DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

BATHINDA

C.C. No. 88 of 28-03-2017.

Decided on : 28-02-2022.

Hemraj Kaur Wd/o Jagpal Singh, aged about 56 years R/o MCB-Z-2-03897, opposite Street No. 5, Dhobiana Nagar, Bathinda.

........Complainant

Versus

1. MD India Health Care Services (TPA) Pvt. Ltd. Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali 160 056, through its Director/MD

2. The Oriental Insurance Co. Ltd., Divisional Office, Bank Bazar, Bathinda, through its Divisional Manager

3. Max Super Speciality Hospital, Bathinda, unit of Hometrail Buildtech Pvt. Ltd., NH-64, Near District Civil Hospital, Mansa Road, Bathinda, through its Owner/MD/Director/Auth. Signatory

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986

QUORUM

Sh. Kanwar Sandeep Singh, President

Smt. Paramjeet Kaur, Member

Present

For the complainant : Sh. Naresh Garg, Advocate

For the opposite parties : Sh. M L Bansal, Advocate, for OP No. 1 &2.

Sh. Vinod Garg, Advocate, for OP No. 3.

ORDER

Kanwar Sandeep Singh, President

1. The complainant Hemraj Kaur (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 M D India Health Care Services (TPA) Ltd., and others and (here-in-after referred to as opposite parties).

2. Briefly stated, the case of the complainant is that she is class I legal heir of deceased Jagpal Singh, who was duly insured with opposite parties No. 1 & 2 under Punjab Government Employee and Pensions Health Insurance Scheme ( here-in-after referred to as 'PGEPHIS') w.e.f. 1-1-2016 to 31-12-2016. The opposite party No. 3 is the network hospital of above said insurance scheme with opposite parties No. 1 & 2 as the said Insurance is cashless Insurance. That the complainant is the widow of Jagpal Singh now deceased. Jagpal Singh deceased has also other L.R.s which are Baljeet Singh, Jagjeet Singh, Partit Singh and Gurdeep Singh (sons) and they have given affidavits to the effect that they have no objection if the claim is paid to their mother i.e. complainant. That Jagpal Singh, husband of complainant was insured with opposite parties No. 1 & 2 vide Membership No.MDI5- 07837463260 w.e.f. 01-01-2016 to 31-12-2016 under cashless scheme. The opposite parties never issued any complete policy to the complainant. They have issued ID Card only. Under this scheme, in case of any medical assistance, the insured can go to any network hospital in Punjab and can take cashless treatment.

3. It is alleged that Jagpal Singh insured fell in the house on 31-08-2016 and his Left femur was fractured. He was immediately taken to opposite party No. 3. At the time of admission, the card of the Insured Jagpal Singh was submitted to opposite party No. 3 and they assured that the treatment is cashless and no payment will be charged under this scheme. Jagpal Singh was admitted with opposite party No. 3. The opposite party No. 3 prepared total bill of Rs. 98,001.83 and submitted the same alongwith treatment papers to opposite parties No. 1 & 2. After treatment, the opposite party No. 3 at the time of discharge of Jagpal Singh on 8-9-2016 demanded Rs.78,001.83 from the complainant on the ground that they received Rs.20,000/- only from opposite parties No. 1 & 2. Jagpal Singh insured came under mental stress due to illegal act of the opposite parties and ultimately he died on 13-09-2016.

4. The complainant alleged that the amount of Rs.78,001.83 is still pending with the opposite parties. The opposite party No. 3 illegally charged the said amount from insured against the rules and law. The complainant repeatedly visited opposite party No.2 at Bathinda and also handed over the photocopy of total medical treatment file and bills and demanded the balance amount of Rs.78,001.83, but to no effect. The opposite parties did not pay the balance claim of Rs.78,001.83 without any reason. The opposite parties till date neither supplied any clause for retaining this amount nor rejected the claim of Rs. 78,001.83. Due to non-payment of claim amount of Rs.78,001.83, the complainant is suffering mental agony and pain for which complainant claims compensation to the tune of Rs. 25,000/-.

5. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay claim amount of Rs. 78,001.83 with interest @18% p.a. and Rs. 25,000/- as compensation in addition to Rs. 25,000/- as litigation expenses.

6. Upon notice, the opposite parties put an appearance through their respective counsel. The opposite parties No. 1 & 2 filed their joint written reply raising legal objections that the present complaint has been filed by the complainant only to injure the goodwill and reputation of the opposite parties. Even otherwise, the complaint is false, frivolous and vexatious to the knowledge of the complainant. That the intricate questions of law & facts are involved in the present complaint, which requires voluminous documents and evidence for determination which is not possible in the summary procedure and appropriate remedy, if any, lies only in the Civil Court. That the complainant has concealed material facts and documents from this Commission.

