1.      The present Revision Petition has been filed under Section 21(b) of the Consumer Protection Act, 1986 (the “Act”) against order dated 21.07.2017, passed by the learned State Consumer Disputes Redressal Commission, Punjab (‘State Commission’) in First Appeal No. 546 of 2017. In the impugned order, the Appeal by Petitioner (OP-3) was dismissed, thereby, upholding the District Consumer Dispute Redressal Forum, Amritsar (“District Forum”) order in CC No. 217 of 2016 dated 12.06.2017, wherein the Complainant’s complaint was allowed.

2.    For convenience, the parties in the present matter are referred to as per the Complaint before District Forum. ‘Care Well Hospital’ (Petitioner herein) is referred to as the ‘OP-3’, whereas ‘Mr. Anil Arora’ (Respondent 1 herein), ‘National Insurance Company Ltd’ (Respondent 2 herein) and ‘Park Mediclaim TPA Pvt. Ltd.’ (Respondent 3 herein) are referred to as ‘Complainant’, ‘OP-1’ and ‘OP-2’ respectively.

3.    The brief facts of the case, as per the complainant, are that he obtained a Mediclaim policy No. 401209/48/15/8500000355 dated 23.6.2015 paying a premium of Rs. 23,259. The policy provided medical coverage of Rs. 3,00,000 for himself and Rs. 2,00,000 for his wife from 26.06.2015 to 25.06.2016. Since the complainant had not filed any claims for over 4 years, Rs. 60,000 cover had accumulated, thereby increasing his coverage to Rs. 3,60,000. The complainant fell ill on 08.09.2015 and was admitted to OP-3 Hospital, wherein he and his relatives were assured that he would be covered under the cashless treatment package of OP-1 insurance company. The complainant was informed by OP-3 that he needed to undergo PTCA and was briefed about the PTCA package and cashless treatment. Subsequently, he proceeded with the treatment from OP-3. However, at the time of discharge, he was required to pay Rs. 2,71,579 to OP-3. It is the case of the complainant that he approached OP-1, who instructed him to deposit the amount with OP-3 and assured him that the same would be reimbursed. Accordingly, complainant paid Rs. 2,71,579 to OP-3. OP-1 later replied to his email, stating that OP-3 was still on their panel and that the claim would be settled as per the PPN (Preferred Provider Network), advising him to make a representation before OP-2. The complainant then made a representation to OP-2, but OP-1 only issued an RTGS payment of Rs. 1,71,579, which was Rs.1,00,000/- short. Despite further representations to OP-2, there was no resolution. The complainant filed consumer complaint No. 217 of 2016 seeking payment of the remaining amount, compensation and litigation cost etc.

4.    In reply before the District Forum, OP-1 denied the case of the complainant and contended that the contract of insurance was subject to its terms and conditions of the policy and there was no procedure for any oral sanction of cashless treatment to any policy holder. It had already settled the claim of the complainant as per terms and conditions of the policy. OP-2 did not opt to put in appearance despite service, as such it was ordered to be proceeded against ex-parte. In reply, OP-3 denied that Sandeep Kapoor assured and told the complainant and his relatives that they were under the panel of OP-1 and would provide cashless treatment to him. OP-3 conveyed its inability for the cashless treatment and the same was immediately told to the representatives of the complainant on 09.09.2015. It was denied that any assurance for cashless treatment was given to the complainant.

5.      The learned District Forum vide Order dated 12.06.2017, allowed the complaint with the following reason /findings:

“This fact that the hospital is enlisted on the panel of the opposite party is proved as the complainant has placed on record User Guide Book in which name of the opposite party No.3 hospital has been mentioned. But even then the cashless treatment of the complainant has been denied by opposite party No.3. As such the complainant has to pay the treatment expenditure to the tune of Rs. 2,71,579/- from his own pocket. However, when the complainant lodged claim with opposite party No.1, opposite party No.1 has issued RIGS in the account of the complainant which was to the tune of Rs. 1,71,579/- i.e. 1 lac short from the amount incurred by the complainant on his treatment. In this regard complainant made representation to opposite party No.1, but no fruitful result has come forward. On the other hand, it was the case of opposite party No.1 that opposite party No.3 i.e. Care well hospital had been under the purview of PPN Hospitals (preferred provider Network hospital as the hospital has authorization for the same from GIPSA i.e. an Autonomous body of General Insurance Companies, who give authorization to hospitals to come under the purview of PPN and no PPN hospital can over charge from the policy holder for the medical treatment taken by him from the rates already settled between the hospital and GIPSA under any circumstances and if it is proved on record then the hospital concerned is solely responsible for the same. So it stands proved on record that opposite party No.3 is on the panel of opposite party No. 1 for cashless treatment to the policy holder and by not giving cashless treatment to the complainant being insured under policy No. 401209/48/15/8500000 355 dated 23.6.2015, opposite party No.3 itself caused harassment to the complainant and his family members and compelled the complainant to make payment of the treatment charges from his own pocket. ...

