Punjab

Faridkot

CC/19/30

Kewal singh - Complainant(s)

Versus

State of Punjab - Opp.Party(s)

Manpreet Singh

21 Oct 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

Complaint No. :     30 of 2019

Date of Institution: 28.01.2019

Date of Decision :  21.10.2019

 

Kewal Singh aged about 72 years, s/o Mukhtiar Singh r/o Near Dharamshala Lamb Wali, Bajakhana, District Faridkot.

 

                                                                           .........Complainant

Versus

1. State of Punjab through its Principal Secretary, Department of Health & Family Welfare Punjab, Chandigarh.
2. Oriental Insurance, MD India, Health Care Services TPA Pvt Ltd, Max Pro. Info Park, D-38, Industrial Area, Phase-I, Mohali through its Managing Director.
3. Managing Director, Punjab Health System Corp. State Institute Complex, Health and Family Welfare Complex, Near Civil Hospital, Phase-6 Mohali.
4. District Coordinator, Oriental Insurance Co. Civil Hospital, Faridkot.
5. Principal Govt. Sr. Sec. School, Village Wander District Moga.
6. District Education Officer Secondary, Moga.
7. Deputy Commissioner, Faridkot.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

cc no.-30 of 2019

 

Quorum: Sh. Ajit Aggarwal, President,

               Ms Param Pal Kaur, Member.

 

Present: Sh Manpreet Singh, Ld Counsel for Complainant,

              Sh Kashmir Lal, Ld Counsel for OP-1 and OP-3,

               Sh Vinod Monga, Ld Counsel for OP-2 and OP-4,

               Sh Bharat Bhushan, Ld Counsel for OP-5 to OP-7.

ORDER

(Ajit Aggarwal, President)

                                      Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of Rs.72,235/- on account of reimbursement of expenses spent by complainant on his treatment with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.25,000/-.

2                            Briefly stated, the case of the complainant is that complainant is a retired government employee and as per Health Insurance Scheme for Pensioners, complainant alongwith his wife was fully covered under Punjab Government Employees and Pensioners Health Insurance Scheme. The policy was valid from 1.01.2016 to 31.12.2016 and as per policy, complainant is entitled for cashless treatment and OPs are liable to pay the cashless insurance claim upto Rs.3,00,000/- and also reimbursement upto Rs.3 lacs. Premium for

cc no.-30 of 2019

enrolment under scheme was paid by Punjab Government. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that during subsistence of said policy complainant suffered with a Debridement with Burr Hole (partial) of Vault under GA as per discharge summary. He remained admitted in Dayanand Medical College and Hospital, Ludhiana for the period from 26.11.2016 to 21.12.2016 and spent an amount of Rs.72,235/-on his treatment and as per Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by him on his treatment. Complainant submitted his claim for medical reimbursement to OP-2 and 3 and made several requests to them to make reimbursement of the amount spent on treatment of complainant, but OPs kept putting off the matter on one pretext or the other and then, finally repudiated the claim of complainant on the ground that no reimbursement is admissible where cashless treatment is available. Complainant made several requests to OPs for making payment of amount of Rs.72,235/-, but they declined the genuine request of the complainant. All this amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation alongwith litigation expenses besides the main relief. Hence, the complaint.

 

 

cc no.-30 of 2019

3                                   The counsel for complainant was heard with regard to admission of the complaint and vide order dated 4.02.2019, complaint was admitted and notice was ordered to be issued to the OPs.

4                                    On receipt of the notice, the OP-1 and OP-3 filed written statement wherein they have denied all the allegations of complainant being wrong and incorrect and asserted that there is no deficiency in service on their part and matter regarding payment of reimbursement of claim is between complainant and OP-2, OP-5 and OP-6. All the other allegations are denied being incorrect with prayer to dismiss the complaint.

