State Consumer Disputes Redressal Commission
Oriental Insurance Company Ltd. vs Joginder Singh Dhatt on 13 June, 2018
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No. 719 of 2017
Date of Institution : 17.10.2017
Date of Reserve : 01.06.2018
Date of Decision : 13.06.2018
Oriental Insurance Company Limited, Hoshiarpur, through
Divisional Manager, through its Authorized Signatory, Oriental
Insurance Company Limited, Regional Office, Surendra Building,
109-111, Sector 17-D, Chandigarh.
....Appellant/Op No.2
Versus
1. Joginder Singh Dhatt, aged 81 years, son of Wattan Singh,
resident of House No. 64, Ajit Nagar, Islamabad, Hoshiarpur.
2. Gurmeet Kaur aged 76 years, wife of Joginder Singh Dhatt,
son of Wattan Singh, resident of House No. 64, Ajit Nagar,
Islamabad, Hoshiarpur, Mobile No. 95011-80291.
....Respondents No.1&2/Complainants
3. Shivam Hospital Multi Super Speciality Hospital, Phagwara
Road, Near Railway Crossing, Hoshiarpur, through its Chairman.
....Respondent No.3/Op No.3
4. M.D. India Health Care Services Scheme (TPA) Private
Limited, an ISO 9001:2000 Company IRDAL Licence No. 005,
Maxpro Infopark Industrial Area-D 38, Phase-1, Mohali, Punjab
160056, through Secretary.
...Performa Respondent/Op No.1
First Appeal No. 719 of 2017 2
First Appeal against the order dated
18.08.2017 of the District Consumer
Disputes Redressal Forum, Hoshiarpur.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member.
Shri Rajinder Kumar Goyal, Member
Present:-
For the appellant : Sh. Satpal Dhamija, Advocate
For respondent No.1&2: Mrs. Bandana Rana, Advocate
with Sh. Joginder Singh, in
person
For respondent Nos.3&4: Service dispensed with.
GURCHARAN SINGH SARAN, PRESIDING JUDICIAL MEMBER
ORDER
The appellant/Op No.2 (hereinafter referred as Op) has filed the present appeal against the order dated 18.08.2017 passed in consumer complaint No. 11 dated 2.2.2017 by the District Consumer Disputes Redressal Forum, Hoshiarpur (hereinafter referred as the District Forum) vide which the complaint filed by the complainant was partly accepted and Op Nos. 1 & 2 were directed to pay the amount of bill of Rs. 99,873/- alongwith interest @ 12% from the date of filing the complaint till its realization. They were further directed to pay compensation for mental harassment to the tune of Rs. 10,000/- and litigation expenses of Rs. 3,000/-. It was further ordered to comply with the order within a period of one month.
First Appeal No. 719 of 2017 3
2. Complaint was filed by the complainant under the Consumer Protection Act, 1986 (in short 'the Act') against the Ops on the averments that complainant No. 1 is a retired Punjab Government Employee and complainant No. 2 is wife of complainant No. 1. The Punjab Government introduced a cashless health insurance scheme known as Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) vide notification No. 21/28/12-5HB5/268 to cover indoor medical treatment expenses. It also ensured cashless and indoor medical treatment, pre and post hospitalization and medical expenses upto a sum of Rs. 3,00,000/- per family per year. The treatment could be taken from any empanelled hospitals in Punjab, Chandigarh and NCR area. Op No. 3 is the panel hospital. Op No. 2 had provided Rs. 25 Crores for providing medical services by covering insurance to each employee/pensioner and their beneficiaries' upto Rs. 3 Lacs. The benefit under this scheme was started from 1.1.2016 and was available upto 31.12.2016. The complainant was enrolled from Hoshiarpur and he was registered under Punjab Government Health Scheme with I.D. No. MD15-09501180291. Complainant No. 2 is the wife of complainant No. 1, hence, both are the consumers. Complainant No. 2 suffered fracture and was admitted on 8.9.2016 with Op No. 3 and was discharged on 13.9.2016. She paid Rs. 54,900/- at the time of discharge, Rs. 14,973/- on medicines and Rs. 30,000/- on Physiotherapy treatment. The complainant requested Op No. 3 that complainant No. 1 is retired employee of Punjab Government and entitled for First Appeal No. 719 of 2017 4 cashless treatment under the scheme of the Government but they refused to attend complainant without cash, therefore, no other alternative for the complainant but to pay at the time of admission and discharge. The documents were submitted to the Ops for reimbursement but Ops failed to make the payment. Alleging deficiency in service on the part of Ops, the complaint was filed by the complainant seeking directions against the Ops to pay the amount of Rs. 99,873/- alongwith interest, Rs. 50,000/- as compensation and litigation expenses.
