Order dictated by:

Ms.Rachna Arora, Presiding Member

1.       Gurinder Singh, complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, on the allegations that the complainant is an employee in Health department under the Punjab Government, as such he has got cashless facility under Punjab Government Employee and Pensioners Health Insurance Scheme vide ID card No. MD15-09915444426, GPF/PPO No. 15321. Son of the complainant namely Karanbir Singh fell ill and admitted in Fortis Escort Hospital on 14.9.2016 and was discharged on 27.9.2016. During the said term while he remained admitted in the hospital, complainant had to spent Rs. 2,06,250/- towards treatment/hospitalization/ medical expenses/various tests etc. At the time of hospitalization the complainant could not avail the cashless facility under the scheme at the Fortis Escorts Hospital , as such the complainant was required to pay cash for all their treatment of his child from his own pocket. After discharge from the hospital, complainant approached the opposite parties to refund the amount that was spent by the complainant during hospitalization of his child, but the opposite parties did not pay any heed to the genuine request of the complainant . The complainant also written various letters to the opposite parties to pay the amount spent by the complainant under this scheme but all in vain.  After being harassed by the opposite parties, the complainant filed a complaint before this Forum on 3.1.2017 and in that complaint, counsel for opposite party No.2 appeared and suffered a statement that claim in question has not been decided yet by the opposite party and the present complaint is pre matured . However, the opposite party be given time of 45 days to decide the claim case of the complainant , as such on the basis of the statement suffered by the counsel for the opposite party the complaint of the complainant stand disposed off with the direction to the opposite party No.2 to decide the claim of the complainant within one month from the receipt of required documents from the complainant. It is worth while to mention here that during the earlier complaint, the complainant received Rs. 1,00,500/- through NEFT but the remaining amount was being withheld by the opposite parties which is illegal and against the principles of natural justice.  As per direction of this Forum in the earlier complaint, complainant submitted all the required documents  before the opposite parties on 5.4.2017 but inspite of that  the complainant has not received the remaining amount . The abovesaid act of the opposite parties clearly amounts to deficiency in service which results in mentally and physically harassment to the complainant . Vide instant complaint, complainant has sought for the following reliefs :-

(a)     Opposite party be directed to pay Rs. 1,05,750/-  which the complainant incurred on the treatment of his son/person insured ;

(b)     Compensation to the tune of Rs. 50000/- alongwith litigation expenses to the tune of Rs. 25000/- may also be awarded to the complainant.

Hence, this complaint.

2.       Upon notice, opposite party No.2 appeared and filed written version taking certain preliminary objections therein inter alia that complainant is stopped from his own act and conduct to file the present complaint and the present complaint is not maintainable under law and hence liable to be dismissed ; that complainant does not fall within the ambit of consumer under section 2 of the CP Act as contract of insurance pertaining to policy in question was executed between the Punjab Government and the replying insurance company and no premium has been paid or received from the complainant by the replying opposite party and if any dispute has been arisen qua the complainant  being beneficiary then as per clauses of the Insurance policy district level and State lever grievance cell have been formed and the complainant has to approach those grievance cells. However, the present complainant has no right to file complaint against insurance company directly in his personal capacity as there is no contract of insurance between the insurance company and the present complainant  ; that since the complainant has not produced complete record with the complaint, opposite party reserves the right to rebut the allegations or document, if any, produce in subsequent period ; that the present complaint is bad for non joinder for necessary parties. The complaint contains the averment  with regard to treatment taken from the Fortis Hospital, Amritsar by the complainant. However the said hospital has not been impleaded as party in the present complaint and further the Punjab Government who is one of the party of the contract of insurance in question has also not been impleaded as party in the present complaint. On merits, it was submitted that complainant has submitted all the relevant medical record alongwith medical bills of expenses vide Claim No. CCNMD10095819 for an amount of Rs. 1,60,213/- out of which Rs. 1,00,566/- has been paid to the complainant as per PGEPHIS Rates which are applicable as per the terms and conditions of the present policy. Even the medical bills received alongwith copy of present complaint shows the same amount of Rs. 1,60,213/- as amount of medical bills instead of claiming  Rs. 2,06,250/-. In the present case, the claim of the complainant has been scrutinized processed and decided as per terms and conditions of the policy and a payment of Rs. 1,00,566/- as per PGEPHIS Rates has already been credited to the account of the complainant . So , any amount which has been charged by the network hospital from the said rates, the said hospital is solely responsible for that and the replying opposite parties have nothing to do  with this . While submitting that there is no deficiency in service and while denying and controverting other allegations, dismissal of complaint was prayed.

3.       On the other hand when the opposite party No.1 has not filed written version , the right of the opposite party No.1 to file written version stand forfeited vide order of this Forum on 1.8.2017.

4.       In his bid to prove the case Sh. Anil Bhatia,Adv.counsel for the complainant tendered into evidence affidavit of the complainant Ex.CW2/A, copy of health Insurance card Ex.CW2/1, copy of payment receipt Ex.CW2/2, copy of main bill Ex.CW2/3, original postal receipt Ex.CW2/4, original OPD bills Ex.CW2/5  to Ex.CW2/11 and closed the evidence on behalf of the complainant.

