DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA

C.C. No.127 of 05-02-2014

Decided on 24-07-2014

Dr.Rajesh Jindal Owner of Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda.

Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda, through its owner Dr. Rajesh Jindal.

........Complainants

Versus

ICICI General Insurance Company Limited, Sharma Complex, First Floor, Guru Kashi Marg Corner, Power House Road, Bathinda, through its Branch Manager.

ICICI General Insurance Company Limited, SCO 24-25, Sector 8C, Madhya Marg, Chandigarh, through its Manager/Regional Manager.

MD India Healthcare Services (TPA) Pvt. Ltd., Regional Office Maxpro Info Park, D-38, Industrial Area, Phase-I, Mohali 160055, through its Manager/Regional Incharge.

Bhai Ghanhya Sehat Sewa Scheme Trust (BGSSS), SCO No.16, Section 7C, Chandigarh, through its Chief Executive Officer.

Jaspal Kaur W/o Bakshish Singh R/o Village Killi Nihal Singh Walla.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt.Vikramjit Kaur Soni, President.

Smt.Sukhwinder Kaur, Member.

Sh.Jarnail Singh, Member.

For the Complainants: Sh.Naresh Garg, counsel for the complainants.

For Opposite parties: Sh.Vinod Garg, counsel for the opposite party Nos.1 to 3.

Sh.K.S Dabrikhana, counsel for the opposite party No.4.

Opposite party No.5 ex-parte.

O R D E R

VIKRAMJIT KAUR SONI, PRESIDENT

This complaint has been filed by the complainant under section 12 of the Consumer Protection Act, 1986 as amended upto date (here-in-after referred to as an 'Act'). Briefly stated the case of the complainant is that he i.e. Dr. Rajesh Jindal, is practising as D.M Cardiologist under the name and style of Jindal Heart Institution & Infertility Centre for his livelihood. The opposite party No.4 lodged a scheme in Punjab known as Bhai Ghanhya Sehat Sewa Scheme ( here-in-after referred to as 'BGSSS'), in which it provided the cashless insurance and treatment to the general public of the Punjab and for this scheme it has purchased the insurance from the opposite party Nos.1 and 2 and claims were settled by the opposite party No.3 as TPA. Under this scheme, the opposite party Nos.1 to 4 nominated and recognized the hospitals and doctors in Punjab from where the patient could take the treatment under the BGSSS Scheme and treatment payment was to be reimbursed to the hospitals/doctors directly. For this purpose the opposite party Nos.1 to 4 also used to take a fix amount from the hospitals/doctors annually. The opposite party Nos.1 to 4 duly authorized the complainant and took the amount of Rs.8000/- as annual fee vide demand draft No.657249 dated 10.12.2012 of OBC Bank, Bathinda. from him and recognized him under BGSSS Scheme The opposite party No.3 is a third party administrator (TPA) on behalf of the opposite party Nos.1, 2 and 4, they also gave the clearance to the complainant from time to time for the treatment of the admitted patients and after clearance the complainant treated the concerned patients and submitted the bills alongwith the claim forms and discharge report etc. to the opposite party No.3 for the reimbursement of the claim under the Cashless Hospitalization Scheme. Under this scheme the complainant treated Jaspal Kaur W/o Bakshish Singh admitted on 1.6.2013 and Cart was done on the same day and emergency PTCA stent to LCX done on 2.6.2013 and thereafter PTCA stent to LAD done on 10.6.2013 and finally she was discharged on 17.6.2013. The patient, Jaspal Kaur was duly insured under BGSSS Scheme vide Card No.MD15-BGSSS00168139-SP with the opposite party Nos.1 to 4. The complainant intimated the opposite party Nos.1 to 4 as per the rules of BGSSS Scheme and opposite party No.3 duly authorized him to give the treatment firstly of Rs.20,000/- and again of Rs.75,000/- i.e. total of Rs.95,000/- against the total expenses of Rs.3,26,700/-. The patient, Jaspal Kaur discharged on 17.6.2013 without taking the said payment as the above said amount of Rs.95,000/- was duly sanctioned by the opposite party Nos.1 to 4. The complainant firstly prepared the discharge summary on 15.6.2013, but she could not be discharged in the last hours due to medical complications, however the said discharge summary had been sent to the opposite party Nos.1 to 4. Thereafter the complainant duly informed the opposite party Nos.1 to 4 that the patient Jaspal Kaur was not discharged due to last minute medical complications. The official of the opposite party Nos.1 to 4 visited the hospital and checked the patient on 16.6.2013 and finally, the patient discharged on 17.6.2013 and all the original papers alongwith the original discharge summary were submitted by the complainant to the opposite party Nos.1 to 4 for the reimbursement of Rs.95,000/-. The complainant time and again approached the officials of the opposite party Nos.1 to 4 and wrote them reminder dated 8.10.2013 and finally, got issued a legal notice dated 10.12.2013, but they did not pay any heed to his requests. Hence the complainant has filed the present complaint to seek the directions of this Forum to the opposite parties to reimburse the insurance claim amount of Rs.95,000/- alongwith interest @ 18% per annum w.e.f. 1.6.2013 till the date of payment besides cost and compensation or to give him any other additional or alternative relief for which he may be found entitled to.

