PER:

Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35, 36 and 38 against the opposite party on the allegations that the complainant is subscriber to the Insurance scheme vide card No. PHQL0JVOK issued under Ayushman Bharat Scheme i.e. National Health Protection mission by the central government through Punjab Government. Under this scheme, the expenses up to Rs. 5,00,000/- on health related treatment / expenditure will be covered by the insurance. Guru Nanak Dev Super Specialty Hospital, Tarn Taran is empanelled hospital under the above scheme as such is duty bound to provide treatment to the subscribers patients of the above scheme up to the expenses of Rs.5,00,000/-. On 5.5.2020, the complainant has met with an accident and received severe injuries and the complainant got admission in the opposite party hospital and the attendant of the complainant i.e. his wife namely Davinder Kaur has provided all the necessary documents including the copy of Ayushman Bharat Scheme Card to the hospital authority. Thereafter, the complainant was treated at the Guru Nanak Dev Super Specialty Hospital, Tarn Taran and the total expenditure on the treatment comes to Rs. 2,00,000/-. As already submitted that the complainant has already submitted the insurance/ scheme card with respective authority of the hospital but the concerned authority of the hospital has insisted upon getting payments from the complainant. The complainant has requested that the hospital is under duty to claim the expenditure amount from the concerned government authority but the hospital authority remained adamant and told the complainant that firstly he has to make the payment and thereafter the same will be reimbursed as such the same were paid by the complainant to the hospital. The complainant has to make payment of Rs.2,00,000/- approximately to the hospital out of his pocket for the treatment. It is the duty of the hospital to reimburse Rs.2,00,000/- i.e amount of insurance/ scheme out of the total expenditure but the hospital authority has done nothing in this regard. As such later on, the intimation with regard to the treatment & expenditure were given the complainant to the concerned authority on toll free No.104 vide complaint No.1225147 dated 5.6.2020. Afterwards, the complainant has visited the hospital for several times and further has contacted concerned officials for so many times but no positive response has been given by the concerned officials and further the hospital has done nothing favorable in this respect in order to settle the claim of the complainant. As per the directions and orders passed by the central as well as Punjab Government, all the medical expenses incurred by the subscriber under the scheme, will be reimburse by the concerned empanelled hospital by adopting adequate procedure. As such the opposite party hospital is under obligation to reimburse the medical claim in favour of the complainant but the opposite party has done nothing favourable in this respect despite making so many requests by the complainant. Afterwards, the complainant has served a legal notice bearing reference No. F-70/20 dated 7.6.2020 upon the opposite party and requested to reimburse the medical treatment expenses up to Rs.  2,00,000/- to the complainant. The opposite party has given the reply of the above legal notice to the complainant and submitted that “the hospital is not treated the patients under the policy of Ayushman Bharat Scheme as they has sent one month notice to the DMC Ayushman Bharat dated 1.4.2020 and after service of the notice, the hospital stopped treating the patients under the scheme”. In its reply, the opposite party has leveled more allegations against the complainant, which are irrelevant and have been specifically denied and will be answered at appropriate time. Mere serving of the notice, to the DMC Ayushman Bharat, does not de-empanelled the opposite party from the Ayushman Bharat scheme till the notice accepted by the concerned central/ State Government authority. As such the opposite party hospital cannot deny from providing treatment under the scheme by itself and has wrongly repudiated the claim of the complainant. The above said act on the part of the hospital is an arbitrary, unbusinesslike act and gross deficiencies in services as the complainant has provided each and every document and information to the hospital as demanded by its employees and have never withheld any document alongwith him. The alleged submissions have never been dictated to the complainant or his attendant at the time of admission or before starting of the treatment. Before starting the treatment, the hospital has never told the complainant and his attendant that the hospital is not treating the patient under the scheme and after starting of treatment, the attendant of the complainant has to deposit the amount under compulsion and fear of any mis-happening. As such, it is a grave deficiency in services on the part of the hospital to decide the claim on the basis of unattached, unexplained, inappropriate and wrong allegations. The complainant has further made several requests to the hospital to reimburse his amount but the opposite party has done nothing in this respect. The opposite party is under obligation to reimburse the amount spent by the complainant on his treatment. The complainant has suffered mental and physical harassment on account of act and conduct of the hospital for which the opposite party is liable to compensate the complainant. The complainant has prayed that the opposite parties may be directed to reimburse the expenses up to Rs. 2,00,000/- as incurred by the complainant on the treatment of the insured and also prayed Rs. 20,000/- as compensation and Rs.  10,000/- as litigation expenses and counsel fee and interest @ 12% per annum from the date of complaint. Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, affidavit of Davinder Kaur Ex. C-2 alongwith documents i.e. Ayushman Bharat Scheme Ex. C-3, self attested copies of the bills Ex. C-4 to Ex. C18, self attested copy of discharge certificate Ex. C-19, Self attested copy of Adhar Card of Daljit Singh Ex. C-20, Self attested copy of Adhar Card of Davinder Kaur Ex. C-21, Self attested copy of Legal notice Ex. C-22, Self attested copy of reply of legal notice Ex. C-23.

