| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.277 of 18-09-2017 Decided on 18-12-2019 1.Dr.Rajesh Jindal Director of Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda. 2.Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda, thorugh its Director Dr.Rajesh Jindal. ........Complainants Versus 1.ICICI Lombard General Insurance Company Limited, Sharma Complex, First Floor, Guru Kashi Marg, Corner, Power House Road, Bathinda, through its Branch Manager. 2.MD India Healthcare Services (TPA ) Pvt. Ltd., Regional Office, Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali-160055, through its Manager/Regional Manager. 3.MD India Healthcare Services (TPA) Pvt. Ltd., Head Office, 46/1 E Space, A-2 Building, 3rd Floor, Pune Nagar Road, Vadgaonsheri, Pune-411014, through its Director/MD. 4.Bhai Ghanhya Sewa Scheme Trust (BGSSS), Sector 34-A, Co-operative Bank Building, Ground Floor, Chandigarh-160022, through its Chief Executive Officer. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Smt.Manisha, Member. Present:- For the complainants: Sh.Naresh Garg, Advocate. For opposite party Nos.1 to 3: Sh.Vinod Garg, Advocate. For opposite party No.4: Sh.K.S Dabrikhana, Advocate. ORDER M.P Singh Pahwa, President This complaint has been filed by Dr.Rajesh Jindal and others complainants against ICICI Lombard General Insurance Company Limited and others opposite parties under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act'). Briefly stated, the case of the complainants is that Dr.Rajesh Jindal is practicing as D.M Cardiologist under the name and style of Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda. He is director of hospital and he is practising as Heart Specialist for his livelihood. Opposite party No.4 lodged a scheme in the Punjab known as Bhai Kanhiya Sehat Sewa Scheme (BGSSS) in which it provided cashless insurance and treatment to the general public of Punjab. The complainants have purchased insurance from opposite party No.1 and claims were settled through opposite party Nos.2 and 3 as TPA. Under this scheme, opposite parties also nominated and recognized the hospitals and doctors in the Punjab from where the patient can take treatment under BGSSS and treatment payment be reimbursed to the hospitals/doctors directly. For this, opposite parties also took a fixed amount from the hospitals/doctors annually. The complainants are duly authorized by opposite parties. Opposite parties took Rs.8000/- from the complainants and recognized them under BGSSS scheme. It is alleged that opposite party Nos.2 and 3 are Third Party Administrator (TPA) on behalf of opposite party Nos.1 and 4. Opposite party Nos.1 and 4 also gave clearance to the complainants time to time for the treatment of admitted patients and after clearance, the complainants treated the concerned patients and submitted bills alongwith claim forms and discharge report etc., to opposite party No.2 for reimbursement of the claim under cashless hospitalization scheme. It is further alleged that under the scheme, the complainants treated the following patients:- Patient Name | D.O.A | D.O.D | Bill Amount | Authorized Amount | Sukhram Singh | 16/01/16 | 19/01/16 | 19207 | 14090 | Surjeet Singh | 22/01/16 | 26/01/16 | 22648 | 16930 | Pritam Singh | 22/02/16 | 26/02/16 | 27457 | 15850 | Gurdial Kaur | 29/01/16 | 02/02/16 | 24050 | 17693 | Sukhpal Kaur | 01/03/16 | 05/03/16 | 21542 | 12330 | Baldev Singh | 09/03/16 | 12/03/16 | 26124 | 16370 | Surjeet Singh | 14/03/16 | 17/03/16 | 18431 | 109431 | Jaspal Kaur | 15/03/16 | 16/03/16 | 13510 | 6330 | Kamlesh Bansal | 06/04/16 | 13/04/16 | 28289 | 18240 | Balbir Singh | 20/04/16 | 23/04/16 | 22034 | 13743 | Harbans Kaur | 21/04/16 | 26/04/16 | 21055 | 11070 | Gurdeep Kaur | 21/05/16 | 24/05/16 | 10450 | 9360 | Pargat Singh | 31/05/16 | 01/06/16 | 66020 | 49408 | Satwant Kaur | 01/06/16 | 12/06/16 | 42324 | 27245 | Harbans Singh | 05/06/16 | 12/06/16 | 30415 | 20050 | Harbans Singh | 15/06/16 | 17/06/16 | 16852 | 8637 | Surjeet Kaur | 06/07/16 | 10/07/16 | 21301 | 13651 | Gurmukh Singh | 12/07/16 | 13/07/16 | 15043 | 7300 | Neta Singh | 04/06/16 | 06/09/16 | 11268 | 6070 | Mahinder Kaur | 07/09/16 | 10/09/16 | 18883 | 11090 | Baldev Kaur | 08/09/16 | 16/09/16 | 38140 | 26140 | Joginder Singh | 17/09/16 | 23/09/16 | 38661 | 16890 | Angrej Kaur | 27/09/16 | 06/10/16 | 27132 | 19060 | Sukhdev Singh | 27/09/16 | 02/10/16 | 89218 | 3100 | Gurtar Singh | 27/09/16 | 04/10/16 | 25069 | 19410 | Jagroop Singh | 28/11/16 | 03/12/16 | 24041 | 15746 | Jagroop Singh | 12/12/16 | 15/12/16 | 184431 | 109431 | Gurdeep Kaur | 22/12/16 | 24/12/16 | 19045 | 14229 | Gurdeep Kaur | 24/12/16 | 16/12/16 | 9274 | 3450 |