5                                 OP-2 and OP-4 filed reply taking preliminary objections that complainant has no cause of action to file the present complaint. It is admitted that complainant was insured under policy in question and it is also no denied that he underwent treatment during said period from DMC Hospital, Ludhiana. It is averred that as per notification of Health Insurance Scheme launched by Punjab Government, the treatment can be availed by any enrolled beneficiaries in government or in empanelled hospitals in Punjab, Chandigarh and NCR area. No reimbursement will be available to employees or pensioners in Punjab Chandigarh and Panchkula where cashless treatment is available. It is admitted that complainant took treatment of Post Auricular Infection in said hospital for the period from 26.11.2016 to 21.12.2016, but as per instructions of government, reimbursement sought by complainant is not

cc no.-30 of 2019

admissible to him. Claim of complainant was duly processed and considered and it was found that nothing is payable to him and they have rightly repudiated the claim of complainant on the basis of para no. 4 of notification vide which no reimbursement of medical treatment is pursuable as complainant had not availed the cashless treatment which is available in Punjab and complainant was duly informed about this. It is reiterated that there is no deficiency in service on the part of OPs and they refuted all the other allegations alongwith allegations for relief sought by complainant and also prayed for dismissal of complaint with costs.

6                              Ld Counsel for OP-5 to OP-7 filed written statement wherein they have denied all the allegations of complainant being wrong and incorrect and asserted that complaint in hand is not maintainable in present form and no cause of action arises against answering OPs. It is further averred that it is bad for non joinder of necessary parties as Secretary, Government of Punjab, Department of Education Punjab, Chandigarh and Director Department of Education (S.E.) S.A.S. Nagar are necessary parties. It is  admitted that State of Punjab has launched cashless scheme for its employees and pensioners and complainant was insured under said scheme and as per notification, complainant was to submit his reimbursement bills to concerned hospital. All the other allegations are denied being wrong and incorrect and prayer for dismissal of complaint is made with costs.

 

cc no.-30 of 2019

7                                    Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence affidavit of complainant Ex.C-1 and documents Ex C-2 to C-15 and then, closed their evidence.

8                                        In order to rebut the evidence of the complainant, Counsel for OP-1 and OP-3 tendered in evidence affidavit of Dr Chander Shekhar Ex OP-1,3/1 and closed the same on behalf of OP-1 and 3. Counsel for OP-2 and OP-4 tendered in evidence affidavit of Vikas Kataria Ex OP-2,4/1 and document Ex OP-2,4/2 and also closed the same on behalf of OP-2 and OP-4. Ld counsel for OP-5 to OP-7 tendered in evidence affidavit of Jasbir Singh Ex OP-5 to 7/1 and notification Ex OP-5 to 7/2 and then also closed the evidence.

9                                         We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

10                                       The case of the complainant is that being a retired Government employee, complainant was insured under the policy in question. He got conducted his treatment for Post Auricular Infection at DMC Hospital, Ludhiana and spent about Rs.72,235/-on his treatment. He lodged claim with Ops, but Ops repudiated the claim of complainant on the ground that where cashless treatment is available, reimbursement on account of medical treatment is not admissible, which

cc no.-30 of 2019

amounts to deficiency in service. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of claim amount to him which amounts to deficiency in service and trade mal practice. He has prayed for accepting the complaint. On  the other hand, OP No.2 and 4 have stressed mainly on the point that as per rules, terms and conditions and package rate of policy, reimbursement for expenses incurred on treatment is not admissible where cashless treatment is available. In the hospital cashless treatment was available but he did not took cashless facility, as such, complainant is not entitled for any relief of claim amount as sought by him.  As per OPs, they rejected the medical bills of treatment of complainant on the basis of para no. 4 of notification vide which no reimbursement of medical treatment is pursuable as complainant had not availed the cashless treatment which is available in Punjab and complainant was duly informed about this. They have prayed for dismissal of complaint with costs.

