State Consumer Disputes Redressal Commission
United India Insurance Company Limited vs Balwinder Singh on 12 March, 2026
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.214 of 2024
Date of institution : 03.05.2024
Reserved on : 10.02.2026
Date of Decision : 12.03.2026
United India Insurance Co. Ltd., Divisional Office: SCO 72, Phase IX,
Mohali through its Divisional Office i.e. United Insurance Company,
Legal Department, 108, Surya Towers, 3rd Floor, Mall Road,
Ludhiana -141001 through Lipi Moitra, Deputy Manager, United India
Insurance Company Limited.
....Appellant/Opposite Party No.4.
Versus
1. Balwinder Singh son of Kaka Singh R/o Village Kheri, Tehsil and
District Sangrur.
.......Respondent No.1/Complainant
2. The Kheri Multi Purpose Co-operative Agriculture Service Society
(MPCASS) Ltd., Village Kheri, Tehsil and District Sangrur through
its Secretary-148001.
3. Manager, MD India Health Care Services (TPA) Pvt. Ltd., Regional
Office, D-38, Max-pro Info Park, First Floor, Phase-I, Industrial
Area, Mohali -160056.
4. Bhai Ghanahyia Trust through Deputy Registrar, Co-operative
Societies, Punjab Gill Road, Kartar Singh Sarabha Market, New
Kartar Nagar, Ludhiana -141001.
.......Respondents No.2,3&4/OPs No.1,2&3.
First Appeal under Section 41 of the
Consumer Protection Act, 2019
against the order dated 11.12.2023
passed by the District Consumer
Disputes Redressal Commission,
Sangrur in CC No.558 of 2019.
FA No.214 of 2024 2
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, 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 appellant : Sh.Munish Goel, Advocate
For respondent No.1 : Sh.M.K.Jindia, Advocate
For respondents No.2,3&4: None
SIMARJOT KAUR, MEMBER :
The Appellant/Opposite Party No.4 has filed the present Appeal to challenge the impugned order dated 11.12.2023 passed by the District Consumer Disputes Redressal Commission, Sangrur (in short, "the District Commission"), whereby the Complaint filed by the Complainant had been allowed.
2. It would be apposite to mention here that hereinafter the parties will be referred, as were arrayed before the District Commission.
3. The brief facts of the case as made out by the Complainant in the Complaint filed before the District Commission are that the Complainant was the 'Consumer' of OPs as he had availed their services by becoming the member of the Scheme i.e. Bhai Ghanhya Sehat Sewa Scheme through OP No.1. Under this scheme, OPs had taken Medical Insurance Policy for its members FA No.214 of 2024 3 (including spouse & other family members) from OP No.4 through OP No.3. An identity card number MD15-BGSSS-00299633-S was issued to the Complainant by the OPs. OP No.2 was appointed as TPA for processing the claims under the policy. As per scheme, the Members were entitled for treatment within a period of one year from any network hospital as mentioned in the list/booklet given by the Ops. The Complainant/Respondent was issued identity card/preauthorization card. It was to be presented to the Hospital authorities (empaneled Hospitals). In the event of taking treatment from the Government Hospitals, the expenses were to be reimbursed by the OPs later on. The Complainant had suffered severe chest pain on 30.10.2014 and was immediately taken to Patiala Heart Institute, Patiala by his family members being an emergency case. He was admitted in emergency and angiography was done which revealed RCA 99% stenosis. The treating Doctor performed PTCA and stenting on the same day. The Complainant was discharged on 01.11.2014. An amount of Rs.1,60,649/- was spent on his treatment. Thereafter, the Complainant had submitted all the original bills along with the record of treatment to the OPs for reimbursement claim amount. However, the claim amount was not paid by the OPs. The Complainant had also filed Petition Number 330 dated 01.11.2017 before the Permanent Lok Adalat, Sangrur which was decided on 10.04.2019. The Complainant was directed to submit the claim papers along with the documents to OP No.2 through OP No.1. OP No.2 was directed to decide the claim within two months from the date of receipt of claim papers. Thereafter, the Complainant vide FA No.214 of 2024 4 application dated 24.07.2019 had submitted the documents to OP No.1. OP No.4 had repudiated the claim of the Complainant vide letter dated 27.9.2019 on the ground that the treatment undertaken by him was from non-network hospital which was not covered under the policy. The Complainant had alleged "deficiency in service" on the part of the OPs. Hence, the present Complaint was filed by the Complainant with the prayer to issue directions to the OPs to pay an amount of Rs.1,60,649/- along with interest @ 18% p.a. from the date of discharge i.e. 01.11.2014 till its actual payment and also to pay Rs.50,000/- on account of mental tension, agony, pain, harassment and also to pay Rs.7500/- as litigation expenses.
