DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 251
Instituted on: 01.06.2017
Decided on: 14.09.2017
Ashwani Kumar Mehta son of Sh. Jagdish Chand, resident of H.No.160, Housing Board Colony, Sangrur.
…Complainant
Versus
1. The State of Punjab through District Collector, Sangrur.
2. Civil Surgeon, Punjab Health System Corporation, Sangrur.
3. Oriental Insurance Company, Nabha Gate, Sangrur through its Branch Manager.
4. Oriental Insurance Company, Quiet Office No.15, Sec. 35-A, Chandigarh through its M.D.
5. M.D.India Health Care Services (TPA) Pvt. Limited, Maxpro Info Park, D-38, 1st Floor, Industrial Area, Phase-I, Mohali through its MD.
..Opposite parties.
For the complainant : Shri Amit Aggarwal, Adv.
For Opp.party No.1to2: Ms.Amandeep Kaur, Adv.
For Opp.Party No.3&4: Shri Ashish Garg, Adv.
For Opp.party No.5 : Exparte.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Vinod Kumar Gulati, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Ashwani Kumar, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is a government employee as he is working as Steno in the office of District Collector, Sangrur and as such he was insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme. The case of the complainant is that during the subsistence of the insurance period, on 02.11.2016, the wife of the complainant was got admitted in Sangrur Surgical and Laparoscopic Centre, Sangrur in critical condition with the uterus problem, where she was got operated and the complainant spent an amount of Rs.33,224/- on her treatment. Thereafter the complainant submitted all the bills and documents to the Ops for reimbursement, but the Ops number 4 and 5 repudiated the claim of the complainant alleging that the complainant got treatment from the non empanelled hospital and it was not a case of emergency. It is further stated that nothing happened despite serving of legal notice upon the OPs. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.33,324/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply filed by Ops number 1 and 2, it is stated that the matter is between the insurance company and the complainant and the Ops number 1 and 2 have nothing to do. The other allegations levelled in the complaint have been denied.
3. In reply filed by Ops number 3 and 4, legal objections are taken up on the grounds that there are complicated questions of law and facts, that the complainant is not a consumer and that the complaint is not maintainable, that the policy was issued in favour of the Govt. of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Punjab, Mohali, but the complainant has not impleaded it as a party. On merits, it is admitted that the policy in question was issued in favour of the Govt. of Punjab for the period from 1.1.2016 to 31.12.2016 subject to the terms and conditions of the policy under which sum of Rs.3,00,000/- was insured per family on floater basis. It is further stated that as per the schedule, the liability of the company to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room. It is admitted that the complainant was admitted in Sangrur Surgical Laparoscopic Centre, Sangrur on 2.11.2016 for treatment of fibroid uterus with B/L ovarian Cyst and submitted a bill for Rs.33324/- for reimbursement, but the claim was found not payable being admission in non empanelled hospital in Punjab and Chandigarh in non emergency cases. It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee.
4. Record shows that the OP number 5 did not appear as such was proceeded exparte.
5. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-31 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1 and 2 has produced Ex.OP1&2/1 to Ex.OP1&2/4 copies of documents and affidavits and closed evidence. The learned counsel for OPs number 3 and 4 has produced Ex.OP3&4/1 to Ex.OP3&4/9 copies of documents and affidavit and closed evidence.
6. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.
7. It is an admitted fact between the parties that the complainant being a Punjab government employee was insured with the OPs under the medical policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 1.1.2016 to 31.12.2016. It is also not in dispute that during the subsistence of the insurance period, the wife of the complainant suffered illness and remained admitted in Sangrur Surgical Laparascopic Centre, Sangrur on 2.11.2016 for treatment of fibroid uterus with B/L ovarian Cyst, where she spent an amount of Rs.33324/- only and submitted the bills thereof to the Ops after discharging from the hospital. In the present case, the grievance of the complainant is that the Ops have wrongly repudiated the claim of the complainant vide letter dated 21.3.2017 on the ground that the wife of the complainant took treatment from the non empanelled hospital and further there was no emergency case for immediate treatment, as such it is contended that the claim has rightly been repudiated being not payable by the Ops.
8. It is worth mentioning here that the learned counsel for the OPs has contended vehemently that the complainant has not produced any documentary evidence on record to show that it was a case of emergency and the wife of the complainant was required to be got admitted immediately in the hospital on 2.11.2016 for emergent treatment. On the other hand, we may mention that the OPs number 3 and 4 has produced nothing on record to show that it was not a case of emergency for the complainant. Further record shows that the Ops number 3 and 4 has paid the claim to one Balwinder Kaur, who had took treatment from the same hospital i.e. Sangrur Surgical and Laparoscopic Centre, Sangrur, as is evident from the copy of claim detail, Ex.C-12, but the Ops number 3 and 4 have produced nothing on record to show that the case of the said Balwinder Kaur was an emergency case. As such, we are unable to accept such a contention of the learned counsel for the OPs number 3 and 4 that the case of the wife of the complainant was not an emergency one.
9. We have very carefully perused the Annexure XX PGEPHIS Schedule of Rates Ex.OP1&2/3, wherein in para 3 it is mentioned that “package rate shall mean and include lump sum cost of in-patient treatment/ daycare/diagnosis procedure for which a beneficiary has been authorised by the TPA to have cashless treatment at provider hospital from the time of admission to the time of discharge including patient’s diet, operation charges, injection charges, dressing charges, doctor/consultation visit charge, ICU/ICCU charges, monitoring charges etc….” In the present case, it is worth mentioning here that as per the PGEPHIS schedule of rates, the complainant is entitled as per serial number 835 as he has took treatment from the semi private hospital, which we feel as per serial number 835 the complainant is entitled to get an amount of Rs.12,674/- plus 10% i.e. Rs.1267/- total Rs.13,941/-. Further it is worth mentioning here that there is nothing mentioned by the Ops number 3 & 4 in their written reply that the case of the wife of the complainant was not an emergency one. As such, we feel that the ends of justice would be met if the OPs number 3 and 4 are directed to pay to the complainant an amount of Rs.13.941/- on account of the claim, as discussed above.
10. The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.
11. Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 3 and 4 to pay to the complainant an amount of Rs.13,941/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 01.06.2017 till realisation. We further order the OPs number 3 and 4 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.
12. This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
September 14, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
(Vinod Kumar Gulati)
Member
