DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA

C.C. No. 272 of 18-9-2017

Decided on : 25-03-2022

1. Kaka Singh aged about 51 years S/o Kaur Singh

2. Charanjit Kaur aged about 43 years W/o Kaka Singh

   - Both R/o #20071, Parinda Road, Gali No. 30, Guru Teg Bahadur Nagar, Bathinda.

........Complainants

Versus

1. MD India Health Care Services (TPA) Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali 160 056 through its Director/MD

2. The Oriental Insurance Co. Ltd., Divisional Office, Bank Bazar, Bathinda, through its Divisional Manager

3. State of Punjab Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, PhaseVI, Near Civil Hospital, S.A.S. Nagar, Mohali, Punjab, through its Secretary/Authorised Signatory

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Sh. Kanwar Sandeep Singh, President

Sh. Shivdev Singh, Member

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Naresh Garg, Advocate

For opposite parties : Sh. Vinod Garg, Advocate, for OPs No. 1 & 2.

Sh. Lachman Kumar, Advocate, for OP No. 3.

ORDER

Kanwar Sandeep Singh, President

1. The complainants Kaka Singh and Charanjit Kaur (here-in-after referred to as complainants) have filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against MD India Health Care Services (TPA) Ltd., and others (here-in-after referred to as opposite parties)

2. Briefly stated, the case of the complainants is that complainants Kaka Singh & his wife Charanjit Kaur are duly insured with the opposite parties under Punjab Govt. Employee and Pensioners Health Insurance Scheme (PGEPHIS) under cashless insurance scheme as Kaka Singh being the Govt. employee upto Rs.5,00,000/-.

3. It is alleged that Jindal Heart Institute & Infertility Centre, Bathinda is the network hospital under said insurance scheme with the opposite parties and the Insurance is cashless Insurance. Complainant No. 2 Charanjit Kaur, being the wife of Kaka Singh was also insured with the opposite parties under cashless insurance scheme vide Membership
   Card No. MD15-09417024901 w.e.f. 1-1-2016 to 31-12-2016.

4. The complainants alleged that the opposite parties never issued any policy to the complainants rather they have issued ID card only. Under this scheme, in case of any medical assistance, the insured can go to any network hospital in Punjab and his total medical bills are free and total treatment is cashless under this scheme. The Complainants demanded the Insurance Policy and other papers under RTI Act from opposite party No.2, but the opposite party No. 2 denied to supply the same and said that the same is related to opposite party No. 3, as such they cannot supply the copy of the Insurance policy and other documents to the insured and they illegally rejected the application under RTI Act dated 15.07.2017.

5. It is alleged that in this scheme, opposite party No. 3 purchased this insurance scheme for all the Punjab Government employees and their families from opposite party No.2, and opposite party No. 1 was TPA.

6. The complainants alleged that IVF is also duly covered under the scheme of the opposite parties and in this regard, charges are also duly specified by the Govt. up to the total insured amount of Rs.5,00,000/-.

7. It is alleged that Charanjit Kaur/Complainant No. 2 was first time admitted for 1VF on 04.02.2016 and discharged on 07.02.2016 and second time admitted for IVF on 15.04.2016 and discharged on 17.04.2016. Both times, she was admitted in Jindal Heart Institute & Infertility Centre, Bathinda. At the time of admission, the said Hospital assured the complainants that treatment is cashless under the scheme. During treatment, the opposite parties did not release the payment and at the time of discharge on 07.02.2016 and 17.04.2016, Jindal Heart Institute & Infertility Centre, Bathinda charged full amount of Rs.1,23,014/- for both admissions from the complainants.

8. It is further alleged that the opposite parties did not release the amount of Rs.1,23,014/- and started enquiry about treatment. Doctors of said hospital duly explained to the opposite parties the total treatment and its necessity. The doctors also clarified that they charged the amount as per IVF admitted rates with opposite parties. Since the opposite parties did not approve cashless treatment, after discharge from hospital, complainants lodged claim with the opposite parties along complete original bills for an amount of Rs.1,23,014/- with original medical file.