7. It has been pleaded that the true facts are that on receipt of claim, opposite party No.1/TPA (Third Party Administrator), who has been appointed and authorized to settle the mediclaim cases scrutinized the claim of the insured and on scrutiny, it was found that the claim of the insured falls under `Package' Code 1176 Hemiarthroplasty-Hip-Rs.20,000/- and accordingly, answering opposite parties paid Rs. 20,000/- on account of claim of the insured, as per terms & conditions of the policy and now nothing is due and payable to the insured. An intimation in this regard .has already been given to the complainant. Now the complainant has filed the present complaint on flimsy grounds by concealing all the aforesaid true and material facts and rather by twisting the actual facts.

8. Further legal objections are that the complaint is bad for non-joinder of necessary parties. All the legal heirs of deceased insured have not been impleaded as parties. That the complainant has no locus standi or cause of action to file the present complaint against the opposite parties. That the present complaint is not maintainable in its present form. That the complainant is not a consumer and that this Commission has got no jurisdiction to try and entertain the present complaint.

9. On merits, the opposite parties No. 1 & 2 reiterated their stand as taken in legal objections, detailed above. In the end, the opposite parties No. 1 & 2 prayed for dismissal of complaint.

10. The opposite party No. 3 in its written reply 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 summary procedure under the 'Act' and appropriate remedy, if any, lies only in the Civil Court. That there is no cause of action against opposite Party No 3.

11. The opposite party No. 3 pleaded that the doctors at hospital (opposite party No. 3) treated Late Shri Jagpal Singh, husband of the complainant as per the standard medical protocol and to the best of their ability and judgment. As per records, the total bill for the treatment of Late Mr, Jagpal Singh was of Rs.98,001.83 of which opposite party No. 2 gave the final authorization for Rs.20,000/-, so opposite party No. 3 was within its rights to receive the balance amount of Rs.78,001.83 from the complainant, which was legally due to opposite party No. 3 against the aforesaid bill of medical treatment. At the time of admission of the patient in hospital i.e. opposite party No. 3, the son of the patient, Mr. Prateek Singh undertook to clear all bills of opposite party No. 3 as and when asked for and in any event, prior to discharge of the patient from the opposite party No. 3, irrespective of the fact whether the authorization for cashless treatment is received by the opposite party No. 3, or not.

12. Further legal objections are that the complainant has concealed material facts and documents from this Commission as well as opposite party No. 3. The complainant has failed to allege and prove any deficiency of service at all. That the present complaint is not maintainable in the present form. That the complaint is bad for non-joinder of necessary party as all the legal heirs of Late Shri Jagpal Singh have not been impleaded as party in the present complaint. That the complaint is bad for mis-joinder of parties. The presence of opposite party No. 3 is not required to adjudicate any matter in issue.

13. The opposite party No. 3 has further pleaded that without prejudice to all above, it is further submitted that processing and disbursement of cashless facility, as well as acceptance/rejection of claim under medical/health insurance policies is a matter between the insured patient and TPA/Insurance Company (opposite parties No. 1 & 2). The opposite party No. 3 has absolutely no role or responsibility either in the sanction or rejection of the cash less facility and/or the claim by the Insurance companies.

14. Further legal objections are that the complainant is not consumer of opposite party No. 3 qua alleged cause of action since the allegations and claims pertain to an insurance policy. That the present complaint qua opposite party No. 3 is unfounded and not maintainable. It is false, frivolous and vexatious to the knowledge of the complainant, as such the same is liable to be dismissed with special costs. That the allegations in the complaint have been presented in a distorted manner, with mala-fide intention to mislead this Commission.

