BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.518 of 2019
Date of Instt. 01.11.2019
Date of Decision: 16.02.2024
Surinder Kumar aged 73 year son of late Babu Ram resident of H. No.-B-7/549, Mohalla Abadpura, Ward No.9, Phillaur, District Jalandhar.
..........Complainant
Versus
1. The Oriental Insurance Company Pvt. Ltd, Having its head office at A-25/27, Asaf Ali Road, New Delhi, through its Manager.
2. The Oriental Insurance Company Pvt. Ltd, local office at 2 SCO, 50, Puda Complex, Near Court Road, Jeevan Raksha, Near Central Bank of India, Opposite Tehsil, Rajinder Nagar, Jalandhar through its Manager.
3. MD India Health Insurance TPA Private Ltd, Max pro Info Park, D-38, 1st Floor, industrial Area, Phase-1. Mohali Punjab, through its Manager.
4. S.P.S Hospital (Satguru Partap Singh Health Care), Sherpur Chowk, G.T. Road, Ludhiana, through its Managing Directors.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member) Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Rinku Chumber, Adv. Counsel for Complainant.
Sh. Brijesh Bakshi, Adv. Counsel for OPs No.1 to 3.
Sh. Anupam Pathania, Adv. Counsel for OP No.4.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant was working as Govt. Teacher and in the year 2016, he was posted as Head master at Govt. High School, Memsampur, Tehsil Phillaur, District Jalandhar. Now the complainant is retired from his job, after giving valuable services. The complainant availed, the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), during his job, being employee under Punjab Government, which was being run by the OP No.1 to OP No.3 in collaboration with Punjab Government. Under this scheme, the complainant got himself and his wife medically insured. One card was issued to him under this scheme. No insurance cover containing terms and conditions, was issued to the complainant, as such he was not aware about the terms and condition of the medical insurance policy. However, it was told to the complainant by the insurance person that he can avail free of cost medical treatment from the Hospital approved with this Cash less network. Unfortunately, in the year 2016, the complainant started facing acute pain, due to problem in his knees, as such after consultation with doctors and after verifying about the Hospitals approved with Cash Less Scheme of OPs No.1 to 3, the complainant got admitted himself with the OP No.4 on 24.10.2016. On 24.10.2016, when the complainant was admitted in the hospital run by the OP No.4, he was told by the OP No.4, that he has to deposit, the expenses of treatment firstly from his own pocket and after that they will replace his knees and the amount so deposited would be reimburse to the complainant by the OPs No.1 to 3 and it was also assured to the complainant by the OP No.4, that they will submits his claim file to the insurance company as they have daily dealing with the company. As the complainant was in acute pain and he has no other option except to agree with the OP No.4. As such he deposited the amount of medical expenses and treatment from his own pockets, coming into the words of the OP No.4. Thereafter, the OP No.4, operated upon the complainant and replace his knees and the complainant remains admitted in the hospital of OP No.4, since 31.10.2016. Thereafter, the complainant was on bed for about three/four months. The complainant was under bona fide belief that his claim file was submitted by the OP No.4, with the insurance company as assured by them. Thereafter, when the complainant gain some heath and he enquired about reimbursement of his medical insurance claim, he got shocked, to learn that the opposite parties has not reimburse the amount of medical expenses, which he was paid from his own pocket and he was in shock state of mind to know that no efforts was made by OP No.4, to get reimburse the amount paid to them by the complainant, as they promised/assured to do so. The complainant submitted the detailed claim application for the re imbursement of medical claim in all prescribed form and the same was duly received by the OPs No.1 to 3. But even after the receipt of claim, the claim was not settled unnecessarily and unlawfully, which tantamount to deficiency in service and unfair trade practices cognizable under the consumer protection Act, 1986. The complainant then wrote number of letters to OPs No.1 to 3 and the department of the complainant also sent number of representations to the OPs No.1 to 3, for reimbursement of medical insurance claim of the complainant, but the OPs was not even bother to sent any reply to representations sent to them. Last representation was sent to the OPs by the complainant on 15/11/2017 through his school, from where he was retired. Now few months ago, one undated letter was received from the OP No.3 by the complainant, stating that he has to apply for reimbursement of claim within 30 days. No insurance cover containing terms and condition was supplied to the complainant, so the question of knowingly and willing, not submitting claim within 30 days, as mention in the undated letter written by the OP No.3 does not arise. There is no delay on the part of the complainant for submitting claim application. More particularity, when it was assured by the OP No.4, who is approved agent of the OPs No.1 to 3, to get the money paid by the complainant reimburse from the insurance company. There has been a deficiency in service on the part of the OPs as the OPs have failed to reimburse the medical insurance claim to the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to settle and reimburse the medical claim of Rs.1,92,225/- along with interest at the rate of 12% Per Annum. Further, OPs be directed to pay a compensation of Rs.2,00,000/- and Rs.15,000/- as litigation expenses.
