DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

BATHINDA

C.C. No. 111 of 17-04-2018

Decided on : 24-07-2019

Jaswinder Singh aged about 65 years S/o S. Kartar Singh R/o Village Mehma Sarkari, P.O. Mehma Swai, Tehsil & District Bathinda.

…...Complainant

Versus

1. State of Punjab, through its Secretary (Education), Punjab Sector-9, Chandigarh.

2. The Director Education Public Instructions, Secondary Education, Punjab, Sahibzada Ajit Singh Nagar, Phase-8, Complex Punjab School Education Board (Mohali) (Pb.) 160 062. (deleted vide order dated 18-4-2018)

3. The District Education Officer, Secondary Education, Mini Secretariat, Bathinda. (deleted vide order dated 18-4-2018)

4. Government Senior Secondary School, Village Mehma Sarja, District Bathinda, through Principal (deleted vide order dated 18-4-2018)

5. Oriental Insurance Co. Ltd., Divisional Office 4501, Ist Floor, Bank Bazar, Bathinda, through its Senior Divisional Manager

6. MD India Health Insurance TPA Pvt. Ltd., Maxpro Info Park, D-38, Industrial Area, Phase-1, Mohali (Punjab) 160 056, through its Chairman-cum-Managing Director

7. MEDANTA Global Health Pvt. Ltd., Regd. Office : E-18, Defence Colony, New Delhi, 24, through its Director/Chairman-cum-Managing Director, Authorized Signatory (deleted vide order dated 18-4-2018)

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

Quorum :

Sh. M.P.Singh Pahwa, President

Smt. Manisha Member

Present :

For the complainant : Sh. Ish Kumar, Advocate.

For the opposite parties : Sh. Sajan, Government Pleader of OP No.1

OP No. 2 to 4 and 7 deleted.

Sh. Vinod Garg, Advocate for OP No.5&6.

O R D E R

M. P. Singh Pahwa, President

1. Jaswinder Singh, complainant (here-in-after referred to as 'complainant') has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against State of Punjab & Others ( here-in-after referred to as 'opposite parties').

2. Briefly stated, the case of the complainant is that he was posted in Education Department. Lastly he was posted with opposite party No. 4 from where he has retired as Master/Teacher D.P.E. (Diploma in Physical Education) on 31-12-2010. Since then, he is a pensioner and his PPO No. is 243248/PB.

3. It is pleaded that as per Punjab Govt. Scheme known as Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS), he was/is beneficiary of said scheme. He was medically insured with the opposite parties and opposite party No. 5 allotted him ID Card No. MD15-09876391349 1, having GPF/PPO No. 243248. Lastly, said health/medi-claim policy was effective from 1-1-2016 to 31-12-2016. Under the aforesaid policy/scheme, in case of any ill-health, the complainant was/is entitled for cashless treatment. The opposite party No. 5 appointed opposite party No. 6 as Third Party Administrator (TPA) for the settlement of medi-claim cases. No detailed terms & conditions of the insurance were ever supplied to the complainant by either of the opposite party. In the 2nd week of January, 2016, complainant was not feeling well. There was some health disorder. He was feeling some heart problem. His family took him to opposite party No. 7 for consultation. After examination and conducting the required tests on 12-1-2016, attending Dr. Anil Bhan, conveyed the complainant and his attendants that he has diagnosed it to be a case of 'Coronary artery disease with Type Dar & HTN' (heart problem). His condition was conveyed critical. He was advised for immediate treatment as indoor patient. Accordingly complainant was got admitted with opposite party No. 7 on 12-1-2016. At the time of admission, the complainant and his attendants disclosed the hospital authorities about cashless insurance of insured-patient while showing the insurance card. Copy of card was also supplied to them. Later on, it was conveyed to the complainant that the expenses of the treatment shall be borne by the complainant and his attendants themselves. Finding no other alternative, complainant was got admitted with opposite party No. 7 for required treatment by showing willingness to bear the expenses at their own. The complainant remained admitted under treatment with opposite party No. 7 from 12-01-2016 to 15-01-2016. During this period, various X-rays and tests were conducted. Stents were also inserted. He was discharged by opposite party No. 7 on 15-1-2016. He spent Rs. 3,90,758.74 on his treatment, which includes Doctor's fee, consultation fee, room rent, lab charges, radiology charges, stent charges, medicine charges, etc. The complainant had to pay this amount to opposite party No.7. After discharge, complainant lodged claim for reimbursement with opposite party No. 4 for forwarding the same to competent authority and furnished all the requisite documents. He also completed all the requisite formalities for settlement of claim. The claim papers were further forwarded by opposite party No. 4 to competent authority for settlement of claim.