In this way, the total bills of Rs.10,97,914/- as per approved rate list duly sent to opposite parties alongwith treatment files. It is further alleged that opposite parties released the amount to the tune of Rs.6,32,344/- against the total bills of Rs.10,97,914/- as per their rate list. An amount of Rs.4,65,570/- (Rs.10,97,914/- (-) Rs.6,32,344/-) is still due towards opposite parties. It is further alleged that the complainants also treated three patients first Harjinder Kaur w.e.f. 20.6.2016 to 24.6.2016 and sent final bill of Rs.1,09,431/- as per rates of opposite parties alongwith treatment file. They treated Baldev Kaur w.e.f. 17.9.2016 to 26.9.2016 and sent final bill of Rs.1,34,933/- as per rates of opposite parties, but opposite parties approved only Rs.1,09,431/-. They also treated Baltej Singh w.e.f. 27.12.2016 to 31.12.2016 and sent final bill of Rs.1,09,431/- as per rates of opposite parties with treatment file. Out of these three bills, one bill is still pending against opposite parties, but they still did not clear regarding it. As such, Rs.1,09,431/- is still pending with the them. Opposite parties duly authorized the claims of the complainants to give permission for the treatment of the patents for amount of Rs.5,75,001/- (Rs.4,65,570/- + Rs.1,09,431/-). It is further alleged that the complainant many times approached the officials of the opposite parties and also sent e-mails, but to no effect On this backdrop of facts, the complainants have alleged deficiency in service on the part of the opposite parties. They have claimed Rs.1,00,000/- as compensation and Rs.50,000/- as cost of litigation in addition to reimbursement of insurance amont i.e. Rs.5,75,001/- (Rs.4,65,570/- + Rs.1,09,431/-) with interest @ 18% per annum from the date of admission till payment. Hence, this complaint. Upon notice, the opposite parties appeared through their counsel and contested the complaint by filing their written version. opposite party Nos.1 to 3 in their joint written version raised the legal objections that the complainants are not 'consumers' of opposite parties. They are themselves service providers under the scheme and provided medical services to patients insured under scheme. They are involved in commercial activities on large scale. That 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 summary procedure under 'Act' and appropriate remedy, if any, lies only in civil court. That complainants have concealed material facts and documents from this Forum and opposite parties. As such, they are not entitled to any relief. They concealed the fact that a scheme named Bhai Ghanaya Sehat Sewa Scheme was floated by Government of Punjab wherein opposite party No.2 i.e. M.D. India Health Care Services Pvt. Ltd., was appointed as Third Party Administrator (TPA). TPA impaneled various hospitals in the list of scheme including the hospital of complainants to provide medical services to various insured patients strictly as per BGSSS Scheme. The hospitals were bound to provide cashless treatment to the patients after getting approval from TPA and to claim the reimbursement from opposite party Nos.1 to 3 strictly as per Bhai Ghanaya Schedule of rates. The complainants entered into memorandum of understanding with opposite party Nos.1 and 2 dated 24.12.2015 to provide the services and to charge strictly as per scheme and rates. Opposite parties have already paid all the admissible claims at rates and provisions of BGSSS Scheme. Now, the complainants have filed this complaint claiming total amount of bills of treatment beyond the admissible and agreed Bhai Ghanaya Schedule of rates. As such, opposite parties are not liable to pay any amount. Further legal objections are that the complainants have no locus-standi or cause-of-action to file the