ASHOK KINRA vs CENTRAL COTTAGE INDUSTRIES CORPORATION AND ORS
* IN THE HIGH COURT OF DELHI AT NEW DELHI
Date of decision: 02nd JULY, 2024
IN THE MATTER OF:
+ W.P.(C) 1732/2023 & CM APPL. 6614/2023
ASHOK KINRA ….. Petitioner
Through: Mr. Ravikesh K. Sinha, Mr. Aasheesh Gupta, Mr. Kamal Kumar and Mr. Harshit Garwal, Advocates.
versus
CENTRAL COTTAGE INDUSTRIES CORPORATION AND ORS.
….. Respondents
Through: Mr. Naginder Benipal, SPC for UoI with Mr. Ankit Siwach, Ms. Anjali Pandey, Advocates and Mr. Rudra Paliwal, GP for UOI.
CORAM:
HON’BLE MR. JUSTICE SUBRAMONIUM PRASAD
JUDGMENT
1. Aggrieved by the decision of Respondent No.1 in refusing to reimburse Rs.2,54,946/- to the Petitioner which was spent by the Petitioner for the treatment of his wife who is suffering from cancer, the instant writ petition has been filed by the Petitioner with the following prayers:
A. Direct the Respondent No. 1 to release the payment of Rs 2,54,946/- (Two Lakh Fifty Four Thousand Nine Hundred and Forty Six Only) alongwith interest to the Petitioner against Medical Reimbursement and Rs. 1,00,000/- towards mental harassment and legal expenses.
B. Pass such further order(s) as it may deem fit and proper in the facts and circumstances of the case.
2. The facts, in brief, reveal that the Petitioner herein joined Respondent No.1/Central Cottage Industries Corporation (CCIC) as a Company Secretary at the level of Deputy Manager in the year 1991. Material on record indicates that Respondent No.1 invited a tender for providing a Group Mediclaim Insurance Policy for regular and ex-employee of Respondent No.1/CCIC. Material on record indicates that Oriental Insurance Company Limited was successful in the tender process and it is providing a Group Mediclaim Insurance to the employees and ex-employees of Respondent No.1/CCIC. The Petitioner being an ex-employee of Respondent No.1/CCIC is covered by the Group Mediclaim Insurance. The salient features of the insurance reads as under:
1. Family: 1+5 (Self+Spouse+2 kids+any of two dependent parents as : Mother, Father, Mother in Law, Father in law) Son till he attains the age of 25 or starts earning whichever is earlier.
Daughter till she starts earning or gets married.
Exception Son or Daughter suffering from permanent Disability of any kind (physical or mental no age limit).
2. Waiver: 4.1, 4.2, & 4.3 pre- existing disease cover.
3. New Born Child cover from day one.
4. Dreaded disease covered as per list in the tender.
5. 30 days Pre and Post Hospitalization Cover
6. Congenital Diseases : Internal on life threatening cases.
7. Room rent limit/ day: 2% for all S.I. Subject to Max Rs.5000/-. Overall limit under Room Rent and ICU 25% of SI per illness.
8. Ambulance charges : 1% for Sum Insured.
9. Corporate buffer : 30 lacs as per the tender to be disbursed by CCIC Authorities.
10. Total Number of live at inception : 1105 (Emp : 291+spouse :237, dependent child : 455, parents : 122)
11. ICU Limit per day: Rs.4% for all S.I. Subject to Maximum Rs.10,000/-.
12. COVERAGE WILL BE FROM THE 1st DATE OF THE MONTH SUBJECT TO SUFFICIENT BALANCE IN THE CD ACCOUNT & DELITION FROM LAST DATE OF THE MONTH OF EXIT.
13. Sum Insured Rs.1,50,000/- per family.
14. Cost of Aid : Rs.10,000/- as per tender conditions.
15. Day Care Coverage as per list in tender and as per policy.
16. No restriction on single disease / 100 days and investigation forming part of the treatment.
17. cost of travel as per tender conditions maximum Rs.3000/- per employee or actual expenses whichever is less.
