State Consumer Disputes Redressal Commission
The Oriental Insurance Company Ltd. & ... vs Santokh Singh & Another on 13 July, 2022
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.214 of 2021
Date of institution : 17.06.2021
Reserved On : 05.07.2022
Date of decision : 13.07.2022
1. The Oriental Insurance Company Ltd., Regional Office, S.C.O.
No.109, 110, 111, Surindera Building, Sector 17-D, Chandigarh,
through its Regional Manager.
2. M.D. India Healthcare Services (TPA) Pvt. Ltd. (Punjab
Government Employees and Pensioners Health Insurance
Scheme (PGEPHIS), MD India Health Insurance TPA Pvt. Ltd.,
Maxpro Info Park, D-38, Industrial Area, Phase-1, through its
Authorized Representative, Mohali.
Now through its Authorized Signatory Gurupdesh Kaur,
Manager, The Oriental Insurance Company Ltd., Regional
Office, SCO No.109-111, Sector 17-D, Chandigarh.
....Appellants/Opposite Parties No.1 & 2
Versus
1. Santokh Singh s/o Sh. Gangu, R/o B-IX-49/63, New Hardyal
Nagar, P.O. Shekhey Pind, Hoshiarpur (Jandu Singha) Road,
Jalandhar, Punjab.
....Respondent/Complainant
2. SGL Superspeciality Charitable Hospital, Garha Road,
Jalandhar.
....Respondent/Opposite Party No.3
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 27.04.2021 passed by the
First Appeal No.214 of 2021 2
District Consumer Disputes Redressal
Commission, Jalandhar.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Mr. Rajinder Kumar Goyal, Member
Mrs. Urvashi Agnihotri, Member.
1) Whether Reporters of the Newspapers
may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported
in the Digest? Yes/No
Present:-
For the appellants : Sh. J.P. Nahar, Advocate
For respondent No.1 : Sh. Varun Goyal, Advocate
For respondent No.2 : None.
JUSTICE DAYA CHAUDHARY, PRESIDENT
Appellants/opposite parties No.1 & 2 i.e. Oriental Insurance Company Ltd. and another have filed the present appeal under Section 41 of the Consumer Protection Act, 2019 to challenge the impugned order dated 27.04.2021 passed by the District Consumer Disputes Redressal Commission, Jalandhar (in short, "the District Commission"), whereby the complaint filed by respondent No.1/complainant was allowed and a direction was issued to the appellants/opposite parties No.1 & 2 to reimburse an amount of ₹6,38,476/-, which was spent by him on the treatment of his wife while remained admitted in various hospitals along with interest at the rate of 5% per annum from the date of filing of the complaint till its realization. First Appeal No.214 of 2021 3 Respondent No.1/complainant was also held entitled for ₹8,000/- as compensation for causing mental harassment to him and also litigation expenses. The appellants/opposite parties No.1 & 2 were also directed to deposit an amount of ₹3,000/- as costs in the Consumer Legal Aid Account of the District Commission.
2. It would be apposite to mention here that hereinafter the parties will be referred, as have been arrayed before the District Commission.
3. Briefly the facts of the case as made out by respondent No.1/complainant in the complaint filed by him before the District Commission are that the complainant was employed in Punjab State Government and retired from the Irrigation Department, Shahpur Kandi. He along with his wife Chanan Kaur and grandson Sher Singh was insured under Cashless Health Insurance Scheme introduced by the Government of Punjab. It was the beneficial health insurance scheme called as 'Punjab Government Employee's & Pensioners Health Insurance Scheme" (hereinafter to be referred as "PGEPHIS"). The policy was issued and premium as consideration was paid by the State Government to cover the risk under the said Scheme. One ID Card No.MD 150987255998 was issued by the opposite parties. The wife of the complainant fell ill and was got admitted in the hospital on 23.06.2016 for treatment as Indoor Patient. Thereafter also, she remained admitted in different hospitals on First Appeal No.214 of 2021 4 different occasions, like DMC, Ludhiaana, Vedanta Hospital, Jalandhar and Patel Hospital, Jalandhar. In all the said hospitals, the medical expenses amount was paid by the complainant.
4. Notice in the said complaint was issued by the District Commission. The complaint was contested by the opposite parties by filing replies thereto.