9. The complainants further alleged that the opposite parties did not release the claim amount of Rs.1,23,014/- and illegally withheld the same without any cogent reason whereas IVF is duly covered under this scheme. The complainants repeatedly visited the office of opposite party No.2 at Bathinda and demanded the claim amount of Rs.1,23,014/-, but to no effect. The complainants alleged that due to non payment of Rs.1,23,014/- by the opposite parties, they suffered mental agony and pain for which they claimed compensation to the tune of Rs.50,000/-.

10. On this backdrop of facts, the complainants have prayed for directions to the opposite parties to pay claim amount of Rs.1,23,014/- with interest @18% P.A. alongwith Rs. 50,000/- as compensation besides litigation expenses to the tune of Rs. Rs.25,000/-.

11. Upon notice, the opposite parties appeared through their respective counsel and filed written version. The opposite parties No. 1 & 2 in their joint written reply raised legal objections that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in summary procedure under the 'Act' and appropriate remedy, if any, lies only in the Civil Court. That Punjab Government has entered into an agreement to provide cashless medical facility to its employees including pensioners under PGEPHIS (Punjab Government Employees and Pensioners Health Insurance Scheme) regarding which Punjab Government has issued notification to its employees also. Punjab Government along with Insurance Company and TPA i.e. opposite party No.1 has empanelled various hospitals to provide cashless treatment to employees of State Government. Rates of each and every treatment/operation have been finalized between empanelled Hospitals and TPA with consent of Punlab Government and Insurance Company is only liable to pay the same to the employees of the Punjab Government as per said agreement/insurance policy. Any treatment not provided in the agreement or mentioned in the exclusions is not payable at all. That the complainants have concealed material facts and documents from this Commission as well as opposite paties.

12. It has been pleaded that complainants have concealed the fact that the treatment/claim arose of infertility. As PGEPHIS is a public health scheme, the claim is not admissible within the standard exclusions of IRDA, hence the claim was repudiated. The complainants are claiming against Punjab Government Employees and Pensioners Health Insurance Scheme wherein the benefit has been given by the government of Punjab against specific diseases and up to specific amount as per scheme. The opposite parties are bound to decide the claim strictly as per final scheme. As per said scheme, any claim arising out of infertility is not covered and payable. So the claim has rightly been decided/repudiated and letter dated 03.01.2017 has been issued, The insurance policy is always subject to its terms and conditions.

13. Further legal objections are that the complainants are not consumers; the complainants have no locus standi or cause of action to file the present complaint and that the complaint is not maintainable.

14. On merits, the opposite parties No. 1 & 2 have pleaded that the insured in this case is State of Punjab and the complainants along with other covered persons are beneficiaries under the scheme. The benefits and coverage under the scheme have been finalized and no benefit beyond the scheme may be claimed. It is denied that total treatment is cashless under the scheme. It has been pleaded that cashless benefit is available in network hospitals and that too subject to certain limits and also subject to fulfillment of various conditions and after approval for cashless treatment. The opposite parties No. 1 & 2 denied that IVF or claim arising out of infertility is covered under the scheme and that there is coverage of total insured amount of Rs.5,00,000/-. It has been pleaded that the coverage was strictly subject to terms and conditions and limits of the scheme. The treatment taken by complainant No. 2 is not covered or payable under the scheme. So, the claim has been rightly repudiated. The opposite parties No. 1 & 2 denied that they did not supply terms and conditions of the policy rather the terms and conditions and benefits and limits of the scheme are to the knowledge of the complainants and other insured persons including opposite party No.3, who got the coverage for its employees. The opposite parties No. 1 & 2 denied all other averments of the complainants.

15. The opposite party No. 3 filed its separate written reply raising legal objections that the complainants have no cause of action and locus standi to file the present complaint ; complaint is not maintainable ; complainants have not come with clean hands and have suppressed the material facts; complainants are not consumers; the complainants have not exhausted the remedy available to them as per the Scheme. The State Govt. of Punjab has constituted a Grievance Redressal Committee at the District level as well as at the State level. The complainants have not made any representation to the said Committee, rather opted to approach this Commission directly and as such, the present complaint is liable to be dismissed. That the complainants did not issue mandatory notice provided under Sec.15 of the Punjab Health Systems Corporation Act, 1996 to the Punjab Health Systems Corporation prior to filing the present complaint. That intricate questions of law and facts are involved in the matter, which cannot be decided under the summary procedure under the 'Act'. That the complaint is bad for non joinder of necessary parties. That the complaint is false, frivolous and vexatious in nature and has been filed in violation of the provisions of PHSC Act and in order to cause undue harassment and botheration to the employees of opposite party No. 3.

