condition, she was admitted in P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh on 13.5.2016, where the complainant remained admitted from 13.05.2016 to 17.5.2016 and in hospital at Chandigarh,  the complainant spent Rs.54,781/- from the complainant. Said hospital also issued the complainant, the emergency certificate, copy of which is also enclosed herewith. When the complainant could not recover from Panratites Attack problem, at last on 29.6.2016, she was again admitted in P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh  where said hospital conducted the operation upon the complainant and  removed the Gall Bladder of the complainant and the complainant was discharged on 30.06.2016, where again the P.N. Urology & Surgical Hospital Pvt.Limited, # 1359, Sector 40-B, Chandigarh   charged Rs.50,651/- from the complainant. After discharge from the hospital, the complainant submitted the claim  of her reimbursement of expenditure spent by her on the treatment alongwith copies of bills and essentiality certificate and completed all the formalities, with Opposite Party No. 2-MD India through Suvidha Centre, Counter No. 13, Moga well within time, but very shockingly the Opposite Party No. 2 returned the claim of the complainant  on 29.9.2016 and 18.10.2016 without any reasonable cause mentioning that the complainant should take the treatment from some cashless hospital. Not only this, after the rejection of the claim of the complainant by Opposite Parties No.1 and 2, the complainant also submitted her medical claim with her parent department i.e. Opposite Party  No.4-DEO on 30.01.2017, but Opposite Party  No.4 refused to reimburse  the claim of the complainant vide letter No. 2518 dated 10.3.2017 stating that during the period 1.1.2016 to 31.1.2016, there was cashless scheme issued by Opposite Parties No.1 and 2 to the Punjab Government Employees and Pensioners, copy of the said letter is also enclosed herewith.  Ld.counsel for the Complainant further contended that  the Complainant was got admitted in unconscious condition in nearest hospital when she was suffering with Severe Acute Panratites Attack with severe pain abdomen and vomiting and the complainant was immediately in emergency brought to the nearest hospital i.e. Sidhu Hospital, Dutt Road, Moga by her husband with the help of neighbors where due to emergency and threat of her life, the doctors advised immediate care of the complainant to save here life and attendants of the complainant were not aware about the insurance in question and in emergency, they done as per the advice of the doctors to save only the life of the complainant. But after the treatment when the complainant lodged the claim for reimbursement with the Opposite Parties, now the Opposite Parties are denying the genuine claim on the basis of certain terms and conditions, where were never explained or supplied to her at the time of inception of insurance policy by any of the Opposite Parties.  Moreover, from the medical record of the complainant, it is clear that she was admitted in hospital in emergency conditions and in emergency, the treating doctors gave her treatment best available at that time to save her life. It is quite natural in the time of emergency where there is threat to the life of patient, the patient or her attendants immediately will approach to the nearest hospital or doctors and will take treatment as per the advise of doctors to save the life of the patient and not supposed to find the hospital or go for the treatment as per alleged terms and conditions of insurance company, which can be fatal for patient. Even as per notification date 20.10.2015 regarding said insurance scheme at clause no.4, it is clear that reimbursement can be taken by any employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances. In view of the above, the insurance companies can not deny the reimbursement of his medical bills to patient or hospital. Further,  the repudiation of the genuine claim of the complainant was made by Opposite Party No. 2-MD India Health Insurance TPA Private Limited, but said TPA has no authority to reject the claim- such power lies, exclusively with the Insurance Companies. Thereafter, the complainant approached the Opposite Parties time and again for the reimbursement of her  genuine medical claim and  initially, the Opposite Parties have been lingering on the matter on one pretext but at last, Opposite Party No. 2 repudiated the claim of the complainant vide letter dated 10.01.2018 and flatly refused to reimburse the claim of the complainant, as such, there is deficiency in service on the part of the Opposite Parties.