The opposite party Nos.1 to 3 filed their joint written statement and took legal objection that the complaint is not maintainable under the 'Act', as the complainant is not the consumer of the opposite party Nos.1 to 3, rather he himself is a service provider under the Scheme. It has been pleaded that Bhai Ghanhya Sehat Sewa Scheme, being run by the government of Punjab for the member of various eligible Rural Co-operative Societies of Punjab to provide the medical health insurance. Under this scheme the opposite party No.3 is the TPA (Third Party Administrator) for processing the claim. The opposite party Nos.1 and 2 issued the Group Health Insurance Policy (Floater) in the name of The Bhai Ghanya for the period from 20.11.2012 to 19.11.2013. As per scheme the registered member of the society who obtained the insurance policy and paid the requisite premium are entitled to get the benefit under the policy. The total insurance cover of the policy is Rs.1,50,000/- per family on floater basis. The guide book containing all the terms and conditions of the policy and details of network hospital alongwith health card were duly supplied to every insured member by the opposite party No.3. The persons who paid the premium are covered under the policy. The opposite party Nos. 1 to 3 have further pleaded that the complainant has concealed the fact that as per the terms and conditions of the policy and guide book, the provider hospital had to lodge the claim within 30 days from the date of discharge and not later than that in any case. The opposite party No. 5 discharged the patient on 15.6.2013, whereas the documents were submitted on 16.7.2013, but later on the complainant changed the date of discharge of the patient from 15.6.2013 to 17.6.2013 in order to get the claim one way or the other, in connivance with the opposite party No.5. The opposite party Nos.1 to 3 have admitted that the complainants are nominated as a hospital under the scheme but denied that they took the fix amount from the complainant. It has been pleaded that the alleged payment has been made to the opposite party No.4, who is a trust of various societies/beneficiaries under the scheme. Jaspal Kaur was not discharged on 17.6.2013, rather she was discharged on 15.6.2013, but later on the complainant has changed the date of discharge from 15.6.2013 to 17.6.2013 in connivance with the opposite party No.5 in order to bring the claim as lodged on the part of the complainant within 30 days from the date of discharge as per the terms and conditions of the policy and guidebook.

The opposite party No. 4 filed its separate written statement and took preliminary objection that this complaint is not maintainable against the opposite party No. 4 as neither the complainant is consumer of opposite party No. 4 nor there is any deficiency in service on its part. The members/beneficiaries have been clearly informed that 'the complete financial and legal liabilities, if any, arising consequent to the operationalization of the Scheme or the policy shall rest exclusively and unconditionally with MD India Health Care Services (TPA) Ltd., the opposite party No.3 & ICICI Lombard GIC Pvt. Ltd., the opposite party Nos.1 and 2. The opposite party Nos.1 and 2 were insurer during the period from 20.11.2012 to 19.11.2013. Every member enrolled under the Scheme has given undertaking on the enrollment form that has been supplied to him/her that 'he had read and understood all the terms and conditions of the Scheme'. He undertook to abide by and adhere to all such terms and conditions which were contained in the service level agreement executed between Trust and the Insurer on behalf of the beneficiaries. Further, he unconditionally agreed that only the courts of Chandigarh alone shall have the exclusive jurisdiction to entertain any petition or claim by any beneficiary under this Scheme and Trust shall not be legally and financially liable towards the beneficiary. The opposite party Nos.1 and 2 were appointed as insurer by the Trust during the period 20.11.2012 to 19.11.2013 which had appointed opposite party No.3 as TPA (Third Party Administrator) to implement the Scheme. Third Party Administrator was to issue the identity cards, to inspect the hospitals and recommend to the Trust for their empanelment, to grant authorization, to settle the claims, to make the payment to the empanelled hospitals for providing the cashless services to the beneficiaries of the Scheme. The opposite party No.4 is neither the service provider nor the complainant is its consumer. It is the insurer and TPA who were the service providers and claim settling authorities under the scheme, as such the present complaint is not maintainable against the opposite party No.4 and it cannot be held liable for any payment to the complainant. The network hospitals under the scheme have been approved on the recommendations of the opposite party No.3, which was the service provider under the scheme appointed by the opposite party Nos.1 and 2. ID cards have been issued by the opposite party No.3 and not by the opposite party No.4. The opposite party No. 4 has admitted that Jindal Heart Institute & Infertility Centre was an approved hospital under BGSSS during the policy plan period from 20-11.2012 to 19.11.2013.