... Consequently, the instant complaint succeeds and opposite any No.3 is directed to reimburse the amount of Rs. 1 lacs over charged from the complainant as per PPN rates. Opposite party No.3 is also directed to pay compensation to the tune of Rs. 5000/- while litigation expenses are assessed at Rs. 3000/-. Compliance of this order be made within a period of 30 days from the date of receipt of copy of order; failing which, the complainant shall be entitled to get the order executed through the indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.”

6.      Being aggrieved, OP-3 filed FA No. 546 of 2017 and the State Commission vide order dated 21.07.2017 dismissed the appeal with following observations:-

“Counsel for the appellant was unable to prove on the record the date on which it was depanelled? Whether he had intimated to the complainant in writing on the patient file that the complainant will not be entitled to cashless facility or PPN rate? This matter has been exclusively dealt with by the District Forum and ultimately, came to the conclusion that Op No. 3 was at fault in not intimating the, complainant that their hospital is not a panel hospital when as per User Guide Book, it was a panel hospital. If later on, it was depanelled; it was exclusively in the knowledge of Op No. 3 on which date, it was depanelled. In case, it was depanelled after the admission of the complainant then certainly PPN rates will be applicable in the treatment of the complainant. However, Op No. 3 has not charged the PPN rates, it had charged the rates applicable to ordinary patient. In this way a sum of Rs. 1 Lac in excess was charged from the complainant. Op No. 1 has reimbursed to the complainant only the charges, which are applicable on PN rates, therefore, complainant got a sum of Rs. 1,00,000/- less on account of conduct of Op No. 3 as he did not bring it to the notice of the complainant that it is not a panel hospital on the date of admission oi that cashless facility will not be available to the complainant for which he should compensate to the complainant. In that context, the order passed by the District Forum is justified.

14. Sequel to the above, the counsel for the appellant was not able to make any point for admission of the appeal, the same is hereby dismissed. However, keeping in view the facts and circumstances of the case, in case Op No. 3 has any grouse against Op No. 1, he will be at liberty to recover the amount, from Insurance Company in accordance with law.

15. The appellant No. 1 had deposited an amount of Rs. 25,000/- with this Commission in the appeal. This amount along with interest accrued, thereon, if any, shall be remitted by the registry to the concerned District Forum, after the expiry of 90 days, from the despatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court; for the release of the above amount and the District Forum may pass the appropriate order in this regard.”

7.      Being dissatisfied by the Order dated 21.07.2017 passed by the State Commission, OP-3 filed the instant Revision Petition mainly advancing the following grounds:-

A.    The lower fora did not apply the settled legal principle that when a TPA denies cashless facilities, even at a PPN network hospital, the hospitalization should be treated as if it occurred at a non-network hospital. As such, the insurer must cover the difference between PPN and non-PPN rates.

B.    The finding that the complainant could have chosen another empaneled hospital is unreasonable in the absence of any policy condition requiring the insured to use only empaneled hospitals or cashless facilities.

C.    It was wrongly held under the facts of the case and misreading of records that cashless treatment was denied by OP-3. Whereas, it was OP-2 who refused stating that OP-2 is not a panel hospital at the time of claim settlement, and rendered self-contradictory version that OP-3 is a panel hospital, without bringing any record to show that at the relevant time OP-2 was a panel hospital.

D.    Even if it is presumed for the sake of argument that OP-3 was a panel hospital, when cashless facility was denied by the OP-2/ TPA, PPN rates would not apply and the insurance company would be liable to reimburse the patient as per Non-PPN rates.

8.      In his arguments, the learned Counsel for OP-3 reiterated facts, evidence, written version and asserted that OP-2 addressed letter dated 06.10.2015 to the complainant asking him to sign consent letter and provide certain information/documents including reason for not availing the cashless facility as it was an empanelled hospital. He emphasised that the TPA/OP-2 itself denied the cashless treatment on the ground that the OP-3 was not a panel hospital, contrary to their own version and questioned that the complainant did not avail cashless treatment.

9.      The learned counsel for the complainant emphasized the facts of the complaint and asserted that the Petitioner/OP-3 Hospital was at fault in not intimating him that their hospital is not a panel hospital when as per User Guide Book it was a panel hospital. He argued that decisions of the lower forums were well-reasoned and on merit.

10.    OP-2 was proceeded ex-parte in the lower fora. In the present petition, OP-2 (Respondent No.3 herein) has failed to appear or submit any arguments in its defense. Hence, OP-2 was placed ex-parte vide order dated 30.04.2024.

