New Complaint No.212 of 2023.
Date of Institution:26.10.2023.
Old Complaint No:204 of 2018.
Date of Institution: 20.04.2018.
Date of order:01.03.2024.
Balvinder Singh aged 76 years, resident of Village Jhawar P.O. Babri Jiwanwal, Tehsil and District Gurdaspur.
….........Complainant.
VERSUS
1. M.D. Punjab Health System Corporation, Phase – 6, S.A.S, Nagar, Mohali.
2. The Oriental Insurance Company Ltd., Regd. Officer Oriental House, P.B. No. 7073, A-25/27, Asaf Ali Road, New Delhi – 110002.
3. The Principal Secretary, Govt. of Punjab Health & Family Welfare Health V Branch, Chandigarh.
4. Director, Health & Family Welfare, Punjab, Chandigarh.
5. Divisional Forest Officer, Gurdaspur, Near Gandhi School, Gurdaspur.
….Opposite parties.
Complaint under section 12 of the Consumer Protection Act, 1986.
Present: For the Complainant:Sh.Harmeet Singh Bathanwala, Advocate.
For the Opposite Parties No.1, 3 and 4: Sh.Rahul Vashisht, Advocate.
For the Opposite Party No.2: Sh. A.K. Joshi, Advocate.
For the Opposite Party No.5: None.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Balvinder Singh, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against Punjab Health System Corporation Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant was an employer of Punjab Forest Department and retired on dated 31.05.2000. He was insured under Govt. employer and pensioner Health Insurance Scheme (PGEPHIS). The complainant ID No. is MDI-008296. The complainant had suffered with sinus syndrome with AF disease and he approached IVY Hospital Super Specialty Health Care, Airport Road, Amritsar for treatment. It is pleaded that as per the letter dated 28.12.2016 issued by the Punjab Govt. if the employee gets treatment before and after the date of 31.12.2016. The employee is entitled to get cashless scheme benefit from Oriental Insurance Company i.e. opposite party No. 2. It is further pleaded that after treatment the medical reimbursement claim bill amounting to Rs.1,23,381/- was submitted to D.H.S. Mohali for approval, but D.H.S. Mohali directed to forward the same medical bill claim to M.D. Punjab Health System Corporation Phase – 6, S.A.S. Nagar Mohali since the subject bills comes under cashless scheme. It is further pleaded that M.D. India Health Insurance TPA Pvt. Ltd. declined the medical claim of the complainant illegally without any justification with the comment that claim was not submitted within 30 days whereas the information regarding the claim was given well within the 30 days to the M.D. India Health Insurance TPA Pvt. Ltd. It is a clear cut deficiency on the part of M.D. India Health Insurance Company. It is further pleaded that the complainant has made request to all the opposite parties to clear the bill and make the payment to the complainant, but till date no action has been taken regarding this matter. Hence, the complainant filed the present complaint. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to settled the medical claim of the complainant, amounting to Rs.1,23,381/- along with interest @ 18% and also directed to pay Rs.20,000/- as a mental harassment and litigation charges to the complainant, in the interest of justice.
3. Upon notice, the opposite parties No.1, 3 and 4 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint of the complainant under reply is not maintainable against the answering opposite parties No. 1, 3 & 4 as the complainant had to take sanction first from the Corporation before initiating any legal proceeding against the answering opposite parties No. 1, 3 & 4 as per Section 15 of Punjab Health System Corporation Act, 1996 and the same is clear from the perusal of Section 15 Punjab Health Corporation Act, 1996 as follows:-
Section 15
- No suit or prosecution shall be entertained in any court against the Corporation or against any officer or servant of the Corporation or person acting under the order or direction of the Corporation for anything which is in good faith done or intended to be done under this Act or any regulation made there under.
- No suit, prosecution or other legal proceedings shall lie against any officer or servant of the Corporation for any act done of purporting to be done under this Act or any regulation made there under without the previous sanction of the Corporation.
It is further pleaded that the present complaint under reply is also liable to be dismissed on the ground that the complainant has not made any representation to District Grievance Redressal Committee constituted vide notification dated 21.09.2016 by Govt. of Punjab in order to lay his claim, if any. It is further pleaded that no cause of action even arose to the complainant for filing the present complaint and the present complaint of the complainant is time barred.
On merits, the opposite parties No.1, 3 and 4 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Upon notice, the opposite party No.2 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint of the complainant is not maintainable, as the complainant has not submitted his claim for reimbursement alongwith the requisite documents to the M.D. India Health Insurance TPA Pvt., Mohali, within stipulated period of 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 Scheme (PGEPHIS).
As per the SLA clause 6.4.10:-
“In an event a Member goes to a Provider Hospital of showing his/her ID Card to the hospital authorities within stipulated time period, is denied cashless hospitalization by the hospital, for any reason whatsoever, including but not limited to, denial by the hospital at its own end without receiving any denial from the TPA or the wrongful denial by the TPA or delay in issuance of authorization by the TPA for any reasons or any other circumstances whatsoever and no fault lies with the Member, he/she may submit his/her claim to the TPA as per the check list for reimbursement within 60 days of date of discharge from the hospital. In such cases, the TPA shall extend full cooperation to the Beneficiary and depending upon merit/genuineness of the case determines the admissibility of the claim within the purview of the Scheme and settles the claim 15 days of receipt of the claim, accordance with terms and conditions of the Scheme”.
