| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 294 of 9-10-2017 Decided on : 31-03-2022 Jai Narain Goel aged about 70 years S/o Sh. Rameshwar Das Bimla Devi aged about 61 years W/o Sh. Jai Narain Goel S/o Sh. Rameshwar Das
Both R/o # 64, Near T V Tower, Model Town, Phase -1, Bathinda. ........Complainants
Versus Food Corporation of India, Regional Office, Punjab Bays No. 34-38, Sector 31-A, Chandigarh 160 047 through its Assistant General Manager (Admin) Food Corporation of India, District Office, Grain Market, Bathinda 151 001. through its Area Manager
.......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. Naresh Garg, Advocate For opposite parties : Sh. Vinod Garg, Advocate. ORDER Kanwar Sandeep Singh, President The complainant Jai Narain Goel (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 Food Corporation of India and another (here-in-after referred to as opposite party). Briefly stated the case of the complainants is that Jai Narain Goel (Retd.) CPF. No. 6498 is the retired employee of opposite party No.1. Under the agreement and scheme of the opposite parties Jai Narain & his wife Bimla Devi are duly covered under Mediclaim insurance scheme with opposite parties under FCI Post-Retirement Medical Scheme (PRMS) under cashless Insurance scheme. It is alleged that Max Super Speciality Hospital, Bathinda, is the network hospital of the above said insurance cashless scheme. The opposite parties never issued any complete policy to the complainants rather they have issued only ID Card No. 25. In this Insurance Scheme, Jai Narain Goel (TA-II Retd.) No.6498 & Bimla Devi his dependant wife were insured in this scheme and paid Rs.50/- vide Receipt No.3349 dated 06.04.2017. The complainants has not taken any medical insurance scheme payment for the last more than 9 Years from the opposite parties. It is alleged that Bimla Devi, complainant No.2 was admitted in Max Hospital, Bathinda with the problem of Joint Replacement and Surgery. Prior intimation, in this regard, was given to the opposite parties. At the time of admission on 05.04.2017, the complainants took permission from the opposite parties but the opposite parties gave permission only for the Rs.1,50,000/- against the admissibility of general deceases for Rs.3,00,000/. (As the complainant not taken any claim for more than 7 Years) and Additional Special Lifetime Ceiling of Rs.4,00,000/- is permissible for Joint Replacement and Surgery as per circular No.ESTT.1(Circulars) /2017/Co-Ordination 09.02.2017 and Clause 6.8. Max Super Speciality Hospital, Bathinda charged Rs.3,51,999.92 out of which Rs. 1,50,000/- were paid by the opposite parties and balance amount of Rs.2,02,000/- was paid by complainants. The opposite parties did not release the payment and at the time of discharge on 12.04.2017, Max Hospital charged balance amount of Rs.2,02,000/- from the complainants and the opposite parties illegally withheld the same without any cogent reason. The complainants alleged that in the said insurance, the total treatment is cashless and the total amount was payable by the opposite parties, but till date, opposite party No.1 did not release the balance claim of Rs.2,02,000/-. The complainants repeatedly visited the opposite parties and demanded the balance amount of Rs.2,02,000/-, but to no effect. The opposite parties did not pay the balance claim of Rs.2,02,000/- without any reason and till date neither supplied any clause for retaining this amount nor rejected the claim. The complainants further alleged that the opposite parties are not releasing the said amount of the complainants under clause 6.8 whereas the opposite parties settled the same Mediclaim of another employee Ashok Kumar Gupta (A/1 3309/2008) as per Clause 6.8 vide Letter No. ESTT./Medical Authorisation/CAT II/2016-17 Dated 21.08.2017 for same Joint Replacement of the wife of Retired Employee. It is alleged that in this case, the opposite parties are sitting on the legal claim of the complainants and the balance claim is still pending with them, which shows gross negligence of deficiency in services. Due to non payment of Rs.2,02,000/-, the complainants suffered mental agony and pain for which they claim compensation to the tune of Rs.50,000/-. On this backdrop of facts, the complainants have prayed for directions to the opposite parties to pay to complainants balance claim amount of Rs 2,02,000/- with interest loss @18% P.A. from the date of discharge 12.04.2017 till payment in addition to compensation to the tune of Rs. 50,000/- besides Rs. 25,000/- as litigation expenses. Upon notice, the opposite parties appeared thorugh counsel and contested the complaint by filing joint written reply. In written reply, the opposite parties raised legal objections 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 complainants have concealed material facts and documents