5.       To rebut the aforesaid evidence Sh. Subodh Salwan,Adv.counsel for opposite parties No.1 & 2 tendered into evidence affidavit of Sh.R.K.Sharma, Divisional Manager Ex.OP1,2/1, copy of calculation sheet Ex.OP1,2/2, copy of detail of package rate part of PGEPHIS rates Ex.OP1,2/3, copy of  PGEPHIS rates Ex.OP1,2/4, copy of investigation rate as per PGEPHIS Ex.OP1,2/5, copy of Pb.Govt. notification Ex.OP1,2/6, copy of Insurance policy Ex.OP1,2/7 and closed the evidence on behalf of opposite parties No.1 & 2.

6.       We have heard the Ld.counsel for the parties and have carefully gone through the record on the file.

7.       From the appreciation of the facts and circumstances of the case, it becomes evident that complainant being employee in Health Department  under the Punjab Govt.  is covered under the policy issued by Govt.of Punjab. It was not denial the fact that complainant was issued ID card No. MD15-09915444426 in which son of the complainant was also insured. It was also not denial the fact that son of the complainant remained admitted in Fortis Escort Hospital for the period from 14.9.2016 to 27.9.2016 . The case of the complainant is that he incurred an expenditure of Rs. 2,06,250/- on the treatment of his son. In this regard complainant earlier filed a complaint before this Forum on 3.1.2017 which was disposed of with the direction to the  opposite parties to decide the claim within 45 days . However, opposite party settled the claim to the tune of Rs. 1,00,500/- and with-held the remaining amount of Rs. 1,05,750/-. In this regard the only plea of the opposite party is that bill is to the tune of Rs. 1,60,214/- and to prove this fact opposite party summoned clerk from the Accounts department of Fortis Escort Hospital namely Kulwinder Singh, who after appearing in this Forum has duly deposed that an amount of Rs. 1,60,214/- was paid by the patient during hospitalization and this amount includes only indoor expenses  and expenses of OPD etc. are not included in the present bill. Moreover, he brought the certified copies of main bill and payment receipts which are  Ex.C-2 to Ex.C-13. So from the abovesaid statement, it is clear that the medical bill was to the tune of Rs. 1,60,214/- and not Rs. 2,06,250/- out of which Rs. 1,00,500/- was paid by the opposite party as per PGEPHIS rates and nothing remains due  and no illegality has been done by the opposite party. In this regard Ld. Counsel for the complainant has placed reliance upon  MD India Vs. Sushil Dhawan in First Appeal No. 870 of 2017 of the Hon’ble State Commission, Punjab Chandigarh wherein it has been held that the opposite parties have already paid the amount of Rs. 61,137/- according to PGEPHIS rate, therefore, in case the complainant has spent more amount than the admissible rates then he is required to pay from his own pocket because the Government cannot pay more than the rates fixed under PGEPHIS rates.

8.       But, however, when we go through the  list of PGEPHIS rates, copy of which is  Ex.OP1/3, we have notice that  the Doctors indoor consultation fee is Rs. 300/- per visit, but as per calculation sheet  Ex.OP1,2/2 of the opposite parties, the doctor fee was approved by TPA @ Rs. 200/- and the same was multiplied with 16 visits of doctor , so the TPA has calculated the amount as per Dr fee @ Rs.200X16=3200, whereas as per PGEPHIS rates complainant is entitled to doctor fee of Rs. 300/- and when we multiplied the same by 16 visits the same comes to Rs. 4800/- and as such the complainant is entitled to difference of Rs. 1600/- (Rs. 4800/- minus Rs. 3200/-) .  Not only this regarding lab charges the hospital bill was to the tune of Rs. 36870/-, whereas the TPA has approved the same to the tune of Rs. 26101/-, so there is a difference of Rs. 10769/- in lab charges. So are per PGEPHIS rates the complainant is entitled to Rs. 12369/- more i.e. (Rs. 10769/- + Rs. 1600/-).

9.       However, the complainant claimed Rs. 5200/- per day  for room rent  but the TPA has approved  the room rent @ Rs. 750/-  and multiplied the same with 13 days i.e. to the tune of Rs. 9750/- which is as per PGEPHIS rates because the complainant is entitled to Twin Sharing room and the charges for Twin sharing room per day is Rs. 750/-. So when the room rent @ Rs. 750/- multiplied with 13 days the same comes to Rs. 9750/-  which the complainant is entitled to and not for Rs. 52000/-.

10.     In view of the above discussion, the complaint is disposed of with the direction to the opposite parties to pay Rs. 12369/- as difference of doctor fee as well as lab charges . There is no order as to costs. Compliance of the order be made within 30 days from the date of receipt of copy of this order ; failing which complainant shall be entitled to get the order executed through the indulgence of this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum