| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C. No. 55 of 21-02-2018 Decided on : 23-11-2021 Balbir Kaur aged about 6o years, W/o Sh. Jasmail Singh, R/o Street No. 10/5, Guru Gobind Singh Nagar, Bathinda. .......Complainant Versus The State of Punjab through its Collector, District Bathinda. Chawla Hear Care Centre Multi Super Speciality Hospital, 521 New jawahar Nagar, Guru Nanak Mission Chowk, Jallandhar, through its Chief Administrator Harpreet Singh Goldy (Deleted) The Divisional Manager, The Oriental Insurance Co. Ltd., #4501, 1st Floor, Bank Street, Bathinda.
.......Opposite parties
Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Kanwar Sandeep Singh, President Sh. Shivdev Singh, Member. Smt. Paramjeet Kaur, Member Present For the complainant : Sh. Jasvir Singh, Advocate. For opposite parties : OP No. 1 exparte OP No. 2 deleted Sh. Vinod Garg, Advocate, for OP No. 3. ORDER Kanwar Sandeep Singh, President The complainant Balbir 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 State of Punjab and others (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that she retired from Punjab Education Department and her GPF/PPO No. is 23721/PB. The Punjab Government has introduced a cashless Health Insurance Scheme for its employees referred as Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) vide notification No. 21/28/12/5HB5/268 dated 20-10-2005 to cover indoor medical treatment for diseases as given in the scheme and got insured with opposite party No.3 The complainant being retired/ pensioner employee of Govt. of Punjab provided the scheme and the opposite parties issued General policy/ID card No. MD15-09530695641 issued on 1-1-2016 to 31-12-2-016 under cashless scheme and all the dependants of complainant have also been insured. The opposite parties never issued any complete policy/cover note rather they have issued insurance card only. The said insurance is cashless Insurance. The opposite parties also assured the complainant that in case of any emergency, the claim can be lodged within 24 hours of hospitalization in authorized/notified Hospital anywhere in Punjab and the opposite parties will pay the entire claim upto the sum assured directly to the hospital immediately. It is alleged that the husband of the complainant is a heart patient. He was serious and being dependent upon the complainant, she got admitted her husband with opposite party No. 2, which is authorized and notified hospital as indoor patient vide IPD No.1902C/R2 and discharged on 26-2-2016. After conducting clinical test the opposite party No. 2 advised the husband of the complainant for implant of pace maker and informed the complainant that this surgery will cost more than Rs.2,00,000/-. The complainant immediately approached the opposite party No. 3 for cashless insurance, but during the period of indoor hospitalization the opposite parties have not paid the amount to complainant or direct to the hospital. The complainant incurred expenses of Rs.2,27,231/- and paid the entire amount from her own pocket under compelling circumstances. It is further alleged that after surgery for implant of pace maker, the complainant sent the bills to opposite parties for reimbursement of Rs. 2,27,231/-, but the opposite parties did not reimburse the amount to her. Due to non reimbursement/refund of payment of Rs.2,27,231/-, she suffered mental agony and pain for which she claimed compensation to the tune of Rs.1,00,000/-. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay claim amount of Rs. 2,27,231/- with interest @ 18% P.A. and compensation to the tune of Rs. 1,00,000/- besides litigation expenses to the tune of Rs. 50,000/-. Registered A.D. Notice of complaint was sent to the opposite parties. The opposite party No. 1 put an appearance through authorised representative and filed written reply. Thereafter none appeared on behalf of opposite party No. 1. As such, exparte proceedings were taken against opposite party No. 1. On the statement of learned counsel for complainant, recorded separately, name of opposite party No. 2 was deleted from the array of opposite parties vide order dated 22-2-2018. In written reply, the opposite party No. 1 has taken legal objections that the complainant has got no locus standi to file the present complaint. That there is no deficiency in service on the part of the opposite party. That the complainant is not entitled to any compensation as he has failed to place any material on record in order to substantiate his claim. That no notice under section 80 ,CPC has been served upon the opposite party On Merits, the opposite party No. 1 has admitted that complainant retired from Punjab Education Department and her GPF/PPO No. is 23721/PB. The Punjab Government has introduced a cashless Health Insurance Scheme for its employees referred as Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) vide notification No. 21/28/12/5HB5/268 dated 20-10-2005 to cover indoor medical treatment for diseases as given in the scheme and got insured with opposite party No.3 The complainant being retired/ pensioner employee of Govt. of Punjab provided the scheme and the opposite parties issued General policy/ID card No.MD15-09530695641 issued on 1-1-2016 to 31-12-2-016 under cashless scheme and all the dependants of complainant have also been insured. It is mentioned that the State Government is the intermediator. In further reply, the opposite party No. 1 has stated that averments mentioned in further paras of complainant do not relate to opposite party No. 1. After controverting all other averments, the opposite party No. 1 prayed for dismissal of complaint. The opposite party No. 3 in its separate written version has taken legal objections that the claim in question relates to Jasmail Singh husband of complainant and complainant has no