5. Ultimately, the complaint was allowed by the District Commission vide impugned order dated 27.04.2021 and the appellants/opposite parties No.1 & 2 were directed to pay an amount of ₹6,38,476/- along with interest at the rate of 5% per annum from the date of filing of the complaint till its realization with ₹8,000/- as compensation including litigation expenses. A further direction was issued to opposite parties No.1 & 2 to deposit an amount of ₹3,000/- as costs in the Consumer Legal Aid Account of the District Commission.
6. Said order dated 27.04.2021 passed by the District Commission has been challenged by the appellants/opposite parties No.1 & 2 before this Commission by way of filing the present appeal by raising a number of grounds.
7. Mr. J.P. Nahar, learned counsel for the appellants submits that the impugned order has been passed by the District Commission by awarding an amount of ₹6,38,476/-, whereas the insured amount under the Insurance Policy i.e. ₹3 lac only was payable. The amount First Appeal No.214 of 2021 5 awarded by the District Commission is more than the sum assured as provided under the policy. Learned counsel also submits that the terms and conditions of the policy have not been taken into consideration and the impugned order has been passed in violation thereof. A preliminary objection was also raised by the appellants/opposite parties No.1 & 2 that the complaint was not maintainable, as the complainant was not their consumer but still said objection has not been taken into consideration. It has further been submitted that the complaint was also not maintainable on the ground of non-joinder of necessary parties, as the State of Punjab was the necessary party, as the Insurance Policy was issued in the name of State of Punjab. Those objections raised by the appellants/opposite parties No.1 & 2 have not been dealt and considered. Learned counsel has also relied upon the order dated 24.07.2019 passed by this Commission in F.A. No.343 of 2018 in the case titled as "The Oriental Insurance Company Limited v. Naveen & Ors.", in support of his contentions.
8. Mr. Varun Goyal, learned counsel for respondent No.1/complainant submits that the impugned order passed by the District Commission is well reasoned and the same is based on proper appreciation of evidence and a number of judgments have been relied upon by the learned counsel for respondent No.1/complainant in support of his contentions.
First Appeal No.214 of 2021 6
9. Heard arguments of learned counsel for the parties except respondent No.2/opposite party No.3 as none appeared on its behalf at the time of arguments. We have also perused the impugned order passed by the District Commission and all other documents available on the file.
10. Facts relating to filing of the complaint, terms and conditions of the policy, allowing of the complaint and thereafter being aggrieved by the impugned order, the filing of appeal by the appellants/opposite parties No.1 & 2 are not disputed.
11. Admittedly, respondent No.1/complainant being employee of Punjab Government was beneficiary of the health insurance Scheme known as PGEPHIS Scheme. Under said Scheme, the complainant, his wife Chanan Kaur and grandson Sher Singh were insured and ID Card Card No.MD 150987255998 was issued by the Appellants-Insurance Company. During subsistence of the policy, the wife of the complainant namely Chanan Kaur fell ill and remained admitted in various hospital namely DMC Hospital, Ludhiana, Vedanta Hospital, Jalandhar and Patel Hospital, Jalandhar. As per version of the complainant, an amount of ₹6,38,476/- was spent on treatment of his wife. After discharge from the hospital, the claim was lodged with the opposite parties for reimbursement but only an amount of ₹3 lac was payable as per terms and conditions of the policy. The impugned order passed has been challenged by the appellants on the grounds First Appeal No.214 of 2021 7 that the District Commission has not taken into consideration the amount payable as per terms and conditions of the policy and awarded the amount beyond the specified limit by ignoring the terms and conditions of the policy.