complaint. This Forum has no jurisdiction to try and decide the complaint. As such, it is liable to be dismissed with costs. On merits, launching of scheme is not dispute. It is also mentioned that the hospitals were to provide cashless treatment to the patients and were to claim reimbursement only at agreed rates and provisions of Bhai Ghanaya Schedule rates. It is admitted that opposite party Nos.1 to 3 nominated and empanelled various hospitals under the scheme wherein the hospitals agreed to provide cashless treatment to the patients and also agreed to charge/seek reimbursement at Bhai Ghaniya Schedule Rates. It is denied that opposite parties took any fix amount from hospitals annually as alleged. Authorization of cashless treatment of various patients insured under the scheme is stated to be matter of record. It is denied that opposite party Nos.1 and 2 have not released full bill amount. Opposite party Nos.1 to 3 have also furnished details of payment in tabular form, reproduction of which is not considered necessary for sake of brevity. However, version of opposite party Nos.1 to 3 is that bills are paid according to Bhai Ghaniya Schedule Rates. It is further mentioned that the amount due under the scheme against patients Harjinder Kaur, Baldev Kaur and Baltej Singh on the basis of Bhai Ghaniya Schedule Rates has already been paid. All other averments of the complainants are denied. In the end, opposite parties Nos.1 to 3 have prayed for dismissal of complaint. Opposite party No.4 in its separate written version raised preliminary objections that the complaint against it is neither competent nor maintainable. The complainants are not 'consumers' of opposite party No.3. The hospital was the service provider under Bhai Ghanhya Sehat Sewa Scheme during the scheme period from 1.1.2016 to 31.12.2016. The complainants are not covered under the definition of 'Act'. As such, this Forum has no jurisdiction to entertain this complaint under 'Act'. The complaint is false, frivolous and vexatious. No cause-of-action accrued to the complainants for filing this complaint. Bhai Ghanhya Trust is a Trust registered with Registrar, of Firms and Societies with the object of formulating and administering the Bhai Ghanhya Sehat Sewa Scheme for the benefit of members and employees of the Cooperative Societies and Cooperative Department in the Punjab State. A service level agreement was entered in between the Bhai Ghanhya Trust (opposite party No.4), ICICI Lombard General Insurance Company (opposite party No.1) and MD India Health insurance TPA Pvt. Ltd (opposite party Nos.2 and 3) for implementation of the scheme. Opposite party No.2 was appointed as Third Party Administrator (TPA) by opposite party No.1 for the implementation of the scheme. According to the provisions of the scheme, Third Party Administrator was responsible for issuing of identity cards to the beneficiaries and providing of a handbook containing policy instructions and list of network hospitals while issuing identity cards to the beneficiaries, for inspection of hospitals and thereafter recommend them to be taken on panel of hospitals, to grant authorizations, to settle the claims of hospitals and beneficiaries to make the payments to the empanelled hospitals. The complainants must have entered into an agreement with opposite party Nos.1 and 2 that they will provide cashless services to the members enrolled by them. Opposite party No.4 is neither necessary nor a proper party in this complaint. On merits, opposite party No.4 has reiterated its stand as taken in the preliminary objections and detailed above. In the end, opposite party No.4 has prayed for dismissal of complaint. Parties were afforded opportunity to produce evidence. In support of their claim, complainants have tendered into evidence affidavit of Dr.Rajesh Jindal dated 18.1.2018 (Ex.C1), photocopy of medical treatment record and bills, (Ex.C2 to Ex.C34); photocopy of legal notice (Ex.C35); photocopies of e-mails, (Ex.C36 to Ex.C42) and closed the evidence. In order to rebut this evidence, opposite party Nos.1 to 3 have tendered into evidence photocopy of memorandum of understanding, (Ex.OP1/1); affidavit of Apurva Sharma dated 11.4.2018, (Ex.OP1/2); photocopy of