STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

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, 3^rd 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.

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 (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 p