15. On merits, it has been pleaded that opposite party No. 3 is network hospital of opposite parties No. 1 & 2. As per Tripartite Memorandum of Understanding between 'The Oriental Insurance Company Limited', 'MD lndia Healthcare Services TPA Private Limited' and 'Max Super Speciality Hospital Bathinda' dated 30-12-2015 (hereinafter referred as "MOU": (a) opposite party No. 2 has agreed to provide health insurance to the employees & pensioners of Punjab State Government under the PGEPHIS (b) opposite party No. l has been appointed as third party administrator ("TPA") by opposite party No. 2 to administer the PGEPHIS on behalf of opposite party No. 2 and (c) opposite party No. 3 had agreed to extend the medical facilities to PGEPHIS beneficiaries. In view of the above, the opposite party No. 3 has also submitted that as per the MOU, in case of planned admissions of PGEPHIS beneficiaries, the opposite party No. 3 has to seek pre-authorization by sending Pre-authorization Letter or "PAL" to opposite party No. 1. Then, the opposite party No.2 either directly or through opposite party No.l authorizes or rejects such request for pre-authorization for cashless treatment of PGEPHIS beneficiaries depending upon the entitlement of the PGEPHIS beneficiaries. After the final authorization of opposite party No. 2, the PGEPHIS beneficiary can get discharge from the hospital after making the payment to the opposite party No. 3 of the differential amount between actual final bill and final authorization. In the present case, patient, Late Shri Jagpal Singh was admitted to opposite party No. 3 hospital on 31.08.2016 with documents pertaining to PGEPHIS and as per the requirements of MOU, the opposite party No. 3 on 31.08.2016 submitted the PAL with an estimated cost of Rs. 20,000/- alongwith the cost of implant for the cashless treatment of the patient on website of PGEPHIS maintained by Opposite Party No. 1. The opposite party No. 3 received an initial authorization of an amount upto Rs. 20,000/-. On the date of discharge of the patient i.e. 9.9.2016, the outstanding amount from the final bill i.e. Bill No. BHIC23094 dated 9.9.2016 of opposite party No. 3 (for the treatment provided to the patient) after the adjustment of initial authorization of opposite party No. 2 was Rs.78,001.83 In terms of the MOU, on the date of the discharge of patient, the opposite party No. 3 made the final request to opposite party No.2 for preauthorization of the residual amount i.e. Rs.78,001.83 alongwith copy of final bill and requisite documents. The opposite party No 1, upon the request for final pre-authorization by opposite party No. 3 communicated to opposite party No. 3 that initial authorization of Rs. 20,000/- is the final authorization. Upon receiving the final authorizationof Rs. 20,000/-, the final bill for the treatment of the patient was presented for payment by opposite party No. 3 to the attendants of the patient which was duly paid by them without protest only after duly confirming the final authorization amount from opposite party No. 1. After controverting all other averments, the opposite party No. 3 prayed for dismissal of complaint.

16. In support of her complaint, the complainant has tendered into evidence her affidavit dated 7-6-2017 (Ex. C-1), photocopy of claim form (Ex. C-2), photocopy of Vat Invoice (Ex. C-3), photocopy of PAL details/authorization (Ex. C-4 to Ex. C-6), affidavits of Baljeet Singh, Jagjeet Singh, Partit Singh, Gurdeep Singh, all dated 28-3-2017 (Ex. C-7 to Ex. C-10 respectively), photocopy of Dishcharge summary (Ex. C-11), photocopy of Inpatient bill (summary) (Ex. C-12), Photocopy of Health Card of Insurance Scheme (Ex. C-13), photocopy of death Certificate (Ex. C-14).

17. In order to rebut the evidence of complainant, the opposite parties No. 1 & 2 have tendered into evidence affidavit dated 4-5-2017 of R L Baleem (Ex. OP-1/1), photocopy of policy (Ex. OP-1/2), photocopy of e-mail (Ex. OP-1/3), photocopy of memorandum (Ex. OP-1/4), photocopy of list of eye clinics (Ex. OP-1/5), photocopy of list of labs (Ex. OP-1/6), photocopy of treatment rate list (Ex. OP-1/7).

18. The opposite party No. 3 has tendered into evidence affidavit dated 24-8-2017 of Sunil mehta (Ex. OP-3/1), photocopy of resolution (Ex. OP-3/2), photocopy of Memorandum of understanding (Ex. OP-3/3), photocopy of Face Sheet (Ex. OP-3/4), photocopy of Insurance Scheme (Ex. OP-3/5), photocopy of interim Inpatient Bill (Ex. OP-3/6), photocopy of schedule of rates (Ex. OP-3/7), photocopy of e-mail (Ex. OP-3/8), photocopy of pre-authorization detail (Ex. OP-3/9), photocopy of discharge summary (Ex.OP-3/10), photocopy of inpatient bill summary (Ex. OP-3/11) and photocopy of letter (Ex. OP-3/12).

19. The learned counsel for the parties reiterated their stand as taken in their respective pleadings and detailed above.

20. We have heard learned counsel for the parties and gone through the record.

21. These are undisputed facts between the parties that Jagpal Singh husband of complainant was insured with opposite parties No. 1 & 2 under Punjab Govt. Employee and Pensioners Health Insurance Scheme (PGEPHIS) w.e.f. 01-01-16 to 31-12-16. Jagpal Singh, insured was fell in the house on 31-08-16 and suffered fracture of his left femur. He was admitted with opposite party No. 3 for the period from 31-8-2016 to 9-9-2016 wherein he spent Rs.98001.83 on his treatment. The opposite parties No.1 and 2 paid only Rs.20,000/- under the aforesaid insurance scheme.

