Complainant Bhagat Ram had filed the present complaint U/s 12 of the Consumer Protection Act against the opposite party and praying that the directions may kindly be issued to the opposite party to pay the reimbursement of the amount of Rs.2,54,904/- paid by him to the hospital for treatment alongwith interest @ 12% per annum from the date it becomes due till its realization and further be directed to pay Rs.20,000/- for harassment and deficiency in services and Rs.10,000/- as litigation expenses, in the interest of justice.
2. The case of the complainant in brief is that he was serving in the Education Department under Govt. of India and retired in the month of January, 1997 as Central Head Teacher from Govt. Primary School Naushehra Block Dorangla, Tehsil and Distt. Gurdaspur and was insured by the Govt. of Punjab being its employee and as per the policy employees/pensioners were covered for health benefits. It was pleaded that as per scheme complainant being beneficiary was covered under the policy and a card bearing No.MD 15-09501468815 was issued in his favour and he is entitled for cashless facility in empanelled hospital or in Govt. hospital and opposite party had to pay the claim as the card was duly issued by them to the complainant which was upto Rs.3,00,000/- for health benefits including cashless facility. It was further pleaded that unfortunately, complainant suffered from chronic disease during the period of policy and in emergency he was taken to Fortis Hospital Mohali where he remained indoor patient from 12.10.2016 to 17.10.2016 and got treated there. As the said hospital was on the panel but no cashless facility was given to the complainant and he paid an amount of Rs.2,54,904/- to the hospital authorities from his own pocket and his family members also requested to the hospital to provide the cashless facility as complainant was not in fit condition and amount deposited by him due to required urgent treatment. It was also pleaded that after getting discharge as per instructions of the opposite party all the required documents were sent through registered post by the complainant on 15 February, 2017 by completing all the formalities to the opposite party for getting the reimbursement of claim but no claim paid by them and after that even a reminder letter was sent on 30.03.2017 through registered post but nothing was done by the opposite party. It was next pleaded that there was deficiency in services on the part of the opposite party as they failed to pay the genuine claim of the complainant inspite of completing all the formalities, hence this complaint.
3. Upon notice opposite party appeared through their counsel and filed their written reply by taking the preliminary objections that the present complaint is not maintainable as the claim of the complainant had rightly been rejected by the opposite party on the notification No.21/28/12-5HB5/268 dated 20.10.2015 as the reimbursement cannot be made where cashless facility is available; As per the this notification no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available and the Fortis Hospital Mohali where complainant allegedly remained admitted, not empanelled for the said ailment. Para No.4 of the notification is as under:-
"The treatment can be taken by any enrolled beneficiaries in Government or in empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). No reimbursement will be available to employee/pensioner in the Punjab, Chandigarh and Panchkula, where cashless treatment is available…….."
that there was no insurance contract exists between the complaint and opposite party. It was stated that scheme was sponsored by the Punjab Government to its employees/pensioners and no insurance consideration was deducted from their salaries and as such opposite party has contractual liability towards Punjab Govt. only, not against the complainant as he is not covered within definition of 'Consumer' under CPA; that present complaint is mis-joinder and non-joinder of the necessary parties as the The Oriental Insurance Company and Punjab Government are the necessary parties which was not made party of the present complaint. On merits, it was stated that the employees or pensioners are entitled for the health insurance benefits under the PGEHIS Scheme only under the terms and conditions of the same and opposite party had rightly been rejected the claim of the complainant under the provisions of above said notification of the scheme. All other averments made in the complaint have been denied and prayed for dismissal of the complaint with litigation costs and any other relief which the opposite party is found entitled under the law.
4. Counsel for the complainant to prove the case had filed affidavit of complainant with copies of documents Ex.C1 to Ex.C47 and closed the evidence on behalf of complainant.
5. On the other hand counsel for the opposite party had filed affidavit of Mr. Md Samiyoddin Patel Sr. Legal Manager with copies of documents Ex.OP-1 to Ex.OP-3 and closed the evidence on behalf of opposite party.
