Punjab

StateCommission

A/413/2018

The Oriental Insurance Company Ltd. - Complainant(s)

Versus

Hari chand and others - Opp.Party(s)

J.P. Nahar

14 May 2019

ORDER

FIRST ADDITIONAL BENCH

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,                           PUNJAB, CHANDIGARH

 

  First Appeal No.413 of 2018                                 

Date of Institution  :     23.07.2018

Order Reserved on:     09.05.2019

Date of Decision     :    14.05.2019

 

1.      The Oriental Insurance Company Limited, Regd. Office : Oriental House P.B. No.7037, A-25/27, Asaf Ali Road, New Delhi-110002 through its Incharge.

 2.     Managing Director India Health Insurance (TPA) Private   Limited, D-38, Near Max Pro Park, Industrial Area, Phase-1,         Mohali.

          Now both through authorized signatory, Alka Bansal,         Manager, Regional Office, SCO No.109-110-111, Surendra   Building, Sector 17-D, Chandigarh.

….Appellants/opposite parties No.1 & 2

 

Versus

 

1. Hari Chand (Mobile No.09417715326) aged about 60 years son of Sh.Sona Ram of Sh. Bulaki Ram resident of House No.2395, St. No.2, Aggarwal Colony, Jalalabad (W) Distt. Fazilka.

….Respondent/complainant

2. S.S.P. Sahib, Fazilka.

…..Respondent/opposite party No.3

 

First Appeal against the order dated 06.04.2018 of the District Consumer Disputes Redressal Forum, Ferozepur.

Quorum:- 

                    Mr. J.S.Klar, Presiding Judicial Member                                 Mr. Rajinder Kumar Goyal, Member

Present:-

          For the appellants    :   Sh.J.P.Nahar, Advocate

          For respondent No.1:   Sh.R.S.Bhatta, Advocate

          For respondent No.2:   Ex-parte

RAJINDER KUMAR GOYAL,  MEMBER

ORDER

            The instant appeal has been filed by the appellants/opposite parties No.1 & 2 against the order dated 06.04.2018 passed by District Consumer Disputes Redressal Forum, Ferozepur (in short, ‘District Forum’), whereby the complaint filed by the complainant was allowed by directing the opposite parties to pay the remaining amount of Rs.1,80,364/- spent on his treatment along with interest at the rate of 9% per annum from the date of filing of the complaint till its realization.  Whereas the complaint filed against opposite party No.3 was dismissed.

            It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Forum.

2.         Brief facts, as averred in the complaint are that the complainant was an Inspector in Punjab Police (now retired). Being a govt. employee, the Punjab Government issued a cashless insurance policy of Rs.3 lacs bearing Policy No.231102/48/2016/769 under the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), which covered the complainant, his wife and two children.  An ID Card No.MD15 08558806405 was also issued by the opposite parties. On 27.03.2016, a problem in his back bone was increased and in emergency he had to be admitted in Neurological Institute of Medical Science Pvt. Ltd., Jallandhar City; which is an enlisted hospital of the opposite parties. The complainant remained admitted there from 27.03.2016 to 11.04.2016. A surgery of his back bone was conducted and during surgery; 4 Pedicle Screw Poly 6.5 x 50 mm worth Rs.52,000/-, 2 ROD 5.5 x 50 mm worth Rs.16,000/- and TIT TLIF CAGE 10 mm worth Rs.7,000/- were installed in his back bone. For his treatment, on medicines, tests and medical charges etc., he had to pay Rs.3,10,716/-. Thereafter the complainant claimed the amount from opposite party No.2 by submitting all relevant original documents/medical record/bills and claim forms etc.  On 15.10.2016, the complainant was shocked to know that against the total claim amount of Rs.3,10,716/-, opposite party No.2 deposited only Rs.22,851/- as reimbursement and rest Rs.2,77,149/- were withheld by opposite party No.2.  The complainant then gave an application dated 29.10.2016 to opposite party No.2 and to other authorities with the request to clear his claim; but the request of the complainant was refused on the ground that Rs.22,851/- has been paid as per PGI rates.  On 17.01.2017, a legal notice dated 16.01.2017 was served upon opposite parties No.1 & 2 through his counsel, to which no reply has been received.  Alleging deficiency in service and unfair trade practice on the part of opposite parties No.1 & 2, the complainant filed the complaint before the District Forum and sought the following reliefs:-

i)        to pay remaining amount Rs.2,77,149/- along with    interest at the rate of 18% per annum from the date of his treatment till realization.

ii)       to pay Rs.1100/- as cost of legal notice;

iii)      to pay Rs.50,000/- as compensation for mental        harassment and agony; and

iv)      to pay Rs.4,400/- as cost of the instant complaint     including expenses.