confirmation, (Ex.OP1/3); photocopy of guide book, (Ex.OP1/4); photocopy of service level agreement, (Ex.OP1/5); photocopy of policy, (Ex.OP1/6); photocopy of payment detail, (Ex.OP1/7) and closed the evidence. The opposite party No.4 has tendered into evidence affidavit of Balbir Singh dated 4.10.2017, (Ex.OP4/1) and closed the evidence. We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stqand as taken in their respective pleadings and detailed above. In support of his submissions, learned counsel for the complainants has cited following case law :- (i) 2007(2) CPJ 3 case titled Alok Shanker Pandey Vs. Union of India; (ii) I (2007) CPJ 3 (NC) case titled Jmaya Appliances Pvt. Ltd Vs. United India Insurance Company Ltd.; (iii) Decision of Hon'ble State Commission, Punjab, Chandigarh rendered in First Appeal No.1550 of 2014, Decided on 17.11.2015 in case titled ICICI Lombard General Insurance Company Limited & Ors. Vs. Dr.Rajesh Jindal and Others; (iv) Decision of Hon'ble State Commission, Punjab, Chandigarh rendered in First Appeal No.1382 of 2016, Decided on 4.8.2016 in case titled ICICI Lombard General Insurance Company Limited & Other Vs. Dr.Kanwaljeet Deol and Other; (v) III (2018)CPJ 260 (NC) case titled Sr.Supdt. of Post Offices Vs. Sayyeda Madiha; (vi) IV (2007) CPJ 340 Punjab Metal Works (P) Ltd. Vs. Pareekh Marine Agencies Pvt. Ltd.; (vii) III (2007) CPJ 221 (NC) case titled Maharashtra Mathadi and Unprotected Labour Board Vs. Tata Iron & Steel Company; (viii) IV (2006) CPJ 144 (NC) case titled Container Corporation of India Ltd. Vs. U.K Paints Industries. We have given careful consideration to these rival submissions and gone through the case law cited by learned counsel for complainants. Since first objection of opposite party Nos.1 to 3 is that the complainants do not fall under definition of 'consumers' as provided under 'Act'. Therefore, before coming to the main controversy, it is to be examined that the complainants are covered under definition of 'consumers' or not. In case ICICI Lombard General Insurance Company Limited (Supra), Hon'ble State Commission examined this matter. Facts of the case were similar to the matter involved in this case and it was concluded that there is relationship of 'consumers' and 'service providers' between the complainants and opposite parties. Therefore, the contention of opposite party Nos.1 to 3 that the complainants do not fall under definition of 'consumers' is not acceptable. Now coming to the main controversy. The complainants have pleaded that under scheme launched by opposite parties, treatment was provided to the following patients:- i) Sukhram Singh ii) Surjeet Singh iii) Pritam Singh iv) Gurdial Kaur v) Sukhpal Kaur vi) Baldev Singh vii) Surjeet Singh viii) Jaspal Kaur ix) Kamlesh Bansal x) Balbir Singh xi) Harbans Kaur xii) Gurdeep Kaur xiii) Pargat Singh xiv) Satwant Kaur xv) Harbans Singh xvi) Harbans Singh xvii) Surjeet Kaur xviii) Gurmukh Singh xix) Neta Singh xx) Mahinder Kaur xxi) Baldev Kaur xxii) Joginder Singh xxiii) Angrej Kaur xxiv) Sukhdev Singh xxv) Gurtar Singh xxvi) Jagroop Singh xxvii) Jagroop Singh xxviii) Gurdeep Kaur xxix) Gurdeep Kaur xxx) Harjinder Kaur xxxi) Baldev Kaur xxxii) Baltej Singh
This fact is not disputed by opposite parties. Only controversy is regarding treatment charges. As per complainants, amounts mentioned in the complaint are still due, but version of opposite party Nos.1 to 3 is that authorized amount has already been paid to the complainants. It is also case of the complainants that authorization is sort of tentative decision. Thereafter the complainants were to submit the bills and opposite party Nos.1 to 3 were to honour the claim as per terms and conditions. Keeping in view the point involved in this case, the complaint is disposed of with the directions to opposite party Nos.1 to 3 to furnish detail of amounts paid to the complainants under different heads and if any, amount is payable as per terms and conditions, same be released to the complainants within 45 days from the receipt of copy of this order. 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 : 18-12-2019 (M.P.Singh Pahwa ) President (Manisha) Member
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