DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 209 of 2.6.2017
Decided on: 5.4.2019
Jagjit Singh aged about 69 years S/o Sh.Sujan Singh, resident of H.No.83-D, Model Town, Patiala (Retired as Senior Asstt. from Govt. Medical College, Patiala Punjab)
…………...Complainant
Versus\
1. M.D.India Health Care Service TPA Pvt. Ltd. Max Pro Info Park,D-38, Ist Floor, Industrial Area, Phase-I,Mohali, Punjab through its Managing Director
2nd Add: M.D.India Health Care Services,F-539,Industrial Area, Phase VIII-B, Mohali Tower, Mohali (Punjab)
1A. The Oriental Insurance Company Limited, Head Office: Oriental House, A-25/27, Asaf Ali Road, New Delhi-110002.
2. State of Punjab through Principal Secretary/Secretary, Department of Health & Family Welfare, Govt. of Punjab, Chandigarh.
3. The Collector-cum-Deputy Commissioner District Patiala, Mini Sectt., A-Block, Patiala on behalf of State of Punjab
…………Opposite Parties
4. Fortis Hospital(Multi Specialty Hospital),Sector 62, Phase VII, Mohali through its Administrative Incharge/Manager.
………..Proforma Opposite parties.
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Sh. M.P.Singh Pahwa, President
Smt. Inderjeet Kaur, Member
Sh.B.S.Dhaliwal, Member
ARGUED BY
Sh.P.S.Baweja, counsel for complainant.
OP No.1 ex-parte.
Sh.B.L.Bhardwaj, counsel for OP No.1/A
ORDER
SH. M.P.SINGH PAHWA,PRESIDENT
1.This is the complaint filed by Jagjit Singh (hereinafter referred to as the complainant) against M. D. India Health Care Service TPA Pvt. Ltd. and others (hereinafter referred to as the OP/s).
2.Briefly the case of the complainant is that he retired as Sr. Asstt. from Medical College, Patiala and is getting his pension vide PPO No.123162/Punjab. Being retired Pb.Govt. employee, complainant is entitled to reimbursement of indoor bills for his medical treatment as well as for his dependant family members. In order to ensure proper health services for its pensioners, the State of Punjab purchased services of OP No.1 for cashless medical treatment of its employees/retirees/pensioners and got insured his employees and ex-employees with OP No.1 under Medical health Insurance Scheme from its enlisted and approved hospitals/clinics apart from Govt. run hospitals.
3.As per list of approved hospitals designated by Govt. of Punjab and accepted by OP No.1, one of the approved hospitals for cashless medi claim facility is Fortis Hospital, which is multi specialty hospital at Mohali from which employees can avail cashless medical treatment facility, for which the OPs are liable to pay.
4.It is pleaded that under the Punjab Govt. Employees and Pensioners Health Insurance Scheme, for short referred to be as scheme, complainant is covered and enrolled as an insured for availing cashless mediclaim facility vide ID card No.MD1509814949952 valid w.e.f.1.1.2016 to 31.12.2016 by OP No.1, whereby the complainant alongwith his dependent family members were insured for cashless treatment at designated hospitals in all around Punjab including Fortis Hospital at Mohali.
5.As per complainant, he was having acute knee joint pain for which he himself got checked up at Fortis Hospital, Mohali on 17.9.2016 as an indoor patient vide ID No.646553.After diagnosis, he was advised and recommended urgent total knee replacement of his right side knee mentioning, “Adv.-needs total knee replacement Rt.side”. Complainant also paid charges of Rs.5500/- for checkups and tests. Thereafter, the complainant contacted the concerned section at Fortis Hospital for processing of cashless claim with insurer i.e. OP No.1 under the scheme but he was shocked to hear from concerned staff that payments of Fortis Hospital, Mohali under cashless scheme has been withheld by the insurer since 2.9.2016.Telephonic request was also made by the concerned to insurer but same was declined. Ultimately hospital staff told complainant will have to pay from his own pocket. Since the complainant was suffering from financial crises due to prolonged treatment of his daughter who had expired on 1.6.2016 being a cancer patient, so in order to get his surgery done, which was urgently required, complainant requested in writing through registered post to Principal Secretary, Health & Family Welfare , Punjab and Secretary, Medical Education & Research, Punjab Chandigarh to consider his request and for directing OP No.1 to reimburse the bills under cashless scheme to enable complainant to undergo required urgent surgery of knee replacement but his request for cashless treatment was not entertained. Under compelled circumstances, he arranged the funds and deposited the same to undergo urgent knee replacement surgery from Fortis Hospital, Mohali. He remained admitted at Fortis Hospital, Mohali w.e.f. 23.9.2016 to 30.9.2016. The total bill for medical treatment of the complainant was Rs.2,23,332/-. The original bills had already been submitted with OP No.1. Complainant after undergoing surgery submitted all the bills to OP No.1 as per their guidelines. He had been requesting the OP to reimburse the bill amount of his knee replacement to which he is legally entitled. He also written a request on 27.10.2016 through registered post alongwith all the requisite documents but he has not been paid a single penny.
