Complainant Baldev Krishan has filed the present complaint U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the opposite party to release the amount of Rs.1,30,875/- against medical bills alongwith interest @ 18% per annum from the date of due till its actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation on account of mental agony and harassment to him alongwith Rs.15,000/- as litigation expenses.
2. The case of the complainant in brief is that he retired as AFSO (Assistant Food Supply Officer) attaining the age of 58 years having PPO No.128130/Pb on 31.5.2000. His wife namely Smt.Chanchala Rani suffering from knee problem and due to that reason she was admitted at AIIMS, New Delhi and he got her treatment of left knee replacement from AIIMS, Near Delhi from 7.11.2016 to 5.12.2016 and a sum of Rs.1,30,875/- was spent on his wife’s treatment. Date of admission in the hospital was 7.11.2016 and date of discharge from hospital was 5.12.2016 and all the expenses afforded by him on her treatment. He after the treatment and discharging his wife approached to opposite party no.2 in the month of December 2016 but the opposite party no.2 delaying the matter pending with one pretext or other. On 16.1.2017, he approached to opposite partyno.2 for reimbursement of medical bills/claim but the dealing hand of opposite party no.2 told him to come after State Election. Again on 11.2.2017 he visited to the office of opposite party no.2 for reimbursement of medical bill but they advised him to submit all the medical bills alongwith all the required documents in the office of SDM, Gurdaspur but the dealing hand refused to accept the medical bills and told him that the cashless scheme/agreement has already been expired on 1.1.2017 and nobody come to the SDM, Gurdaspur from the office of opposite parties for collecting the files of reimbursement of bills. Thereafter, he being aggrieved called on helpline No.104 and dealing person of help line number advised him to submit the medical bills to the office of the opposite party no.1. Then he approached opposite party no.1, but they told him that cashless scheme was closed on 31.12.2016 and refused to receive the documents for settlement of the claim and advised him to submit all the original medical bills alongwith requisite documents in the office of the opposite party no.2. Accordingly, he sent a request letter alongwith original medical bills amounting to Rs.1,30,875/- and other requisite documents to opposite party no.2 for settlement of claim through registered post on 21.2.2017. After receiving his letter, opposite party no.2 sent all the original medical bills amounting to Rs.1,30,875/- alongwith all the required documents and verified by Dr.Vikrant Manhas, Asst. Professor Department of Orthopedics, AIIMS, New Delhi submitted to the opposite parties by him and also informed him vide letter no.2017/583 dated 23.02.2017 for the same. His ID Card No. is MD15-09815409473. Again on 14.3.2017, opposite party no.2 gave a reminder for the settlement of his claim to opposite party no.1 and information of the same had also given to him vide letterNo.2017/815 dated 14.3.2017 but till date opposite party no.1 has not settled his claim. He has made requests to the opposite parties to release the amount against the medical bills but all in vain. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.
3. Upon notice, the opposite party no.1 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable and the present complaint of the complainant is mis-joinder and non-joinder of the necessary parties. On merits, it was submitted that he has lodged his claim with the opposite party alongwith all the requisite documents and medical treatment record on 23.2.2017, while he had discharged from the hospital on 5.12.2016,which is the clear cut violation of the provisions of the Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEHIS). As the complainant has not submitted his claim for reimbursement alongwith the requisite documents to the India Max Pro Health Care Service TPA Pvt.Mohali within stipulated period 30 days from the date of discharge from the Hospital, which is the mandatory condition under the terms and conditions of the Punjab Govt. Employees and Pensioners Health Insurance (PGEHIS). Hence, the opposite party India Max Pro Health Care Service TPA Pvt. has rightly not entertained the claim under the terms and conditions of the PGEHIS. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
4. The opposite party no.2 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable; the complaint is bad for non serving of legal notice under section 80 of C.P.C.; the complainant has not approached the Forum with clean hands and has suppressed and concealed the material facts from the Hon’ble Forum. Therefore, the complaint is also liable to be dismissed on this ground only. On merits, it was submitted that complainant never approached the opposite party except the request letter alongwith medical bills sent by the complainant through speed post. The opposite party no.2, without any delay forwarded the request letter alongwith medical bills to the opposite party no.1 as party no.2 has nothing to do with the passing of the medical bill since party no.1 was the concerned party for passing medical bill, the same was forwarded to party no.1 by party no.2 and complainant was informed about it also. Opposite party further submitted that the Department of health and family welfare (Health Branch) Government of Punjab vide notification no.21/28/12-5hb5/262 DATED 20.10.2015 issued CASHLESS Health Insurance Scheme to cover indoor medical treatment expenses and said scheme was applicable to all the Government serving and pensioners on compulsory basis. Benefits of this scheme remained available to beneficiaries for one year i.e. 1.1.2016 to 31.12.2016. During the currency of this scheme treatment could be taken by enrolled beneficiaries from Government and empanelled hospitals. No reimbursement was available to employee/pensioner in Punjab, Chandigarh and Punchkula where cashless treatment was available and this cashless medical treatment is made available to employee/pensioner through insurance company. Due to this scheme employees/pensioners had to take their treatment from government or empanelled hospitals and medical expenses of hospital incurred on employees/pensioners were to be directly reimbursed by the opposite party. This policy of government is within knowledge of the complainant. The opposite party no.2 without any delay forwarded the request letter alongwith the medical bills to opposite party no.1 wherein it was also written to the opposite party no.1 to take any information direct from the complainant. The opposite partyno.2 is not responsible for making any reimbursement to the complainant. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.