12. Admittedly, the PGEPHIS Scheme is applicable to the case of the respondent/complainant. As per the said Scheme, all the expenses relating to hospitalization of beneficiary members up to ₹3 lac per family per year in any of the Empanelled Hospitals/Nursing Homes/Day Care Unit subject to prescribed rate on cashless basis through photo ID Cards would be covered. This benefit is available to each and every member of the family on floater basis. Meaning thereby, the total cover of ₹3 lac is available to every individual or collectively to all members of the family. In case, the sum insured of ₹3 lac per family is exhausted, the amount/expenses will be met out from the Buffer Sum Insured of ₹25 Crore as available to each and every member of the group on 'Group Floater Basis', as maintained by the Insurance Company. In case the Buffer Sum Insured of ₹25 Crore has exhausted completely, the cashless reimbursement of more than ₹3 lac would not be available to any employee/pensioner and the amount over and above ₹3 lac shall be met by the State Government to the extent of medical reimbursement policy and procedures. Under such circumstances, the Insurance Company is to inform the concerned employee/pensioner that the further treatment shall not been available First Appeal No.214 of 2021 8 on cashless basis but on reimbursement basis as per existing pattern at PGI/AIIMS rates. The employee/pensioner was required to seek reimbursement over and above the amount of ₹3 lac as per the existing pattern to the extent of medical reimbursement policy and the procedures. It has further been provided that the concerned DDO is required to seek reimbursement from the concerned Civil Surgeon/Directorate of Health and Family Welfare, who is required to examine the bill as per the entitlement of the claimant as per State Services (Medical Attendant Rules) [CS (MA)] Rules, 1940. In case the entitlement amount is less than ₹3 lac, then no amount would be reimbursed to the employee and in case the bills are more than ₹3 lac then the additional amount would be reimbursed to the employee through Treasury Route. The relevant provisions of PGEPHIS Scheme under Clause-6-A 'Sum Insured and Buffer/Corporate Sum Insured' are reproduced as under:
"6. SUM INSURED AND BUFFER / CORPORATE SUM INSURED:
A. BASE SUM INSURED:
The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs.3,00,000/- per family per year in any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to prescribed rates on cashless basis through Photo ID Cards. The benefit shall be available to each and every member of the family on floater basis i.e. the total cover of Rs. 3.00 lakh can be availed by one individual or collectively by all members of the family. In an event the sum insured of Rs 3 lacs per family is exhausted, the coverage of the family shall be met through the Buffer Sum Insured of Rs 25 Crore available to each and every beneficiary of the group, on group floater basis, to be maintained by the Insurance Company.First Appeal No.214 of 2021 9
In an event the Buffer Sum Insured of Rs 25 crores gets completely exhausted, the cashless reimbursement more than Rs 3.00 lacs will not be available to any employee/ pensioner and the over and above expenses shall be met by the State Government as per the extent of the medical reimbursement policy and procedures. In such circumstances, the Insurance Company will inform the employee/pensioner that further treatment shall not be available on cashless but reimbursement basis as per existing pattern at PGI/ AIIMS rates and the employee/pensioner will seek the reimbursement over and above Rs. 3.00 lacs as per existing pattern to the extent of the medical reimbursement policy and procedures. The concerned DDO will seek the reimbursement from concerned Civil Surgeon/Directorate of Health & Family Welfare who will examine the bill as per the entitlement of the claimant as per State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940. If that particular bill(s) as per the entitlement(s) is less than Rs. 3.00 lacs then no amount will be reimbursed to the employee and if the bill(s) is more than Rs. 3.00 lacs then additional amount will be reimbursed to the employee through Treasury Route.
13. In Clause 6-B of the said Scheme, 'Buffer/Corporate Sum Insured' has been provided, which is reproduced as under:
"B. BUFFER / CORPORATE SUM INSURED:
An additional Sum Insured of Rs. 25 Crore shall be provided by the Insurer as Buffer/Corporate Floater. This will be used in case hospitalization expenses of a family exceed the base sum insured of Rs 3.00 lakhs. Insurer is required to inform the Nodal Department with the details on case to case basis electronically."
14. As per said provisions of aforesaid Clause 6-B, an Additional Sum Insured of ₹25 Crore is to be provided by the insurer as Buffer/Corporate Floater. This amount is to be used in case the hospitalization expenses of a family exceed the base sum insured of ₹3 lac. The insured is duty bound to inform the Nodal Department with the details on case to case basis.
15. In the present case, admittedly the case of the respondent/complainant is squarely covered by the features of the Scheme, as mentioned above. The District Commission, while allowing First Appeal No.214 of 2021 10 the complaint, has held that the complainant was entitled for reimbursement of an amount of ₹6,38,476/-, which was spent by him on the treatment of his wife in different hospitals, along with interest at the rate of 5% per annum from the date filing of the complaint till its realization as well as compensation amount of ₹8,000/-, which was to be paid by the appellants/opposite parties No.1 & 2 jointly and severally, whereas a specific mechanism has been provided under the said Scheme for the amount to be reimbursed towards the treatment expenses of the beneficiary member for the treatment undertaken from the Empanelled Hospitals/Nursing Home/Day Care Unit subject to prescribed rates only on cashless basis through photo ID Cards, as detailed above.
