DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR

Complaint No.314 of 2017 Date of Instt. 29.08.2017 Date of Decision: 27.04.2021

Santokh Singh, aged 80 years son of S. Gangu, resident of B-IX-49/63, New Hardyal Nagar, P.O. Shekhey Pind, Hoshiarpur (Jandu Singha) Road, Jalandhar.

….. Complainant

Versus

1. M.D India Healthcare Services (TPA) Pvt. Ltd., (Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), MD India Health Insurance TPA Private Limited, Maxpro Info Park, D-38, Industrial Area, Phase 1, Mohali, Punjab-160056, through its authorized representative.

2. The Oriental Insurance Company Ltd., Regional Office, SCO No. 109, 110, 111, Surindera Building, Sector 17-D, Chandigarh through its Regional Manager.

3. SGL Superspeciality Charitable Hospital, Garha Road, Jalandhar. (Punjab)

..…Opposite Parties

Complaint under the Provisions of Consumer Protection Act.

QUORUM:

SH.KULJIT SINGH, PRESIDENT

MRS.JYOTSNA, MEMBER

ARGUED BY :

For Complainant : Sh.Vivek Jain, Advocate

For OPs No.1 to 2 : Sh. Brijesh Bakshi, Advocate

For OP No.3 : Ex-parte.

ORDER:-

KULJIT SINGH, PRESIDENT

1. The present complaint has been filed by complainant against the OPs on the averments that the complainant was employed in Punjab State Government retired from Irrigation Department, Shahpur Kandi was insured along with his wife Chanan Kaur and grandson, Sher Singh in a cashless Health Insurance Scheme introduced by Government of Punjab to cover indoor medical treatment expenses, specified daycare procedure and treatment of chronic diseases as specified or to be specified by Punjab State Government. This beneficial health insurance scheme called PGEPHIS Scheme floated by State Government. OP No.2 issued policy to State Government Punjab and premium as consideration was paid by State Government to cover risk under PGEPHIS. Policy bearing no.231102/48/2016/769. The wife of the complainant is also covered in PGEPHIS and ID Card Number MD 150987255998 issued by OP No.1. The OP No.2 is insurer and OP No.1 third party Administrator as per tie-up arrangement between OPs and State Government Punjab. The complainant has become entitled to the reimbursement of expenses incurred subject to peril covered under PGEPHIS for medical expenses illness/and surgical operation to the extent of sum insured on the happening of contingency incorporated PGEPHIS Group Medical Insurance Policy issued by OP no.2. The wife of the complainant admitted on 23.06.2016 in Dermatology Department under Admn no. 132737/118845 for treatment as indoor patient and discharged on 23.06.2016 by OP no.3, which is empanelled for treatment under this scheme and referred to higher centre/CMC Ludhiana. Thereafter, his wife was admitted in DMC Ludhiana w.e.f. 23.06.2016 to 09.07.2016 in Vendata Hospital Jalandhar from 09.07.2016 to 14.07.2016 and 02.08.2016 and 08.08.2016 and then admitted to Patel Hospital Jalandhar w.e.f. 08.08.2016 to 13.08.2016. Thereafter, discharge from OP no.3, she remained admitted in DMC Ludhiana, Vedanta Hospital Jalandhar and then in Patel Hospital, Jalandhar. The complainant has incurred expenses for medical treatment of his wife in sum of Rs.7,394/- in OP No.3 and sum of Rs.2,31,678/- in DMC Hospital Ludhiana for the reimbursement of expenses incurred and paid to above said hospital for an total amount of entire medical treatment expenses incurred and paid to these hospitals was Rs.6,38,476/-. The complainant submitted original bills, receipts of payment, original reports and original discharge summary along with claim for duly signed and also completed and complied with all the formalities and requirements. Due to act and conduct of OPs, the complainant has filed the present complaint and prayed that the OPs be directed to pay Rs.6,38,476/- along with interest @ 12% per annum from the date of payment to the hospital under reference as mentioned in letter dated 04.01.2017 of complainant sent to OP No.3 which was duly acknowledged, besides Rs.20,000/- as compensation for mental harassment and Rs.5500/- as costs of litigation.

