Punjab

Patiala

CC/17/473

Dev Raj Garg - Complainant(s)

Versus

MD India Health Care Services - Opp.Party(s)

SH.G.P.S Baweja

17 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

 

                                     

Consumer Complaint No.	:	CC/ 473/2017
Date of Institution	:	22.12.2017
Date of Decision	:	17.3.2023

 

Dev Raj Garg aged about 76 years S/o Sh.Sakhi Chand, Naib Tehsildar (Retd.) r/o H.No.19, Ram Bagh Colony, Patiala (Aadhar Card No.728354863027).

 

                                                                   …………...Complainant

                                      Versus

1. MD India Health Care Service TPA Pvt. Ltd., Max Pro Info Park, D-38, Ist Floor, Industrial Area, Phase-1, Mohali, Punjab through its Managing Director.
2.  
2. The Oriental Insurance Company Limited, Head office: Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002.

                                                                   …………Opposite Parties

 

Complaint under the Consumer Protection Act

 

QUORUM

                                      Hon’ble Mr.S.K.Aggarwal, President

                                      Hon’ble Mr.G.S.Nagi, Member        

 

 

PRESENT:                   Sh.P.S.Baweja, counsel for complainant.

                             Sh.B.L.Bhardwaj, counsel for OPs.

         

                              

 

                                     

 ORDER                                          

1. The instant complaint is filed by Dev Raj Garg S/o Sh.Sakhi Chand        (hereinafter referred to as the complainant) against MD India Health Care Service and another (hereinafter referred to as the OP/s) under the Consumer Protection Act (for short the Act).
2. The averments of the complainant are that he being a retired Govt.of Punjab, employee, covered under Cashless Medi Claim insurance, under Punjab Govt. Employees & Pensioners Health Insurance Scheme w.e.f.1.1.2016 to 31.12.2016 vide MD India ID-MD15-09417017038 and policy No.231102/48/2016/769. Under this policy he is entitled for reimbursement of indoor bills for his medical treatment as well as for his dependent family members from approved hospitals/clinics apart from Govt., run hospitals. OP No.1 is TPA of OP No.2.

Complainant was having acute and un-tolerable pains. He got him checked from Columbia Asia Hospital, Patiala on 19.4.2016.After requisite tests and investigations, he was advised surgery by treating doctors. Complainant contacted concerned section of the hospital and apprised them that he is covered under cashless insurance medi claim, who further discussed the matter with OPs but complainant was conveyed that since the insurer had stopped all the payments so complainant would have to deposit the requisite charges for surgery from his own pocket. Under forced circumstances, on 20.4.2016 complainant got admitted to said hospital for surgery called ‘Right Talonavicular Fusion’ and on the same day he was operated upon and was discharged from the hospital.

Thereafter complainant claim total amount of Rs.65621/- incurred on his treatment w.e.f.19.4.2016 to 1.6.2016 from OPs. All the relevant documents were submitted by the complainant on 1.7.2016 vide receipt No.34719 to TPA for his claim. Complainant was reimbursed only Rs.10,000/-.No reasons have been assigned to withhold the remaining amount of Rs.55621/-.Complainant sent legal notice dated 13.6.2017 to OPs through registered post dated 15.6.2017 but of no avail. OPs on vague grounds denied the claim vide reply dated 7.9.2017 stating that claim is not tenable, which caused mental agony and harassment to him. There is thus deficiency in service on the part of the OPs. Consequently, prayer has been made to accept the complaint.    

3. Upon notice, OPs appeared through counsel and filed written statement having raised certain preliminary objections. It is pleaded that as per para 4 of Government of Punjab Notification No.21/28/12-SHB5/268 dated 20.10.2015, it has been specified that no reimbursement will be made available to the pensioners of the Punjab Govt. under the subject medical claim policy, in Punjab and Chandigarh where cashless treatment is available to the Punjab Govt. Employees/Pensioners.

On merits, it is admitted that complainant and his family members are insured under the subject medical policy, subject to reimbursement of the payment which shall made to the insured at Govt. Hospital Rates or PGEPHIS rates, whichever is less but no reimbursement shall be made as per para 4 (aforesaid) of Govt. of Punjab Notification. It is admitted that claim amounting to Rs.65621/- was received in respect of the complainant for hospitalization in Columbia Asia Hospital from 20.4.2016 to 21.4.2016 and amount of Rs.10,000/- as per PGEPHIS rates/package rate has been paid to him by the TPA on the ground that, “this is a surgical procedure. So TPA paid as per PGEPHIs rates only i.e. Rs.9782/- on account of arthrodesis of Major Joint (code 778.2) & Medicine (Post) Rs.218/- & no other amount is payable by the OPs as per terms and conditions of subject medical policy. Further Columbia Asia Hospital is not empanelled with MDINDIA for PGEPHIS scheme. This fact is also admitted by the complainant in his complaint stating that cashless medical facility was denied by Columbia Asia Hospital as well as by the OPsat the time of admission itself. So complainant was required to go to the requisite hospital for his medical treatment where cashless facility as per State of Punjab was available. The reimbursement of the medical expenses amounting to Rs.10,000/- has been rightly made by the OPs at the PGEPHIS rate/package rate. There is no deficiency in service on the part of the OPs. After denying all other averments, OPs prayed for dismissal of complaint.

