DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No. 143 of 26.4.2017

                                      Decided on:                    16.4.2018

Vikram Singh aged about 39 years, son of Sh.Daler Singh, resident of House No.14-F, Tripuri Town, Patiala.

                                                                   …………...Complainant

                                      Versus

1.       Indian Health Care Services Pvt. Ltd. Max Pro Info Park, D-38, Ist Floor, Industrial Area, Phase-1, Mohali, through its Managing Director.

2.       The Oriental Insurance Co.Ltd. Divisional Office, Sai Market, Patiala through its Divisional Manager.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Smt. Neena Sandhu, President

                                      Smt. Neelam Gupta, Member                              

ARGUED BY:

                                       Sh.D.S.Behgal,Advocate,counsel for complainant.

                                       Opposite party No.1 ex-parte.

                                        Sh.Amit Gupta,Advocate, counsel for

                                           opposite party No.2                             

 ORDER

                                        SMT.NEENA SANDHU, PRESIDENT

Sh.Vikram Singh, complainant has filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.)                

2.       The brief facts of the complaint are that the Govt. of Punjab, Department of Health and Family Welfare (Health V-Branch) introduced a cashless health insurance scheme, under the name of Punjab Government Employees and Pensioners Health Insurance Scheme (PHEPHIs) vide notification No.21/28/12-5HB5/28 dated 20.10.2015, in which, it was mentioned that the scheme would be applicable to all the government serving employees. The premium of the said scheme was to be paid by the State Govt. and treatment could be taken by the enrolled beneficiaries upto the sum of Rs.3lac per family , per year on floater basis. For the said scheme , the State Govt. hired  the services of Oriental Insurance Co. i.e. OP no.2.The said scheme started on 1.1.2016 and was to be availed upto 31.12.2016. It is stated that the complainant being a govt. employee got issued a policy No.231102/48/2016/769, under his name being the main beneficiary. Wife of the complainant, son and mother were also covered under the said policy. Thereafter a card bearing No.MD15-09646900735 was issued by Op no.1 in the name of Op no.2. It is stated that approximately in the month of June, wife of the complainant namely Gurpreet Kaur, conceived. Her regular treatment was taken up. Unfortunately, in the last days of October,2016, medical complications arisen to the wife of the complainant, due to which she was taken to PGI for treatment , where after consulting doctor of Genetic Department, she was admitted vide admission No.2016075508 for giving blood sample for foetus.  Blood sample was taken and sent to Sandor Life Sciences Pvt. Ltd.,Hyderbad and test namely Micro Array & MCC was conducted there. Wife of the complainant was discharged on the next date i.e.3.11.2016. Thereafter report was received on 7.12.2016. It was said by the concerned doctor of Genetic Department , PGI, Chandigarh, that there was some deletion of cytoband in the fetus and the baby was required to be aborted. Finding no other alternative, on 10.12.2016, wife of the complainant was admitted in PGI, Chandigarh  and abortion was done under the provision of medical emergency on 12.12.2016. On the whole treatment of his wife, the complainant incurred an amount of Rs.38,937/-. He lodged the claim with Op no.1 vide letter dated 15.12.2016 alongwith claim form and original bills but the OP did not pay even a single penny. On enquiry from Op no.1, it was replied that no claim has been lodged with them. Then he enquired the matter from the Postal officer. As per the record of the postal office, letter dated 15.12.2016 was duly sent to Op no.1 which was duly received by it. Thereafter, the complainant personally visited the office of Op no.1 and requested to disburse the amount of the claim. The OP No.1 deposited some amount in the account of the complainant vide two different cheques No.4441U17083116065 dated 24.3.2017 amounting to Rs.11,741/- and cheque No. 4441U17083100696 dated 24.3.2017 amounting to Rs.3235/-. The complainant again enquired the matter as to why whole amount of claim had not been disbursed. The OP flatly refused to disburse the remaining amount of claim on the ground that the amount of Rs.11471/- in total had already been disbursed .Finding no alternative, the complainant got served a legal notice dated 5.4.2017, upon the OPs. The OPs did not respond the said legal notice. The OPs have thus not only indulged into mal-practice but also committed deficiency in rendering service, which caused mental agony and physical harassment to the complainant. Hence this complaint, with the prayer for giving direction to the OPs to disburse the balance amount of Rs.27196/- alongwith interest @ 9% per annum w.e.f.15.12.2016 ( date of lodging of claim) till actual realization; to pay Rs.50,000/-as compensation for causing mental agony and physical harassment and to pay Rs.5500/- as litigation expenses.Any other relief, which this Forum may deem fit may also be granted.

3.       On being put to notice OP no.2 appeared and filed written version, whereas OP no.1 despite service failed to come present and was accordingly proceeded against exparte vide order dated  16.6.2017.