3.         Upon notice, opposite parties appeared and filed their reply by taking preliminary objections that the complaint is not maintainable. The complainant has not come to the court with clean hands and concealed the material facts.  The Forum has no jurisdiction to entertain, try and decide the present complaint.  The scheme was introduced by the Punjab Government as per notification No.21/28/12-5HB5/268 dated 20.10.2015 to provide in patient health care services to all personnel of the State Government including all India Services Officers, serving and pensioners and others. As per notification dated 21.09.2016 of Punjab Government, the Grievance Committee was constituted on District Level as well as State level to redress the grievances of the beneficiaries; but the complainant did not avail this legal remedy. The complainant is not a consumer of the answering opposite parties; as the opposite parties issued the policy to the State Government. Punjab Government which has sponsored this scheme to its employees and pensioners and no insurance premium was deducted from their salaries and it was provided free of cost. The answering opposite parties have only contractual liability towards the Punjab Government. Thus, the Government of Punjab and MD Punjab Government Pensioners and Health Insurance Scheme are also necessary parties to the present proceedings.  The claim has already been settled by the answering opposite parties as per PGEPHIS rates for Rs.1,30,352/-.  There is no deficiency in service or unfair trade practice on their part. On merits, all the averments as averred by the complainant in his complaint were denied and opposite parties No.1 & 2 prayed to dismiss the complaint; as there is no deficiency in service or unfair trade practice on their part.

4.         On the other hand, opposite party No.3 filed its reply and took preliminary objections that the complaint is not legally maintainable. On merits, it was contended that the complainant has failed to prove any deficiency in service or unfair trade practice on its part and prayed that the complaint filed against opposite party No.3 be dismissed with costs.

5.         The parties produced the evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel appearing on their behalf, allowed the complaint, vide impugned order. Hence, this appeal by the appellants/opposite parties No.1 & 2 .

6.         Notice of this appeal was issued to respondent being complainant and respondent No.2 being opposite party No.3. Respondent No.2 has not appeared despite service, therefore, it was ordered to be proceeded against ex-parte vide order dated 11.09.2018.

7.         We have heard learned counsel for the appellants/opposite parties No.1 & 2 and the respondent No.1 / complainant and have carefully gone through the records of the case.

8.         Learned counsel for the appellants/opposite parties No.1 & 2 argued that the order passed by the District Forum is against the facts and settled principles of law.  The District Forum has wrongly held that the appellants/opposite parties No.1&2 have not disclosed the terms and conditions of the policy to the complainant.  The District Forum has awarded an amount of Rs.1,80,364/- in addition to Rs.1,30,352/- already paid, which is more than the sum insured of Rs.3,00,000/-.  The District Forum has also not taken any judicial notice of the contents of para 7 of the preliminary objection; wherein the complete details have been given as to the amount paid for Rs.1,30,352/- as per the PGEPHIS Schedule of Rates. The District Forum has also not gone through the PGEPHIS Schedule of Rates before deciding the matter.  There is no deficiency in service or unfair trade practice on the part of the opposite parties. It is prayed that the appeal be allowed and the order passed by the District Forum be set aside.

9.         On the other hand, learned counsel for the respondent No.1/complainant argued that there is no illegality in the order passed by the District Forum and it needs no interference. The District Forum has passed the order in favour of the complainant after going through the proper evidence on record. There is no merit in the appeal and prayed to dismiss the appeal with costs.

10.       Admittedly, the respondent No.1/complainant being a Punjab Government Pensioner was insured with the opposite parties under PGEPHIS scheme and issued ID Card No. MD15-08558806405.  On 27.03.2016, a problem in his back bone increased and in emergency, he was admitted to Neurological Institute of Medical Sciences Private Limited, Jalandhar City. The respondent/complainant remained admitted from 27.03.2016 to 11.04.2016 for surgery of his back bone and during surgery four Pedicle Screw Poly and 2 ROD and TITTLIF cage 10mm got installed in his back bone.  For the said treatment, the complainant paid Rs.3,10,716/- to the hospital, whereas the appellants/opposite parties No.1 & 2 already settled the claim of the complainant for Rs.1,30,352/-. Punjab Government purchased a master insurance policy from the opposite party-Insurance Company for a sum insured of Rs.3,00,000/- for each employee. The District Forum while deciding the issue allowed a full payment of Rs.3,10,716/- i.e. (Rs.3,10,716 – Rs.1,30,352 = Rs.1,80,364/-) and has ignored the basic terms of the policy/scheme. Even, the complainant has also stated the insured amount of Rs.30 lacs in para 1 of the complainant.