2. Notice of the complaint was sent to the OPs and accordingly, OPs No.1 to 3 appeared through its counsel and filed its joint written reply and contested the complaint by taking preliminary objections that the above noted complaint is not maintainable under the law and liable to be dismissed with costs. It is further averred that the present complaint is not maintainable and the claim cannot be considered by the OP having been raised after the lapse of the policy itself. The insurance company issued a insurance policy namely Punjab Govt. employee and pensioner Health Insurance Scheme (PGEPHIS) w.e.f. 1.1.2016 to 31.12.2016 as per terms and conditions framed and implemented by Punjab State Government. In the present case the reimbursement claim was not raised within the statutory limitation of 30 days from the date of discharge from the hospital. As such the same is a clear cut violation of the essential policy condition. The TPA received the claim much after the expiry of the Policy Period even and as such the same could not be entertained and the TPA/OP was justified in declining the reimbursement under the Terms and Conditions of the Scheme. Hence, the present complaint deserves to be dismissed on this short score alone. It is further averred that the compliant is barred by limitation. The present complaint for reimbursement of the alleged medical expenses has been filed after lapse of more than two years from date of the alleged expenses made on the alleged treatment received. The present claim was not raised during the subsistence of Policy and as such the claim raised subsequently is not maintainable under the law or the Policy RFP/Conditions. Hence, the present complaint deserves to be dismissed on this short score alone. It is further averred that the OPs No.1 to 3 have been dragged in to unnecessary litigation hence entitled for compensatory costs of Rs.20,000/-. It is further averred that there is complicated question of law and facts involved in the matter and the same cannot be adjudicated in summary proceedings, therefore this Forum has got no jurisdiction to try and decide the present complaint. It is further averred that from the allegations of the complaint the complainant does not fall under the definition of 'Consumer' under the Consumer Protection Act and thus the complaint is liable to be dismissed. No amount of premium has been charged from the complainant and the Scheme was provided by the Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab as a Health Benefit Scheme free of cost or any kind of charges to its complainant being a consumer of the OPs. No insurance contract ever exists between the beneficiaries i.e. complainant and the OP/Oriental Insurance Co. Ltd. hence there is no point of any contractual liability or otherwise for the present complaint filed against the OP/Oriental Insurance Co. Ltd. there is no consideration taken from the beneficiaries by the Company. Thus the present complaint is preliminarily not maintainable. It is further averred that the policy was issued in favour of Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab, but the complainant has not impleaded it in the present complainant, therefore the present complaint is liable to be dismissed on this short score alone. It is further averred that it is the prerogative and right of Respondents to process and verify claim as per policy terms and conditions along with prescribed requisites and valuable right conferred by agreement between the parties i.e. the Government and the OPs cannot be taken away by filing the instant complaint. On merits, it is admitted that the Punjab Government Employees and Pensioners Health Insurance Scheme was launched and the complainant availed this facility during his job being employee of Punjab Govt. It is also admitted that there was a collaboration of the OPs No.1 to 3 with the Punjab Govt and it is also admitted that it was a cashless policy where there were hospitals in their panel available, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. OP No.4 filed its separate written reply and contested the complaint by taking preliminary objections that the OP No.4 is a hospital run by SJS Healthcare Ltd. and its board of directors vide its resolution dated 26/12/2019 has appointed Dr. Jatinder Arora chief operating officer SPS Hospital as authorized signatory to sign verify and submit reply on behalf of OP No.4. The complaint under reply is not legally maintainable against the OP No.4, it deserves to be dismissed as there is no cause of action against OP No.4. The complainant has falsely enroped in the OP No.4 by concocted a false story and by mistaking the facts. The truth of the matter is that the complainant got treatment from respondent no.4 for his ailment and after his treatment, he was happily discharged. All the payments i.e. from the date of his admission till the time of his discharge were made in cash by the complainant. There is no deficiency in service on the part of respondent no.4. Neither there are any allegations of medical negligence or deficiency in service against respondent no.4. Moreover, the complainant has not leveled any allegations against the respondent no.4 in the applications moved to his department by him. It is further averred that the OP No.4 has been intentionally/deliberately made party in this complaint by the complainant just to cause undue harassment to the OP No.4. On merits, it is admitted that in the year 2016, the complainant started acute pain in his keens and the complainant was admitted in the hospital of OP No.4 on 24.10.2016 to 31.10.2016, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
5. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
6. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
7. It is admitted that the Punjab Government Employees and Pensioners Health Insurance Scheme was launched and the complainant availed this facility during his job being employee of Punjab Govt. It has been admitted that there was a collaboration of the OPs No.1 to 3 with the Punjab Govt. The complainant has proved on record that he faced pain due to the problem in his knees and got admitted himself with the OP No.4, where the hospital authorities asked the complainant to deposit the amount of expenses prior to the surgery and as per their instructions, the amount was deposited by the complainant, therefore, he could not avail the cashless benefit. The complainant has proved on record the discharge summary alongwith the bills. As per the discharge summary Ex.C-2, he was admitted in the hospital of OP No.4 on 24.10.2016 and was discharged on 31.10.2016. As per submission of the complainant, since there was knee replacement, therefore, he could not file claim immediately and when he felt slight better, he went to the office of the OPs and filed claim, but his claim was not settled. He has proved on record the letters recommended and issued by his School, which were Ex.C-15, Ex.C-16 and his own letters written to the Principal for settling the claim and disbursing the amount Ex.C-17 and Ex.C-18 alongwith all the documents. He has proved on record the medical reimbursement certificate. All these documents have been proved by the complainant Ex.C-19 to Ex.C-22. But his claim has not been settled as yet.
8. The contention of the OP is that the claim could not be given and settled because the insurance policy was issued for one year 01.01.2016 to 31.12.2016 and as per terms and conditions framed and implemented by Punjab Govt., the reimbursement claim was to be filed within 30 days from the discharge, but that has not been done by the complainant. The complainant did not avail the cashless treatment under the scheme. As per para No.4 of the notification, no reimbursement will be available for the treatment in Punjab, where the cashless treatment is available.
9. The OP has not produced on record any document to show that the scheme was only for one year i.e. 01.01.2016 to 31.12.2016. The complainant has produced on record the card Ex.C1/B issued by the Punjab Government Employees and Pensioners Health Insurance Scheme. This card nowhere shows that this policy was only for one year. Admittedly, the complainant raised a claim in the month of March 2017, when he felt better as per his own submission. On the one hand, the OPs are saying that no reimbursement is available and on the other hand, they are alleging that the reimbursement claim should be filed within 30 days as per the guidelines of the Punjab Government Ex.C1/A, in which the MD India Health Care TPA has refused to entertain the case under reimbursement on the ground that ‘the treatment availed by the beneficiary shall be on reimbursement basis subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital.’ This certificate refers the Clause 11.6 of the guidelines. Perusal of Clause 11.6 shows that for the purpose of reimbursement, filing of the claim is mandatory within 30 days only for Govt. Hospitals in Punjab and Chandigarh and with regard to private hospitals in Punjab and Chandigarh, this clause is silent, but the certificate clearly show that the reimbursement can be given under this scheme. The complainant has specifically alleged that since his knee was replaced, therefore, he could not file the claim within time, but thereafter he kept on corresponding with the OPs, but his claim was never settled nor the same was considered. It has been held by the Hon’ble Supreme Court in a case titled as ‘Jaina Construction Company v The Oriental Insurance Company Ltd & Anr.’ in Civil Appeal No. 1069 OF 2022, decided on 11 February, 2022 that ‘the insurance company could not have repudiated the claim merely on the ground that the consumer intimated them about the clam, after a long period of time.’ Therefore, only on the ground that he has not filed the claim within 30 days of the discharge does not disentitle him for filing the claim or for reimbursement, but the delay should be reasonable and well explained. If the delay is well explained and within reasonable time, then the claim should not be refused to have accepted or settled. The claim is to be settled as per the documents i.e. medical record including bills, reports etc. In such circumstances, the complainant is directed to submit the claim alongwith documents, if not submitted to the OPs, within 10 days from the date of receipt of the copy of the order and then the OPs will settle the claim of the complainant within 15 days from the date of submitting the claim by the complainant, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.
10. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
16.02.2024 Member Member President