4. It is alleged that to the utter surprise of the complainant, he received letter dated 15-3-2017 from opposite party No. 4, whereby it was directed that since during the policy period of 1-1-2016 to 31-12-2016, cashless facility was applicable, so the claim be lodged with the Insurance company and returned all the documents submitted by the complainant with opposite party No. 4. The complainant approached opposite party No. 5 and it was advised to him to lodge the claim with opposite party No. 6. Accordingly, the complainant sent the entire documents to opposite party No. 6 on 7-4-2017 through Courier.

5. It is alleged that although a period of about one year has already been elapsed, but till date nothing has been done by either of the opposite party whereas such like claim cases should be settled on priority basis.

6. It is also pleaded that due to non settlement of claim within reasonable period, the complainant has suffered mental tension, agony, loss of physical health. For these sufferings, he has claimed compensation to the tune of Rs. 50,000/- in addition to reimbursement of Rs. 3,90,758.74 with interest @ 12% p.a. and Rs. 20,000/- litigation expenses. Hence, this complaint.

7. In view of the statement of learned counsel for the complainant, name of opposite parties No. 2 to 4 and 7 were deleted.

8. Notice to opposite parties No. 1, 5 & 6 were ordered to be issued.

9. The opposite party No. 1 appeared through Authorised Representative but failed to file written version within stipulated period.

10. The opposite parties No. 5 & 6 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 which require voluminous documents and evidence. It is not possible in summary procedure under the 'Act'. The appropriate remedy, if any, lies only in civil court. That the complainant has concealed material facts and documents from this Forum as well as opposite parties. The complainant has concealed the fact that he has violated the terms and conditions of the insurance and scheme. The treatment availed by the beneficiary under the scheme is on reimbursement basis i.e. subject to submission of claim to the TPA within 30 days from the date of discharge from the hospital. In this case the complainant got admission on 12-01-2016. He was discharged on 15-01-2016. Claim file was submitted on 07-04-2017 i.e. after more than 1 year and 3 months. Therefore, the claim was submitted for reimbursement in violation of terms and conditions of the scheme. Hence no amount is payable. The insurance policy is always subject to its terms and conditions. That Punjab Government has entered into an agreement to provide cashless medical facility to its employees including pensioners under PGEPHIS ( Punjab Government Employees and Pensioners Health Insurance Scheme) regarding which Punjab Government has issued notification to its employees also. Punjab Government along with Insurance Company and TPA i.e. opposite party No.1 has empaneled various hospitals to provide cashless treatment to employees of State Government and rates of each and every treatment/operation have been finalized between empaneled hospital and TPA with consent of Punjab Government. Insurance Company is only liable to pay the same to the employees of the Punjab Government as per aforesaid agreement/ insurance policy. Any treatment not provided in the agreement or mentioned in the exclusions is not payable at all. The Punjab Govt. floated a tender notice called Punjab Government Employees & Pensioners Health Insurance Scheme, Department of Health & Family Welfare, PHSC Government of Punjab, having specified conditions. The tender of Punjab Government was accepted by the Insurance Company which was effective from 1-1-2016 to 31-12-2016. As per clause 24 of the tender, this Forum has got no jurisdiction to try and decide the complaint. There is specific provision regarding dispute between beneficiary and Health Care Provider/Care Provider and the TPA/Insurance Company. The dispute shall be referred to District Level Grievance Redressal Committee. The opposite parties have also reproduced clause 24, the reproduction of the same is not considered necessary at this stage. That the complainant has no locus standi or cause of action to file the complaint and lastly that the complaint is not maintainable.

11. On merits, the opposite parties have controverted all the material averments of complainant and prayed for dismissal of complaint.