6. Written arguments filed by both the parties.
7. We have carefully examined all the documents/evidence produced on record for its contained statutory merit and have also judiciously considered and perused the arguments duly put forth by the learned counsels for the parties.
8. From the over all circumstances as enumerated in respective pleadings of the parties, it reveals that the complainant was serving in the Education Department and retired in the month of January, 1997 as Central Head Teacher from Govt. Primary School Naushehra Block Dorangla, Tehsil and Distt. Gurdaspur. He was insured by the Govt. of Punjab being its employee and as per the policy employees/pensioners were covered for health benefits. Thereafter a card bearing No.MD 15-09501468815 was issued in his favour and he is entitled for cashless facility in empanelled hospital or in Govt. hospital and opposite party had to pay the claim which was upto Rs.3,00,000/- for health benefits including cashless facility. Thereafter complainant suffered from chronic disease during the period of policy and in emergency he was taken to Fortis Hospital Mohali where he remained admitted from 12.10.2016 to 17.10.2016 and he paid an amount of Rs.2,54,904/- (Ex.C-12) to the hospital authorities from his own pocket which are as Ex.C10 to Ex.C47. There after complainant submitted all the required documents to the opposite party for getting the reimbursement. There after a reminder letter was sent on 30.03.2017 through registered post which is as Ex.C2, but the opposite parties had rejected the claim of the complainant (Ex.OP-2) with the plea that Fortis Hospital Mohali where complainant remained admitted was not empanelled for the said ailment and as per the notification No.21/28/12-5HB5/268 dated 20.10.2015 which is as Ex.OP-2 and Ex.OP-3, the reimbursement cannot be made where cashless facility is available; As per this notification no reimbursement will be available for the treatment in Punjab, Chandigarh and Panchkula where cashless treatment is available.
9. The Ld. counsel for complainant argued that opposite parties cannot repudiate the claim of the complainant on the ground of alleged terms and conditions, which were never supplied or explained to him at the time of inception of insurance Policy. He placed reliance on citation 2001(1)CPR 93(SC) 242 titled as M/S Modern Insulators Ltd., Vs The Oriental Insurance Co. Ltd wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it generally seen that insurance companies are only interested in earning the premium and find ways and means to decline the claims. Ld. counsel for complainant further argued that complainant was taken to Fortis Hospital Mohali in emergency under compelling circumstances. Attendants of the complainants were not aware about the insurance in question and in emergency they did to save the life of complainant and not supposed to find hospital for treatment as per alleged terms and conditions of Insurance Policy, which can be fatel for patient. Even as per notification dated 20.10.2015 regarding said insurance scheme copy of which is Ex.OP3 at clause no.4, it is clear that reimbursement can be taken by any employee/pensioner for medical treatment taken in any other state in India in exceptional circumantances. In view of the above, we are of the opinion that it is generally seen that insurance companies rejected the claim on various grounds.
10. Therefore, as a sequel of the above discussion, facts and circumstances of this case this commission is of the considered opinion that the complaint took his treatment in emergency conditions and at that time he cannot be supposed to approach any empanelled hospital of opposite parties, which might be risk for his life. The Opposite parties wrongly and illegally repudiated the claim of the complainant for reimbursement of his medical treatment which amounts to deficiency in service on their part.
11. Hence the present complaint is partly allowed and OPs are directed to make the payment of insurance claim as per PGI rates alongwith interest @ 6% per annum from the date of filing of the present complaint i.e. 27.07.2017 to the complainant within 45 days from the date of receipt of copy of this order, failing which opposite parties shall pay the amount alongwith interest @ 9% P.A. till its realization. In addition to this the Opposite parties are directed to pay Rs.5000/- on account of deficiency in service and litigation expenses to the complainant.
12. 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.
13. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
(Kiranjit Kaur Arora)
President
Announced: (B.S.Matharu)
April 06, 2023 Member
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