DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/325

Date of Institution   : 27.04.2018/29.11.2021

Date of Decision    : 04.07.2022

Smt. Balwinder Kaur wife of S. Harpal Singh resident of 431, East Mohan Nagar, Sultanwind Road, Amritsar.      

                …Complainant Versus

1.M.D. India Health Insurance TPA Private Limited, Mohali Tower, 1st Floor, F-539, Industrial Area, Phase 8 – B, Mohali through its Manager/Executive Officer/Managing Director/Authorized Signatory.

2.Dr. Pruthi's Capitol Hospital, Nurturing Health – Touching its Director/Authorized Signatory, Jalandhar Pathankot Road, NH – 44, Near Reru Chowk, Jalandhar. 

3.Oriental Insurance Company Limited, through its Regional Manager, having its regional office at SCO No. 109 – 110 – 111, Suriendera Building, Sector 17 – D, Chandigarh.  

               …Opposite Parties

 

Complaint Under Section11,  12 and 13 of Consumer Protection Act, 1986. As Amended Upto Date.

 

Present: Mrs. Monika Khanna Adv counsel for complainant.

Sh. Rajinder Nayyar Adv counsel for opposite party No. 1 & 3.

Opposite party No. 2 exparte.

 

Quorum:-

1. Sh. Ashish Kumar Grover : President

2.Sh. Navdeep Kumar Garg : Member 

 

(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):

1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 11, 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against M.D. India Health Insurance TPA Private Limited and others (hereinafter referred as opposite parties).

2. Brief facts of the case are that the complainant has retired as a JBT Teacher from Government Primary School, Amritsar and she is a pension holder of Punjab Government being a retired Teacher under Punjab School Eduction Board and is entitled to all the benefits of a pension holder being retired Punjab Government Employee. It is alleged that the complainant was suffering from Osteoarthritis Bilateral Knee Joints problem and was advised surgery for the same. Accordingly, the complainant opted to get the surgery of Knee Replacement done from Dr. Pruthi's Capitol Hospital, Jalandhar Pathankot Road, Jalandhar and was admitted in the hospital on 20.9.2016 and discharged on 27.9.2016 after seven days. It is further alleged that at the time of admission in the hospital the complainant deposited the card issued under the Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) in her name. She is having ID Card No. MD -15 – 09780179413 and the policy period was from 1.1.2016 to 31.12.2016 and the said card was of Oriental Insurance Company Limited i.e. opposite party No. 3 and the same was kept by the hospital authorities. On the basis of this card the opposite party No. 1 was to get the payment from opposite party No. 3 to be paid to either complainant or the hospital authorities. It is further alleged that before the operation of both Knee Replacement the complainant deposited earlier an amount of Rs. 5,000/- as security on 17.9.2016 vide receipt No. FRT/16 -17/00023066 and Rs. 1,50,000/- on 20.9.2016 vide receipt No. FRT/16 – 17/00023514 and finally the last payment was taken from complainant on 27.9.2016 of Rs. 1,00,000/- vide receipt No. FRT/16 – 17/00024361 upon the demand of hospital authorities even after deposit of card with the assurance that the total amount of Rs. 2,55,000/- received from the complainant by the hospital will be reimbursed to her through MD India Insurance TPA Private Limited or from the opposite party No. 3. Discharge Summary and Post Discharge Prescription Slip and follow up advice was given to the complainant on 27.9.2016 alongwith essentiality certificate duly signed by the Medical Officer of Capitol Hospital and signed by the complainant and the complainant given the attested copy of the same to Punjab Government Employee and Pensioners Health Insurance Scheme Card duly signed by authorities persons of Capitol Hospital, Jalandhar and the same was signed by the complainant also. It is further alleged that when she went for getting the stitches removed the complainant talked to the hospital authorities about the charges of operation received from her then the hospital authorities stated that she will be reimbursed by the insurance company i.e. opposite party No. 3 through opposite party No. 1 and asked her to apply for reimbursement. The complainant wrote a letter in December, 2016 to the MD India Health Care Service Private Limited at Mohali for reimbursement of Rs. 2,55,000/- spent by her on treatment but of no use. Thereafter, the complainant started regularly visiting the hospital authorities to get the reimbursement of the above said amount for complainant from insurance company through opposite party No. 1 but to no effect. Finally, on 20.2.2018 the complainant served a legal notice through counsel upon the MD India Health Care Private Limited, Naxpro Park D – 38, 1st Floor, Industrial Area Phase – 1, Mohali to reimburse the complainant and the same was duly served but no reimbursement was done to the complainant and in reply dated 10.3.2018 to the above notice the MD India Health Care Private Limited totally refused their liabilities of reimbursement. All this has been done by opposite party No. 1 & 3 in connivance with opposite party No. 2. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice on their part. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To reimburse the amount of Rs. 2,55,000/- of medical expenses. 

ii) To pay Rs. 75,000/-  as compensation on account of mental agony and harassment and Rs. 11,000/- as litigation expenses.    