Registered A.D. notice of this compliant was sent to opposite party No.5, but despite service of notice, none appeared on its behalf, as such exparte proceedings were taken against it.

The parties have led their evidence in support of their respective pleadings.

Arguments heard. The record alongwith written submissions submitted by the parties perused.

These are undisputed facts of the parties that the opposite party No.4 lodged a scheme in Punjab known as Bhai Ghanhya Sehat Sewa Scheme, in which it provided the cashless insurance and treatment to the general public of the Punjab and for this scheme it has purchased the insurance from the opposite party Nos.1 and 2 and claims were settled by the opposite party No.3 as TPA. Under this scheme, the opposite party Nos.1 to 4 nominated and recognized the hospitals and doctors in Punjab from where the patient could take the treatment under the BGSSS Scheme and treatment payment was to be reimbursed to the hospitals/doctors directly. The opposite party Nos.1 to 4 duly authorized the complainant and took the amount of Rs.8000/- vide demand draft No.657249 dated 10.12.2012 of OBC Bank, Bathinda. from him and recognized him under BGSSS Scheme Under this scheme the complainant treated Jaspal Kaur W/o Bakshish Singh, but the claim filed by the complainant for medical expenses reimbursement was rejected by the opposite parties on the ground that as per terms and conditions of the policy and guide book, the provider hospital had to lodge claim within 30 days from the date of discharge and not later than that in any case. The treatment of Jaspal Kaur is not in dispute.

The submission of the learned counsel for the complainant is that Jaspal Kaur is duly insured under BGSSS scheme vide Card No. MD15-BGSSS00168139-SP with opposite parties and she was admitted with complainant on 1.6.2013. The complainant immediately intimated to the opposite parties as per rules of BGSSS scheme and the opposite party No. 3 duly authorized the complainant to give treatment upto total Rs. 90,000/- against the total expenses of Rs. 3,26,700/-. The complainant treated Jaspal Kaur and finally discharged her on 17-6-2013 without taking the payment of Rs. 90,000/- as the same was duly sanctioned by the opposite parties. The complainant firstly prepared the discharge summary on 15-6-2013 but she could not be discharge on the same day due to medical complication in the last hours. The complainant duly informed the opposite parties that the patient Jaspal Kaur was not discharged due to last minute medical complication and the official of the opposite parties visited the hospital and checked the patient on 16-6-2013 and finally the patient was discharged on 17-6-2013. All the original papers alongwith the original discharge summary were submitted by the complainant to the opposite party Nos.1 to 4 for the reimbursement of Rs.95,000/-, but till date the opposite parties neither replied nor paid any single penny to the complainant.

The learned counsel for opposite party Nos. 1 to 3 submitted that complainant is neither a consumer nor the complainant may allege availing of any services at all. No consideration has been paid or alleged. The complainant is claiming amount of medical treatment i.e. price of services provided by him. The submission of the learned counsel for the opposite parties is that as per terms and conditions of the policy and guide book, the provider hospital had to lodge claim within 30 days from the date of discharge and not later than that in any case. The patient i.e. opposite party No. 5 was discharged on 15-6-2013 whereas documents were submitted on 16-7-2013 but later on the complainant changed the date of discharge of patient from 15-6-2013 to 17-6-2013 in order to get the claim one way or the other in connivance with opposite party No. 5. The submission of the learned counsel for the opposite parties is that the insurance is a contract between the parties and both the parties are bound by the terms and conditions of the same.

