PER:

Nidhi Verma, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant Dalbir Singh Inspector Police No.292/J retired is a permanent resident of H.No.827/14, Gali Dr. Komal Wali, Court Road Patti, District Tarn Taran and retired from the Punjab Police Department on 31.10.2002 and is getting the pension vide PPO No.165672/PB from the Department of Police of opposite party and his nominee was his wife Davinder Kaur. The complainant is having PPO No.165672/Punjab and his account number in Punjab and Sind Bank Patti is 03091000015734 having IFSC code PSIB0000309. The above said opposite parties committed deficiency and negligence in service by not reimbursing the whole sum of medical expenditure amounting of Rs.3,90,051/- made by the complainant to the Fortis Escort Hospital Amritsar. The complainant Dalbir Singh Inspector Police No.292/J retired, R/o H.NO.827/14, Gali Dr. Komal Wali, Court Road Patti, District Tarn Taran as per the policy of Punjab Government to provide Health Insurance Cover to its employees and their family members and for this purpose had contracted by the opposite parties with each other. The opposite parties undertook to provide reimbursement for the expenses done by the Punjab Govt. Employees/pensioner after they pay the expenses for the pre and post hospitalization of employees/ pensioner and their family member's treatment. The complainant Dalbir Singh fell ill and was hospitalized and under treatment/ operation with the Fortis Escort Hospital Amritsar from 10.10.2016 to 16.10.2016 and he spent expenditure of Rs. 3,90,051/- by himself to the Fortis Escort Hospital Amritsar. After discharge from the hospital, the complainant immediately forwarded case for reimbursement alongwith treatment record and bills of expenses paid by complainant himself to the Fortis Escort Hospital, legally and as per procedure laid down for the same, to the opposite party Nos. 3 and 4. On submission of reimbursement case to the opposite parties No. 3 and 4, directed the complainant to produce the bill alongwith representation to opposite party No. 1 i.e. M.D. India Health Insurance Care service (TPA) Pvt. Ltd. Branch Mohali with the instruction that the case for preparing card for health insurance was forwarded to the above said insurance company which was recommended by opposite party No. 3 after deducting the insurance amount of Rs. 199/-. As such opposite party No. 3 had returned the original representation and bill on 7.1.2017 to the complainant. The complainant sent the reimbursement medical bill to the opposite party No. 1 i.e. M.D. India Health insurance Care service (TPA) Pvt. Ltd. Branch Mohali through registered post. After that the complainant repeatedly contact personally to the opposite party No.1 but opposite party No.1 refused to accept the claim of complainant by saying that the Health Insurance Card was not prepared and returned the documents alongwith reimbursement bills by opposite party No.1 with the direction to produce the same before the office of opposite party No.3 & 4 for reimbursement being a pensioner and consumer with opposite party No.3 & 4.  The complainant again filed the case of reimbursement of bills alongwith original reimbursement form, duly attested bill, self attested affidavit/declaration and other required documents on 25.4.2018 submitted before the opposite party No.3 and 4 legally and as per procedure laid down for the same. On the repeated request and representations but take no action by the opposite parties No.3 and 4 but delaying the payment on the one pretext or the other without any logical reason for the same since last four months and lastly refused to accept the claim of complainant on 28.7.2019. The opposite parties No.1 to 4 are liable to pay the amount of reimbursement of medical bills for Rs.3,90,051/- being pensioner and liable to get the benefit of Health Insurance Cover as per the policy of Punjab Govt. to provide Health Insurance to its employee/pensioner and their family members being consumer alongwith 18% per annum interest and compensation for harassment. The complainant issued legal notice through counsel Sh. Gurmit Singh Advocate Chamber No. 23 Judicial Court complex Tarn Taran on 12.9.2019 but no reply or compliance has been made by the opposite party / respondent till date. As per the terms and conditions and as per the Govt. policy, the complainant and his dependent spouse/ family members are entitled to get the benefit of reimbursement of medical bills from the opposite parties being the consumer. The complainant has prayed the following reliefs:-