4. Upon issuance of notice of the Complaint, the OPs No.1&4 had appeared and filed their separate written version. OP No.1 had raised legal objections that the present Complaint was not maintainable. The Complainant had no cause of action and locus standi to file the present Complaint. The Complainant had dragged the OP No.1 into unwanted litigation. On merits, it was admitted that the Complainant was insured being the member of the OP No.1. It was also admitted that the direction was given by the Permanent Lok Adalat Sangrur to the Complainant to submit the claim papers to the OPs through OP No.1. It was stated that the claim had to be settled and paid by OP No.4. OP No.1 had nothing to do in the said Complaint. Lastly, OP No.1 had prayed that the Complaint be dismissed qua OP No.1.
5. OP No.4 had filed its separate written reply by raising certain preliminary objections that the Complaint was not FA No.214 of 2024 5 maintainable. The Complainant had filed the Complaint by concealing correct and material facts from this Commission. The Complainant had unnecessarily dragged the OP No.4 into unwanted litigation. On merits, it was admitted that the beneficiaries were enrolled under the said scheme were entitled for treatment within one year from any network hospital as mentioned in the list/booklet given by the OPs. They were to produce identity card/pre-authorization card to the hospital authorities or in the event of taking treatment in Govt. Hospitals, the expenses were to be reimbursed by the OPs later on. It was denied that the Complainant had submitted all the original bills along with the record of treatment. OP No.4 had also denied that the Complainant had requested for settlement of his claim and for payment of the claim amount. It had been admitted that the Complainant filed a petition before the Permanent Lok Adalat and the documents were submitted. Thereafter, vide letter dated 27.09.2019 the claim of the Complainant was repudiated as he had taken treatment from non-network hospital which was not covered under Bhai Ghanahyia Sehat Sewa Scheme. OP No. 4 denied any deficiency in service on its part. It had prayed for dismissal of the Complaint.
6. Notice of the Complaint was issued to OPs No.2&3. OPs No.2&3 did not appear before the District Commission and were proceeded against ex-pare vide order dated 20.02.2020.
7. By considering the averments made in the Complaint, the Complaint filed by the Complainant was allowed vide order FA No.214 of 2024 6 dated 11.12.2023 passed by the District Commission. The relevant part of said order is reproduced as under:-
"12. So, in view of our above discussion, we allow the Complaint and direct OP No.4 to pay to the Complainant an amount of Rs.1,50,000/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 30.10.2019 till its realization. We further direct OP No.4 to pay to the complainant an amount of Rs.1,50,000/- alongwith interest @7% per annum from the date of filing of the present complaint i.e. 30.10.2019 till its realization. We further direct OP No.4 to pay to the Complainant an amount of Rs.5,000/- on account of compensation for mental tension, agony and harassment and further an amount of Rs.5,000/- on account of litigation expenses."
8. The Appellant/OP No.4 has filed the present Appeal being aggrieved by the order dated 11.12.2023 passed by the District Commission by raising a number of arguments.
9. Mr.Munish Goel, Advocate learned Counsel for the Appellant/OP No.4 has argued on the similar lines as mentioned in the written reply. Learned Counsel has submitted that the Complainant was admitted to Patiala Heart Institute on 30.10.2014 due to severe chest pain, where stenting in heart was done. He was discharged on 01.11.2014. Although he had submitted documents for reimbursement still the claim was not paid. Permanent Lok Adalat vide its order dated 10.04.2019, Complainant was directed to resubmit documents, which he had submitted on 24.07.2019. FA No.214 of 2024 7 However, the claim of the Complainant was repudiated on 27.09.2019 as the treatment was taken from the non-network hospital. As per the terms and conditions of the policy, treatment was required to be taken from a network hospital listed in the booklet provided to the insured, upon showing the identity/pre-authorization card. Reimbursement was permissible only if treatment was taken from the Government hospital. Since the Complainant had taken treatment from a non-network private hospital hence, the claim was not payable. The Complainant had failed to comply with the terms and conditions of the policy. He had not submitted the original bills and treatment records. Therefore, the claim was not admissible under the policy. The District Commission had wrongly allowed the Complaint without properly appreciating the policy terms and the non- compliance by the Complainant. Learned Counsel has also relied upon the judgment passed by Hon'ble Madras High Court in CWP No.480 of 2009 titled "Star Health and Allied Insurance Co. Ltd. Vs. A.Chokkar" on 26.02.2010 and had also relied upon the judgment passed by this Commission in First Appeal No.484 of 2023 titled as "National Health Authority Vs. Mr.Malkit Singh & Anr." on 26.09.2025. Learned Counsel has prayed that the impugned order is illegal and liable to be set aside. He has also prayed that present Appeal be allowed and the Complaint be dismissed.
