Punjab

Nawanshahr

CC/41/2017

Head Constable Rattan Lal - Complainant(s)

Versus

The Project Coordinator - Opp.Party(s)

MK Dutta

09 Jul 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHAHEED BHAGAT SINGH NAGAR. 

 

Consumer Complaint No    :    41 of 2017

Date of Institution                         :    18.08.2017          

Date of Decision                 :    09.07.2018

Head Constable Rattan Lal, Belt No.273, Punjab Police/Shaheed Bhagat Singh Nagar.

                                                          ….Complainant

Versus

  1. M.D. India Health Insurance TPA Private Limited, through the Project Co-Ordinator, Max Pro Info Park D-38, Industrial Area, Phase-1, Mohali, Punjab 160056.
  2. Oriental Insurance Company Limited having its Branch Office at Rahon Road Nawanshahr, through its Branch Manager.

Opposite parties

Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:         

S.A.P.S. RAJPUT, PRESIDENT

S.KANWALJEET SINGH, MEMBER

COUNSEL FOR THE PARTIES

For Complainant           :         Sh.M.K. Dutta, Advocate

For OPs                         :         Sh. P.K Dhir, Advocate

 

ORDER 

PER S.KANWALJEET SINGH, MEMBER

  1. This complaint filed by complainants under Section 12 of the Consumer Protection Act, 1986.  Further, it is averred that complainant is serving as Head Constable in Punjab Police and is one of beneficiary of Bhai Kanhaiya Sehat Sewa Scheme launched by State of Punjab vide which he was entitled to get his medical treatment cashless from the authorized Medical Institution.  Complainant got his medical treatment from Dayanand Medical College and Hospital Ludhiana where he admitted from 12.06.2016 to 19.09.2016.  During this period medical reimbursement certificate to the tune of Rs.41611/- was issued by concerned official of said Hospital which was to be reimbursed by OPs.  After completion of required documentation the reimbursement certificate of complainant was submitted through proper channel to the OPs but same was repudiated vide letter dated 20.01.2017 issued by OP-1 to OP-2 and subsequently same was sent to complainant by OP-2 while denying the said claim of complainant.  Thereafter, office of SSP SBS Nagar vide letter dated 30.03.2017 address to SHO, Police Station Balachaur refused to reimburse the medical expenses on the ground of objection raised by Ops. The said objection as stated in letter dated 20.01.2017 upon which claim of complainant repudiated are false and frivolous and complainant is legally entitled to medical reimbursement as stated by concerned official of DMC, Ludhiana vide its Medical reimbursement certificate received by OPs on 16.09.2016.  Lastly it is prayed that order directing the OPs make payment of Rs.41,111/- on account medical reimbursement certificate issued by DMC Ludhiana and also claimed Rs.25,000/- on account of harassment and Rs.10,000/- as litigation expenses.    
  2. Notice of the complaint was given to the OPs and  accordingly OPs appeared through counsel but later on vide order dated 27.09.2017 the counsel for OPs has made statement that he has no further instruction to press the case on behalf of OP-1. As such, counsel for OP-1 has filed written statement and contested the complaint by taking preliminary objections that this complaint is not maintainable.  The claim of complainant does not fall within the preview of policy terms and conditions.  As per doctor report complainant was suffering from fever ALD/CLD(Alcholic Liver Disease).  The claim arose out of use of alcohol abuse/drug abuse.  As PGEPHIS is public health scheme, hence the claim is not admissible within standard exclusion of IRDA. The Op No.2 has no relation/co-ordination with the OP-1 and as well as Bhai Kanhaiya Sehat Sewa Scheme.  The complaint is bad for non-joinder and mis-joinder of necessary party.  MD India Health Insurance TPA Private Limited is a necessary party.  OP No.2 has no contractual liability qua the complaint, the employee does not make any payment to be entitled to benefit under the scheme.  No consideration is deducted or paid by the employee under this scheme which is free of cost.  Thus complainant is not consumer of OP-2.  There is no privity of contact between complainant and OP-2.  