3. Upon notice of this complaint, the opposite parties No. 1 & 3 appeared and filed written version by taking preliminary objections interalia on the ground of complaint is not maintainable because the beneficiary under Punjab Government Employee And Pensioners Health Insurance Scheme doesn't fall under the category of consumer. The complainant is not a consumer of the opposite parties because there is no direct contract between the opposite parties and employees covered under Punjab Government Employee And Pensioners Health Insurance Scheme. Further, as per the Government of Punjab department of health and family welfare Notification No. 21/28/12-5 HB 5-268 dated 20.10.2015 the Government has introduced a cashless health insurance scheme to its employees to cover indoor medical treatment expenses and for this purpose the government has notified the hospitals as described in Para 4 of the notification which read that treatment can be taken by any enrolled beneficiary in government or in empaneled hospitals in Punjab, Chandigarh and Panchkula where cashless treatment is available. The rates of treatment for private hospital in Punjab and Chandigarh determined in accordance with Punjab Government Employees And Pensioners Health Insurance Scheme Rates, the rates shall be internal rates of the respective government hospital. The treatment provided shall be on essentially on cashless basis on the empaneled hospital where cashless services has not been rendered by the hospital due to any reason whatsoever. 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. It is further alleged that the complainant has not come with clean hands because the complainant has taken her treatment from Dr. Pruthi's Capitol Hospital, Jalandhar Pathankot Road, Jalandhar which is not empaneled hospital. In Para No. 4 of the Gazette notification No. 21/28/12-5 HB 5-268 dated 20.10.2015, where it has been specifically mentioned that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available as such the present complaint is not maintainable. It is further alleged that as per the version of the complainant that she has spent Rs. 2,55,000/- on her treatment for knee replacement. However, as per the government notification the prescribed rates for the knee replacement is covered under Code 1132 for which she is only entitled for Rs. 1,98,148/-, but in this case the complainant has violated the terms and conditions of the notification issued by the Government of Punjab. On merits, the opposite parties No. 1 & 3 denied the case of the complainant. It is alleged that the complainant has informed the opposite party No. 1 regarding her treatment in December, 2016 as mentioned in the complaint which is about 3 months after the admission of the complainant in the hospital. The opposite parties No. 1 & 3 replied the legal notice served by the complainant in which it has been clearly mentioned that the replying opposite parties were not liable to pay any claim to the complainant because she has violated the terms and conditions of notification issued by the Government of Punjab. As such, there is no deficiency in service on their part and prayed for the dismissal of complaint.

4. Notice was sent to opposite party No. 2 but the opposite party No. 2 failed to appear and was proceeded against exparte vide order dated 15.6.2018. 

5. In support of her case the complainant tendered into evidence her own affidavit Ex.CA, affidavit of Harpal Singh Ex.CB alongwith documents Ex.C-1 to C-8 and closed the evidence. 

6. To rebut the case of the complainant the opposite parties No. 1 & 3 tendered into evidence affidavit of Sh. Om Parkash Dhawan, Divisional Manager Ex.O.P1.3/1, copy of letter dated 2.3.2016 Ex.O.P1.3/2, copy of notification of the Department of Health and Family Walfare Ex.O.P1.3/3, copy of insurance policy Ex.O.P1.3/4, copy of the PGEPHIS schedule of rates Ex.O.P1.3/5, copy of prescribed rate list Ex.O.P1.3/6, copy of reply of legal notice Ex.O.P1.3/7 and the evidence of opposite parties No. 1 & 3 is closed by order dated 24.4.2019.   

7. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties. Written arguments filed by opposite parties No. 1 & 3. 

 