1. The opposite party be directed to make the payment of reimbursement bill amounting to Rs. 3,90,051/- alongwith interest at the bank rate and compensation
2. The complainant is also entitled for Rs. 5,00,000/- for mental torture, harassment, agony and financial loss which he has suffered because of wrongful act of opposite party.
3. The complainant is also entitled for litigation expenses and counsel fees amounting to Rs. 40,000/-

Alongwith the main complaint, the complainant has placed on record his affidavit Ex. CW1/A, Self attested copy of PPO No. 165672/PB Ex. C-1, Self attested copy of Adhar Card of Davinder Kaur Ex. C-2, self attested copy of Adhar Cared of complainant Ex. C-3, Self attested copy of application to SSP Tarn Taran Ex. C-4, self attested copy of reimbursement Bill issued by Medical director Fortis Escort Hospital Majitha Verka Byepass road Amritsar Ex. C-5, Self attested copy of detail of reimbursement bill Ex. C-6. Self attested copies of Bills Ex. C-7 to C-24, Self attested copy of Performa for claiming reimbursement of medical charges Ex. C-25, Self attested copy of declaration(affidavit) Ex. C-26, Performa application for reimbursement of claim Ex. C-27, 28, Copy of legal notice Ex. C-29, Photocopy postal receipt of legal notice Ex. C-30, Photo copy postal receipt to MD India Health Care Service SAS Nagar Mohali Ex. C-31.