4. In evidence, complainant tendered his affidavit, Ex.C1, alongwith documents Exs.C2 copy of PPO, Ex.C3 copy of identity card, Ex.C4 copy of Aadhar card, Ex.C5 copy of discharge summary dated 20.4.2016, Ex.C6 to Ex.C14 copies of bills, Ex.C15 receipt No.34719 to the TPA representative, Ex.C16 receipt No.24749 dated 2.11.2016, Ex.C17 copy of legal notice, Exs.C18 and C19 postal receipts, Ex.C20 copy of Punjab Govt. Notification No.21/28/12-5HB5/268 dated 20.10.2015 and closed the evidence.
5. On the other hand, ld. counsel for the OPs has tendered in evidence Ex.OPA affidavit of Mukesh Malhotra, DM, OIC, alongwith documents Ex.OP1 copy of e-mail dated 27.3.2018, Ex.OP2 copy of email dated 29.3.2018, Ex.OP3 copy of notification dated 20.10.2015 of Punjab Govt., Ex.OP4 an extract of relevant terms and conditions/MOU of insurance policy, Ex.OP5 copy of claim form and closed the evidence.
6. We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
7. The complainant is a retired person from the services of Pb.Govt..To prove this fact he has placed his PPO order, Ex.C2 on the record. The complainant is covered under the cashless mediclaim insurance of Punjab Govt. Employees and Pensioners Health Insurance Scheme, valid from 1.1.2016 to 31.12.2016, as per notification Ex.C20.The complainant had pain in his right foot and he approached Columbia Asia Hospital, Patiala on 19.4.2016 for treatment. He went under various tests & investigations and was advised surgery called Right Talonavicular Fusion. Complainant approached the hospital authorities for cashless treatment claiming that he was covered under mediclaim insurance policy of the Pb.Govt. However, the same was refused by the hospital .The complainant, however, got himself admitted and then underwent surgery on 20.4.2016 in Columbia Asia Hospital, Patiala and cleared bill of Rs.65621/- from his own pocket. He made a claim for the same to the Ops. As per the complainant his claim was settled for Rs.10,000/- without assigning any reason to withhold the balance amount of Rs.55621/-.Legal notice, Ex.C17 was served by the complainant to OP No.1 but no fruitful purpose was served.
8. The OPs in the sworn affidavit, Ex.OPA of Sh.Mukesh Malhotra, Divisional Manage, OIC has deposed that as per para 3 of notification dated 20.10.2015 E.C20/Ex.OP3 the employees/pensioners and their dependants family members are covered under the subject insurance policy subject to the payment of reimbursement which shall be made to the insured at Govt. Hospital rates or PGEPHIS rates i.e. whichever is less. Ld. opposite counsel has further submitted a copy of the schedule of rates of PGEPHIS. As per the notification under surgical procedure relating to major joint under the head 778.2, OPs made payment of Rs.9782/- on account of arthrodesis of Major Joint and medicine (Post) Rs.218/- totaling Rs.10,000/-as per the terms and conditions of the subject mediclaim policy and notification of the Govt. of Punjab.
9. He has further deposed that complainant was refused cashless medical facility by the Columbia Asia Hospital initially at the time of admission itself which has been duly admitted by the complainant in his averments, even then the complainant got himself admitted in the said hospital knowing fully well that cashless facility was not available in the said hospital.
10. Moreover,  complainant was admitted for pain in his foot which was not an emergency and did not require any immediate procedure. Further, when the complainant was refused cashless facility by the hospital authorities, he would have reported to some other hospital where cashless facility was available. It has also not been brought on record by the complainant that cashless facility was available in Columbia Asia Hospital and was allegedly and wrongfully denied to the complainant. As such, complainant was fully aware that cashless facility was not available in Columbia Asia Hospital and got himself treated knowing fully well that the same is not available in the said hospital. Moreover, claim of the complainant, as per the terms and conditions of mediclaim insurance policy taken by the Govt. of Punjab and admissible as per PGEPHIS schedule of rates had already been settled by the  OPs for Rs.10,000/-. As such, finding no merit in the complaint, the same is hereby dismissed with no order as to costs.  
11. The instant complaint could not be disposed of within stipulated period due to Covid protocol and for want of Quorum from long time.
85109252238716.  
85109252238717.  

 

                                              G.S.Nagi                           S.K.AGGARWAL

                                              Member                          President