11.       As per the PGEPHIS notification, the payment of claim is to be paid as per the PGEPHIS rates agreed upon between the networked hospitals and the opposite parties. Now the issue is to decide, how much amount is payable to the complainant as per PGEPHIS rates. The District Forum while deciding the issue have ignored the PGEPHIS rates and awarded the total balance amount of Rs.1,80,364/-. The complainant is not entitled to any other amount beyond the scheduled rates. We have perused the PGEPHIS rates vis-à-vis bills of the hospital submitted by the complainant to the opposite party-Insurance Company. The complainant lodged the claim for Rs.3,10,716/- but appellants settled only for Rs.1,30,352/- as per details below:-

Item Head		Amount
ICU (1870*1) room rent (750x15)	:	Rs.13,120/-
Consultation (32x100)	:	Rs.3200/-
Investigation Charges	:	Rs.6960/-
Medicine Charges	:	Rs.52,795/-
Spinal Ostectomy and internal fixations (Pkg code 773)	:	Rs.22,852/-
Spinal Ostectomy and internal fixations (Pkg Code 773) 50% of second package	:	Rs.11,426/-
Cost of implant	:	Rs.20,000/-
Total	:	Rs.1,30,352/-

           

12.       As per Clause 3 of Annexure XX of PGEPHIS, Schedule of Rates, Ex.OP-2/2 i.e. cost of implant is reimbursable in addition to the package rates to the provider hospitals. Medicines, investigations, consumables outside the purview of package but utilized in special circumstances, complications related to the treatment of the deceased for which authorization has been sought from the TPA by the provider hospital are also reimbursable in addition to the package rates to the provider hospitals. As per Ex.C-5, the complainant has paid Rs.75,000/- as cost of the implant, whereas TPA has allowed only Rs.20,000/-. No evidence to reimburse only Rs.20,000/- as cost of implants has been placed by appellants/opposite parties No.1 & 2. Therefore, the cost of implant is to be reimbursed on actual basis.

13.       We are of the opinion that the claim of the complainant is entitled to amounts as under:-

Detail of Treatment	Amount as per TPA	Payable as per PGEPHIS rates	Remarks
ICU (1870*1) room rent (750x15)	Rs.13,120/-	Rs.13,120/-	-
Consultation (32x100)	Rs.3200/-	Rs.3,200/-	-
Investigation Charges	Rs.6960/-	Rs.20,880/-	As per hospital bill detail.
Medicine Charges	Rs.52,795/-	Rs.66,836/-	As per Actual since there is no prescribed rates.
Spinal Ostectomy and internal fixations (Pkg code 773)	Rs.22,852/-	Rs.22,852/-	-
Spinal Ostectomy and internal fixations (Pkg Code 773) 50 of second package	Rs.11,426/-	Rs.22,852/-	There is no evidence produced by the insurance company that 50% is to be paid for second package.
Cost of implant	Rs.20,000/-	Rs.75,000/-	On actual basis.

         

          As such, the total claim payable is Rs.2,24,740/- to him.

14.       In view of the above discussion, the appeal filed the appellants/opposite parties is partly allowed and the order of the District Forum is modified to the extent that opposite parties No.1 & 2 are directed to pay the remaining amount of Rs.94,388/- instead of Rs.1,80,364/- as awarded by the District Forum. Other part of the order of the District Forum shall remain the same.

15.       The appellant had deposited a sum of Rs.25,000/- at the time of filing of the appeal. This amount, along with interest which has accrued thereon, if any, be remitted by the registry to the respondent/complainant, after the expiry of 45 days of the sending of certified copy of the order to them.

16.       Arguments in this appeal were heard on 09.05.2019 and the order was reserved. The certified copies of the orders be communicated to the parties, as per rules.

17.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

 

                                                          (J.S.KLAR)

                                         PRESIDING JUDICIAL MEMBER

 

 

                                          (RAJINDER KUMAR GOYAL)

                                                          MEMBER 

 

May 14, 2019                                               

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