locus standi to file the complaint. That the 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 complainant has concealed material facts and documents from this Commission. The complainant has concealed the fact that complainant or the hospital (opposite party No. 2) did not provide reply to additional information required/query and did not clarify the diagnosis and package code. Since additional information was not submitted and query was not replied, the claim was closed and no authorization for cashless was given. The complainant has not lodged any claim for reimbursement and did not submit any claim for reimbursement along with medical record and bills. The opposite party No. 3 reserves its right to decide the claim as per terms and conditions of the policy in case, and as and when the said documents are submitted. That the complaint is bad for non-joinder of necessary parties. That Punjab Government has entered into an agreement to provide cashless medical facility to it employees including pensioners under EPHIS (Punjab Government Employees and Pensioners Health Insurance Scheme) regarding which Punjab Government has issued notification to its employees also and Punjab Government along with Insurance Company and TPA has empanelled various hospitals to provide cashless treatment to employees of State Government and rates of each and every treatment/operation have been finalized between empanelled hospital and TPA with consent of Punjab Government and 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. That the complaint is not maintainable in the present form. On merits, the opposite party No. 3 has reiterated its version as pleaded in legal objections and detailed above. After controverting all other averments, the opposite party No. 3 prayed for dismissal of complaint. In support of his claim, the complainant has tendered into evidence her affidavit (Ex. C-1), photocopy of Insurance policy (Ex. C-2), photocopy of Lab report (Ex. C-3), photocopy of payment receipt (Ex. C-8), photocopy of cash receipts (Ex. C-9 to Ex. C-19), photocopy of prescriptions (Ex. C-20 & Ex. C-21), photocopy of cash memo (Ex. C-22), photocopy of detail of medicine (Ex. C-23 & Ex. C-24), photocopy of cash receipt (Ex. C-25), photocopy of patient record book (Ex. C-26), photocopy of report (Ex. C-27), photocopy of cash memo (Ex. C-28), another affidavit of complainant (Ex. C-29) and closed the evidence. In order to rebut the evidence of complainant, opposite party 1 tendered into evidence affidavit of Smt. Rubi Gupta (Ex. OP-1/1) and closed the evidence. The opposite party No. 3 has tendered into evidence affidavit of Dr.
Geeta Bhardwaj (Ex. OP-3/1), affidavit of Roop Lal Baleem (Ex. OP-3/2), photocopy of notification (Ex. OP-3/3), photocopy of scheme (Ex. OP-3/4), photocopy of claim documents (Ex. OP-3/5) and closed the evidence. We have heard learned counsel for the parties and gone through the record. In the case in hand, there is no dispute that complainant is retired from Punjab Education Department and her GPF/PPO No. is 23721/PB and that the Punjab Government has introduced a cashless Health Insurance Scheme for its employees referred as Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) vide notification No. 21/28/12/5HB5/268 dated 20-10-2005 to cover indoor medical treatment for diseases as given in the scheme and got insured with opposite party No.3. It is also not disputed that the complainant being retired/pensioner employee, Govt. of Punjab provided the scheme and the opposite parties issued General policy/ID card No.MD15-09530695641 on 1-1-2016 to 31-12-2-016 under cashless scheme and all the dependants of complainant have also been insured. The husband of complaint remained admitted with opposite party No. 2 for the period from 24-2-2016 to 26-2-2016 for the implant of pace maker wherein she incurred expenses to the tune of Rs. 2,27,231/-. The complainant alleged that she filed claim with the opposite parties for reimbursement under cashless shceme, which is pending with the opposite parties. The plea of the opposite party No. 3 is that the complainant or the hospital (opposite party No. 2) did not provide reply to additional information required/query and did not clarify the diagnosis and package code. Since the additional information was not submitted and query was not replied, the claim was closed and no authorization for cashless treatment was given. Keeping in view the facts, circumstances and the evidence placed on file by the parties, this Commission is of the considered opinion that opposite parties have not rejected/repudiated the claim to complainant rather they have closed her file and not allowed/given authorization for cash less treatment to opposite party No. 2 as neither opposite party No. 2 nor complainant provided information/replied query and clarified the diagnosis and package code. The complainant has not placed on file any document to prove that he furnished the documents/ information demanded by opposite parties. The complainant has not placed on file any document to show that she filed her claim with opposite party No. 3 for reimbursement. Therefore, in such circumstances, in the interest of justice, direction can only be given for submission of claim documents by complainant and thereafter settlement of claim by opposite party No. 3. In view of what has been discussed above, this complaint stands disposed off with direction to opposite party No. 3 to settle the claim of the complainant as per terms and conditions of the policy in question, within 60 days from the date of receipt of claim documents by complainant. 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 : 23-11-2021 (Kanwar Sandeep Singh) President (Paramjeet Kaur) (Shivdev Singh) Member Member
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