16. On merits, the opposite party No. 3 admitted that complainant Kaka Singh and his wife Charanjit Kaur are insured under Punjab Govt. Employee and Pensioners Health Insurance Scheme. The said Insurance Scheme is free of costs and no such premium has been paid by either of the complainants. Thus the complainants are not consumers as defined under the 'Act'.

17. It has been pleaded that the complainants firstly did not approach the Civil Hospital, Bathinda, where treatment of all citizens including employees is given free of costs. The complainants did not lodge their claim with opposite parties No.1 & 2. Since the terms and conditions of the Insurance were duly supplied to complainant No. 1 and he was not competent to demand the Insurance Policy or any other paper under RTI Act from opposite party No. 2. The opposite party No.1 & 2 are liable to deal with the Scheme directly.

18. It has been further pleaded that the liability to pay the Insurance claim, if any, is that of the opposite parties No.1 & 2 under the Scheme. The opposite party No. 3 has no liability to pay any such amount to the complainants or any other employee. After controverting all other averments of the complainants, the opposite party No. 3 prayed for dismissal of complaint.

19. In support of their complaint, the complainants have tendered into evidence two affidavits of complainant No. 1 & 2 both dated 24-11-2017 (Ex. C-1 & Ex. C-2), photocopy of Insurance Card (Ex. C-3), photocopy of bill & receipts (Ex. C-4 to Ex. C-13), photocopy of prescriptions (Ex. C-14 & Ex. C-15), photocopy of No Claim Letter (Ex. C-16), photocopy of RTI application alongwith postal receipt (Ex. C-17), photocopy of letter & RTI information (Ex. C-18 to Ex. C-20).

20. In order to rebut the evidence of complainants, opposite parties No. 1 & 2 tendered into evidence affidavit dated 5-2-2018 of Dr. Geeta Bhardwaj (Ex. OP-1/1), affidavit of R L Baleem dated 6-3-2018 (Ex. OP-2/1), photocpopy of customer information sheet (Ex. OP-2/2), photocopy of PGEPHIS scheme (Ex. OP-2/3), photocopy of Notification (Ex. OP-2/4), photocopy of medi-claim Insurance Policy (Ex. OP-2/5), photocopy of guidelines (Ex, OP-2/8), photocopy of letter dated 3-7-13 (Ex. OP-2/7), photocopy of guidelines (Ex. OP-2/8).

21. Opposite party No. 3 has tendered into evidence photocopy of letter dated 10-10-2017 (Ex. OP-3/1) and affidavit dated 17-4-2018 of Dr. S S Romana (Ex. OP-3/2).

22. The learned counsel for the parties have reiterated their stand as taken in their respective pleadings.

23. We have heard learned counsel for the parties and gone through the record.

24. There is no dispute between the parties that Kaka Singh, complainant No. 1 being Government Employee, is insured under Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) with the opposite parties w.e.f. 1-1-16 to 31-12-16 upto Rs. 5,00,000/- and in this regard Insurance Card Ex. C-3 has been issued by the opposite parties. Complainant No. 2 Charanjit Kaur, being wife of Kaka Singh, complainant No. 1 is also covered under the said Insurance as is evident from Insurance Card Ex. C-3. The complainant No. 2 was admitted for IVF treatment in Jindal Heart Institute & Infertility Centre, Bathinda, twice i.e first time on 4-2-16 and discharged on 7-2-16 and second time 15-4-16 and discharged on 17-4-16. The complainants filed claim with the opposite parties and vide letter dated 23-11-16 (Ex. C-16) opposite parties No. 1 & 2 repudiated the claim of the complainant.

25. A perusal of No Claim Letter (Ex. C-16) reveals that opposite parties No. 1 & 2 repudiated the claim of the complainants on the ground that :

    “Having examined the claim papers, it is observed that the claim arose of Infertility. As PGEPHIS is a public health scheme, hence the claim is not admissible within the standard exclusion of IRDA. The claim is, hence, repudiated.”

