Punjab

Sangrur

CC/98/2019

Darashana Devi - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Sh.Sanjeev Goyal

10 Dec 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 98

 Instituted on:   12.03.2019

                                                                         Decided on:     10.12.2024

 

Darshana Devi aged about 68 years wife of Late Sh. Budh Ram, resident of Agar Nagar, Street No. 1, House No.215, Gaushala Road,  Sangrur.

                                                          …. Complainant.     

                                Versus

1.             The Oriental Insurance Company Ltd. CBO-III, SCO No.37, Sector 30-C, Chandigarh through its Branch Manager 160030.

2.             M.D. India Health Care Services Pvt. Ltd. Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director 160055.

3.             Director, Health and Family Welfare, Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh 160022.

4.             PWD B&R, Sangrur through its XEN, 1^st Floor, Block-B, DC Office, Sangrur 148001. (Notice to OP number 4 not issued).

5.             State of Punjab through Deputy Commissioner, Sangrur 148001.

                                                        ..Opposite parties.

 

For the complainant    :       Shri G.S.Nehal, Adv.

For Opp.Party No.1to2:      Shri Ashish Garg, Adv.

For Opp.Party No.3&5:       Exparte.

 

Quorum                                           

Jot Naranjan Singh Gill                           :President

Sarita Garg                                                :Member

Kanwaljeet Singh                                      :Member

 

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

 

1.             Smt. Darshana Devi, complainant  has preferred the present complaint against the opposite parties  on the ground that husband of the complainant  Shri Budh Ram was the pensioner and retired from the office of the OP Number 4, as such he being the pensioner alongwith the complainant was insured with the OPs under Punjab Government Employees and Pensioners Health Insurance scheme vide card number MD15-09478992117 for the period from 01.01.2016 to 30.12.2016.   The case of the complainant is that during the subsistence of the insurance policy, the husband of the complainant fell ill on 06.05.2016 and immediately taken to IVY Hospital, Mansa Devi complex, Sector 4, Panchkula, where he was diagnosed with the disease of hernia and spent an amount of Rs.42,769/- on the treatment and was discharged from the hospital on 9.5.2016. Thereafter the complainant lodged the claim with the OP number 2 through letter dated 1.7.2016 and in this regard OP number 2 issued a receipt number 46347 dated 4.7.2016 and assured that the claim amount will be released but no amount was paid.  Further case of the complainant  is that husband of the complainant died on 30.10.2018. Further case of complainant is that on 17.12.2018 the complainant again sent a registered letter to OP number 2 for releasing the claim amount of Rs.42,769/- and also submitted relevant documents for release of the claim amount, but neither the claim amount was paid nor the claim was repudiated, which is said to be deficiency in service on the part of the OPs. Thus alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.42,769/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by OPs number 1, it is admitted that the policy in question was issued for the period from 01.01.2016 to 31.12.2016 subject to the terms and conditions of the policy under which a sum of Rs.3,00,000/- was insured per family on floater basis.   It is further stated that as per the schedule, the liability of the company was to pay Rs.500/- as room rent per day for general ward, Rs.750/- per day for semi private room and Rs.1000/- per day for private room.  It is further averred that the liability of the company was to pay the rates as per package to General Ward category, for semi private category room, the liability of the company will be 10% higher than the rates application to General Ward category contained in the above said package. It is admitted that husband of the complainant remained admitted in Ivy Hospital from 06.05.2016 to 09.05.2016 and submitted the bill of Rs.42,769/- for re-imbursement. The TPA processed the claim of the complainant and passed the same for Rs.13,200/- as per package rates/scheme of the family, but due to inlias error the above said amount could not pay to the beneficiary, however spending of an amount of Rs.42,769/- for treatment has been denied. It is further averred that this Commission has no jurisdiction to try and decide the complaint.  Lastly, It is further averred in the reply that if any dispute arises between the parties during the subsistence of the policy period or thereafter in connection with the validity, interpretation, implementation or alleged breach of any provisions of the scheme, then it will be settled by the District Level Grievance Redressal Committee. In last, the OPs have prayed for dismissal of the complaint with costs.

3.             Record shows that the OPs number 3 & 5 were proceeded against exparte on 16.05.2019.

4.             The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-9 copies of documents and closed evidence. On the other hand, the learned counsel for the OPs number 1 and 2  has produced Ex.OP1&2/1 to Ex.OP1&2/4 copies of documents and Ex.OP1&2/5 affidavit and closed evidence. 

5.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties.

6.             It is an admitted fact between the parties that husband of the complainant Shri Budh Ram being a retired Punjab government employee was insured with the OPs under the medical policy, namely, Punjab Government Employees and Pensioners Health Insurance Scheme for the period from 01.01.2016 to 31.12.2016.  It is also not in dispute that during the subsistence of the insurance period, the husband of the complainant suffered from disease of hernia, as such he was admitted in the IVY Hospital Panchkula and remained admitted there from 6.5.2016 to 9.5.2016.  It is also an admitted fact of the complainant that an amount of Rs.42769/- was spent on his treatment as mentioned in the claim form  Ex.C-6. Now, the case of the complainant is that despite the fact the complainant submitted the bills to the Ops number 1 and 2 for reimbursement, but the claim of the complainant was neither repudiated nor settled despite the fact a long period has already has elapsed. The complainant has not produced on record the copies of the medical bills etc. But, a bare perusal of the written reply in para number 3, OPs number 1 and 2 have clearly mentioned that the TPA processed the claim of the complainant and passed the same for Rs.13,200/- as per package rates/scheme of the policy, but the same could not be paid to the beneficiary due to inlias error. But the fact remains that it was open for the OPs number 1 and 2 to pay the claim amount of Rs.13200/-  to the beneficiary by adopting other modes, but it was not done which is a deficiency in service on their part.  Now since Shri Budh Ram has already died on 30.10.2018 and we feel that the ends of justice would be met if the said amount of Rs.13,200/- is ordered to be paid to the complainant being the wife/nominee of Shri Budh Ram as per Ex.C-5.

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 (Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct the OPs number 1 and 2  to pay to the complainant an amount of Rs.13,200/- along with interest @ 7% per annum from the date of filing of the present complaint i.e. 12.03.2019 till realisation.  We further order the OPs number 1 and 2 to pay to the complainant an amount of Rs.5000/- in lieu of compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses.

9.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

10.            This order be complied with within a period of sixty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

 

Pronounced.

                        December 10, 2024.