It is further pleaded that after perusal of the above said condition of the Scheme, it is crystal clear that the complainant must submit his claim with the TPA within stipulated time under the terms and conditions of Scheme, but in the present case, the claim of the complainant was received for pre-authorization through hospital on cashless network, but due to non-reply of queries raised by the OP No. 1 TPA, the same was closed. Thereafter, the complainant did not approach with the answering OP for claim in reimbursement. Hence, the answering OP is not liable for the claim under the terms and conditions of the Scheme. The present complaint of the complainant is liable to be dismissed on this score only. It is further pleaded that the answering OP’s insurance company is not liable for the claim of the complainant for reimbursement; however, in case if the Hon’ble Commission fastened the liability of the answering OP’s insurance company that should be according to the tender rates implemented by State Government as following:-
- Pacemaker (single chamber).......Rs.18,129/-
- Cost of Pacemaker.....................Rs.44,928/-
- Coronary Angiography..............Rs.3,630/-
Total...........Rs.66,687/-.
It is further pleaded that the present complaint is not maintainable against the answering OP’s insurance company, as there is no insurance contract exists between the complainant and the answering OP. Hence, there is not any contractual liability of the answering OP against the complainant under the Consumer Protection Act. Punjab Government has sponsored this scheme to its Employees and Pensioners and no insurance consideration is deducted from their salaries, hence, the answering OP’s insurance company has contractual liability towards Punjab Govt. only, not against the complainant, as the complainant is not covered within the definition of 'CONSUMER' under the Consumer Protection Act.
On merits, the opposite party No.2 has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
5. Upon notice, the opposite party No.5 appeared through its Forester i.e. Sh. Sawinder Singh and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint of the complainant is not maintainable. All the medical bills have been pending in the office of the OP No.1. So, all the amount of re-imbursement bills will be paid by the OP’s No. 1 to 4 and the complaint may be dismissed on this ground against the answering OP No. 5. It is pleaded that the Govt. of Punjab, Department of Health & Family Welfare, (Health V Branch) vide notification No. 21/28/12-5I IB5/268 dated 20.10.2015, introduce a Cashless Health Insurance Scheme here-in-after referred as Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical treatment expenses, specified daycare procedure and treatment of Chronic diseases as specified or to be specified by State Govt. It is further pleaded that the Scheme will be applicable to all the Government serving employees (whether covered under old or new pension Scheme) and pensioners on compulsory basis. So, as per notification The Oriental Insurance Company, Chandigarh is liable to pay the amount of Rs.1,17,181/-. It is further pleaded that as per office record, the office of Department of Forest & Wildlife Preservation, Railway Road, Gurdaspur vide No. 1924 dated 16.10.2017, sent all the re-imbursement of medical bill of Rs.1,17,181/- has been sent to Managing Director, Health Corporation, Phase No. 6 S.A.S. Nagar Mohali, for payment. Thereafter, a letter No. 144 dated 11.04.2018 written by Punjab Health System Corporation, S.A.S. Nagar, Mohali, has informed to this office that medical re-imbursement bill under PGEPHIS Scheme and send registered mobile number or Health Insurance Card be supplied for further action. It is further pleaded that the answering OP No. 5 has sent letter No. 490 dated 09.05.2018 to the complainant to supply the above said documents, but the complainant has failed to produce the entire documents. So, the complainant is fully liable to this act.
On merits, the opposite party No.5 has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
6. Learned counsel for the complainant has tendered into evidence affidavit of Balvinder Singh, (Complainant) as Ex.C-1 alongwith other documents as Ex.C-2 to Ex.C-12.
7. Learned counsel for the opposite parties No.1, 3 and 4 has tendered into evidence affidavit of Dr. Amandeep Singh, (Deputy Medical Commissioner, Punjab Health System Corporation) as Ex.OP-1,3,4/1 alongwith reply.
8. Learned counsel for the opposite party No.2 has tendered into evidence affidavit of Sh. Karam Singh, (Senior Divisional Manager, Oriental Ins. Co. Ltd., Pathankot) as Ex.OP-2/1 alongwith other documents as Ex.OP-2/2 to Ex.OP-2/4 alongwith reply.
9. The opposite party No.5 has tendered into evidence affidavit of Sh. Narinder Pal, (Accountant Office of Divisional Forest Office, Gurdaspur) as Ex.OP-5/A alongwith other documents as Ex.OP-5/1 to Ex.OP-5/3 alongwith reply.
10. Rejoinder not filed by the complainant.
11. Written arguments filed by the opposite parties No.1, 3, 4 and 5, but not filed by the complainant and opposite party No.2.
12. Counsel for the complainant has argued that complainant has retired from Punjab Forest Department on 31.05.2000 and was insured under Govt. employer and pensioner Health Insurance Scheme (PGEPHIS). It is further argued that complainant had undergone treatment at IVY Hospital in respect of disease sinus Syndrome with AF and since as per the scheme of the Punjab Govt. the complainant was entitled to cashless treatment from opposite party No.2 insurance company. It is further argued that after getting treatment medical reimbursement claim for Rs.1,23,381/- was submitted by the complainant through D.H.S. Mohali for approval but D.H.S. Mohali had directed to forward the same to M.D. Punjab Health System Corporation S.A.A. Nagar Mohali. It is further argued that M.D. India Health Insurance TPA Pvt. Ltd. declined the claim with the excuse that the same was not submitted within 30 days inspite of the fact that the information was given within 30 days. The act of the opposite parties of having declined the bills amounts to deficiency in service.
13. On the other hand counsel for the opposite parties No.1,3 and 4 has argued that complaint is not maintainable as per the provisions of Section 15 Punjab Health System Corporation Act, 1996, in which it is mentioned that no litigation shall be entertained against the answering opposite parties before obtaining prior sanction from the corporation. It is further argued that complainant had not approached District Grievance Redressal Committee. It is further argued that complaint of the complainant is time barred as the policy was valid upto 31.12.2016.
14. Counsel for the opposite party No.2 has argued that since the complainant has failed to submit his claim for reimbursement alongwith documents to opposite party No.1 within 30 days after the discharge from the hospital, as such complainant is not entitled to reimbursment of the medical bills. It is further argued that if any liability is fastened in that case liability is only upto Rs.66,687/- as per the tender rates implemented by the State Government.
15. On the last so many dates none had appeared on behalf of opposite party No.5. However, in the written reply opposite party No.5 has stated that opposite party No.2 insurance company is liable to pay the reimbursement amount of Rs.1,17,181/- to the complainant and has further stated that complaint is not maintainable against opposite party No.5.
16. We have heard the Ld. counsels for the complainant and opposite parties No.1,3,4 and 2 and gone through the record.
17. To prove his case complainant has placed on record his duly sworn affidavit Ex.C1, copy of letter dated 29.03.2017 Ex.C2, copy of letter dated 02.01.2017 Ex.C3, copy of letter dated 28.12.2016 Ex.C4, copy of certificate by way of which claim was declined Ex.C5, cop of letter dated 31.08.2017 Ex.C6, copy of letter dated 19.09.2017 Ex.C7 and copies of medical bills Ex.C8 to Ex.C12 whereas opposite party No.2 has placed on record affidavit of Karam Singh Sr. Div. Manager Ex.OP-2/1, copy of E-mail Ex.OP-2/2, copy of tender document Ex.OP-2/3 and copy of notification Ex.OP-2/4. Opposite parties No.1,3 and 4 have placed on record affidavit of Amandeep Singh Deputy Medical Commissioner Ex.OP-1,3,4/1, copy of letter dated 14.08.2018 Ex.OP2/1, copy of notification Ex.OP-2/1-A and copy of enrollment period Ex.OP-2/2. Opposite party No.5 has placed on record affidavit of Narinder Pal Ex.OP-5/A, copies of letters Ex.OP-5/1 to Ex.OP-5/3.
18. It is admitted fact that complainant has retired from Punjab Forest Department on 31.05.2000. It is further admitted fact that complainant was insured under Govt. employer and pensioner Health Insurance Scheme (PGEPHIS). It is further admitted fact that complainant undertook treatment regarding sinus syndrome with AF from IVY Hospital Amritsar. It is further admitted fact that as per letter dated 28.12.2016 if the employees get treatment before and after 31.12.2016 the said employee is entitled to get insurance treatment from opposite party No.2. It is further admitted fact that complainant has spent amount on his treatment from his own pocket on being denied cashless treatment. It is further admitted fact that opposite party No.1 has declined the claim on the ground that the same was not submitted within 30 days from the date of discharge. The only disputed issue for adjudication before this Commission is whether the non-reimbursement of the amount/medical expenses amounts to deficiency in service.
19. Perusal of file shows that complainant had submitted his claim with opposite party No.5 within time and the same was sent to D.H.S. Mohali and on receiving back the same, the same was again sent to opposite party No.1 but opposite party No.1 had vide Ex.C5 refused to entertain the case of reimbursement on the ground of delay of 30 days. Perusal of file further shows that OPD bills of IVY Hospital Ex.C12 is of 09.09.2017 and the delay in sending the bills/claim if any has taken place on account of the mistake by opposite party No.5 for having wrongfully sent the bill to D.H.S. Mohali instead of opposite party No.1 and as such complainant cannot be made to suffer for the wrong act on the part of the opposite party No.5. Accordingly, we have no hesitation in holding that non-settlement of medical bills of the complainant by the opposite parties amounts to deficiency in service.
20. Accordingly, present complaint is partly allowed and opposite parties No.1 to 4 are directed to settle and pay the claim of the complainant within 30 days of the receipt of copy of this order as per terms and conditions of the policy of insurance. However, it is made clear that if claim is not settled and paid to the complainant within 30 days, then the payable amount of reimbursement shall carry interest @ 9% P.A. from the date of filing of the present complaint till realization.
21. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
22. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
March 01, 2024 Member.
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