26. The opposite parties have not mentioned or produced/proved on file under which standard exclusion of IRDA the claim of complainants is not admissible. Ex. OP-2/3 is the PGEPHIS (Scheme) which finds mentioned at Sr. No. 3 – Insurance Coverage (b) :-

    “Coverage of Pre-existing diseases - All diseases under the Scheme shall be covered from day one. A person suffering any any disease prior to the inception of the policy shall also be covered.”

27. Ex. OP-2/5 is the terms and conditions of Medi-claim Insurance (Individual) policy whereas complainants are insured under Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) , thus terms and conditions of this policy are not applicable on the complainants.

28. Ex. OP-2/6 is the Guidelines on product Filing in Health Insurance Business – Ref. IRDA/HLT/REG/CIR/150/07/2016. These guidelines have been issued on 29-7-2016 whereas the insurance policy of complainants is effective from 1-1-2016, hence these guidelines are also not applicable on the complainants since these guidelines are of later date.

29. Ex. OP-2/8 is Annexure IV - List of Expenses Generally Excluded (Non-admissible Expenses) in Hospitalization Policy – Guidelines on standardisation in Health Insurance – IRDA Circular No. IRDA/HLT/CIR/036/2013 dated 20-2-2013. In this document, it is mentioned at Sr. No. B that :

    'Items specifically excluded in policies :

    64. Inferility/Subfertility/Assisted Conception Procedure:

    The said IRDA Circular/guidlines have been issued on 20-2-2013. There is nothing mentioned that regarding which Health Insurance Policy these guidelines stands issued as there are so many health insurance schemes/polices provided by Insurance Companies.

30. Therefore, as detailed above, the opposite parties failed to produce any evidence to prove their so called Exclusion Clause. The repudiation letter (Ex. C-16) does not clarify under which Exclusion (standard exclusion of IRDA) the claim of the complainants was repudiated. The opposite parties have not produced on file that specific Insurance Policy w.e.f 1-1-2016 to 31-12-2-16 alongwith terms and conditions under which card Ex. C-3 has been issued to complainants.

31. On the other hand, the complainants when did not receive any response to their query raised under RTI, from the opposite parties regarding terms and conditions of their insurance policy and exclusion thereof, sought information under RTI from Public Information Officer, Office, Civil Surgeon, Mansa. Ex. C-19 & Ex. C-20 are the letter/information issued by Public Information Officer, Office of Civil Surgeon Mansa, which reveals that expenses incurred on IVF treatment are payable. The opposite parties could not rebut this evidence.

32. Hon'ble Supreme Court in the case titled Om Prakash Vs. Reliance General Insurance & Another 2018 (1) RCR Civil 43 (SC) has held that the decision of the insurer to reject the claim has to be based on valid grounds. Rejection of the claims on purely technical grounds in a mechanical manner will result in loss of confidence of policy-holders in the insurance industry.

33. It appears that hypertechnical view has been taken by the opposite parties just to repudiate the claim on one pretext or the other. The opposite parties are mixing different policies and different terms and conditions just to deny claim of complainant which cannot be permitted.

34. Therefore, keeping in view the facts, circumstances and the evidence place on file by the parties, this Commission is of the considered opinion that there is deficiency in service on the part of opposite parties No. 1 & 2 in repudiating the claim of the complainants without any basis. Hence, the complainants are entitled to Rs. 1,20,000/- being charges of IVF package. (Limitation of payable amount Ex. C-19/C-20 show Rs. 60,000/- per cycle AIMS rate).

35. In view of what has been discussed above, this complaint is partly allowed with Rs. 10,000/- as cost and compensation against opposite parties No. 1 & 2 and stands dismissed qua opposite party No. 3. The opposite parties No. 1 & 2 are directed to pay to complainant Rs. 1,20,000/- with interest @9% p.a. from the date of payment till realization.

36. The compliance of this order be made by the opposite parties No. 1 & 2 jointly and severally within 45 days from the date of receipt of copy of this order.

37. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    25-3-2022 (Kanwar Sandeep Singh)

    President

     

     

    (Shivdev Singh)

    Member

     

    (Paramjeet Kaur)

    Member