On merits, it is submitted that claim of complainant was repudiated by respondent No.2 on the recommendation by the MD India Health Insurance TPA Pvt Ltd.  As per scrutiny of claim documents, date of inception 1st Jan 2016.  Patient was treated for ALD/CLD with Fever K/CO DM & HTN from 12 Sept 2016 to 19 Sep. 2016.  It means patient was habitual for using the alcohol.  The arose out of use of alcohol abuse/drug abuse.  As PGEPHIS is a public Health Scheme, hence the claim is not admissible within the standard exclusion of IRDA.  As per para -4 of notification No.21/28/12-5HBS/260 dated 20.10.2015, it has been specified that no reimbursement will be available for treatment in Punjab and Chandigarh where cashless treatment is available.   Rest of the averments have been denied by OPs and prayed for dismissal of the present complaint with costs.  Later, Sh.P.K. Dhir, Advocate has filed POA on behalf of OP-1 also and made statement on 22.11.2017 that as per instruction of his client i.e. OP-1, written statement which has already been filed on behalf of OP-2 be read as written statement on behalf of OP-1 also and as per order dated 22.11.2017 written statement filed by OP-2 be read as written statement on behalf of OP-1 also. 
  3. In order to prove complaint, counsel for complainant, tendered into evidence affidavit of complainant Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-6 and then closed the evidence.
  4. In order to rebut the evidence of the complainant, counsel for OPs tendered into evidence, affidavit of Dr.Geeta Bhardwaj Ex.OPA, alongwith documents Ex.OP-1 to Ex.OP-4, then tendered policy terms and conditions Ex.OP-5 and closed the evidence.
  5. We have heard counsel for the parties and also gone through the case file as well as written arguments filed on behalf of OPs very carefully.
  6. Learned counsel for both the parties argued similar to their respective pleadings. So no need to reproduce for want of repetition. Counsel for the OPs argued that claim is not admissible within the standard exclusion of IRDA guidelines/rules. Counsel for OPs neither mention any specific rule of IRDA in his written version nor in Ex.OPA affidavit of Dr.Geeta Bhardwaj.  Moreover, Ex.OP-1 claim file reimbursement describe only ALD/CLD (Alcoholic Liver disease) but counsel for OPs miserably fails to prove from this angle that ALD/CLD (Alcoholic Liver disease) is sufficient to repudiate the claim as per terms and conditions of the policy. 
  7. As per Ex.OP-1, the relevant portion is reproduced as:- Para No.4 of the notification No.21/28/12 5HB5/268 dated 20.10.2015.  It has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available.  On the other hand, cashless Public Health Scheme to the Punjab Government employee and pensioners was introduced by the OPs.  Ex.C-4 is a medical reimbursement certificate issued by the OPs specified penal hospital list.
  8. OPs does not explain under which specific IRDA rules applicable in the present case.  Moreover, Punjab Government Health Scheme neither justify that any particular clause or rule not applicable towards alcoholism is a disease.
  9. The Hon’ble State Consumer Disputes Redressal Commission Himachal Pradesh vide Judgment titled as Life Insurance Corporation of India Versus Smt. Krishna Devi reported in 2011 (CTJ) (CP) SCDRC has held that “Chronic Alcoholism and Alcoholic withdrawal syndrome cannot be termed as deceased.” 
  10. In view of above discussion, the present complaint is partly allowed and the OPs are directed to reimburse the claim of the complainant amounting to Rs.41,111/- alongwith interest @9% P.A. from the date of filing claim till realization. Further, the OPs are directed to pay a compensation of Rs.3,000/- for mental harassment and agony and also directed to pay litigation expenses of Rs.2,000/-.
  11. Entire compliance of aforesaid order be made within 30 days from the date of receipt of copy of this order.
  12. Copies of the order be sent to the parties, as permissible, under the rules.

Dated 09.07.2018                                                         

 

 

(Kanwaljeet Singh)                (A.P.S. Rajput)

Member                                  President

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