18. All other terms and conditions as per Tender.
3. A perusal of the insurance policy schedule shows that the total sum insured is Rs.4,38,00,000/- and total premium is Rs.43,05,414/-. The Petitioners wife was suffering from cancer and was being treated at Ganga Ram Hospital, being a panel hospital of the insurance company. The Petitioners wife was advised to undergo an immediate surgery. It is stated that in view of the urgency and non-availability of doctor, the surgery took place in B. L. Kapoor Hospital which is not empanelled with the Respondents. The total bill raised by the B. L. Kapoor Hospital towards medical expenses for the surgery was Rs.3,57,158/- A sum of Rs.2,85,726/- was given as advance since B. L. Kapoor Hospital was not in the panel of hospitals of the Respondents. The Petitioner claimed the reimbursement of the amount of Rs.3,57,158/- after deducting Rs.2,85,726/-. The Respondent No.1/CCIC wrote a letter dated 13.06.2016 to the Petitioner stating that a sum of Rs.2,85,726/- has been given as an advance and since the Petitioners wife was treated in a hospital other than the empanelled hospital, and the Petitioner is only entitled to the reimbursement at AIIMS rates and, therefore, amount payable as per AIIMS rates is Rs.1,02,212/- and a sum of Rs.1,83,514/- is recoverable from the Petitioner. The letter dated 13.06.2016 is being quoted below in its entirety:
The amount of Rs.1,83,514/- has been recovered from the Petitioner.
4. A perusal of the aforesaid letter shows that three bills have been submitted by Respondent No.1/CCIC to the Insurance Company for settlement, one in respect of Mr. Uttam Singh, the second in respect of Petitioner and the third for Mr. Harsh Mahant. The letter further indicates that Respondent No.1/CCIC has approached the Consumer Forum against the Insurance Company praying for recovery of Rs.13,23,359/- which has been paid by Respondent No.1/CCIC for the treatment of Mr. Uttam Singh in an empannelled hospital which is being sought to be recovered from the Insurance Company.
5. It is also pertinent to mention at this juncture that the entire amount of Rs.3,57,158/- which has been claimed by the Petitioner has already been reimbursed by the Insurance Company. This fact is evident from the correspondence dated 21.06.2016 addressed to the Petitioner by Respondent No.1/CCIC. The letter dated 21.06.2016 reads as under:
6. Material on record also indicates that aggrieved by the fact that the Petitioner is not being reimbursed the entire amount of Rs.3,57,158/-, the Petitioner had approached the Central Government and a recommendation has been made by the Central Government to Respondent No.1/CCIC for reimbursement of the entire amount of Rs.3,57,158/- to the Petitioner which has yet not been complied with by Respondent No.1/CCIC.
7. It is the case of the Petitioner that after receiving the entire amount of Rs.3,57,158/- from the Insurance Company by the Respondent No.1/CCIC, it was obligatory on the part of Respondent No.1/CCIC to reimburse the entire amount to the Petitioner.
8. Per contra, learned Counsel appearing for Respondent No.1 states that the Petitioner is entitled to be reimbursed the maximum amount of Rs.1,02,212/- as per AIIMS rates since the Petitioner has not got the treatment of his wife from an hospital which is empanelled with the Respondents, and therefore, the Respondent No.1/CCIC is entitled to recover the amount of Rs.1,83,514/- from the Petitioner in accordance with the policy. It is also stated by the learned Counsel for Respondent No.1/CCIC that in case Respondent No.1/CCIC wins the case before the Consumer Forum, the Respondent No.1/CCIC would pay the entire amount of Rs.3,57,158/- to the Petitioner.