                    In the written version, filed by Op no.2, it is admitted that complainant being Govt. employee was covered under the Punjab Govt. Employees & Pensioners Health Insurance Scheme for short PGPHIS and the insurance policy coverage was commenced from 1.1.2016 to 31.12.2016 . It is stated that the coverage is specifically provided under Clause 10 of PGEPHIS,wherein it was clarified that the rates applicable should be as per PGEPHIS schedule of rates and for the treatments  where no rates have been mentioned , the rates should be as per CGHS rates  or negotiated rates with the hospital, whichever would be less, which would be with regard to private hospital in Punjab, Chandigarh and Panchkula .For Govt. Hospitals in Punjab & Chandigarh, the rates applicable would be PGEPHIS schedule of rates fixed by the Nodal Department and for the treatments which have not been mentioned should be internal rates of the Govt. Hospitals. It was also clarified that for PGIMER, GMCH 32 and State Medical Colleges, internal rates of hospital should be applicable and likewise everything was specified within the Rules. It is stated that coverage of complainant and his family was as per the Scheme PGEPHIS, terms and conditions of the policy. On submissions of the bills/claim, the complete amount has been paid to the complainant as per the applicable terms and conditions of the policy and as per PGEPHIS. Thus the claim of the complainant for excess amount than the coverage applicable, is not maintainable. There was no deficiency of service in rendering service by the OP. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.

4.       On being called to do so, the ld.counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 toC45 and closed the evidence of the complainant.

          The ld. counsel for OP no.2 has tendered in evidence Ex.OPA, affidavit of Dr.Geeta Bhardwaj, Ex.OPB affidavit of Sh.Rajswant Rai, Sr.DM.Oriental Insurance Company Ltd. alongwith documents Exs.OP1 to OP2 and closed the evidence of OP no.2.

5.       We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.

6.       Admittedly, the complainant being the employee of the Pb.Govt. was duly covered alongwith his family,  under the Pb.Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS), and insured with the Oriental Insurance Company Ltd. for the period from 1.1.2016 to 31.12.2016, vide policy document, Ex.C4.The grievance of the complainant is that  he lodged the claim of Rs.38,937/- incurred on the treatment of his wife, but the OPs paid him only Rs.11,741/-  and still they are liable to pay Rs.27,196/- to him.

7.       It may be stated that the wife of the complainant was taking treatment from the PGI and doctor concerned  advised  her to get conducted the test of Micro array and MCC test.  From the copy of receipt  dated 2.11.2016, Ex.C14, it is evident that the complainant had incurred expenses of  Rs.28,000/- on the said test.                We have perused the  Salient Features of PGEPHI Scheme, Ex.OP1. In the column No.23 OPERATIONAL TERMS AND CONDITIONS APPLICABLE TO THE REIMBURSEMENT CLAIMS, it is stated that:

• ……………………………..
• The reimbursement to the beneficiary against the claim of the treatment availed in the private hospital located anywhere in India except Punjab, Chandigarh and NCR area ( Gurgaon,Noida and Delhi), shall be made in accordance with the PGEPHIS rates, irrespective of the actual expenditure incurred by the beneficiary, subject to the submission of claim within 30 days from the date of discharge from the hospital. For treatments that have not been mentioned in the PHEPHIS rate list, the reimbursement shall be made in accordance with the PGIMER Rates, Chandigarh.

       As per the OPs, the claim of the complainant was processed as per the terms and conditions of the policy under PGEPHIS and due amount of Rs.11741/-was already paid to the complainant.

8.    It may be stated here that there is no dispute with regard to the reimbursement of the amount incurred on medicines, consultation, hospital bill, USG, KFT, HBAIC & Glycosylated hemoglobin, Total Protein, ECG, FWB, Fetal Echo. However, the dispute is only with regard to the reimbursement of the amount incurred on Chromosomal Microarray Analysis  & Maternal Serum Screen Test. As per the OPs an amount of Rs.2700/- was  paid for Chromosomal Microarray Analysis  and Rs.900/- was paid for Maternal Serum Screen Test, as per the list of the hospital charges, issued by PGI. The same is annexed alongwith the letter dated 2.3.2016,Ex.OP2. We have perused the above said list. In the said list the total rate of Maternal Serum Screen Test as per code GN063, GN064 and GN065 has been mentioned as Rs.1050/-(Rs.300+Rs.300+Rs.450/-) and for Chromosomal Microarray Analysis Test as per  code PD059 and PD060, Rs.500/- and Rs.2000/- have been mentioned. No doubt the complainant had paid Rs.150/-less than the quoted charges for the  Maternal Serum Screen Test but at the same time this fact cannot be ignored that  the OPs had paid  Rs.200/- more for the Chromosomal Microarray Analysis Test than the quoted charges. Since the OPs had disbursed the amount to the complainant as per the rates recommended by the PGIMER, in accordance with PGEPHI Scheme, therefore,  the OPs cannot be said be deficient in providing services.

9.       In view of the aforesaid discussion, we do not find any merit in the complaint and the same is hereby dismissed without any order as to costs. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter file be indexed and consigned to the Record Room.

                                                                   NEENA SANDHU

                                                                       PRESIDENT

                                                                   NEELAM GUPTA

                                                                         MEMBER