2        Notice of this complaint was sent to the opposite parties and opposite parties No. 1 and 2 appeared through counsel and filed written version by interalia pleadings that the complainant is not covered under the definition of "Consumer" as defined in Consumer Protection Act 1986. The present complaint is barred by law of limitation. The alleged treatment pertains to 10.10.2016 whereas the instant complaint has been filed after a long unjustified delay of more than 3 years. The present complaint is not maintainable. There is no contract of insurance between the complainant and the OP Ins. Co. as far as the present claim is concerned, since the complainant never got himself and his dependents enrolled/registered under the Policy/Scheme in question. As such, the OPs are not liable to pay any medical expenses allegedly incurred by the complainant. The OP insurance Co. has issued the policy to the Punjab Govt. subject to terms and conditions as envisaged in "The Punjab Government Employees and Pensioners Health Scheme", by which all the parties i.e. Punjab Govt., Healthcare provider TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition No.8 of the scheme, "Every employee/pensioner will ensure his/her enrolment alongwith dependents before 15.12.2015 enabling the insurance company to deliver the insurance cards upto 31.12.2015" Similarly, as per para 8 of Notification No. 21/28/12-5HB5/268 dated 20.10.2015. "Every employee/pensioner will ensure his/her enrolment alongwith dependents before 15.12.2015 enabling the insurance company to deliver the insurance cards upto 31.12.2015. No fresh enrolment of serving employees or pensioners shall be allowed after the date of expiry of Enrollment period" Furthermore, as per condition No. 17 (a) of the scheme. "No fresh enrolment of serving employees or pensioners will take place after the date of expiry of Enrollment period". The complainant is not covered under the Punjab Govt. Employee Pensioner Health Insurance Scheme as he failed to submit his enrollment form within the prescribed period. Hence, the complainant is not entitled to get the relief claimed for. The complainant is estopped from filing the present complaint. Vide Notification No. 21/28/12-5H5/758236/1 dated 20/05/2016, the Govt. of Punjab had extended the enrollment period for employees and pensioners under PGEPHIS upto 30.06.2016. It was further mentioned in the notification that the beneficiaries who could not get enrolled under the scheme will be entitled for medical treatment reimbursement as per the existing State Services (Medical Attendant Rules) (CS(MA)) Rules, 1940 as amended from time to time, through treasury route. Despite the extension upto 30.6.2016, given by the Punjab Govt. to those who failed to enroll earlier, the complainant failed to enroll himself and his dependents under the PGEPHIS scheme. As such the complainant and his dependents are not covered under the Punjab Govt. Employee Pensioner Health Insurance Scheme and he has himself waived off his entitlement as far as the present claim is concerned. The complaint filed by the complainant is otherwise bad for mis-joinder and non- joinder of necessary parties and causes of action. The complainant has failed to implead Government of Punjab, which is a necessary party to the present complaint, is not entitled to the relief claimed for. It is only the Govt. of Punjab which is legally entitled to file a complaint pertaining to the insurance claim, if any. The present compliant is technically defective as the same has not been filed in accordance with the law. The complainant is neither a party to contract of insurance nor a beneficiary under the same. The present insurance policy is subject to terms and conditions as envisaged in "The Punjab Government Employees and Pensioners Health Scheme", by which all the parties i.e. Punjab Govt. Healthcare provider. TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition No.21 of the scheme, the mechanism with regard to Dispute Resolution and Grievance Redressal has been set up by providing Grievance Redressal Committee in each District which will constitute the following members: (a) Deputy Commissioner. (b) Civil Surgeon. (c) Deputy Medical Commissioner, (d) Representative of Insurance Company. The said committee will resolve the Grievance within 30 days from the date of application. It has been further provided in the scheme that dissatisfied party may approach the State Level Grievance Redressal Committee whose decision shall be final and binding to all the parties. As such, in the light of above mentioned provision of the Scheme, this Commission has no jurisdiction to try and decide the present complaint. The complainant has got no cause of action to file the present complaint against the OPs. The complainant has failed to get himself and his dependents registered under the Policy/Scheme in question, he is not entitled to the present claim and as such the complaint is liable to be dismissed. Even otherwise, if the complainant is able to prove before this Commission that he had duly enrolled himself in the present Scheme, the liability of the OP Ins. Co. has to be assessed in the light of PGEPHIS Schedule of rates. As per condition No.23 of the PGEPHIS scheme, "the reimbursement to the beneficiary against the claim of treatment availed in the private hospital shall be made in accordance with the PGEPHIS rates irrespective of the actual expenditure incurred by the beneficiary" Besides, as per para 4 of Notification No. 21/28/12-5HB5/268 dated 20.10.2015 "The Insurance co. will reimburse the bill of employee upto Rs 3 lacs as per the package rates defined under the scheme". Hence, it clearly indicates that the Maximum liability of the Ins. Co. is Rs. 3 lakhs per family i.e. the employee alongwith his entire family accumulatively. The complainant has filed two complaints i.e. one on account of his own treatment and another on account of treatment of his wife. As such, if the court awards any claim in favour of the complainant, both the claims are to be considered as one and the accumulative sum assured of both the claims cannot exceed Rs 3 lakhs. Nevertheless, the OPs are not liable to pay any medical expenses allegedly incurred by the complainant since the complainant never got himself and his dependents registered under the policy in question and is not covered under the PGEPHIS scheme. The Complainant has not approached this Commission with clean hands and has concealed the material facts. The present claim is not payable since the complainant is not covered under the PGEPHIS scheme. Therefore, there is no deficiency or delay on the part of opposite parties. The relief towards interest and damages, etc. is not payable. Basically neither there is any provision under the Consumer Protection Act nor there is any agreed clause in the contract of insurance to pay such relief.  The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same.  Alongwith the written version, the opposite parties No. 1 and 2 have placed on record affidavit of Sh. O.P. Dhawan D.M. Ex. OP1,2/1 alongwith documents i.e. attested copy of scheme Ex. OP1,2/2, Attested copy of notification Ex. OP1,2/3, Attested copy of notification Ex. OP 1,2/4, Attested copy of Insurance Policy Ex. OP 1,2/5, Attested copy of order dated 22.5.2018 Ex. OP 1,2/6.

3        The opposite parties No. 3 and 4 appeared through counsel and has filed written version by interalia pleadings that the complaint is not maintainable in the eyes of law. The complainant has filed a wrong and baseless complaint against the opposite parties just to harass them unnecessarily. The opposite parties No.3 & 4 are not competent for the payment of such reimbursement medicals bills for the year 2016, as such, the opposite parties have no concern with the above said reimbursement medical bills for the year 2016. The present complaint filed by the complainant to mislead this commission as such the same is liable to be dismissed. The complainant has not come to this commission with clean hands and has suppressed the material facts from this Commission. The true facts of the case are that the complainant retired from police department as Inspector No.292/J from District Tarn Taran and is drawing his pension Under PPO No.165672/PB. The Government of Punjab issued Punjab Govt. Employees and Pensioner Health Insurance Scheme, in the year 2015. This letter was also circulated in the print media and TV channel by the Punjab Government. The directions were issued to all that every employees/pensioners will ensure his/her enrollment alongwith dependents before 15.12.2015 enabling the insurance company to deliver the enrolled insurance cards up-to 31.12.2015.  The insurance policy coverage/ policy plan shall commence from 1^st January, 2016 and will expire on midnight 12.00 am of 31.12.2016. The complainant submitted photocopies of his own medical bill of Rs.3,90,051/- for the period of 10.10.2016 to 16.10.2016 for reimbursement in this office. The medical reimbursement bill was sent to the Civil Surgeon Tarn Taran vide letter No. 10822/B/A.C-3 dated 15.3.2018 for verification and necessary action. The office of Civil Surgeon, Tarn Taran, returned the same to this office Dairy No.3226 dated 11.4.2018 with the remarks that in this regard, original medical bills for reimbursement may be sent to the MD India Insurance, Punjab Health system Corporation, Mohali i.e. opposite party No.1. Moreover, in this regard the complainant was informed by the dealing hand of this office from his Mobile No.98726-34815. The complainant should send his original medical bills for reimbursement to the MD India health Insurance Company, Mohali at his own level. Thus the opposite parties No.3 & 4 have no concern with the above said medical reimbursement of the bills and are not competent for the payment of such reimbursement medical bills for the year 2016, as such the present complaint filed by the complainant just in order to mislead this commission and is liable to be rejected on this ground only. The complainant is not covered under the definition of "Consumer" as defined in Consumer Protection Act 1986. As such, the complainant has no right to invoke jurisdiction of this Commission and/or to file the present compliant against the Opposite parties. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has got no cause of action to file the present against the opposite parties. On submission of reimbursement case to the opposite parties No. 3 and 4, directed the complainant to produce the bill alongwith representation to opposite party No.1. It is denied that the opposite party No. 3 has deducted the amount of Rs. 199/-.  The opposite parties No. 3 and 4 have denied the other contents of the complaint and prayed for dismissal of the same. The opposite parties No. 3 and 4 have tendered in evidence affidavit of Kulwant Singh Ex. OPs 3,4/1, attested photocopy of letter of Govt. of Punjab issued Punjab Govt. Employees and Pensioner Health Insurance Scheme, in the year 2015 Ex. OPs 3,4/2,  Attested photo copy of office letter No. 10822/B/A-C3 dated 15.3.2018 Ex. OPs 3,4/3, attested Photo copy of letter dairy No. 3226 dated 11.4.2018 Ex. OP 3,4/4.

4        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.

5        In the present complaint , the complainant Dalbir Singh Inspector police no.292/j retired, R/o H.No. 827/14, Gali Dr. Komal Wali ,Court Road Patti, Tarn Taran was undergone treatment from 10.10.2016 to 16.10.2016 at Fortis Escort Hospital Amritsar and spent expenditure of Rs 3,90,051/- by himself . The complainant immediately forward at his case of reimbursement alongwith treatment record and bills of expenses paid by complainant himself to the OP No.3 and 4 . On submission of reimbursement case to the OP 3&4 directed the complainant to produce the bill alongwith representation to OP No.1 and returned the original representation and bill on dated 07.01.2017. After that the complainant sent the reimbursement bills to OP No.1, but OP No.1 refused to accept the claim of the complainant by saying that the Health Insurance Card was not prepared . After that the complainant again filed the bills of reimbursement on dated 25.04.2018 before the OP No.3 & 4 but no action was taken by OP No. 3 &4 and lastly refused to accept the claim of the complainant on dated 28.07.2019.