9. Heard learned Counsel appearing for the Parties and perused the material on record.
10. Material on record indicates that there is a buffer of Rs.30 lakhs. Material on record indicates that six bills have been submitted by the Respondent No.1/CCIC to the Insurance Company a fact which is evident from the letter dated 17.12.2015 which reads as under:
11. The total sum of the claim submitted by the Respondent No.1/CCIC to the Insurance Company comes to Rs. 19,01,874 which is within the buffer of Rs.30 lakhs. This Court is, therefore, unable to understand if the entire amount of money is covered within the buffer of 30 lakhs what prevented the Respondent No.1/CCIC from making the entire payment to the Petitioner. It is an admitted case by the Respondent No.1/CCIC that the entire amount of Rs.3,57,158/- has been received by the Respondent No.1/CCIC from the Insurance Company. The Respondent No.1/CCIC is retaining the amount received in the name of the Petitioner from the Insurance Company and keeping with itself and only giving a sum of Rs.1,02,212/- to the Petitioner. The Respondent No.1/CCIC has taken the entire amount from the Insurance Company but is paying even lesser than the amount of Rs.1.5 lakhs which the Petitioner is entitled to under the insurance policy on the ground that the operation of the wife of the Petitioner was conducted in a hospital which is not empanelled with the Respondents. The stand of Respondent No.1/CCIC is completely inequitable. Another interesting fact is that in the case of Mr. Uttam Singh, the Respondent No.1/CCIC has paid the entire amount of money and now filed a claim before the Consumer Forum for recovery of money from the Insurance Company. There is no reason to differentiate the case of the Petitioner from the case of Mr. Uttam Singh more so when the entire money has been received by the Respondent No.1/CCIC from the Insurance Company. If the Respondent No.1/CCIC could pay the entire amount to Mr. Uttam Singh, there is no reason as to why the Petitioner should be differentiated with Mr. Uttam Singh and, therefore, the Petitioner is entitled to be paid the entire amount. The Respondent No.1/CCIC is a PSU under the control of Ministry of Textiles. An appeal and grievance has been raised by the Petitioner before the Ministry of Textiles and the file notings have also been produced by the Petitioner before this Court. The file notings of the Ministry in the case of the Petitioner are being reproduced below:
2. In this regard, this Ministry has sought clarifications and issued directions to CCIC. This Ministry vide letter dated 30.10.2018 directed CCIC to take the matter to board and find a practical solution to it. CCIC vide letter dated 06.02.2019 has submitted that the CCIC board has decided to keep the matter in abeyance till the outcome/decision of the consumer court case filed by CCIC is received. The case has been examined by this Ministry and there is no link between the case filed by CCIC and the medical claims of Sh. Ashok Kinra. The matter is being delayed by CCIC unnecessarily.
3. Insurance company has paid CCIC Rs. 3.57 Lakhs for settlement of the claim of Sh. Ashok Kinra. As per the insurance claim policy the amount should be paid to Sh. Ashok Kinra only.
4. In view of above, we may direct CCIC to release the full amount to Shri Ashok kinra without delaying it further and to avoid further litigation.
Submitted for approval and further directions please.
12. The Central Government has accepted the case of the Petitioner and has directed the Respondent No.1/CCIC to reimburse the full amount to the Petitioner. For the reasons best known to the Respondent No.1/CCIC, the direction of the Respondent No.1/CCIC is not being followed by the Respondent No.1/CCIC.
13. The Respondent No.1/CCIC which is an instrumentality of the State is adopting the policy of pick and choose inasmuch as it has paid the entire amount of money to Mr. Uttam Singh and has held that Mr. Uttam Singh is entitled to Rs.13,23,359/-. Whereas, the Petitioner for whom the entire amount stands received by Respondent No.1/CCIC from the Insurance Company, the Petitioner is not being paid the money by Respondent No.1/CCIC. The conduct of Respondent No.1/CCIC is inexplicable. The fact that Mr. Uttam Singh got his treatment from an empanelled hospital and the Petitioner has not got the treatment of his wife from an empanelled hospital cannot be a reason to deny the reimbursement of the amount to the Petitioner. The Petitioner should be treated at par with Mr. Uttam Singh inasmuch as Mr. Uttam Singh has been paid the entire amount under the same Insurance Policy which is more than Rs.1.5 lakhs, which according to the Respondent No.1/CCIC is the maximum amount payable under the policy, and therefore, the Petitioner should also be entitled to the entire amount of Rs.3,57,158/-. The Respondent No.1/CCIC is directed to pay the amount of Rs.2,54,946/- to the Petitioner within a period of six weeks from today.
14. With these observations, the writ petition stands allowed. Pending applications, if any, stand disposed of.
SUBRAMONIUM PRASAD, J
JULY 02, 2024
S. Zakir
W.P.(C) 1732/2023 Page 3 of 14