8. Ld. Counsel for the complainant argued that the complainant has retired as a JBT Teacher from Government Primary School, Amritsar and she is a pension holder of Punjab Government being a retired Teacher under Punjab School Eduction Board and is entitled to all the benefits of a pension holder being retired Punjab Government Employee Ex.C-1. It is also argued by the Ld. Counsel for complainant that the complainant was suffering from Osteoarthritis Bilateral Knee Joints problem and was advised surgery for the same and the complainant opted to get the surgery of Knee Replacement done from Dr. Pruthi's Capitol Hospital, Jalandhar Pathankot Road, Jalandhar, where she was admitted in the hospital on 20.9.2016 and discharged on 27.9.2016 after seven days Ex.C-2. It is further argued by the Ld. Counsel for complainant that at the time of admission in the hospital the complainant deposited the card having ID Card No. MD -15 – 09780179413 and the policy period was from 1.1.2016 to 31.12.2016 Ex.C-5 issued under the Punjab Government Employee and Pensioners Health Insurance Scheme (PGEPHIS) in her name and the said card was of Oriental Insurance Company Limited i.e. opposite party No. 3 and the same was kept by the hospital authorities. It is further argued by the Ld. Counsel for complainant that before the operation of both Knee Replacement the complainant deposited earlier an amount of Rs. 5,000/- as security on 17.9.2016 vide receipt No. FRT/16 -17/00023066 and Rs. 1,50,000/- on 20.9.2016 vide receipt No. FRT/16 – 17/00023514 and finally the last payment was deposited by the complainant on 27.9.2016 of Rs. 1,00,000/- vide receipt No. FRT/16 – 17/00024361 Ex.C-3, upon the demand of hospital authorities and Discharge Summary and Post Discharge Prescription Slip and follow up advice was given to the complainant on 27.9.2016 alongwith essentially certificate Ex.C-4 duly signed by the Medical Officer of Capitol Hospital and signed by the complainant and the complainant given the attested copy of the same to Punjab Government Employee and Pensioners Health Insurance Scheme. It is also argued by the Ld. Counsel for complainant that the complainant wrote a letter in December, 2016 Ex.C-6 to the MD India Health Care Service Private Limited at Mohali for reimbursement of Rs. 2,55,000/- spent by her on treatment and thereafter the complainant started regularly visiting the hospital authorities to get the reimbursement of the above said amount for complainant from insurance company through opposite party No. 1 but till date the opposite party No. 1 did not reimburse the amount of Rs. 2,55,000/- to the complainant. 

9. On the other hand, Ld. Counsel for opposite parties No. 1 & 3 argued that as per the Government of Punjab department of health and family welfare Notification No. 21/28/12-5 HB 5-268 dated 20.10.2015 Ex.O.P1.3/3 the Government has introduced a cashless health insurance scheme to its employees to cover indoor medical treatment expenses and for this purpose the government has notified the hospitals as described in Clause 4 of the notification, which read as under;-

“The treatment can be taken by any enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). Further, details of the scheme can be seen on website www.pbhealth.gov.in. No reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. However, reimbursement can be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances, in such circumstances, the insurance company will reimburse the bill of the employee up to Rs. 3.00 lacs as per the package rates defined under the scheme”

It is further argued by the Ld. Counsel for opposite parties No. 1 & 3 that the treatment provided shall be on essentially on cashless basis on the empaneled hospital where cashless services has not been rendered by the hospital due to any reason whatsoever and 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. It is further argued by the Ld. Counsel for opposite parties No. 1 & 3 that the complainant has taken her treatment from Dr. Pruthi's Capitol Hospital, Jalandhar Pathankot Road, Jalandhar, which is not empaneled hospital and in Clause No. 4 of the Gazette notification No. 21/28/12-5 HB 5-268 dated 20.10.2015, where it has been specifically mentioned “that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available”. It is further argued by the Ld. Counsel for opposite parties No. 1 & 3 that the complainant in her complaint alleged that she has spent Rs. 2,55,000/- on her treatment for knee replacement, however as per the government notification the prescribed rates for the knee replacement is covered under Code 1132 Ex.O.P1.3/6 for which she is only entitled for Rs. 1,98,148/-, but in this case the complainant has violated the terms and conditions of the notification issued by the Government of Punjab.  It is also argued by the Ld. Counsel for opposite parties No. 1 & 3 that the complainant has informed the opposite party No. 1 regarding her treatment in December, 2016 as mentioned in the complaint which is about 3 months after the admission of the complainant in the hospital Ex.C-6. The opposite parties No. 1 & 3 replied the legal notice served by the complainant Ex.O.P1.3/7 in which it has been clearly mentioned that the replying opposite parties were not liable to pay any claim to the complainant because she has violated the terms and conditions of notification issued by the Government of Punjab.

10. So, from the perusal of Notification No. 21/28/12-5 HB 5-268 dated 20.10.2015 Ex.O.P1.3/3 it is proved from the Para No. 4 that treatment can be taken by enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi) and no reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. However, reimbursement can be taken by employee/pensioners for medical treatment taken in any other State in India in exceptional circumstances. But in the present case the complainant has taken her treatment from Dr. Pruthi's Capitol Hospital, Jalandhar Pathankot Road, Jalandhar, which is not empaneled hospital and the complainant has violated the terms and conditions of the notification issued by the Government of Punjab. The complainant failed to prove that Dr. Pruthi's Capitol Hospital is empaneled. Moreover, the complainant has informed the opposite party No. 1 regarding her treatment in December, 2016 which is about 3 months after the admission of the complainant in the hospital which proves from Ex.C-6. Therefore, we are of the view that the complainant is not entitled to reimbursement of Rs. 2,55,000/- from the opposite parties No. 1 & 3.

11. In view of the above discussion, there is no merit in the  present complaint and same is dismissed. However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.    

ANNOUNCED IN THE OPEN COMMISSION:

       4th Day of July, 2022

 

 

            (Ashish Kumar Grover)

            President             

 

(Navdeep Kumar Garg)

Member