6        OP No 1 & 2 stated in their written version that the complainant never got himself and his dependents enrolled/ registered under the policy /scheme in question. The OP No.1 insurance Co. has issued the policy subject to terms and conditions as envisaged in “the Punjab Government Employees and Pensioners Health Scheme”, by which all the parties i.e. Punjab Government, HealthCare provider, TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition No.8 of the scheme,” every employee/pensioner will ensure his/her enrolment alongwith dependants before 15.12.2015 enabling the insurance company to deliver the insurance cards upto 31.12 .2015”. Furthermore , as per condition no 17 (a) of the scheme , “ No fresh enrolment of serving employees or pensioner will be taken after the date of expiry of enrolment period”.  The complainant was not covered under the Punjab Government Employee Pensioner Health Insurance Scheme as he failed to submit his enrolment form with in the prescribed period . However, vide notification no 21/28/12- 5H5/758236/1 dated 20/5/2016 , the Government of Punjab had extended the enrolment period for employees and pensioners under PGEPHIS upto 30.06.2016 , that despite the extension given by the Punjab Government to those who failed to enrol earlier , the complainant again failed to submit his enrolment form within the prescribed period .As such the complainant is not covered under the Punjab government employee pensioner health insurance  Scheme and he has himself wavied off his entitlement as far as the present complaint is concerned.

7        Further, As per condition number 21 of the scheme, the mechanism with regard to Dispute Resolution and Grievances Redressal has been set up by providing Grievance Redressal Committee in each district which will constitute the following members:-

• Deputy Commissioner
• Civil Surgeon
• Deputy Medical Commissioner
• Representative of Insurance Company

The set committee will resolve the Grievance within 30 days from the date of application.  It has been further provided in the scheme that dissatisfied party may approach the State Level Grievance Redressal Committee whose decision shall be final and binding to all the parties.

8        However, if the complainant is able to prove his enrolment himself in the present Scheme, the liability of the OP has to be assessed in the light of PGEPHIS schedule of rates . as per condition No.23 of the PGEPHIS Scheme, “ the reimbursement to the beneficiary against the claim of treatment availed in the private hospital shall be made in accordance with the PGEPHIS rates irrespective of the actual expenditure incurred by the beneficiary”. Besides , as per para 4 of notification no. 21/28/12-5HB5/268 dated 20/10/2015 “the Insurance co. will reimburse the bill of employee upto Rs 3Lacs as per the package rates defined under the Scheme”. Further more, as per para No. 1 Annexure XX of PGEPHIS schedule of rates, “In case of admission in semi-private category of room, the rates will be 10% higher than the rates applicable to general ward category contained in the table”. Hence, the insurance company will reimburse the bill of employee upto Rs 3lacs as per the package rates defined under the scheme. The complainant has filed two complaints i.e. one on account of his own treatment and another on account of treatment of his wife . As such ,if court awards any claim in favour of the complainant, both the claims are to be considered as one and the accumulative sum assured of both the claims cannot exceed Rs 3lacs. Nevertheless, the Ops are not liable to pay any medical expenses allegedly incurred by the complainant since the complainant never got himself registered under the policy in question and is not covered under the PGEPHIS Scheme.