5. Notice issued to the opposite party no.4 had not been received back. Case called several times, but none had come present on behalf of opposite party no.4, therefore, it was proceeded against exparte vide order dated 26.3.2018.
6. Complainant tendered into evidence his own affidavit Ex.C-I and of Jarnail Singh Ex.C-2 along with the other docum ents exhibited as Ex. C3 to Ex.C62 and closed the evidence.
7. On the other hand, counsel for the opposite party no.1 tendered into evidence affidavit of Karam Singh S.D.M. Oriental Insurance Company Ex.OP-1/1 alongwith other document Ex.OP1/2 and closed the evidence.
8. Sh.Vikramjit Singh Clerk of opposite party no.2 tendered into evidence affidavit of Munish Narula, Distt. Controller Ex.OP-W-2/A alongwith other documents Ex.OP-2/1 and Ex.OP-2/2 and closed the evidence.
9. Counsel for the opposite party no.3 tendered into evidence affidavit of Dr.Amandeep Singh Deputy Medical Commissioner, Punjab Health System Corpn. Ex.OP-3 alongwith copies of documents Ex.OP-3/1 to Ex.OP-3/3 and closed the evidence.
10. We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants along with the scope of adverse inference that may be discretionarily/ judicially drawn on account of the intentional non-participation/ ex-parte proceedings by one of the titled opposite parties despite the proven service of the summons; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants. We find that the complainant has enjoined the opposite parties 3 and 4 to his complaint at the instance of the opposite party 2 (State Govt. Civil Supplies Dept.) who vide its reply had stated that the State Govt. Health Dept (the OP3) had arranged cashless medical facility to its serving and retired employees in tie up with the OP4 insurers represented vide the OP1 TPA (Third Party Administrators).
11. We observe that the prime dispute (affidavit Ex.C1) prompting the herein deposed complaint pertained not only to alleged non-settlement of the complainant’s insurance claim but as to its very delivery for settlement at the right quarters for reimbursement of medical-expenses of Rs.1,30,875/- by the OP1&4 TPA Insurers allegedly on account of having not received the claim within the mandatory period of 30 days of discharge from the respective treating hospital. However, the OP TPA Insurers have advised vide written reply supported by accompanying affidavit that the impugned claim was not filed within the prescribed period of 30 days and as such the same cannot be entertained at this belated stage. So far so good, as it goes well with the settled statutory principles (vides judge-made law by virtue of superior court of-late verdicts) that the health insurers need to settle the medical treatment claims @ its settled rates with network hospitals to the claimants receiving treatment at non-network hospitals. Further, we find that the medical-treatment rates as settled with the health insurers by network hospitals are quite moderate (and low) measured against its treatment-rates as charged to other individual patients. And, it is for this very reason/logic that pre-sanction is anticipated by the network hospitals from the insurers so that they may claim reimbursement directly but @ network settled rates only. Also, the insured patients who prefer medical-treatment at the non-network hospitals are reimbursed @ network settled rates and the difference is borne by the insured patient.
12. Finally, we find here in the present case the complainant had not received the medical-treatment at the insurers’ network hospital thus he need not apply for pre-treatment sanction with the TPA Insurers. And, the treating hospital has thus charged Rs.1,30,875/- @ higher individual-patient rates whereas the insurers need to reimburse the complainant claim @ network hospital rates and presently difference, if any, had to be necessarily borne by complainant himself but for his delayed submission of the impugned insurance-claim. We find that the complainant had been trying to lodge his hospitalization claim but the same got delayed at the OP2 department on account of some unavoidable circumstances and that could have been rightfully ignored/overlooked while settling an otherwise a genuine claim.
13. We get firm support to the above proposition/ finding in the light of the judgment of the honorable State Consumer Commission, Punjab; in FA # 1100 of 2010 titled Fortis Hospital, Mohali vs. Medsave Healthcare (TPA) Ltd. & Ors; wherein, paragraph ‘22’ reads as: “After producing the ID Card, respondent no. 6 was to get cashless treatment but that was not provided for the reasons known to the appellant hospital or the insurance company (appellant in other appeal). The appellant Hospital has given the treatment and obtained the expenses for the treatment and the insurance company was liable to reimburse the same, but the District Forum held the appellant hospital liable to pay the expenses, compensation and costs jointly and severally and the said order is required to be modified”. However, in the light of the recent ruling by the honorable State Consumer Commission, Punjab in FA # 1105 of 2014 titled: Sukhdev Singh Nagpal vs. New Karian Pehalwal Co-op Ag Service Society & Ors., the insurers are liable to reimburse but only up to the standard-expenses fixed with the network hospitals for that particular medical treatment. The legal proposition has been made ample clear in its paragraph ‘21”.
14. Further, we find that the impugned insurance claim has been inordinately delayed by the OP TPA Insurers (competent authority) who have somehow refused to settle the same that otherwise they were liable to settle but at lower network hospital rates after having first had the expert opinion of the OP1 TPA (Third Party Administrator) but here the OP4 insurers have somehow stayed away from the complaint proceedings nor the impugned claim non-settlement has been supported by some other cogent evidence etc. We also find that the terms and conditions of the related policy are also not exhibited here and it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured complainant and in the absence of the same these cannot be enforced upon him at the stage of settlement of reimbursement of claim(s).
15. In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party (1 & 4) TPA Insurers to pay/refund the medical claim (expenses incurred) of Rs.1,30,875/- to the complainant besides to pay him a sum of Rs.5,000/- as cost and compensation (for having suffered undue harassment) within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment.
16. Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
July 06, 2018 Member.
*MK*