12. In support of his complaint, the complainant has tendered into evidence his affidavit 22-7-2018 (Ex. C-1), photocopy of circular (Ex. C-2), photocopy of health card (Ex. C-3), photocopy of courier receipt (Ex. C-4), photocopy of letters (Ex. C-5 to Ex. C-7), photocopy of bills (Ex. C-8 & Ex. C-9), photocopy of certificate (Ex. C-10), photocopy of bills with payment receipts (Ex. C-11 to Ex. C-26) and closed the evidence.

13. In order to rebut this evidence, the opposite parties No. 5 & 6 have tendered into evidence photocopy of notification (Ex. OP-5/1), affidavit of Md. Samiyoddin Patel dated 23-10-2018 (Ex. OP-5/2), photocopy of scheme (Ex. OP-5/3), affidavit dated 2-1-2019 of Ashwani Kumar (Ex. OP-5/4) , photocopy of claim file (Ex. OP-5/5) and closed the evidence.

14. The opposite party No. 1 and complainant have submitted written arguments.

15. We have heard learned counsel for the parties and gone through written arguments of the parties and the record.

16. The learned counsel for the parties have reiterated their stand as taken as their respective pleadings.

17. The learned counsel for the complainant has also referred the decisions of Hon'ble State Commission, Punjab :-

    (i) First Appeal No. 262 of 2017 decided on 6-11-2017 case titled Oriental Insurance Company Ltd., Vs. Raj Karan Singh

    (ii) First Appeal No. 625 of 2017 decided on 20-11-2017 case titled Oriental Insurance Co. Ltd., Vs. Puran Chand

18. We have carefully gone through the record and have considered the rival contentions.

19. The admitted facts are that the complainant has retired as government servant and is pensioner. He was admittedly covered under the scheme 'PGEPHIS'. The complainant took treatment from 12-1-2016 to 15-1-2016, The complainant has pleaded that he submitted claim shortly after discharge. Ex. C-7 is the letter written by Principal, Senior Secondary School, from where the complainant retired. This letter is dated 2-2-2016. It proves that complainant submitted claim with his employer for reimbursement and the office of Civil Surgeon returned with some query i.e. break up of package for Rs. 1,20,000/-.

20. The point is that complainant has submitted his claim with his employer within one month from the date of discharge. Ex. C-5 is the letter dated 15-3-2017 issued by G.S.S.S, Mehma Sarja (BTI). Vide this letter, the complainant was intimated that his claim has been received back for the reason that cashless scheme was in operation from 1-1-2016 to 31-12-2016. As such, claim is to be submitted with the concerned Insurance Company. It proves that claim file remained with employer or other concerned authority from 2-2-2016 to 15-3-2017. This delay was on the part of the opposite parties in intimating the complainant to submit claim with the Insurance Company. In these circumstances, the complainant is not to suffer for the delay on the part of the opposite parties. Therefore, denial of claim on the ground of delay in submission, is not justified.

21. It is not the case of the opposite parties that complainant was not entitled to reimbursement of claim. Insurance Company was engaged by Punjab Government only with the aim to provide benefit of medical reimbursement on its behalf. The State of Punjab was under obligation to provide medical reimbursement to its employees/pensioners.

22. Now the question is regarding amount for which the complainant is entitled to. Although the complainant has prayed for release of Rs. 3,90,758.74 but it is well settled that in case of treatment by government employees from private hospitals, reimbursement is under the policy/rules/regulations of the government. Therefore, complainant is entitled to the amount as per rules.

23. Resultantly, this complaint is partly accepted with Rs. 10,000/- as cost against opposite party No. 1. The opposite party No. 1 is directed to pay to complainant claim amount as per policy/rules/regulations of the government. The complainant will also be furnished the detail of calculations also.

24. However, it is made clear that this order will not effect the right of opposite party No. 1, if any, against opposite parties No. 5 & 6 to recover this amount.

25. The compliance of this order be made within 45 days from the date of receipt of copy of this order.

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

27. Copy of order be sent to the parties concerned free of cost. File be consigned to the record room.

    Announced :

    24-07-2019

    (M.P.Singh Pahwa )

    President

     

     

    (Manisha)

    Member