| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 341 of 30-11-2017 Decided on : 21-04-2022 Baldev Singh S/o Gokul Singh R/o Village and P.O. Bhokhra, District Bathinda 151 001. ........Complainant
Versus Bhagat Puran Singh, Sehat Beema Yojna through its District Coordinator, Civil Hospital, Bathinda. United India Insurance Co. Ltd., S.C.O. No. 72, Phase-9, Mohali 160062 (Bhagat Puran Singh Sehat Bima Yojna), through its Divisional Officer/MD/Incharge. .......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. H S Dhillon, Advocate. For opposite parties : Sh. Lachman Kumar, Advocate, for OP No.1 Sh. I P Singh, Advocate, for OP No. 2. ORDER Kanwar Sandeep Singh, President The complainant Baldev Singh (here-in-after referred to as complainant) has 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 Bhagat Puran Singh Sehat Beema Yojna and another (here-in-after referred to as opposite parties). Briefly stated the case of the complainant is that he submitted his documents/I.D. proof to get the benefit of Bhagat Puran Singh Health Insurance of Rs.30,000/- per year, as per the scheme of Govt. of Punjab. Accordingly, Baldev Singh, complainant was issued a card under the scheme bearing No. 9304600009603570 after verification of documents. The complainant alleged that wife of the complainant Smt. Surjeet Kaur @ Sukhjeet Kaur was diagnosed stone in her uterus and doctor recommended her operation. Surjeet Kaur @ Sukhjeet Kaur, wife of complainant was got admitted in Chahal Hospital, Bathinda on 17.8.2017 for operation and operation was performed by Dr. J.S. Chahal MBBS, MS (Surgery) and she was discharged from the hospital on dated 21.8.2017. It is alleged that at the time of payment of the bills of the hospital, complainant Baldev Singh told the hospital staff that he is having insurance of Rs.30,000/- per year, as per Bhagat Pooran Singh Health Insurance and he is entitled to get this benefit. The complainant handed over his card to the hospital staff. The staff of hospital told complainant that he is not entitled to get any benefit as no data was shown on the computer regarding his insurance. The complainant told the hospital staff that he had given his all documents as per requirement and a card has already been issued to him. The complainant also alleged that he paid Rs.19,660/- in total on the operation of her wife. According to the scheme of Government, complainant is entitled to get benefit as card bearing No. 9304-6000096035750 has been issued by Government Authority and previously no benefit under this scheme has been claimed by complainant Baldev Singh. The complainant approached to the officials of the opposite parties and requested them to admit his claim, but to no effect. Due to unlawful, illegal and arbitrary act of the opposite parties, the complainant has suffered mental agony and pains for which he claims compensation to the tune of Rs.50,000/-. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay Rs.19,600/- incurred by complainant on the treatment of his wife and also pay him compensation to the tune of Rs. 50,000/- in addition to Rs. 10,000/- as litigation expenses. Upon notice, the opposite parties put an appearance through their respective counsel and contested the complaint by filing written reply. The opposite party No. 1 in its separate written reply, raised legal objections that the complaint is bad for non-joinder of necessary parties as complainant has not impleaded treating hospital i.e. M/s Chahal Hospital, Bathinda & MD India Health Insurance (TPA) Pvt. Ltd. Mohali, which is the claim settlement authority, as party. Moreover, the State Nodal Agency for Bhagat Puran Singh Sehat Bima Yojna i.e. Punjab Health Systems Corporation Mohali has also not been made a party. That the opposite party No.1 has got no relationship with the present claim. That the complainant does not fall under the definition of a consumer as he has not paid any premium for availing facility under the scheme. That the complainant has got no locus standi or cause of action to file the complaint. That this Commission has got no jurisdiction to entertain and decide the complaint. On merits, it has been pleaded that treating hospital is a private hospital and does not come under the control and management of opposite party No. 1. Any benefit whatsoever available with Bhagat Puran Singh Sehat Bima Yojna is for cashless indoor treatment purpose only. As per the guidelines of the said scheme beneficiary card holder must produce the smart card before the empanelled treating hospital within 24 hours of the indoor admission of the patient. The patient (whose name must be present in the said smart card) is then registered through computer software by the treating hospital and authenticated from Aadhar (UID) server by verifying finger print of either patient or any other member present in the smart card. The same process is again repeated while discharging the patient from the hospital. The opposite party No. 2/Insurance Company has a District Kiosk/office at Civil Hospital Bathinda, which could have checked the smart card for any error or blank data. The complainant never approached the kiosk office. The opposite party No. 1 has got no concern with any payment whatsoever made by complainant to any private hospital. It has been further pleaded that as per guidelines of Bhagat Puran Singh Sehat Bima Yojna duly framed by Government of Punjab and implemented by State Nodal Agency i.e. Punjab Health Systems Corporation Mohali, if any dispute arises under this scheme then as per Punjab Government Notification No. 469-560 dated: 02.05.2016 issued by Principal Secretary Health & Family Welfare Punjab, matter was required to be brought before District Grievance Redressal Committee (DGRC). The opposite party No. 1 has also pleaded that any benefit available with the scheme is limited to cashless indoor treatment. No reimbursement for any money incurred during treatment is available. The complainant never approached or contacted any official of opposite party No. 1. As per the scheme guidelines, patient had to be registered online through Aadhar (UID) server for cashless treatment which was not done. Any reimbursement of expenses incurred whatsoever is not payable under this scheme. If the complainant feels that he has been deprived of the claim, he should have brought the matter before DGRC. All other averments of complainant have been denied by opposite party No. 1. In the end, the opposite party No. 1 prayed for dismissal of complaint. The opposite party No. 2 in its written reply also raised legal objections that complaint is liable to be dismissed for non-joinder of necessary parties as the complainant has failed to implead treating hospital i.e. Chahal Hospital, Bathinda, as party wherefrom the complainant got treatment and also MD India Health Insurance (TPA) Pvt. Limited, Mohali which is the third party administrator on behalf of opposite party No. 2 who has to decide all the claims. Moreover, the State Nodal Agency for Bhagat Puran Singh Sehat Bima Yojna i.e. Punjab Health Systems Corporation Mohali has also not been made a party. 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 the summary procedure under the 'Act' That the complainant has concealed material facts and documents from this Commission as well as from opposite party No. 2, therefore the complainant is not entitled to any relief from this Commission. It has been pleaded that complainant has concealed the fact that he took treatment from Chahal Hospital, Bathinda, but no claim has been lodged either with opposite party No. 2 or with the (TPA) i.e. M.D. India Third Party Administrator, by the alleged hospital which is necessary as it is cashless treatment yojna and there is no provision for reimbursement of medical treatment expenses as per the terms and conditions of the scheme as has been mentioned in the scheme guidebook. Further legal objections are that the complainant has no locus standi or cause of action to file the present complaint. That the complainant is estopped from filing the present complaint by his act and conduct. That the complainant does not come within the definition of the consumer. On merits, it has been pleaded that as per guidelines of the said scheme, beneficiary card holder must produce the smart card before the empanelled treating hospital within 24 hours of the indoor admission of the patient. The patient (whose name must be present in the said smart card) is then registered through computer software by the treating hospital and authenticated from Aadhar (UID) server by verifying finger print of either patient or any other member present in the smart card. The same process is again repeated while discharging the patient from the hospital. It has been further pleaded that as per guidelines of the scheme, the complainant has to take only cashless treatment. However, the insured had to take pre-authorization for cashless treatment at least 7 days prior to and not later than 24 hours after admission in the hospital. As such the complainant is not entitled to get benefit of medical reimbursement from opposite party No. 2 due to his own wrongs. After controverting all other averments of the complainant, the opposite party No. 2 also prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence affidavit dated 8-5-18 of Baldev Singh (Ex. C-1), affidavit dated 8-5-18 of Surjeet Kaur @ Sukhjeet Kaur (Ex. C-2), photocopy of legal notice