11.    I have examined the pleadings and associated documents placed on record and rendered thoughtful consideration to the arguments advanced by the learned Counsels for the parties available.

12.    Admittedly, the complainant had obtained a Mediclaim Policy bearing Policy No. 401209/48/15/8500000355 dated 23.06.2015 and paid premium of Rs.23,259 form OP-1. It is undisputed that the complainant fell ill and was admitted to OP-3 Hospital on 08.09.2015 for treatment. It is also undisputed that Rs.2,71,579 was in fact paid by him to OP-3 Hospital for treatment. Complainant alleges that he is entitled to a refund of Rs.1,02,000, being the excess amount paid by him as the said amount was not as per the PPN rates.

13.    The question to be determined is whether he is entitled to the discounted rates? If so, who is liable to refund the remaining amount to the complainant?

14.  It is a well-established principle that this Commission has limited jurisdiction to interfere in the concurrent findings of the District Forum and State Commission except for any patent illegality, material irregularity or jurisdictional error. Hon'ble Supreme Court in Rajiv Shukla v. Gold Rush Sales & Services Ltd., (2022) SCC 31 dated 08.09,2022 held as under:

 "In exercising of revisional jurisdiction the National Commission has no jurisdiction to interfere with the concurrent findings recorded by the District Forum and the State Commission which are on appreciation of evidence on record. Therefore, while passing the impugned judgment and order [Goldrush Sales and Services Ltd. v. Rajiv Shukla, 2016 SCC OnLine NCDRC 702] the National Commission has acted beyond the scope and ambit of the revisional jurisdiction conferred under Section 21(b) of the Consumer Protection Act.”

15.    In Narendran Sons v National Insurance Co. Ltd., 2022 SCC OnLine SC 1760 dated 07.03.2022, wherein it was held as under:

 "The NCDRC could interfere with the order of the State Commission if it finds that the State Commission exercised jurisdiction has not vested in it by law or has failed to exercise its jurisdiction so vested, or has acted in exercise of its jurisdiction illegally or with material irregularity. However, the order of NCDRC does not show that any of the parameters contemplated under Section 21 of the Act were satisfied by NCDRC to exercise its revisional jurisdiction to set aside the order passed by the State Commission. The NCDRC has exercised a jurisdiction examining the question of fact again as a court of appeal, which was not the jurisdiction vested in it"

16.    In Mrs. Rubi (Chandra) Dutta Vs. M/s United India Insurance Co. Ltd. (2011) 11 SCC 269 dated 18.03.2011, wherein it was held as under:

“Also, it is to be noted that the revisional powers of the National Commission are derived from section 21(b) 0f the Act, under which the said power can be exercise only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view than what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the court below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. In this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21(b) of the Act has been transgressed. It was not a case where such a view could have been taken, by setting aside the concurrent findings of two fora.”

17.  We have perused the orders of both the fora below and find that they were correct in holding that the complainant was entitled to the balance amount, after deducting the PPN rates from the amount charged by him at OP-3 Hospital. To this extent, we find no reason to interfere in the impugned order. However, there exists material irregularity in the conclusion as to who amongst the OPs is liable to pay the said relief to the complainant. Evidently, vide letter dated 09.09.2015, OP-2 has stated “cashless request is being denied since CAREWELL HOSPITAL AMRITSAR - NON PANNEL LETTER”. Thus, admitting that OP-3 was a non-panel Hospital and was entitled to charge at normal rates. However, OP-2 in its letter dated 06.10.2015, addressed to the complainant asking him the reason for not availing the cashless facility, wherein it was emphasised that OP-3 was an empanelled hospital. These two statements are contradictory. We find OP-3 had liberty in charging the normal rates during the course of the treatment. Conversations if any, regarding the reimbursement of amount were between the other OPs and the Complainant and OP-1 and 2 cannot take benefit of their own wrong. Clearly, it is OP-2 who misled the complainant by making false assurances about reimbursement. Also, the said User Manual/Guide Book was not issued by OP-3 claiming it to be a panel Hospital. Therefore, OP-3 cannot be held liable for any deficiency in service with respect to false representations made by the other parties. Accordingly, we do not find OP-3 liable in the matter. The liability for compliance of the order of the learned State Commission rests with OPs-1 and 2 to pay the balance amount due to the complainant.

18.  Based on the above discussions and on careful perusal of material on record Revision Petition No.3399 of 2017 is allowed. The order of the learned State Commission dated 21.07.2017 is modified to the extent that the liability for compliance of the order of the learned State Commission rests with OPs-1 and 2 to reimburse the balance amount due to the complainant.

19.  There shall be no order as to costs.

20.    All pending applications, if any, also stand disposed of accordingly.