2        Notice of this complaint was sent to the opposite party and opposite party appeared through counsel and filed written version by interalia pleadings that the complaint is not maintainable. The complainant suppressed material facts from this commission and has not come to this commission with clean hands. The complainant has no cause of action to file the present complaint against the opposite party.  The complainant has no locus standi to file the present complaint. The complainant came for his treatment in the hospital of opposite party on 5.5.2020 and the complainant was discharged on 14.5.2020. At the time of admission in the hospital the complainant or his attendant did not show any card issued under the Ayushman Bharat Scheme to the opposite party and the complainant and his attendant deposited the admission charges and the other charges of initial treatment and medicine by cash and later on at the time of final payment the complainant and his family told the complainant that the complainant had card under the Ayushman Bharat Scheme. The opposite party intimated the complainant that at the beginning of the treatment the complainant has to inform the hospital about the card if the complainant has but the complainant and is attendant failed to do the same. Moreover the opposite party had told the complainant at the time of discharge that he is not treating the patients under the policy of Ayushman Bharat Scheme as the opposite party has sent one month notice to the DMC Ayushman Bharat- Sarbat Sehat Bima Yojana Tarn Taran Dated 1.4.2020, as per the provision and terms of the M.O.U, and after the service of the notice the O.P stopped treating the patients under that scheme. The O.P had intimated the complainant and his attendants about the entire facts, when at time of discharge the complainant showed his card to the O.P but the complainant and his attendant showed their consent in the cash treatment by O.P and the complainant and his attendant gave consent by paying the treatment expenses by on 5.5.2020, 8.5.2020 and finally on 14.5.2020 at the time of discharge from the hospital and the complainant paid the consented treatment expenses without any protest and objection, with his free consent but now in order to harass and blackmail the opposite party, the opposite party, the complainant has filed the present complaint after getting good medical treatment. After the discharge of the complainant from hospital the complainant never visited to any competent authority of the opposite party for any alleged claim nor the complainant gave any written complaint of opposite party. The directions of the central as well as Punjab Government regarding the above detailed scheme are all matter of record. As neither at the time of admission the complainant or his attendant, showed or gave any card of scheme to opposite party nor during the treatment the complainant or his attendant gave any such card to the opposite party rather the complainant and his attendant paid the medical treatment bill by cash without any objection and without any protest from their side from the beginning of treatment till discharge. As already informed that at the end of treatment the opposite party intimated the complainant that when a patient had any card under any scheme he has to show the same to the hospital and then the hospital has to send his case for approval but neither the complainant showed any card during the admission or during the treatment. The complainant has informed the opposite party at the time of discharge so even if the opposite party would have been treating the patients under the said scheme during the period of admission of complainant and treatment then also the case of the complainant cannot be sent for approval after the lapse of 5 days from the date of admission with opposite party. The complainant severed a legal notice dated 7.6.2020 and the opposite party has given the reply to the legal notice on 5.8.2020. The hospital provided the best services and gave the best treatment to the complainant.

3        The complainant has filed rejoinder to the written version filed by the complainant and controverted the stand taken by the opposite party and reiterated the stand as taken in the complaint.

4        We have carefully gone through the record and heard Ld. counsel for complainant and opposite party.

5        From the combined and harmonious reading of documents and pleadings it is transpired that the complainant is subscriber to the Insurance scheme vide card No. PHQL0JVOK issued under Ayushman Bharat Scheme i.e. National Health Protection mission by the central government through Punjab Government. The complainant can avail treatment facility under this scheme to tune of Rs. 5,00,000/-. On 5.5.2020, the complainant met with an accident and received severe injuries and he was admitted in the Guru Nanak Dev Super Specialty Hospital Tarn Taran and the total expenditure on the treatment comes to Rs. 2,00,000/- and the complainant was forced to make a payment of Rs. 2,00,000/- to the hospital out of his pocket whereas it was the duty of the hospital to reimburse the amount as the complainant was insured under the Ayushman Bharat Scheme.

6        Whereas the opposite party stated in their reply that the complainant has not shown any card of Ayushman Bharat Scheme at the initial stage and the attendant of the complaiannt deposited the admission charges and other charges for initial treatment and medicine by cash at the time of final payment and further stated that it was the duty of the complainant to inform the hospital about the Ayushman card. But the complainant as well as attendant failed to do the same. Moreover, the opposite party has sent one month notice to the DMC Ayushman Bharat- Sarbat Sehat Bima Yojana Tarn Taran as per the provision and terms of the M.O.U, and after the service of the notice the opposite party stopped treating the patients under this scheme.

7        It is not disputed that the complainant took policy from the insurance company under Ayushman Bharat Scheme and it is also not disputed that the complainant has taken the treatment from the hospital. It is also not disputed that the complainant has paid a sum of Rs. 2,00,000/- to the opposite party for his treatment and the opposite party has rejected the claim of the complainant on the ground that the complainant has not told about Ayushman Card at the initial stage. Secondly, as per opposite party the hospital is sent a notice to the concerned authority to de-penal the hospital.  But we are not agreed with the opposite party as they have given two statements both are contradictory to each other. One side opposite party is stating that the complainant has not placed on record the Ayushman Bharat Scheme and on the other hands they are stating that as they have sent a notice to the DMC Ayushman Bharat that we have stopped treating the patient under this scheme. The opposite party has not placed on record any notice as well as any letter from the concerned authority which proves that the hospital of the opposite party has been de-paneled from the `impaneled list of hospital. Moreover, it is the duty of the opposite party to inform the complainant/ patient at the initial stage that they are not authorized to treat the patient under said scheme. As such we are of the considered opinion that by not reimbursing the amount incurred by the complainant during the treatment is a deficiency in service and unfair trade practice.  

8        In view of above discussion, the present complaint is allowed and opposite party is directed to reimburse Rs. 2,00,000/- approximately as incurred by the complainant on the treatment of insured. The complainant has been harassed by the opposite party unnecessarily for a long time. The complainant is also entitled to Rs.10,000/- as compensation on account of harassment and mental agony and Rs 7,500/- as litigation expenses. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

Announced in Open Commission

04.04.2024