11                                     Ld Counsel for OPs argued that complainant does not fall under the definition of consumer and the present complaint is not maintainable. The policy in question was issued in favour of Government of Punjab, Department of Health and Family Welfare. As per terms and conditions of the policy and as per para no.4 of the notification dated 20.10.2015 Government of Punjab, Department of Health and Family Welfare, it is specified that no reimbursement will be available for

 

cc no.-30 of 2019

 

the treatment in Punjab and Chandigarh, where cashless treatment is available. Only empanelled hospitals in Punjab, Chandigarh and NCR are eligible for treatment of the enrolled beneficiaries. The complainant has not taken cashless treatment from empanelled hospital, so his claim is rightly repudiated. They argued that this Forum has no jurisdiction to try and decide this complaint, because as per contract with Punjab Government as per clause 24 of the tender, there are District Level Grievance Redressal Committees are constituted and every dispute is to be settled by these committees and complainant did not approach to these committees and filed this complaint before Forum. So, this Forum has no jurisdiction to try this complaint.

12                                          Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being the pensioner of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that the complainant took treatment from DMC Hospital, Ludhiana from 26.11.2016 to 21.12.2016 and spent an amount of Rs.72,235/-on his treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by him on his treatment for Post Auricular Infection. He lodged claim for the reimbursement of medical expenses borne by him

cc no.-30 of 2019

with OPs, which was repudiated by them. Now, the first objection of opposite parties is that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and Grievance Redressal Committees are constituted to settle the dispute, but the complainant did not approach to these committees and filed the present complaint before this Forum. It is settled principle of law that the remedy under Consumer Protection Act is an additional remedy other than available remedies. If there is any contract of arbitration or to settle any dispute by settlement committee under the scheme in that case also the complainant can approach to this Forum instead of arbitrator or dispute settlement committee. In that event the jurisdiction of this Forum is not barred and this Forum can entertain and decide the present complaint. Now, the second and main objection of OPs for non payment of medical expenses of complainant and for repudiation of the claim is that as per notification no reimbursement was available for the treatment in Punjab and Chandigarh, where cashless treatment is available and the beneficiary is entitled for the treatment under the scheme only from the hospitals which are empanelled under the scheme. The OPs argued that complainant did not claim cashless treatment, so he is not entitled for any relief and cannot claim reimbursement of  medical expenses and his claim is rightly repudiated.

13                                         In view of the above, we are of the opinion that it is generally seen that insurance companies rejected pre authorization for cashless treatment on various grounds and do not allow

cc no.-30 of 2019

 

cashless treatment to patient or hospital, then in that case only the resources left for insured is to reimburse the medical bills. Moreover, in case of emergency the patient and his attendants firstly go for the best available treatment and do not search empanelled hospital of Insurance Companies or wait for approval of cashless treatment by the Insurance Companies.  

14                                            From the above discussion, we are of the considered opinion that the during the subsistence of policy in question, complainant suffered from some disease and he underwent treatment for Post Auricular Infection at Dayanand Medical college and Hospital, Ludhiana and spent Rs.72,235/-on his treatment, but OPs have wrongly and illegally repudiated the claim of the complainant for reimbursement of his medical bills, which amounts to deficiency in service on their part. Hence the present complaint is allowed against OP No.2 and OP-4. OP-2 and OP-4 are directed to make payment of insurance claim as per rates admissible under Punjab State Services Medical Attendant Rules alongwith interest @ 9% per annum from 28.01.2019 i.e from the date of filing the present complaint till final realization. OP-2 and 4 are further directed to pay Rs.5000/- (Five thousands only) as consolidated compensation for harassment and litigation expenses to the complainant. Compliance of the order be made within 30 days from the receipt of copy of this order, failing which, the complainant shall be entitled to  initiate

 

cc no.-30 of 2019

 

proceedings under Section 25 and 27 of the Consumer Protection Act. Complaint against OP-1, 3, and OP-5 to OP-7 is hereby dismissed.

Copy of order be sent to the parties free of costs. File be consigned to record room.

Announced in Open Forum

Dated : 21.10.2019                          

(Param Pal Kaur)         (Ajit Aggarwal)

                                                Member                      President