6.It is pleaded that complainant suffered great hardship due to act and conduct and deficiency of OP No.1 as the OP has failed to reimburse the bill despite repeated requests and service of legal notice.
7.It is also mentioned that OP has also withheld bill of Rs.19641/- in respect of treatment of her deceased daughter without any reasonable cause. Under the scheme, the OP is liable to pay medical treatment bills upto limit of Rs.3lac.Earlier under the said scheme complainant has been paid amount of Rs.82237/-.There is no over withdrawal on the part of the complainant. The balance payment of medical bills, reimbursement or otherwise is liability of OPs No. 2 or 3.
8.It is mentioned that as per guidelines issued in this regard by State of Punjab, if, for any reason the insured has failed to pay the amount of bills to any hospital, insurer is liable to reimburse the same after treatment to the claimant.
9.Complainant has claimed Rs. one lac as compensation for mental tension, agony & harassment, Rs.25000/- as litigation expenses. Hence this complaint.
10.In view of the statement of the complainant, notice to OPs No.2to4 was dispensed with as they were impleaded as proforma parties.
11.Upon notice, none appeared on behalf of OP No.1. As such OP No.1 was proceeded against exparte vide order dated 10.8.2017.Thereafter on the application moved by the complainant, OP No.1A being insurer was impleaded as party. Notice to OP No.1A was issued. OP1A appeared through counsel and contested the complaint by filing the written reply. In reply, the contesting OP raised preliminary objection that the complaint is not maintainable; complainant has no cause of action to file the complaint. Complainant was fully knowing that Fortis Hospital, Mohali has refused to him medical treatment against alleged mediclaim policy; that as per para 4 of the Govt. of Punjab notification dated 20.10.2015, it has been specified that, no reimbursement will be available to employee/pensioner in the Punjab and Chandigarh where cashless treatment is available .
12.On merits, it is reiterated that as per notification, no reimbursement is available to the pensioners where cashless treatment is available. The terms and conditions of the subject medi claim policy as well as of Punjab Govt. Instruction/Notification concerning the subject mediclaim policy is explained to the insured or the representative at the time of issue of subject mediclaim insurance policy. Complainant is well aware of the same since he is retired from the Health Department. In the end the version of the OP is that as the Fortis Hospital has denied cashless treatment, therefore, the complainant was not entitled to the reimbursement as per terms and conditions of the policy as well as instructions/guidelines of Punjab Govt.
13.Regarding claim of Rs.19642/-, the version of the OP is that the complainant should provide detail of repudiation letter/less amount paid in respect of his daughter’s treatment with date of admission, discharge etc. to enable the OP to get the requisite information from the TPA and the same shall be given at the time of evidence of the OPs provided complainant submits the detail of claimed amount of Rs.19642/-.In the end, the OP prayed for the dismissal of the complaint.
14.In support of his claim, the complainant tendered into evidence his affidavit, Ex.CA, Ex.CB, copy of PPO order, Ex.C1, copy of identity card, Ex.C2, copy of prescription, Ex.C3, copy of letter, Ex.C4, postal receipts, Exs.C5 to C7, copy of certificate, Ex.C8, copy of letter, Ex.C9, postal receipts, Exs.C10 to C12, copy of legal notice, Ex.C13, postal receipts,Exs.C14 to C16, copy of scheme, Ex.C17, copy of reply to legal notice, Ex.C18, copy of list of hospitals, Ex.C19.
15.The OP tendered into evidence affidavit of Mukesh Malhotra, Ex.OPA, copy of e-mail,Ex.OP1, copy of Pb.Govt. Notification, Ex.OP2 alongwith terms and conditions.
16.We have heard the ld. counsel for the parties and gone through the record of the case, carefully.
17.The ld. counsel for the complainant has reiterated the stand as taken in the complaint. It is further submitted that the material facts are not in dispute. It is admitted that the complainant is retired Govt. employee. He is covered under the medical benefits scheme i.e. Punjab Govt. Employees and Pensioners Health Insurance Scheme. The complainant took treatment from Fortis Hospital, which is empanelled hospital. Of course, the empanelled hospital was under obligation to provide cashless treatment as per the scheme but the hospital illegally denied cashless treatment .Complainant was compelled to pay the bill from his pocket. This fact is also not disputed. The complainant is entitled to reimbursement. But the OP has denied the reimbursement under the shelter of Section 4 of the notification, copy of which is produced as Ex.OP2. Of course as per this section no reimbursement is available to the treatment, where cashless treatment is available. But when the cashless treatment is illegally denied, the OP cannot deny from reimbursement. OP has also placed on record copy of the scheme, Ex.OP2/4. Cashless treatment service is detailed in paragraph 12 of the scheme. It is also mentioned in clause v & vi of the scheme that in case of payment of expenses by the beneficiary, the insurer is to unconditionally and without any demur make the reimbursement of the hospitalization expenses. This fact is also further elaborated in clause vi of the scheme. Therefore, in that situation, the complainant was entitled to reimbursement. OP has illegally denied the reimbursement. Deficiency in service on the part of the OP is established. The complainant is entitled to medical expenses with interest, compensation and costs of litigation.
