Punjab

Sangrur

CC/422/2017

Sukhdev Singh - Complainant(s)

Versus

The State of Punjab - Opp.Party(s)

Sh.Amit Aggarwal

26 Feb 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                              

                                                Complaint No.    422

                                                Instituted on:      23.08.2017

                                                Decided on:       26.02.2018

 

Sukhdev Singh son of S. Fauja Singh, resident of Farid Nagar, Sangrur.

                                                        …Complainant

                                Versus

1.             The State of Punjab through District Collector, Sangrur.

2.             Civil Surgeon, Sangrur.

3.             Oriental Insurance Co. 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. Ltd. Maxpro Info Park, D-38, 1^st Floor, Industrial Area, Phase-I, Mohali through its M.D.

6.             Govt. of Punjab, Department of Health & Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, Near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab.

                                                        ..Opposite parties.

 

For the complainant            :       Shri Amit Aggarwal, Adv.

For Opp.Party No.1,2&6     :       Ms.Amandeep Bhangu, Adv.

For Opp.Party No.3to5       :       Shri Ashish Garg, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Sukhdev Singh, 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 being a government employee is working as Jr. Assistant in the office of SDM Sangrur and as such, he along with his wife Daljit Kaur were insured with the Ops under Punjab Government Employees and Pensioners Health Insurance scheme under card number MD-15-09815532243 for the period from 1.1.2016 to 31.12.2016.   The case of the complainant is that during the subsistence of the insurance policy on 4.10.2016, the wife of the complainant was admitted in Jindal Nursing Home, Sangrur in critical condition, where she was operated in the said hospital and also remained admitted for the said treatment, where she spent an amount of Rs.43,495/-.  Further case of the complainant is that after the treatment of wife of the complainant, the complainant submitted all the bills to the Ops number 4 and 5, but the Ops repudiated the claim of the complainant on the ground that no reimbursement will be available for the treatment in Punjab and Chandigarh, where cashless treatment is available vide letter dated 5.12.2016. The complainant has further averred that though he approached the Ops on various occasion for reimbursement of the amount, but all in vain. 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.43,495/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

 

2.             In reply to the complaint filed by Ops number 1 and 2, legal objections are taken up on the grounds that the complaint is premature, that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint. On merits, it is admitted that the complainant being a government employee, insurance card in question was issued. The other allegations levelled in the complaint are denied as the matter is between the complainant and the insurance company.

 

3.             In reply filed by Ops number 3 to 5, 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. 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 a 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 wife of the complainant was admitted in Jindal Nursing Home, Sangrur on 4.10.2016 for treatment of cholecystitis and the complainant submitted the bills for Rs.43,495/- for reimbursement, but the claim was found not payable being admission in non empanelled hospital in Punjab and Chandigarh in non emergency case, as such according to clause 4 of the Gazette notification dated 20.10.2015, the claim of the complainant was rightly repudiated. 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.             In reply filed by Ops number 6, legal objections are taken up on the grounds that the present complaint is pre mature, that the complaint is not maintainable and that the complainant has no cause of action to file the present complaint and that the complainant has got no locus standi to file the present complaint.  On merits, it is stated that the OP has no liability to reimburse the medical claim/bills as alleged by the complainant. It is stated that as per the policy, the liability to pay the claim is of the insurance company.  The other allegations levelled in the complaint have been denied in toto.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-28 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs number 1,2 & 6   has produced Ex.OP1,2&6/1 to Ex.OP1,2&6/4 copies of documents and affidavits and closed evidence. The learned counsel for OP number 3 to 5 has produced Ex.OP3to5/1 to Ex.OP3to5/7 copies of documents and affidavits 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, he and his were insured with the OPs number 3 to 5 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 was admitted in Jindal Nursing Home, Sangrur in critical condition on 4.10.2016, where she was operated in the said hospital and she remained admitted for the said treatment, where she spent an amount of Rs.43,495/- on her treatment.  It is also an admitted fact between the parties that the complainant spent an amount of Rs.43,495/- on the treatment of his wife.  Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 3 to 5 for reimbursement, but the claim of the complainant was repudiated vide letter dated 5.12.2016 on the ground that the claim is not payable being the treatment taken from non empanelled hospital and as per the clause 4 of the notification 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. The complainant has produced on record the copies of the bills and treatment record Ex.C-2 to Ex.C-16, as such it is contended by the learned counsel for the complainant that the claim has wrongly been withheld/rejected by the OPs.  On the other hand, the stand of the OPs number 1 to 3  is that the claim is not payable as the complainant has not get any treatment of his wife from the empanelled hospital of the Ops nor the case of the complainant was an emergency one and has further contended that the claim has rightly been repudiated. 

 

8.             It is worth mentioning here that the learned counsel for the OPs number 3 to 5 has contended vehemently that the complainant has not produced any documentary evidence on record to show that the Ops are liable to pay the claim of the complainant, if the treatment has been received other than the empanelled hospital. The complainant has  produced on record the copy of bill Ex.C-15  submitted by the complainant to the Ops for reimbursement of the amount of Rs.43,495/- being spent by the complainant on his treatment at Jindal Nursing Home, Sangrur.  We have also perused the certificate of Dr. Sanjeev Jindal, Ex.C-28, wherein it has been clearly mentioned that the patient Daljit Kaur was operated being a case of emergency one and has tried to prove the case of the complainant being an emergency one. On the other hand, the Ops number 3 to 5 has not produced any cogent, reliable and trustworthy evidence to show that the claim was not an emergency one and has not rebutted this plea of the complainant.  Further it is worth mentioning here that there is nothing mentioned by the Ops  number 3 to 5 in their written reply that why the claim is not payable as the complainant has taken treatment and has spent the huge amount on the treatment as mentioned above. It is worth mentioning here that there is no explanation from the side of the Ops that why the claim of the complainant was repudiated/rejected, when it is proved case that the wife of the complainant took treatment from Jindal Nursing Home, Sangrur in an emergency case.  The same view has also been taken by the Hon’ble Punjab State Commission in Sukhdev Singh Nagpal versus New Karian Pehalwal Cooperative Agriculture Service Society and others 2017(3) CLT 120 (Punjab State Commission)  and has further held that when there is an emergency, one cannot wait to find empanelled hospital and loss his life by the time, when he is not in a position to find the said hospital nearby. As such, we are of the considered opinion that the ends of justice would be met if the OPs number 3 to 5 are directed to pay to the complainant an amount of Rs.43,495/- on account of the claim, as discussed above.

 

9.             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.

 

10.            Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 3 to 5  to pay to the complainant an amount of Rs.43,495/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 23.08.2017 till realisation.  We further order the OPs number 3 to 5 to pay to the complainant an amount of Rs.5,000/- in lieu of consolidated amount of compensation and further an amount of Rs.5000/- on account of litigation expenses.

 

11.            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.

                        February 26, 2018.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                    Member