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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
Inderjit Kaushik, Presiding Member and Piare Lal Garg, Member
TELECOM BSNL - Appellant
Versus
GURPAL SINGH - Respondent
First Appeal No. 1434 of 2007
Decided on : 29-05-2012
Mr. G.C. Babbar, Advocate, for the Appellant; Mr. Kailash Sharma, Advocate, for the Respondent
The judgment established that lack of specified time limit for claim submission in the policy, coupled with lack of knowledge about the policy at the time of treatment, could be valid grounds for delayed submission of medical reimbursement claims.
Headnote:
Medical Reimbursement Scheme - Delayed Claim Submission - R.D.S.N.L. policy - B.S.N.L. Employees Medical Reimbursement Scheme - Rule 3.0 - Office Memorandum - CGMT Approval - Late Intimation - Rejection of Claim
Fact of the Case:
The respondent, a retired employee of BSNL, sought medical reimbursement for treatment received at an approved hospital. The appellant rejected the claim due to delayed submission, citing policy terms and conditions. The respondent argued lack of knowledge about the policy at the time of treatment and immediate submission upon awareness.
Finding of the Court:
The District Forum set aside the rejection of the claim, directing the appellant to reconsider the reimbursement as per relevant rules. The appellant appealed, alleging misinterpretation of the scheme and ignoring departmental instructions, but the appeal was dismissed, and costs were imposed for harassing the retired employee without valid grounds.
Issues: The main issue was the rejection of the medical reimbursement claim by the appellant due to delayed submission, based on policy terms and conditions.
Ratio Decidendi: The court found that the policy did not specify a time limit for claim submission, and the rejection was deemed illegal and against the rules of the policy, regulations, and departmental letters. Lack of knowledge about the policy at the time of treatment was considered a valid reason for delayed submission.
Final Decision: The appeal was dismissed, and costs were imposed on the appellant for harassing the retired employee without valid grounds. The appellant was directed to reimburse the claim as per entitlement under the policy within one month.
ORDER
Piare Lal Garg, Member - This is an appeal filed by Telecom BSNL (hereinafter called the appellant ) against the order dated 19.9.2007 of the District Consumer Disputes Redressal Forum, Ropar (hereinafter called District Forum ) by which the complaint of the respondent was accepted by the District Forum.
2. Brief facts of the case are that the respondent had retired as SDE from the office of the appellant on 30.6.2003. In the month of September, 2006, the respondent felt severe pain in his heart and was admitted in the Civil Hospital, Ropar for treatment. He was referred to Fortis Hospital, Mohali on 28.9.2006 by the doctors of Civil Hospital, Ropar and he was operated in Fortis Hospital, Mohali on 29.9.2006.
3. The respondent was covered under para 1.5 in R.D.S.N.L. policy issued on 28.2.2004 for medical reimbursement for all serving and retired employees of BSNL Department. Fortis Hospital was on the panel of approved list of hospitals under the scheme. The respondent on 16.11.2006 applied with the appellant for reimbursement of the medical expenses but the appellant rejected the reimbursement claim of the respondent on the ground that the claim was not filed within the prescribed period of the policy as per terms and conditions. There was no delay on the part of the respondent but the claim of the respondent was rejected on vague and illegal grounds, which was liable to be quashed. The respondent had no knowledge regarding the scheme at the time of operation and after the operation when he came to know regarding the insurance policy, he immediately submitted his claim without any delay along with all documents. There was deficiency in service on the part of the appellant. Appellant was unnecessarily harassing the respondent. Complaint was filed with the prayer that the appellant may be directed to pay Rs. 1,66,654 on account of medical reimbursement claim along with interest @ 12% p.a. from the date of application for reimbursement i.e. 16.11.2006 till realization and also prayed for Rs. 50,000 on account of harassment and Rs. 10,000 as litigation expenses.
Upon notice, the appellant replied by taking preliminary objections that there was abnormal delay in submission of the claim, as such, the claim was liable to be rejected as the respondent has not complied with the terms and conditions of the policy. On merits, the respondent had informed the office of the appellant on 16.11.2006 i.e. after 50 days. As per BSNL Rules in all cases of extreme emergency the employees concerned shall have to inform SSA Head or his controlling officer immediately after hospitalization. Thereafter designated Officer of BSNL visits the hospital to verify the authenticity of the claim. It was pleaded that when treatment was required to be taken from the private hospital or from the hospital which is not empanelled then approval of Chief General Manager was required. In the case of emergency/extreme emergency approval of CGMT was required soon after admission in the hospital. The claim was rightly rejected after due consideration.
4. Learned District Forum after hearing the learned Counsel for the parties and going through the record, allowed the complaint and set-aside the orders of rejection of the reimbursement claim dated 29.11.2006 and 21.12.2006. District Forum directed the appellant to consider the quantum of reimbursement to be allowed to the respondent as per the relevant rules and to pass the order, accordingly within one month.
5. Hence, the appeal.
6. We have gone through the pleadings of the parties, perused the record of the learned District Forum and heard the arguments of the learned Counsel for the parties.
7. The present appeal is filed by the appellant on the grounds that the District Forum has passed the order without jurisdiction, not appreciated the scheme of the medical reimbursement of the appellant, twisted the facts in favour of the respondent and ignored the Departmental Instructions dated 21.11.2006, as such, the order o