8.       On the other hand, ld.counsel for Opposite Parties No.1 and 2 has repelled the aforesaid contention of the ld.counsel for the Complainant on the ground that  there is complicated question of law and facts involved and the same can not be adjudicated in summary proceedings, therefore this District Commission has got no jurisdiction to try and decide the present complaint and Ld.counsel for the Opposite Parties No.1 and 2 further contended that the claim of the Complainant was repudiated under para No.4 of the Notification  No.21/28/12-5HB5/268 dated 20.10.2015 of the Department of Health & Family Welfare as well as letter dated 18.10.2016 and 19.01.2017 of MD India Health Insurance TPA Private Limited and intimation to this effect was sent to the Complainant. As per the tender of Punjab Government, the insurance company issued a insurance policy namely Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) w.e.f. 01.01.2016 to 31.12.2016 as per terms and conditions framed and implemented by Punjab State Government and detail of scheme was made available by State Government in public domain W.W.W.pbhealth.govt.in and hence the claim of the complainant was repudiated under para No.4 of the Notification dated 20.10.2015 of Government of Punjab, Department of Health & Family Welfare. As per para 4 of the notification, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available. Moreover, the bills pertaining to government hospitals like, PGIMER Chandigarh and General Hospital, Chandigarh will be reimbursed to the employees on submission of their bills to the Insurance Company. Hence, there is no deficiency in service on the part of the answering Opposite Parties.

9.       There are three points on which the Opposite Parties have repudiated the claim of the Complainant.

a)       There is complicated question of law and facts involved and the same can not be adjudicated in summary proceedings, therefore this District Commission has got no jurisdiction to try and decide the present complaint.

b)      The claim of the Complainant was repudiated under para No.4 of the Notification  No.21/28/12-5HB5/268 dated 20.10.2015 of the Department of Health & Family Welfare as well as letter dated 18.10.2016 and 19.01.2017 of MD India Health Insurance TPA Private Limited.

c)       The Complainant should take the treatment from some cashless hospital.  

10.     On the other hand, ld.counsel for the Complainant has vehemently contended that (i)at the time of  issuance of the said card to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant, (ii) the Opposite Parties have no authority to reject the genuine claim of the consumer mere on the basis of opinion/ report of TPA (Third Party Agent) and (iii) during the emergency period, the Complainant had no alternative, but firstly it was mandatory to save her life by admitting herself in the nearest hospital.   

11.     First of all, the Consumer Fora/ Commission has fullest jurisdiction to settle the disputes relating to complicated questions of facts, as  per law laid down in case Bharat Sanchar Nigam Limited (BSNL) and another vs. M.D. Imtiyaz-IV (2014) CPJ- 25 (Meghalaya State Consumer Disputes Redressal Commission). So, certainly this District Consumer

12.     Secondly, it is also not disputed that the Complainant remained admitted during the policy period. It is also not disputed that the claim of the Complainant was repudiated by the Opposite Parties  vide repudiation letter dated 10.07.2018 (Ex.OP1,2/7) merely on the report of MDIndia Health Insurance TPA Private Limited. Perusal of the repudiation letter Ex.OP1,2/7 shows that  the claim of the Complainant has been repudiated by the Opposite Parties merely on the basis of MDIndia Health Insurance TPA Private Limited.  But recently, our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperataive Agriculture service Society & Others has held that TPAs have no authority to reject the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27). The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA. In view of this, the repudiation merely on the basis of report of the TPA is not legal.  