10. Mr.M.K.Jindia, Advocate, learned Counsel for the Respondent No.1/Complainant has submitted that the impugned FA No.214 of 2024 8 order dated 11.12.2023 passed by the District Commission, Sangrur is well reasoned and a detailed one. The present Appeal is misconceived, devoid of merit and an abuse of the process of law. The Complainant was the beneficiary under the Bhai Ghanahiya Sehat Sewa Scheme of the OPs. He was entitled to cashless treatment up to Rs.1.5 lakhs to its beneficiaries and their families in Network Hospitals or reimbursement for treatment taken in Government Hospitals.
11. During the subsistence of policy, the Complainant had suffered severe chest pain and was taken in an emergency to Patiala Heart Institute, Patiala. Angiography was performed upon him. It was revealed 99% RCA stenosis. Therefore, stenting was performed on the same day. He was discharged on 01.11.2014 after incurring expenses of Rs.1,60,649/-. The medical record and discharge certificate confirm the fact that he was admitted in an emergency condition. The Complainant had submitted all relevant documents to the OPs. Upon non-settlement of the claim, he had approached the Permanent Lok Adalat, Sangrur. They had directed the OPs to reconsider the claim. However, the claim was repudiated on 27.09.2019 solely on the ground that treatment was taken from a non-Network Hospital.
12. The District Commission, Sangrur after appreciating the evidence on record had allowed the Complaint on 11.12.2023 and directed the OP No.4 to pay Rs.1,50,000/- along with interest @ 7% per annum along with compensation and litigation expenses. FA No.214 of 2024 9
13. It was further submitted that it is a settled principle of law that in emergency situations, treatment taken from a Non-Network Hospital cannot deny for reimbursement. The Complainant was admitted in a life-threatening emergency and immediate stenting was necessary. In such circumstances, it cannot be expected to search for a Network Hospital at the cost of his life, which is protected under Article 21 of the Constitution of India.
14. There are numerous judgments of State Commissions/ Hon'ble High Courts of Punjab & Haryana and Madras wherein it was held that emergency treatment undertaken from a Non-Network Hospital is reimbursable.
15. Learned Counsel for the Respondent No.1 has also relied upon the judgments of cases titled as "Sandeep Kumar Vs. State of Haryana & Ors.", CWP No.138 of 2020 decided on 18.03.2024 by Hon'ble Punjab & Haryana High Court. "C.Mani Vs. Principal Secretary to the Government of Tamil Nadu", CWP No.25304 of 2018 & 22916 of 2018 decided on 05.12.2023 by Hon'ble High Court, Madras. "Sukhdev Singh Nagpal Vs. New Kanan Pehalwal Cooperative Agriculture Service Society & others", 2017(3) CLT
120. "Vijay Kumar Khanna Vs. Deputy Director of Education & Others" 2018 (4) 621 CLT. Learned Counsel for the Respondent No.1 has prayed that in view of the above facts and settled legal position, the Complainant is entitled to reimbursement up to Rs.1.5 lakhs along with compensation and litigation expenses and also FA No.214 of 2024 10 prayed that the Appeal filed by the Insurance Company is liable to be dismissed.
16. We have heard the oral arguments raised by learned Counsel for the Appellant as well as Respondent No.1. None has appeared on behalf of Respondents No.2,3&4 despite service. We have also perused the order dated 11.12.2023 as well as all the relevant documents available on the file.
17. Facts relating to the filing of the Complaint by the Complainant before the District Commission, issuance of notice, raising of oral arguments by learned Counsel for the parties and passing of impugned order dated 11.12.2023 by the District Commission, thereafter filing of present Appeal before this Commission by the Appellant/OP No.4 are not in dispute.
18. The issue for adjudication before us as to whether the OPs had rightly repudiated the claim of the Complainant or not?
19. To deal with the aforesaid issue, we have thoroughly gone through the documents tendered by the parties, the impugned order and the judgments relied upon by the learned Counsel for the parties.