9        OP 3 & 4 stated in their written version that the complainant submitted photocopies of the medical bill of  ₹3,90,051 for the period of 10^th Oct 2016 to 16^th  October 2016  for reimbursement . The medical reimbursement bill was sent to the civil Surgeon, Tarn Taran vide letter No. 10822/B/A.C3 dated 15.03.2018 for verification and necessary action . The office of civil surgeon, Tran Taran returned the same to this office diary number 3226 dated 11^th April 2018 with the remark that in this regard original medical bills for reimbursement may be sent to the MD India Insurance company i.e. OP No.1. Further, it is denied that the OP No.3 has deducted the amount of Rs.199/- as an insurance amount and OP No.3 & 4 have no concern with the above said Medical reimbursement of the bills and are not competent for the payment of such reimbursement .

10      However, after going through the facts and circumstances of the case we are of the considered opinion that the Ld. Counsel for the complainant has submitted that the main controversy involved in the present case is that Ops had returned the original representation and bill to the complainant by stating that the complainant is not covered under Punjab Government Pensioner Health Insurance Scheme , as non- enrolment with them. Punjab Government has sponsored the Scheme to it’s employees and pensioners and no insurance consideration is deducted from their salaries. It is provided free of costs. The scheme was started from 01.01.2016 upto 31.12.2016 and enrolment under the scheme was to start from 20.10.2015 and was to be completed by 31.12.2015.

11      (Ex.OP1,2/2) As per the terms and conditions of the said scheme,  condition number 8 of the scheme stated that “Every employee on pensioner will ensure his/ her enrollment along with dependents before 15^th of December 2015 enabling the insurance company to deliver the insurance card up to 31^st December 2015”. Furthermore as per condition number 17 of the scheme “No fresh enrolment of serving employees or pensioners will take place after the date of expiry of enrolment.”

12      Furthermore, (Ex .Op 1,2/3) vide notification no. 21/28/12-5h5/7582361 dated 20/05/2016 , the Govt. Of Punjab had extended the enrolment period for employees and pensioners under PGEPHIS upto 30.06.2016 . As per the terms and conditions of the said Scheme the enrolment of the employees and pensioners should be must ,as Government has sponsored the Scheme to it’s employees and pensioners and no insurance consideration is deducted from their salaries. It is provided free of costs. After gone through the evidence placed on the record by the Ld. Counsel of the complainant , the complainant  stated that on submission of reimbursement case to the OP No 3 & 4 , directed the deponent to produce the bill alongwith representation to OP No 1 i.e. MD India with the instruction that the case for preparing card for health insurance was forwarded to the above said insurance company which was recommended by OP No.3 after deducting the insurance amount of Rs 199/-  But the complainant failed to prove their enrolment with the Punjab Government. The complainant has not placed any Insurance Card Number or form that can prove that he submit his enrolment form within the prescribed period. Further failed to submit any evidence on record to prove that there is deduction of Rs 199/- for insurance done by Ops.

13      Hence , the complainant is not entitled to get the relief claimed for , because he failed to submit his enrolment form within the prescribed period and in despite of the extension given by the Punjab Government to those who failed to enrol earlier i.e. 15.12.2015 , the complainant again failed to submit his enrolment form upto 30.06.2016 . As such the complainant is not covered under the Punjab Government Employees Pensioner Health Insurance Scheme and he has himself waived off his entitlement by not completing the enrolment within prescribed period. 

14      If Punjab Government started said Scheme to facilitate his/her employees and pensioners without any costs but only required to registered their enrolment within prescribed period. It was the duty of the employees and pensioners to get the benefits as per the terms and conditions of the said Scheme – where enrolment was must but the complainant failed to do so . Hence there is no valid contract of insurance between the insured and the OP  insurance Co. as far as the present claim is concerned, since the complainant never got himself registered under the Policy/Scheme. As such the Ops are not liable to pay any medical expenses allegedly incurred by the complainant.  Therefore, there is no deficiency or delay on the part of the Ops .

15      In view of the above discussion, we do not find any merit in the complaint and the same is hereby dismissed. The parties are left to bear their own costs. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission and due to COVID -19 copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission

28.03.2023