Section 2 (1)(d)(ii) of the 'Act' is reproduced as under :-

2 (1)(d)(ii) 'Consumer' means any person who - hires or avails of any services for a consideration which has been paid or promised or partly paid and partly promised or under any system of deferred payment and includes any beneficiary of such services other than the person who hires or avails of the services for consideration paid or promised, or partly paid and partly promised, or under any system of deferred payment, when such services are availed of with the approval of the first mentioned person but does not include a person who avails of such services for any commercial purpose.

Explanation – For the purpose of this clause, “Commercial purpose” does not include use by a person of goods bought and used by him and services availed by him exclusively for the purpose of earning his livelihood by means of self-employment.”

The aforesaid Section of the 'Act' makes the position crystal clear that the complainant is the consumer being beneficiary. Thus, the objection taken by the opposite parties in this regard is not tenable.

The plea of the opposite party Nos. 1 to 4 in not paying the medical expenses of Jaspal Kaur i.e. opposite party No. 5 to the complainant is that as per terms and conditions of the policy and guide book the provider hospital had to lodge claim within 30 days from the date of discharge and not later than that in any case. In the Discharge Summary Ex. C-3 it has been mentioned :-

“History : 54 Yr old female patient with history of HTN/NIDDM hospitalized with chief complaints of recurrent episode of chest pain since 15-20 days. Associated with ECG (+ST-T changes). Patient bought to our hospital for further management.

Course in the Hospital : CART done on 1-6-2013 which revealed (TVD) and advised multi vessel PCI. Patient had severe chest pain on date 2-6-2013 morning. Patient shifted to cath lab for Emergency PCI. Emergency PTCA Stent to LCX done on date 2-6-2013. PTCA Stent to LAD done on date 10-6-2013. Procedure was well tolerated and her rest of the hospital stay was uneventful and she is being discharged in a stable condition.”

A perusal of medical record placed on file by the complainant reveals that Jaspal Kaur, patient was discharged from the hospital on 17-6-2013 whereas the opposite parties have not placed any evidence on file to prove their version that the patient Jaspal Kaur was discharged from the hospital on 15-6-2013 and the complainant changed the date of discharge of patient from 15-6-2013 to 17-6-2013. In the case in hand, the onus heavily lies upon the opposite parties to prove their version, which they utterly failed to prove by leading cogent and convincing evidence. Moreover, the patient Jaspal Kaur was admitted due to “HTN, CAD/unstable angina, TVD and CART done on 1-6-2013, Emergency PTCA Stent to LCX done on 2-6-2013 and PTCA Stent to LAD done on 10-6-2013. On 15-6-2013, the documents to discharge the patient were prepared and forwarded to the opposite party Nos. 1 to 4, but thereafter the patient could not be discharged on the same day due to some medical complication and discharge on 17-7-2013. Due to the reason that on 15-6 2013, the documents to discharge the patient Jaspal Kaur, were already prepared and mailed/faxed to opposite party Nos. 1 to 4, the doctor cannot avoid the treatment and discharge the patient when she was suffering from some medical complication and was required to be kept under observation. The doctor concerned i.e. complainant did his duty and discharged the patient when she was in stable condition. The Hon'ble Punjab and Haryana High Court in the case Shakuntla vs. State of Haryana 2004(1) Labour & Services Judicial Reports page 327 has held that :

“Treatment taken in emergency – Though, in normal circumstances the procedure prescribed should be followed but the procedure should not be made so cumbersome that one may get frustrated in adhering to it – Emergency knows no law and nor procedures – Emergency act when required to be committed should not be weighed in terms of money especially when human life is at stake.”

Thus, keeping in view the facts, circumstances and the evidence placed on file, this Forum is of the considered opinion that there is deficiency in service on the part of the opposite party Nos. 1 to 4 in not paying the medical expenses of Jaspal Kaur, opposite party No. 5 to the complainant, without any valid reason. Hence, this complaint is accepted with Rs.10,000/- as compensation and cost against the opposite party Nos. 1 to 3 and dismissed qua opposite party No. 4. The opposite party Nos. 1 to 3 are directed to pay Rs. 95,000/- as per authorization Ex. C-3 & Ex. C-4 to the complainant.

The compliance of this order be made within 45 days from the date of receipt of copy of this order failing which an amount of Rs. 95,000/- will carry interest @ 9% p.a. till realization.

A copy of this order be sent to the parties concerned, free of costs and the file be consigned to the record.

Pronounced in open Forum

24-07-2014

(Vikramjit Kaur Soni)

President

(Sukhwinder Kaur)

Member

(Jarnail Singh )

Member