3. Upon notice, Op Nos. 1 & 2 appeared and contested the complaint whereas Op No. 3 was ex-parte before the District Forum. Op Nos. 1 & 2 in their written reply took the preliminary objections that the complainants are estopped by their act and conduct to file the complaint; neither the complainant nor Op No. 3 supplied relevant investigation results/reports to support the diagnosis of the patient inspite of the demand and accordingly, the claim of the complainant was closed. If the complainants or Op No. 3 supply the abovesaid documents then Ops are ready to settle the claim of the complainants as per the terms and conditions of the policy and as per the guidelines under PGEPHIS; intricate question of law and facts are involved, which cannot be adjudicated in summary procedure, therefore, the matter be relegated to the Civil Court and that there is no deficiency in services on the part of Ops. On merits, the averments taken in the preliminary objections were reiterated. It was stated that the claim First Appeal No. 719 of 2017 5 could not be processed for want of documents, therefore, it was closed. There is no deficiency in service on the part of Ops. Complaint is without merit, it be dismissed.
4. Before the District Forum, the parties were allowed to lead their respective evidence.
5. In support of his allegations, the complainant had tendered into evidence his affidavit Ex. C1 and documents C2 to C21. On the other hand, Op Nos. 1 & 2 had tendered into evidence affidavit of Dr. Geeta Bhardwaj Ex. Op-1&2/1.
6. After going through the allegations in the complaint, written version filed by the Ops, evidence and documents brought on the record, the complaint was partly accepted as referred above.
7. Aggrieved with the order passed by the learned District Forum, the appellant/Op No. 2 has filed the present appeal.
8. We have heard the learned counsel for the appellant and learned counsel for the respondent Nos. 1 & 2 and have carefully gone through the record of the case whereas service of respondent Nos. 3 & 4 was dispensed with.
9. It has been argued by the counsel for the appellant/Ops that the District Forum did not appreciate the terms and conditions of the Insurance Policy. The Punjab Government had formulated the scheme known as PGEPHIS in order to cover the risk and the Punjab Government paid the premium and the District Forum erred in not considering the said First Appeal No. 719 of 2017 6 scheme while allowing the claim. Op No. 3 Hospital had charged exaggerated amount beyond the PGEPHIS rates despite being the empanelled hospital and enhanced rates are not to be paid as per the scheme. It has been stated that for the procedure PFN, they charged Rs. 30,000/- whereas as per PGEPHIS rates, it is Rs. 14,000/- and room charges have been charged as Rs. 3200/- per day whereas as per PGEPHIS rates, it is Rs. 1,000/- per day. The PGEPHIS schedule rates were brought to the notice of the counsel for the respondent/complainant. The counsel for the respondent/complainant could not controvert these rates and in case these rates are taken then for PFN and room charges, enhanced rates have been charged by the Hospital whereas Op Nos. 1 & 2 are to pay the reimbursement charges according to PGEPHIS rates. In case the empanelled hospital has charged more amount than the prescribed rates under PGEPHIS then the complainant is to pay from his own pocket or she could recover it from Op No. 3. No cross appeal has been filed by the respondent/complainant, therefore, no such liberty could be given to the complainant in the appeal filed by Op Nos. 1 & 2. In this way, Rs. 27,000/- in excess have been charged by Op No. 3 from the complainant. So far as Physiotherapy charges are concerned, those are payable under the scheme. In this way, the total charges payable to the complainant will be Rs. 72,873/-.
10. No other point was raised.
11. Sequel to the above, we partly accept the appeal. Instead of Rs. 99,873/-, Op Nos. 1 & 2 will pay Rs. 72,873/-. The First Appeal No. 719 of 2017 7 rate of interest, amount of compensation and litigation expenses will be same as allowed by the District Forum.
12. The appellant had deposited an amount of Rs. 25,000/- with this Commission in the appeal. This amount along with interest accrued thereon, if any, shall be remitted by the registry to the concerned District Forum, after the expiry of 90 days, from the despatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court; for the release of the above amount and the District Forum may pass the appropriate order in this regard.
13. Order be communicated to the parties as per rules.
(GURCHARAN SINGH SARAN) PRESIDING JUDICIAL MEMBER (RAJINDER KUMAR GOYAL) MEMBER June 13, 2018.
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