2. Upon notice, OPs No.1 & 2 appeared and filed joint written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. The complicated questions of law and facts are involved in the matter which cannot be adjudicated in summary proceedings. On merits, it was averred that As per terms and conditions framed and implemented by Punjab State Government the sum insured was Rs.3,00,000/- for family on floater basis. OP no.1 has not received any other claim from subjected beneficiary within 30 days from the date of discharge. The liability of the company was to pay compensation as per PGEPHIS Schedule of rates settled by the insured and that too subject to admissibility thereof vis avis the terms and conditions of the RFQ/RFP/Scheme. Treatment at DMC Hospital for the period 23.06.2016 to 08.07.2016 and reimbursement claim raised for Rs.150719/-. As per terms and conditions the treatment availed by the beneficiary shall be on reimbursement basis, subject to submission of claim of TPA within 30 days from the date of discharge from the hospital. Whereas for the first time the claim was raised vide file receipt dated 06.01.2017. In the same way, the second claim raised by the complainant for Chanan Kaur was CCN No. MD10099484. Non cashless with diagnosis of psoriasis, sepsis, bronchial asthma. Treatment at Vedanta Hospital for the period 09.07.2016 to 14.07.2016 and reimbursement claim raised for Rs.148383/-. But as per conditions the treatment availed by the beneficiary shall be on reimbursement basis, subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital. The insurance company rejected the both claims of the complainant as complainant submitted the claim file after 30 days of discharge. Rest of the averments of the complainant were denied by OP nos.1 and 2 and they prayed for dismissal of the complaint.

3. OP No.3 appeared and filed separate written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. The complaint is ex facie misconceived. On merits, it was averred that wife of the complainant was diagnosed with disease Methotrexate, toxicity and was admitted on 23.06.2016. The wife of the complainant discharged from OP no.3 hospital. Rest of the averments of complainant were denied by OP no.3 and it prayed for dismissal of the complaint.

4. The complainant has tendered in evidence his affidavit Ex.C-A along with copies of the documents Ex.C-1 to Ex.C-27 and closed the evidence. On the other hand, OPs no.1 and 2 tendered in evidence affidavit of Sandeep Thapa as Senior Divisional Manager of OIC as Ex.O-A along with copies of the documents Ex.O-9 and closed the evidence.

5. We have perused the written arguments filed by both the parties and have gone through the record very carefully.

6. The complainant has tendered in evidence his affidavit Ex.CA in support of his case. He alleged deficiency in service and unfair trade practice on the part of the OPs. Ex.C-2 is acknowledgement receipt of Govt. Employees and Pensioners Health Insurance Scheme. Ex.C-3 is letter written to Managing Director OIC regarding medical reimbursement claim. Ex.C-4 is copy of medical reimbursement certificate. Ex.C-6 is discharge card of the patient Chanan Kaur wife of the complainant. Ex.C-9 is copy of discharge summary of the patient. In this document, the date of admission is mentioned as 23.06.2016 and date of discharge mentioned as 09.07.2016 and diagnosis mentioned as Psriasis c Methobexate Induced Pancytspenic (Recovered). ILD c Speradded infection INVASIVE ASPCEGILLOSIS. Ex.C-13 to Ex.C-14 are copies of retail invoice cum receipts. Ex.C-15 is discharge summary issued from Patel Hospital Jalandhar, in this document the date of admission is mentioned as 08.08.2016 and date of discharge mentioned as 13.08.2016. Ex.C-17 is copy of letter dated 06.01.2017 addressed to Managing Director OIC regarding medical reimbursement. Ex.C-20 is copy of discharge summary, in which date of admission is mentioned as 09.07.2016 and discharged on 14.07.2016. Ex.C-21 is copy of invoice. Ex.C-22 is copy of medical reimbursement certificate. Ex.C-24 is copy of discharge summary prepared by Vedanta Multispeciality Hospital. In this document, the date of admission is mentioned as 02.08.2016 and discharged on 08.08.2016.

7. To counter this evidence of the complainant, the OPs no.1 and 2 relied upon affidavit of Sandeep Thapa Senior Divisional Manager of OIC as Ex.O-A on the record. This witness denied any deficiency in service or unfair trade practice on the part of OPs. Ex.O-1 is copy of tender notice. Ex.O-2 is copy of request for proposal RFP Ex.O-3 is copy of features of Punjab Government Employees and Pensioners Health Insurance Scheme. Similarly, we have also examined other documents Ex.O-4 to Ex.O-9 placed on the record.

8. OP no.3 filed its separate written reply but due to non presence on the date and neither deposited the cost and nor tender any evidence in support of their case, OP no.3 is proceeded against exparte, vide order dated 21.11.2018 passed by this Commission.

9. In document Ex.O-3, it is clearly mentioned that PGEPHIS shall be compulsory to all Punjab Government Employees who would be joining service after date of notification of the scheme by the State Government. PGEPHIS shall be compulsory to new Punjab Government Pensioners who would be retiring from the service after the introduction of the Health Insurance Scheme i.e. after the date of notification of the scheme by the State Government. In column no.23 OPERATIONAL TERMS AND CONDITIONS APPLICABLE TO THE REIMBURSMENT CLAIMS the hospitals failed to provide cashless treatment, beneficiary shall be entitled to avail reimbursement of his/her claim, subject to the submission of the claim within 30 days from the date of discharge from the hospital. Firstly, the wife of the complainant admitted in the hospital on 23.06.2016 and discharged on 23.06.2016 by OP no.3 and further she was admitted in DMC Ludhiana on 23.06.2016 to 09.07.2016. In Vedanta Hospital Jalandhar from 09.07.2016 to 14.07.2016 and then admitted in Patel Hospital Jalandhar on 08.08.2016 to 13.08.2016. From perusal of letter Ex.C-3 dated 04.01.2017 it is clear that the complainant submitted his claim to Managing Director OIC on 4.01.2017 but wife of the complainant firstly admitted in the hospital on 23.06.2016 and lastly she discharged from the Patel Hospital on 13.08.2016 but complainant submitted his claim on 04.01.2017. The OPs pleaded that as per column no.23 OPERATIONAL TERMS AND CONDITIONS APPLICABLE TO THE REIMBURSMENT CLAIMS, it is mandatory his/her submitted claim within 30 days from the date of discharge from the hospital but complainant has failed to adopt this opportunity. As per 10.2 of PGEPHIS Modus Operandi to be followed for treatment at various Network Hospitals for all types of treatment shall be as under