and postal receipt (Ex. C-3 to Ex. C-5), photocopy of lab reports (Ex. C-6 & Ex. C-7), photocopy of ultra sound reports (Ex. C-8 & Ex. C-9), photocopy of certificate (Ex. C-10), photocopy of bills (Ex. C-11 & Ex. C-12), photocopy of payment receipt (Ex. C-13), photocopy of lab report (Ex. C-14 & Ex. C-15), photocopy of prescription (Ex. C-16), photocopy of discharge slip (Ex. C-17), photocopy of Insurance Card (Ex. C-18) and photocopy of ration card (Ex. C-19). In order to rebut the evidence of complainant, the opposite party No. 1 tendered into e vidence affidavit dated 8-10-18 of Dr.Sukhbirinder Singh Romana (Ex. OP-1/1) and photocopy of notification (Ex. OP-1/2). The opposite party No. 2 has tendered into evidence affidavit dated 4-7-18 of Baldev Singh (Ex. OP-2/1). The learned counsel for the parties have reiterated their stand as taken in their respective pleadings. The complainant alleged that he submitted his I.D. Proof documents to get the benefit of Bhagat Puran Singh Health Insurance as per scheme of Govt. of Punjab, and after verification of documents, smart card bearing No. 9304600009603570 was issued to him. Surjeet Kaur @Sukhjeet Kaur wife of the complainant was operated by Dr. J S Chahal, Bathinda for stone in uterus. The submission of learned counsel for the complainant is that at the time of admission in hospital, complainant handed over his above said smart card to the staff of the hospital, but despite that hospital did not provide cashless treatment to the wife of the complainant and charged Rs.19,600/- from him on the ground that there is no data shown on the computer and it is totally blank. On the other hand, learned counsel for opposite party No. 1 submitted that complainant was required to produce/should have produced the smart card before the empannelled treating hospital within 24 hours of the indoor admission of patient and opposite party No. 2/Insurance Company has a District Kiosk/Office at Civil Hospital, Bathinda which could have checked the smart card for any error or blank data, but the complainant never approached the kiosk office. The learned counsel for of opposite party No. 2 submitted that no claim has been lodged either with the opposite party No. 2 or with the M.D. India (TPA) by the alleged hospital which is necessary as it is cashless treatment yojna and there is no provision for reimbursement of medical treatment expenses as per the terms and conditions of the scheme. In the case in hand, there is no dispute that complainant is covered under Bhagat Puran Singh Health Insurance as per scheme of Government of Punjab, and Smart Card bearing No. 9304600009603570 has been issued to him. The complainant got his wife Surjeet Kaur @ Sukhjit Kaur, operated for stone in uterus at Chahal Hospital, Bathinda spent Rs. 19,600/- on her treatment. Cashless facility under the above said scheme was not provided to complainant/beneficiary of holder of Smart Card. The pleading of the opposite parties is that benefits avaiable with Bhagat Puran Singh Sehat Bima Yojna is for cashless indoor treatment purpose only. It is the case of the complainant that the data of the smart card provided to him was not updated/uploaded on computer due to which he could not get benefit of health insurance. The opposite parties have neither denied this fact nor proved otherwise. So, this Commission is of the considered opinion that if the information regarding Smart Card of the complainant was not updated/uploaded by the opposite parties in their system then, there is no fault of complainant/beneficiary of smart card and he should not be made to suffer due to lapse of the opposite parties. Thus, complainant is entitled to the reimbursement of the expenses incurred by him on the treatment of his wife. In the result, this complaint stands disposed off. The complainant is directed to submit his claim with the opposite parties within 30 days from the date of receipt of copy of this order and the opposite parties are directed to reimburse the expenses incurred by complainant on the treatment of his wife, as discussed, as per bills submitted by complainant within 45 days from the date of receipt of claim. The opposite parties are also directed to update the smart card of the complainant in their system, to enable the complainant to avail benefit under the scheme, in future, if need be. The opposite parties may collect the document, if any, required from the complainant in this connection, for doing the needful. The complaint could not be decided within the statutory period due to covid pandemic and heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 21-4-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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