Complainant Beni Prashad through the present complaint filed U/s 12 of the Consumer Protection Act, 1986 (hereinafter called the Act) has prayed for issuance of the necessary directions to the titled opposite parties to pay Rs.1,78,000/- as Medical Claim as per the Health Insurance Scheme. Opposite parties be further directed to pay Rs.10,000/- as litigation expenses and Rs.10,000/- as damages for illegal tension and harassment and any further relief as this Hon’ble Forum deems fit in the interest of justice.

2.          The case of the complainant in brief is that he  is a retired Punjab Government employee and is a pensioner. As per the policy of the Government under the name of Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) he was insured and was issued an ID card bearing No.MD15-09478943336 by opposite parties. He was insured from the period with effect from 1.1.2016 to 31.12.2016 and as such he is consumer of the opposite parties. On 21.09.2016 he fell severely ill and admitted in the ICU in department of cardiology in Amandeep Hospital Pathankot and was diagnosed HTN, Type II DM. The PCI + Stenting to LAD were done. At the time of admission in the hospital, his son informed the hospital that his father has been insured under the government scheme and has shown the copy of the ID card to the hospital and demanded for the cashless treatment. The hospital after taking the relevant documents from his son told that they are not getting necessary approval from the insurer as such he was made to deposit advance money and all the expenses during the treatment were borne by him.  He has further pleaded that after his recovery he contacted the opposite party and sent them the claim file regarding his treatment with effect from 21.9.2016 to 23.09.2016 done at Amandeep Hospital, Pathankot and Rs.1,78,000/- which was paid in the hospital during treatment was claimed by him from the opposite parties.  He alongwith the claim application sent all the bills and discharge slip, ID card copy, PPO and list showing that Amandeep Hospital Pathankot falls in the list of approved Hospitals. He received a letter from the opposite party dated 24.11.2016 on 13.02.2017 whereby opposite party no.1 had demanded investigation report ECO report, Films, CAG report B ARR CODE + retail invoice of stent. As per the demand of the opposite party no.1 he has submitted all the relevant documents to the opposite party no.1 vide registered letter dated 18.02.2017. Since 18.02.2017 he has made various efforts to approach the opposite parties and requested them to reimburse his claim but all in vain.  Hence this complaint.

3.       Upon notice the opposite party no. 2 appeared and filed its written reply through its counsel taking the preliminary objection that the complaint of the complainant against opposite party is not maintainable; the present complaint is bad for non-joinder and mis-joinder of necessary parties. On merits, it was submitted that the complainant had filed the claim with opposite party no.1 for reimbursement of billed amount of Rs.1,78,000/-, while on settlement of the claim by the TPA,  the Insurance Company has paid Rs.1,09,254/- out of the billed amount Rs.1,78,000/- by deducting Rs.68,746/-. The Insurance Company made the deductions from the bills of the complainant and paid the amount as per the list of tender rates determined in accordance with PGEPHIS. The Insurance Company has paid as full and final payment to the complainant as settled by the opposite party no.1 under the provisions of the scheme and now there is nothing remains payable.  It was next submitted that as soon as the opposite party no.1 i.e. M.D. India Health Care Services Pvt.Ltd., which is the Third Party Claim Settling Authority, received the claim of the complainant, the same was settled under the terms and conditions of the PGEPHIS. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Notice issued to the opposite party no.1 had not been received back. Case called several times, but none had come present on its behalf, therefore, it was proceeded against exparte vide order dated 10.7.2017

5.     Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 alongwith other documents Ex.C2 to Ex.C38 and closed the evidence.

6.       Counsel for the opposite party no. 2 tendered into evidence affidavit of Karam Singh Ex.OP1 alongwith other document Ex.OP2 and closed the evidence.

7.        We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants along with the scope of adverse inference that may be discretionarily/judicially drawn on account of the intentional non-participation/ex-parte proceedings by one of the titled opposite parties despite the proven service of the summons; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants.

8.       We observe that the prime dispute (affidavit Ex.C1) prompting the herein deposed complaint pertained to the alleged non-settlement of the complainant’s insurance claim seeking reimbursement of medical-expenses Rs.1,78,000/- by the OP insurers allegedly on one or the other pretext and that too after having once refused the pre-operative sanction to the treating hospital that otherwise has been eligibly available to network hospitals vide the terms of the applicable insurance scheme/policy. However, the OP insurers have advised vide written reply supported by accompanying affidavit Ex.OP1 that the impugned claim stands settled by them but for Rs.1,09,254/- only qua the settled medical-treatment expenses for the one particular treatment with the network hospitals and as per Ex.OP2 have settled Rs.53,624/- for complete angioplasty procedure against Rs.85,000/- as charged by the treating hospital; and Rs.52,000/- as cost of stent against Rs.85,000/- as charged by the treating hospital and Rs.3,630/- as settled charges for CAG against Rs.8,000/- as charged by the treating hospital from the present complainant. So far so good, as it goes well with the settled statutory principles that the health insurers need to settle the medical treatment claims of its insured @ its settled rates with network hospitals to the claimants receiving treatment at non-network hospitals. Further, we find that the medical-treatment rates as settled with the health insurers by network hospitals are quite moderate (and low) measured against its treatment-rates as charged to other individual patients. And, it is for this very reason/logic that pre-sanction is anticipated by the network hospitals from the insurers so that they may claim reimbursement directly but @ network settled rates only. Also, the insured patients who prefer medical-treatment at the non-network hospitals are reimbursed @ network settled rates and the difference is borne by the insured patient.

9.       Finally, we find here in the present case the complainant had received the medical-treatment at the insurers’ network hospital who had also applied for pre-treatment sanction (with the insurers) that was however refused for un-explained reasons. And, the treating hospital thus charged Rs.1,78,000/- @ higher individual-patient rates whereas the insurers reimbursed the complainant-claim for Rs.1,09,254/- @ network moderate rates and presently the difference of Rs.68,746/- had to be unnecessarily borne by the present complainant but for the lapse on the insurers’ part.

 10.    Further, we find that the impugned insurance claim has been duly filed by the complainant with the OP insurers (competent authority) who have somehow settled the same but at lower network hospital rates after having first refused pre-treatment sanction to treating hospital and have neither produced on record their expert opinion of the OP1 TPA (Third Party Administrator) who have somehow stayed away from the complaint proceedings nor the impugned claim-settlement has been supported by some other cogent evidence etc. We also find that the terms and conditions of the related policy are also not exhibited here and it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured complainant and in the absence of the same these cannot be enforced upon him at the stage of settlement of reimbursement of claim(s).

11.     In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party (1 & 2) insurers to pay/refund the difference in medical expenses of Rs.68,746/- (incurred and settled) to the complainant besides to pay him a sum of Rs.10,000/- as cost and compensation (for having suffered undue harassment) within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment.  

12.     Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.    

                                                            (Naveen Puri)

                                                                President.      

ANNOUNCED:                                 (Jagdeep Kaur)

May, 14, 2018.                                           Member.

*MK*