from this Commission as well as the opposite parties, therefore, they are not entitled to any relief. It has been pleaded that on receipt of application, the opposite parties gave authorization for medical treatment of complainant No.2 i.e wife of complainant No.1 in Max Hospital, Bathinda vide letter No. Estt. /Medical Treatment/ CAT-3/ 2016-17/95 dated 06.04.2017 for Rs.1,50,000/- against general coverage of complainants under under clause 6.7 of FCI Post Retirement Medical Scheme (PRMS). Thereafter, the complainants applied for grant of permission for availing once in a life time facility of Rs.4,00,000/- for knee replacement of his wife complainant No.2 on 08.04.2017 submitted on 10.4.2017 under clause 6.8 of the scheme i.e. FCI Post Retirement Medical Scheme (PRMS) according to FCI Head Quarters New Delhi Circular No.EP-12-2016-23 dated 30.12.2016 in addition to the earlier amount of Rs.1,50,000/- already approved. The complainants enclosed an estimate of Rs.4,22,700/- given by Max Hospital, Bathinda. The opposite party No.2 forwarded the application to opposite party No.1 and same was under consideration. Since the treatment has already been taken and complainant No.2 has been discharged from the hospital on 14.4.17 itself and made payment of balance amount of medical bill, the complainants could submit the claim for reimbursement by submission of original bills. Letter has also been sent at the residential address of the complainants by speed post for submitting claim forms along with bills in original so that the same could be processed and decided as per rules. Therefore, complaint is premature and is liable to be dismissed on this score alone. It has been further pleaded that during pendency of this complaint the complainant has submitted the claim for reimbursement and accordingly opposite party No. 1 has issued office letter No A/1(330)/71/04/4432 dated 23.11.17 and corrigendum No. A/1(1710)/70/PF dated 23.11.17 vide which approval has been conveyed by FCI, RO (PB), Chandigarh for balance payment of admissible and payable amount of Rs. 1,35,311/- of medical bills at CGHS rates to the complainant which has been paid vide invoice No. 89562 dated 23.11.17 & cheque No. 570729 dated 23.11.17. Further legal objections are that the complainants are not consumer of the opposite parties. That the complainants have no locus standi or cause of action to file the present complaint against opposite parties. That the complaint is not maintainable in the present form and is liable to be dismissed. On merits, the opposite parties have admitted that complainant No.1 is retired employee of opposite parties and the complainants are covered under FCI Post Retirement Medical Scheme. It is denied that the scheme is a cashless insurance scheme in all cases. It has been pleaded that in case the authorization is not given for cashless treatment, the reimbursement of bills may be claimed after submission of claim form and original bills in accordance with the scheme. The opposite parties have admitted that Max Super Specialty Hospital, Bathinda is the Network Hospital under FCI Post Retirement Medical Scheme. The scheme has been made effective from 01.04.2016 and a circular has been uploaded on the FCI Website i.e. www.fci.gov.in and copy of scheme has also been circulated. The complainants have themselves placed on file copy of the said circular and FCI- PRMS scheme. The opposite parties denied that they gave permission for only Rs.1,50,000/- against admissible amount of Rs. 3,00,000/-. The opposite parties pleaded that the maximum coverage for general diseases under clause 6.7 of FCI Post Retirement Medical Scheme (PRMS) was only Rs.1,50,000/- as the scheme has become effective only from 01.04.2016 and in the second year the basic ceiling of Rs.1,00,000/- was enhanced with additional ceiling of Rs.50,000/- i.e total Rs.1,50,000/- as per clause 6.7 of scheme. The complainants had applied for authorization against general diseases and accordingly authorization for Rs.1,50,000/- was given vide letter dated 06.04.2017. The complainants applied for grant of permission for availing once in a life time facility of Rs.4,00,000/- for knee replacement of complainant No. 2 under clause 6.8 of scheme vide application dated 8.04.2017 submitted on 10.04.2017 which was under consideration and pending decision at the time of discharge of complainant No.2 from the Hospital. Further balance admissible and payable amount of Rs 1,35,311/- at CGHS rates has been paid to complainant vide cheque No 570729 dated 23.11.17. In further reply, the opposite parties have reiterated their stand as pleaded in legal objections and detailed above. After controverting all other averments, the opposite parties prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence affidavits of Jai Narain Goel and Bimla Devi both dated 19-12-17 (Ex. C-1 & Ex. C-2), photocopy of authorization letter (Ex. C-3), photocopy of letter dated 8-11-17 (Ex. C-4), photocopy of letter dated 13-11-17 (Ex. C-5), photocopy of account statement (Ex. C-6), photocopy of cards (Ex. C-7 & Ex. C-8), photocopy of hospital record (Ex. C-9), photocopy of letter (Ex. C-10), photocopy of circular dated 30-12-16 (Ex. C-11). In order to rebut the evidence of complainants, opposite parties tendered into evidence photocopy of letter dated 23-11-17 (Ex. OP-1/1), photocopy of corrigendum (Ex.OP-1/2), affidavit dated 3-1-18 of Umed Singh, (Ex. OP-1/3), affidavit dated 6-3-18 of Anil Kumar (Ex. OP-1/4), Circular dated 8-9-17 (Ex. OP-1/5), photocopy of application dated 13-11-17 (Ex.OP-1/6), photocopy of letter dated 23-11-17 (Ex. OP-1/7), photocopy of circular dated 26-3-07 (Ex. OP-1/8), Detail of medical bill noting (Ex. OP-1/9), photocopy of Invoice report (Ex. OP-1/10), photocopy of Invoice (Ex. OP-1/11), photocopy of office memorandum dated 1-8-13 (Ex. OP-1/12), photocopy of Implementation Instructions (Ex. OP-1/13) and photocopy of letters (Ex. OP-1/14 & Ex. OP-1/14). The learned counsel for the parties reiterated their stand as taken in their respective pleadings. We have heard learned counsel for the parties and gone through the record. In the case in hand, there is no dispute between the parties that Jai Narain Goel complainant No. 1 and his wife Bimla Devi, i.e. complainant No. 2 were covered under Medi-claim Scheme with the opposite parties under FCI Post-Retirement Medical Scheme (PRMS). Bimla Devi, complainant No. 2 was admitted in Max Hospital, Bathinda, for surgery of Joint Replacement. The complainants incurred total expenses of Rs. 3,51,999.92 out of which prior approval for cash less treatment was given for Rs. 1,50,000/-. In the prayer clause of complaint, the complainant has prayed for directions to the opposite parties to pay balance amount of Rs. 2,02,000/- with interest, in addition to compensation and cost. During the pendency of complaint, the opposite parties paid Rs. 1,35,311/- vide invoice No. 89562 dated 23-11-17 and Cheque No. 570729 dated 23-11-17. The opposite parties paid Rs. 1,35,311/- out of Rs. 2,02,000/- and this fact is admitted by complainants in their affidavits Ex. C-1 & Ex. C-2. Now the dispute is for an amount of Rs. 66,689/- which was not/less paid to complainant. The submissions of learned counsel for the opposite parties is that they have paid the amount to complainants as per CGHS rates. Ex. C-11 is the Circular No. EP-12-2-16-23 dated 30-12-16 issued by Food Corporation of India, Head Quarter, New Delhi, regarding Post-Retirement Medical Scheme (PRMS). Clause 6.13 of this circular reads as under : “In order to protect the beneficiarties from the financial constraints, where the annual financial ceiling has been exhausted, an authorization letter may be issued by indicating Nil balance, with the direction that the hospital should give treatment on cash down basis to the patient at the agreed CGHS rates, so that the hospital shall not charge its own higher rates, if any. Appropriate clauses in this regard for honouring such authorization should also be incorporated while entering into enpanellment agreement with such hospitals.” It is admitted fact of the parties that total expenses incurred on the treatment of complainant No. 2 was Rs. 3,51,999.92 out of which Rs. 66,689/- has not been paid by the opposite parties on the plea that amount is paid on the basis of CGHS rates. As detailed above, it is clearly mentioned in the circular of the opposite parties that direction be issued to the hospital that hospital should give treatment on cash down basis to the patient at the agreed CGHS rates, so that the hospital shall not charge its own higher rates, but the opposite parties have not brought on file any such list of CGHS rates on the basis of which deductions have been made from the expenses of the complainant. Thus, there is deficiency in service on the part of the opposite parties in not paying/settling/withholding the genuine claim of the complainant and thereafter when complainants filed complaint before this Commission, making deductions from the total expenses while making payment of the claim of the complainants, without any basis. In the result, this complaint is partly allowed with Rs.10,000/- as cost and compensation against the opposite parties. The opposite parties are directed to pay Rs. 66,689/- with interest @9% p.a. w.e.f 12-4-17 (date of discharge from hospital) till payment. The opposite parties are also directed to pay interest @9% p.a. on the amount of Rs. 1,35,311/- w.e.f. 12-4-2017 (date of payment) till 23-11-2017. The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced : 31-3-2022 (Kanwar Sandeep Singh) President (Shivdev Singh) Member (Paramjeet Kaur) Member
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