13.     The next plea  raised by the Opposite Party  is that the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  But the Opposite Party could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party,  it is clear that Opposite Party  has failed to prove on record that they did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”  Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that

“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”

14. Further plea of the Opposite Parties that  the Complainant should taken treatment from some cashless hospital. On the other hand, Ld.counsel for the Complainant contended that the Complainant was   got admitted in unconscious condition in nearest hospital when she was suffering with Severe Acute Panratites Attack with severe pain abdomen and vomiting and the complainant was immediately in emergency brought to the nearest hospital i.e. Sidhu Hospital, Dutt Road, Moga by her husband with the help of neighbors where due to emergency and threat of her life, the doctors advised immediate care of the complainant to save here life and attendants of the complainant were not aware about the insurance in question and in emergency, they done as per the advice of the doctors to save only the life of the complainant and the said hospitals were  non-empanelled hospital at the relevant. 
15. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated.  Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Specialty Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. In the facts of the present case, it cannot be denied that the  Complainant was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the Opposite Parties have denied the grant of medical reimbursement to the Complainant and   forcing her to approach this District Commission. To support her version, the Complainant has relied upon the judgement of  Hon’ble Supreme Court of India in case titled  Shiva Kant Jha Vs. Union of India in Civil Writ Petition No. 694 of 2015, decided on 13.04.2018 has held that the government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities even if they receive treatment at non-empanelled hospital and no fetters can be placed on his rights. 

16.     Ld.counsel for the complainant has further contended that  the written version  filed on behalf of the Opposite Party  has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. The Opposite Party  is limited Company and written version has been filed on the basis of special power of attorney given  to ld.counsel for the Opposite Party. He has relied upon the judgment (2011)II Supreme Court Cases 524 titled as “State Bank of Travancore Vs. Kingston Computers India Pvt. Ltd.” and in para no.11 of the judgment, it was held that

“the plaint was not instituted by an authorized person. On the plea that one authority letter dated 02.01.2003 was issued by Sh. R.K.Shukla in favour of Sh. A.K.Shukla. Further plaint failed to place on record its memorandum/articles to show that Sh. R.k.Shukla has been vested with the powers or had been given a general power of attorney on behalf of the Company to sign, verify and institute the suit on behalf of the Company.”

Similar proposition came before the Hon’ble Delhi High Court in “Nibro Ltd. Vs. National Insurance Co. Ltd.”, 2 (2005) 5SCC 30 that the

“bear authority is not recognized under law and ultimately, it was held that the plaint was not instituted by an authorized person. Here also appellant has not placed on record any resolution passed by any Board of Director in favour of Mr. Soonwon Kwon and that he was further authorised to delegate his power in favour of any other person. Further there is no memorandum/articles of the Company to show that Mr. Soonwon Kwon is one of the Director of the Company. In the absence of that evidence on record we cannot say that the special power of attorney given by Director Soonwon Kwon is a competent power of attorney issued in favour of Sh. Bhupinder Singh. In the absence of any resolution of the Company or any memorandum/articles of the Company to show that Sh. Soonwon Kwon is Director and that he was further authorised to issue power of attorney in favour of Sh. Bhupinder Singh.”

Recently our own Hon’ble State Commission, Punjab Chandigarh in FAO No.1235 of 2015 decided on 25.01.2017 in case titled as L.G.Electronics India Private Limited Vs. Sita Ram Chaudhary also held that the plaint instituted by  an unauthorized person has no legal effect.

17.     In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

18.     In view of the above discussion, we are of the opinion that the Opposite Parties have wrongly and illegally repudiated the claim of the complainant. Consequently, we allow the complaint and  the Opposite Parties  No.1 and 2 are  jointly and severally directed to reimburse the medical bill of the Complainant amounting to Rs.1,43,735/- (Rupees one lakh forty three thousands seven hundred and thirty five only)  alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 13.07.2018 till its actual realization.  Opposite Parties No.1 and 2 are also directed to pay the lump sum compensation to the complainant to the tune of Rs.10,000/- (ten thousands only) on account of harassment, mental tension  and litigation expenses.  Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance. 19.     Reason for delay in deciding the complaint.

This complaint could not be decided within the prescribed period because the government has not appointed any of the two Whole Time Members in this Commission since 15.09.2018. Moreover, the President of this Commission is doing additional duties at District Consumer Commission, Bathinda as well as Faridkot. There is only one working day in a week when the quorum of this Commission remains complete.  

Announced in Open Commission.

Dated: 12.03.2021.