22. The allegation of the complainant is that total amount of Rs.98001.83 has been spent on the treatment of Jagpal Singh whereas the opposite parties No. 1 & 2 have paid Rs. 20,000/- only. The learned counsel for the complainant submitted that as per PGEPHIS, complainant is entitled to reimbursement of total treatment expenses of Rs. 98001.83. As per tripartite memorandum of understanding (MOU), the opposite party No. 3 was bound to provide cashless treatment, but in the case in hand, opposite parties neither provided cashless treatment nor thereafter reimbursed the treatment expenses.

23. A perusal of abovesaid MOU (Ex.OP 3/3) reveals that under the heading definitions, it has been mentioned :

    Cashless service : It is a credit arrangement wherein the network provider will treat the patient without charging any fee and insurer/and TPA will settle the bills of the network provider directly subject to terms, conditions and provisions of MOU.

24. This MOU further clarifies that :

    “15. The package will include all complications of the procedure and no cost over and above will be charged from the patient.”

25. As per aforesaid MOU, opposite party No. 3 was bound to provide cashless treatment to insured Jagpal Singh. Ex. C-12 is the bill issued by opposite party No. 3 at the time of discharge of Jagpal Singh. This document reveals that total bill amount is Rs. 98,001.83 out of which Rs. 20,000/- have been paid by Insurance Company and Rs. 78,000/- have been received in cash vide two different receipts from patient Jagpal Singh.

26. Ex. OP-3/8 is the details of expenses incurred by Jagpal Singh and the amount allowed by Company (opposite parties No. 1 & 2). The opposite parties allowed Hemiarthroplasty -Hip – Package start date 31-8-2016 and Package end date 5-9-2016 – Amount Rs. 20,000/-. The opposite parties did not allow cost of Implants Rs. 46,068/-, Room Rent 4 days extra Rs. 2,000/-, Pharmacy, investigations, Consultations and other charges spent by complainant for the period from 6-9-2016 to 9-9-2016.

27. Ex.OP 3/5 is the copy of PGEPHIS. Clause 3 of this document under heading Insurance coverage reveals that -

    a) In patient benefits, the insurance scheme shall pay all expenses incurred in course of medical treatment availed by the beneficiaries in the empanelled hospitals/ nursing homes (24 hours admission clause) within the country, arising out of any illness/disease/ injuries and or sickness.

28. Para C of this clause under the heading Pre and Post Hospitalization benefit further clarified that :

    Benefits upto seven days Pre hospitalization and upto 30 days Post hospitalization respectively which would cover all expenses related to treatment of the sickness for which hospitalization was done. The beneficiary shall avail the benefit on cashless basis in empanelled hospital. The Pre and Post hospitalization investigation shall be covered at CGHS rates.

29. As per clause 10.4 (A)(IV)(c) & (d) of this scheme :

    (c) No additional charge on account of extended period of stay shall be allowed, if the extension is due to infection on the consequences of surgical procedure or due to any improper procedure.

    (d) Cost of implants is payable in addition to package rates as per Punjab Medical Attendance Rules for defined implants or as per actual, in case there is no prescribed ceiling rates.

30. As detailed, Jagpal Singh was entitled to total treatment expenses i.e. Pharmacy, Investigations, Consultations for the period from 31-8-2016 to 9-9-2016 in view of pre and post hospitalization clause mentioned above. Cost of implants was also to be borne by Insurance Company as there is no prescribed ceiling rates regarding implants. Therefore, there is deficiency in service on the part of opposite parties No. 1 & 2 in not allowing pre-authorization to opposite party No. 3 for providing cashless treatment to Jagpal Singh whereas as per MOU and PGEPHIS Jagpal Singh was entitled to cashless treatment.

31. Since Jagpal Singh expired on 13-9-2016 as per Death Certificate Ex. C-16, complainant class 1 legal heir of deceased Jagpal Singh is entitled to claim amount.

32. In view of what has been discussed above, this complaint is partly allowed with Rs.10,000/- as cost and compensation against opposite parties No. 1 & 2 and it stands dismissed qua opposite party No. 3. The opposite parties No. 1 & 2 are directed to pay to complainant Rs. 78,000/- with interest @9% p.a. w.e.f. 9-9-2016 (date of payment to opposite party No. 3) till realization.

33. The compliance of this order be made by opposite parties No. 1 & 2 jointly and severally within 45 days from the date of receipt of copy of this order.

34. The complaint could not be decided within the statutory period due to heavy pendency of cases.

35. Copy of order be sent to the parties concerned free of cost and file be consigned to the record.

    Announced :

    28-2-2022

    (Kanwar Sandeep Singh)

    President

     

     

     

    (Paramjeet Kaur)

    Member