20. Admittedly, the Respondent/Complainant was admitted in emergency condition in Patiala Heart Institute Patiala as he was suffering from severe chest pain. The attending doctors had performed Stenting upon him after assessing his critical situation. Said fact has been proved from the medical record (Ex.C-3) tendered by the Respondent No.1/Complainant. A certificate dated 01.11.2014 FA No.214 of 2024 11 (Ex.C-4) was issued by the attending doctor at the time of his discharge from the hospital wherein it had been certified that he was admitted on 30.10.2014 in an emergency situation. The Respondent No.1/Complainant had lodged the claim for the expenditure incurred by him on his medical treatment. He had lodged his claim with the Appellant/OP No.4 being the beneficiary of Bhai Ghanhya Sehat Sewa Scheme vide Identity Card No.MD15-BGSSS-00299633-S. The Appellant/OP had repudiated his claim on following ground vide letter dated 27.09.2019 (Annexure 7). The contents of the repudiation letter are reproduced as under:-
"Treatment taken in non network Hospitals except in Govt. hospital is not covered. Only cashless Hospitalisation in network hospital and reimbursement in government. Hospitals are to be covered. Treatment at Govt. hospital shall be covered at Govt. hospital rates."
21. In this regard, this Commission has decided a similar issue in case titled as "National Health Authority (Ministry of Health & Family Welfare) Vs. Mr.Malkit Singh & Anr.", wherein reference has been drawn in judgment of Hon'ble Supreme Court in case i.e. Shiva Kanta Jha v. Union of India AIR (2018) Supreme Court 1975, wherein the treatment was taken from an empanelled hospital. The relevant portion of said judgment is reproduced as under:
"13) XXXXXXX Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person FA No.214 of 2024 12 to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds.
14) XXXXXX In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration."
20. By relying upon said judgment passed by the Hon'ble Supreme Court, the Hon'ble Punjab & Haryana High Court has also laid the similar law in the case of Roshan Lal Garg v. State of Haryana & Ors. CWP No.19105 of 2021 decided on 08.07.2024. The relevant portion of said judgment is reproduced as under:
"9. The facts of the present case suggest that it has not been disputed by the Respondent-department that son of the petitioner was taken to the aforesaid hospital in an emergency condition which is also supported by a certificate issued by the aforesaid hospital and also by the Civil Surgeon, Gurugram. Whenever a patient is suffering from an emergency condition then the entire focus is always on saving the life of the patient and in case there is some pain then the focus is also to relieve the pain. It would be inhuman to say that whenever such like emergency situation arises then an employee should keep on searching the list of approved hospitals and should first go to an approved hospital or a government FA No.214 of 2024 13 hospital by ignoring the developing pain and at the risk of life. It would be not only perverse but it will also be violative of Right to Life guaranteed under Article 21 of the Constitution of India."
22. In view of above discussion as well as circumstances of the case in hand and ratio of judgments cited above, we are of the view that the Respondent No.1/Complainant was admitted in Patiala Heart Institute, Patiala in an emergency condition of health. In such situation he/his family members were not supposed to search for network hospitals by ignoring his health condition/risk of his life. It is an admitted case that the Complainant was a beneficiary under Bhai Ghanhya Sehat Sewa Scheme launched by the Government as such he cannot be denied the claim on the basis of technicalities.
23. The impugned order passed by the District Commission is based on proper appreciation of evidence and law as applicable on the facts and circumstances of the case in hand. Therefore, no interference is required by this Commission.
24. Accordingly, finding no force in the contentions raised by the learned Counsel for the Appellant, the Appeal is hereby dismissed. The impugned order dated 11.12.2023 passed by the District Commission is upheld.
25. The Appellant had deposited an amount of Rs.1,02,783/- at the time of filing the appeal with this Commission and deposited an amount of Rs.1,02,783/- in compliance of order dated 10.07.2024. Said amounts, along with interest, which has accrued on the amount deposited by the Appellant, if any, shall be FA No.214 of 2024 14 remitted by the Registry to the District Commission after the expiry of 45 days of sending of certified copy of the order to the parties. The concerned party(s) may approach the District Commission for release of the same and the District Commission may pass the appropriate order in this regard, in accordance with law.
26. Since the main case has been disposed off, so all the pending miscellaneous applications, if any, are accordingly, disposed off.
27. The Appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER (VISHAV KANT GARG) MEMBER March 12, 2026 Rupinder 2