ii) For Govt. Hospitals in Punjab & Chandigarh: Rates shall be determined in accordance with PGEPLHIS Schedule of Rates, fixed by Nodal Department/State Government. For treatments that have not been mentioned in the PGEPHIS rates, the rates shall be internal rates of the respective Govt. Hospital. The treatment provided shall be essentially on cashless basis. The beneficiary shall be eligible for reimbursement, subject to submission of the claim to the TPA within 30 days from the date of discharge from the hospital. The reimbursement shall be made at Govt. Hospital rates or PGEPHIS Rates, whichever is less.

Precisely, the case set up by the complainant is that complainant has become entitled to reimbursement of expenses incurred subject to peril covered under PGEPHIS for medical expenses illness/and surgical operation to the extent of sum insured on the happening of contingency incorporated PGEPHIS Group Medical Insurance policy. His wife diagnosed with disease of Methotrexate, toxicity admitted on 23.06.2016. But his case was not entertained by OPs on the simple ground that as per terms and conditions , medical insurance claim shall be submitted within 30 days from the date of discharge, regarding that the terms and conditions. From perusal of Government order No.S.14025/19/2015-MS, Office Memorandum dated 27 May 2015 issued by Government of India Ministry of Health and Family Welfare Department of Health and Family Welfare, in this document it has specifically mentioned that the submission of such medical bills from 3 months to 6 months . The matter was examined in the Ministry and it has been decided that the period of 3 months for submission of medical claims be revised to 6 months. Henceforth, only the cases in which the bills are submitted after 6 months from the date of completion of medical treatment/discharge of the patient from the hospital are required to be taken up for condonation.

This office order not exhibited but placed on record, this is vital document on the record and we do not discard the same. In this document, it has been specifically the date of submission of claim extended to 6 months instead of 3 months. The ground of rejection of the medical claim of the complainant adopted by OPs is not valid and untenable. As per record, it is clear that the wife of the complainant admitted in various hospitals for further treatment. The complainant submitted all discharge summary of each hospital along with medical claim bills to OPs from time to time. Lastly the wife of the complainant admitted in Patel Hospital on 08.08.2016 and discharged on 13.08.2016 and as per para no.2 of the written submission of OPs the complainant submitted his claim on 06.01.2017. OPs pleaded i.e. after more than 30 days. But in view of Government order No.S.14025/19/2015-MS, Office Memorandum dated 27 May 2015 issued by Government of India Ministry of Health and Family Welfare Department of Health and Family Welfare, the period extended to 6 months instead of 3 months. The complainant submitted his claim on 04.01.2017 as per letter Ex.C-3 on the record. The wife of the complainant lastly discharged from Patel Hospital Jalandhar on 13.08.2016, as such the complainant submitted his claim within 4 months from the date of discharge of his wife from the Patel hospital, Jalandhar. So, rejection of claim of the complainant by OPs on the ground that he has not submitted his claim within 3 months is not valid because the Punjab Government has already extend the period from 3 months to 6 months vide order No.S.14025/19/2015-MS, Office Memorandum dated 27 May 2015 issued by Government of India Ministry of Health and Family Welfare Department of Health and Family Welfare, which placed on the record. Hence, the complainant submitted his medical claim within the stipulated period. We find no force in the submission of counsel for OPs.

10. In the light of our above discussion, we allowed the complaint of the complainant and OPs no.1 and 2 jointly and severally directed to reimburse Rs.6,38,476/- to complainant which has spent by complainant for treatment of his wife in different hospitals along with interest @ 5% p.a from filing the complaint till its realization. The complainant is further entitled Rs.8000/- as compensation for mental harassment including costs of litigation. The opposite parties are further directed to deposit Rs.3000/- as costs in the Consumer Legal Aid Account maintained by this Commission. This complaint could not be decided within stipulated time frame due to rush of work and spread of Covid-19.

11. The compliance of the order be made within 45 days from the receipt of copy of this order.

12. Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.

Announced in open Commission

27^th of April 2021

Kuljit Singh

(President)

Jyotsna

(Member)