18.On the other hand, the ld. counsel for the OP1A has submitted that the reimbursement is available only as per notification dated 20.10.2015. No party can go beyond the notification. Clause 4 of the notification makes it clear that the treatment can be taken by any enrolled beneficiary in the empanelled hospitals and no reimbursement will be available where cashless treatment is available. Admittedly the complainant took treatment at Mohali. As per complainant himself, the hospital authorities denied the cashless benefits. As such complainant was well aware that he cannot take benefit of cashless treatment at Fortis Hospital. He was to approach some other empanelled hospital where cashless treatment was available. The treatment was related to knee transplant which cannot be accepted as a case of emergency. Complainant was having sufficient time to take up the matter with the employer/authorities before getting treatment. Complainant himself is at fault. As such OP is justified to deny the claim.
19.We have given careful consideration to the rival submissions.
20.The admitted facts are that the complainant is retired Govt. employee. The Pb. Govt. launched scheme for medical treatment for the Govt. employees. As per the scheme, the State Govt. availed the services of OP1A for cashless medical treatment to the beneficiaries and other employees. The complainant was also issued ID card entitling him benefits under the scheme. Complainant approached Fortis Hospital for cashless treatment. Admittedly Fortis Hospital is empanelled hospital. List Ex.C9 also proved this fact. Moreover, it is not denied by the OP that the Fortis Hospital is not empanelled hospital. As per Section 4 of the notification,Ex.OP2, employees can take treatment from any empanelled hospitals. It is also mentioned that no reimbursement is available to the employees/beneficiaries in Punjab, Chandigarh and Panchkula, where cashless treatment is available. But in this case the Fortis Hospital has admittedly denied cashless treatment. Whether Fortis Hospital was justified to deny cashless treatment is beyond the scope of this complaint, as this matter is not raised by the complainant. Therefore, this Forum is not going to touch this point whether Fortis Hospital was justified to deny cashless treatment. The fact remains that Fortis Hospital has denied cashless treatment.
21.The next question is when empanelled hospital deny cashless facility, what is the remedy with the patient who is entitled for treatment under the scheme. OP itself has produced on record copy of the scheme containing salient features (OP2/4). Paragraph 12 (v,vi) will be helpful to solve the controversy in that situation. For the sake of convenience, both paragraphs are being reproduced as under:
- In case of payment of expenses by the Beneficiary to the hospital because of non resolution of query of the hospital or delay in issuance of authorization letter to the hospital, the insurer shall unconditionally and without any demur make the reimbursement of the hospitalization expenses incurred by the Beneficiary at the actual rates charged by the hospital, irrespective of the package rates, not exceeding the maximum limit of Rs.3 lacs of the Sum Insured.
- In an event a Member goes to a Provider Hospital and inspite of showing his/her ID card to the hospital authorities within stipulated time period, is 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 theTPA as per the check list for reimbursement within 60 days of date of discharge from the hospital. In such cases, the TPA/Insurer shall extend full cooperation to the Beneficiary and depending upon merit/genuineness of the case, determine the admissibility of the claim within the purview of the Scheme and settle the claim within 15 days of receipt of the claim, in accordance with terms and conditions of the scheme
22.Therefore, aforesaid provisions make it clear that when the payment of expenses is made by the beneficiary to the hospital the insurer is under obligation to reimburse the claim unconditionally and without any demur. Hence, the OP is not justified to deny the claim only for the reason that cashless treatment was denied by the Fortis Hospital.
23.The complainant has claimed expenses of Rs.2,23,332/- for his treatment. This amount is not disputed by the OP. Complainant has also placed on record medical reimbursement certificate, Ex.C8 to support this fact. Therefore, the complainant is entitled to reimbursement of this amount from the OP.
24.Of course, the complainant has also claimed interest on this amount @18% per annum but the complainant is under Punjab Govt. Employees and Pensioners Health Insurance Scheme. For the welfare of the Govt. employees the State Govt. has not charged any premium from the complainant. In such circumstances no interest can be paid on the billed amount. Hon’ble Supreme Court has also so observed in the case of Om Parkash Gargi Vs. State of Punjab (SLP No.19497 of 1996, decided on 7.10.1996).
25.For the reasons recorded above, the complaint is partly accepted with Rs.10,000/- as compensation and costs. The OP1A is directed to pay the amount of Rs.2,23,332/- , the expenses incurred on the treatment alongwith Rs.10,000/- as compensation and costs, to the complainant within a period of 45 days from the date of the receipt of the certified copy of this order.
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.
ANNOUNCED
DATED:5.4.2019
B.S.Dhaliwal Inderjeet Kaur M. P. Singh Pahwa
Member Member President
