BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

                                                                   Complaint  No.130 of 2018

                                                                   Date of Instt. 28.03.2018

                                                                   Date of Decision: 01.10.2019

Smt. Susheela Kumari wife of Madan Lal Chawla r/o 336, Urban Estate, Phase-II, Jalandhar.

                                                                             ..........Complainants

Versus

1.       The Secretary, Health, Government of Punjab Chandigarh.

2.       Oriental Insurance Company, Regional Office, SCO No.109, 110, 111, Surindera Building, Sector 17-D, Chandigarh through its Regional Manager.

3.       MD India Healthcare Services (TPA) Private Ltd. (Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS).

          MD India Healthe Services TPA Private Ltd. Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali, Punjab-160056. Through its Authorized Representatives/M.D.

4.       Modern Hospital through Dr. Harmeet Pal Singh 39, Model Town, Jalandhar.

                                                                           ….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Karnail Singh              (President)

                              Smt. Jyotsna                      (Member)

Present:         Sh. V. B. Mehta, Adv. Counsel for the Complainant.

                              OPs exparte.

Order

                             Jyotsna (Member)

1.                The instant complaint has been filed by the complainant, wherein alleged that the OP No.1 and OP No.2 belongs to Chandigarh, OP No.3 belongs to Mohali and OP no.4 belongs to Jalandhar. The complainant is retired person from Punjab Education Department as a Hindi Teacher from Government Middle School, Kirti Nagar, Jalandhar.

2.                As per the terms of Punjab Govt. Policy guidelines, in case of both husband and wife happens to be Punjab Government Employee or Pensioner or both, only one of them was entitled to get himself/herself enrolled as a main member and the other has to be his or her depended for availing the medical facilities or claiming medical reimbursement on the rates prescribed by the Punjab Government. Since the husband of the complainant Sh. Madan Lal Chawla too had been a Punjab Government Pensioner having PPO No.252264 as such he enrolled as a main member of the scheme and the complainant being his wife was enrolled as his dependant. Accordingly, both of them are entitled to cashless medical facilities under the rules and regulations framed by the state government. On December 12, 2016, the complainant was diagnosed to be suffering from Gall bladder stone and made to undergo surgery from Modern Hospital Model Town. The relative of the complainant told the hospital authority that she had been Punjab Government Pensioner and was entitled to cashless medical treatment but no heed was paid by the said hospital and complainant was made to pay a sum of Rs.23,300/- being the full amount of the bill raised by the hospital. Thereafter, the complainant submitted the medical claim to the representative of OP No.3 and OP No.4 at the Suvidha Centre Jalandhar, vide receipt No.41542 dated 03.01.2017 for reimbursement of the medical bill paid by the complainant. On non-receipt of the reimbursement, the husband of the complainant made a call to toll free number of OP No.3 to enquire about the status of the claim. The complainant was surprised to know that her claim has been rejected without any cogent reason and as such, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse Rs.23,300/- to the complainant along with interest @ 18% per annum and OPs be further directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.30,000/- and litigation expenses of Rs.5500/-.

3.                After formal admission of the complaint, notice was issued to the OPs and OPs were declared to have been duly served, but none appeared on behalf of the OPs and consequently, OPs were proceeded against exparte.

4.                In order to prove her exparte claim, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-11 and closed the evidence.

5.                We have heard the learned counsel for the complainant and also gone through the case file very minutely.

6.                Precisely, the case set up by the complainant is that she and her husband being pensioner availed the insurance facility i.e. Ex.C-2 provided by the Govt. under the scheme known as Punjab Government employees and pensioner health insurance scheme and the complaint of the complainant is in regard to getting her treatment under the above said scheme. The complainant has submitted that she was diagnosed to be suffering from gallbladder stone and was made to undergo surgery from Modern Hospital, Model Town, Jalandhar. For which bill (Ex.C-3 to Ex.C-11) of Rs.23,300/- was paid to the said hospital. She submitted that the insurance claim to OP No.3, vide acknowledgement No.41542 dated 03.01.2017, which is Ex.C-1. However, we find that she had not brought on file any documentary proof, where-from we can construe that the claim of the complainant has been repudiated. The OPs/Insurance Company has not decided the claim of the complainant for more than 2 ½ years without any valid justification and it constitutes deficiency in service on its part. However, we feel that the OP/insurance company should be given an opportunity to decide the claim of the complainant one way or other.

7.                In view of the above detailed discussion, the complaint of the complainant is disposed off with the direction to the OP/insurance company to decide the claim of the complainant one way or other, on the basis of documents already submitted by the complainant within one month from the date of receipt of the copy of the order positively, failing which it shall be presumed that the OP/insurance company has accepted the claim of the complainant in toto. However, complainant is awarded Rs.20,000/- as compensation as the OPs/insurance company has failed to decide her insurance claim till date without any proper justification. The complainant is also awarded Rs.3500/- on account of litigation expenses. This complaint could not be decided within stipulated time frame due to rush of work.

8.               Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated                                     Jyotsna                                Karnail Singh

01.10.2019                            Member                              President