16. No evidence or explanation has been produced/provided by the appellants to show that Buffer Sum Insured of ₹25 Crore has been exhausted. In case Buffer Sum Insured of ₹25 Crore had exhausted, then it was the duty of the Insurance Company to inform the complainant that further treatment would not be available on cashless basis but on reimbursement basis from the State Government. However, this has not been done by the Insurance Company. In absence of any evidence in this regard, it cannot be said that the Buffer Sum Insured of ₹25 Crore had exhausted.
17. It is also relevant to mention here that it was the duty of the appellants-Insurance Company to inform the insured/beneficiary about First Appeal No.214 of 2021 11 the reimbursement of the amount of medical expenses as to from which source the same was to be reimbursed. Admittedly, no such intimation was sent by the Insurance Company to the respondent/complainant in this regard. Nothing has been said about the amount to be reimbursed and the mode of source of payment and from which authority. Since the medical expenses spent by the complainant on the treatment of his wife exceeded ₹3 lac, so the medical expenses are to be met out of the Buffer/Additional Sum Insured of ₹25 Crore available with the appellants-Insurance Company as per provisions of the Scheme. The District Commission has not considered the relevant and applicable provisions of the Scheme, while issuing direction by the District Commission with regard to reimbursement of an amount of ₹6,38,476/-.
18. As far as the preliminary objection raised by the appellants/opposite parties that the complainant was not consumer is concerned, it is relevant to mention here that the complainant was an employee of the Government of Punjab and retired from Irrigation Department. The PGEPHIS Scheme was launched by the Punjab Government for the welfare of its employees/pensioners for providing health insurance benefits, for which certain premium was paid by the State Government to the Insurance Company. The complainant being beneficiary was duly covered under the Scheme, along with his family members. Therefore, the complainant falls under the definition of First Appeal No.214 of 2021 12 'consumer' and the complaint was maintainable before the District Commission.
Admittedly, PGEPHIS is a special Scheme finalized after floating a Tender Document by the Govt. of Punjab. It was just like other contract. The terms and conditions of the Scheme are applicable between both the parties. The claim was to be settled as per the terms and conditions of the Scheme and as per PGEPHIS Rate Schedule agreed between the State and the appellants. However, the District Commission has failed to consider this aspect. The complainant had submitted the different bills of amount totaling ₹6,36,476/- and as per the directions issued by the District Commission, all bills should have been considered for settlement of the claim as per terms and conditions of the Scheme.
19. In view of the facts and circumstances held above, we find some merit in the contentions raised by the learned counsel for the appellants/opposite parties No.1 & 2 and the impugned order passed by the District Commission is liable to be modified.
20. Accordingly, the appeal is partly allowed by modifying the impugned order dated 27.04.2021 passed by the District Commission to the extent that since the medical expenses incurred by the complainant on the treatment of his wife exceeded the prescribed limited of ₹3 lac, so the entire medical expenses of ₹6,38,476/- shall be reimbursed by the First Appeal No.214 of 2021 13 appellants/opposite parties No.1 & 2 out of the Buffer/Additional Sum Insured of ₹25 Crore available with them as per Clause-6 of the Scheme. In case the Buffer/Additional Sum Insured has exhausted, then an amount of ₹3 lac being the Base Sum Insured under the Scheme shall be paid by the appellants/opposite parties No.1 & 2 to the complainant and for said purpose of reimbursement of the remaining amount of ₹3,38,476/-, the appellants shall inform the respondent/complainant as well as the State Government in writing. Thereafter, the respondent/ complainant would be at liberty to seek reimbursement of the remaining amount from the State Government in view of the provisions of Clause 6 of the Scheme.
With this modification, the remaining part of the impugned order with regard to award of rate of interest, amount of compensation/litigation expenses and costs will remain the same and is accordingly upheld.
The compliance of the order shall be made by the appellants/opposite parties No.1 & 2 within a period of 30 days from the date of receipt of certified copy of this order.
21. Since the main case has been disposed of, so all the pending Miscellaneous Applications, if any, are accordingly disposed of.
First Appeal No.214 of 2021 14
22. The appellants have deposited a sum of ₹3,84,025/- at the time of filing of the appeal. Said amount, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The respondent/complainant may approach the District Commission for the release of amount in view of modification of the impugned order made vide this order and the District Commission may pass appropriate order in this regard in accordance with law.
23. The appeal could not be decided within the statutory period due to heavy pendency of court cases and pandemic of COVID-19.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (RAJINDER KUMAR GOYAL) MEMBER (URVASHI AGNIHOTRI) MEMBER July 13, 2022.
(Gurmeet S)