Punjab

Moga

CC/17/64

Vijay Kumar - Complainant(s)

Versus

M.D.India HealthInsurance (T.P.A.) Pvt. Ltd - Opp.Party(s)

In person

01 Nov 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                             CC No. 64 of 2017

                                                                             Instituted on: 03.07.2017

                                                                             Decided on: 01.11.2017

 

Vijay Kumar (Ex-Inspector), Punjab Roadways Patti Depot, District Tarantaran s/o Surjan Dass r/o Jail Wali Gali, House No.807, Ward no.10, Civil Line, Moga Tehsil and District Moga.

                                                                                ……… Complainant

 

Versus

1.       M.D. India Health Insurance TPA Pvt. Ltd. Mohali Tower, First Floor, F-539, Industrial Area, Phase-8B, Mohali.

 

2.       The Oriental Insurance Company, SCO no.99-100, Bank Secure Above Sindi Pasttery, First Floor, Sector 17-B, Chandigarh.

 

3.       General Manager, Punjab Roadways, Patti Depot, District Tarantaran.

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Vijay Kumar, complainant in person.

                   Sh. Jasvinder Singh, Advocate Cl. for opposite party nos.1 & 2.

                   Opposite party no.3 ex-parte.

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against M.D. India Health Insurance TPA Pvt. Ltd. Mohali Tower, First Floor, F-539, Industrial Area, Phase-8B, Mohali and others (hereinafter referred to as the opposite parties) directing them to pay Rs.19,452/- the amount of the claim. Further they may be directed to pay Rs.20,000/- as compensation on account of mental tension, agony and harassment suffered by the complainant.

2.                Briefly stated the facts of the case are that the complainant was retired from Punjab Roadways Patti Depot as Inspector and is a pensioner of Punjab Roadways. Opposite party no.3 has made a contract with opposite party no.1 regarding the medical reimbursement of their employees and officials and on the instructions of opposite party no.1, opposite party no.2 has been made the payment of medical bill of the employees of the opposite party no.3. So, M.D. India Health Insurance and Oriental Insurance Company has been made party to the present complaint. Unfortunately on 24.08.2016, the complainant got ill, as the urine of the complainant was stopped and due to which he was unconscious and he was brought to Lajwanti Hospital and Nursing Home Pvt. Ltd. ADJ A.I.R Jalandhar, where he was treated by the doctors of that hospital and told the complainant about the disease of Post Tur (Residual Prostate) and doctor told that due to unconsciousness of the complainant operation is to be conducted immediately, because of threat to the life of the complainant. To avoid the threat to the life of the complainant, operation of the complainant was got conducted and he was discharged on 25.08.2016. When the complainant was unconscious, the attendants of the complainant was not known about the hospitals which was empanelled by the Punjab Roadways, as such the treatment of the complainant was got conducted from Lajwanti Hospital, Jalandhar. The complainant lodged the claim for the reimbursement of his medical bills, which was sent to opposite party no.2 by opposite party no.1, but they refused to payment of claim on the ground that he has not taken the treatment as per the terms of opposite party no.1. The complainant requested the opposite parties a number of times to release his claim amount. Despite making various requests, the opposite parties had not pay the claim amount to complainant. Due to the acts of opposite parties, the complainant has suffered mental tension, agony and harassment. Hence this complaint.

3.                Upon notice, opposite party nos.1 & 2 appeared through counsel and filed written reply taking certain preliminary objections that opposite party nos.1 & 2 have been dragged into unnecessary litigation; that there is complicated questions of law and facts are involved and the same cannot be adjudicated in summary proceedings, therefore, this Forum has got no jurisdiction to try and decide the present complaint; that from the allegations of the complaint, the complainant does not fall under the definition of Consumer Protection Act; that the complaint is not maintainable under law; that the policy was issued in favour of Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, Phase-VI, near Civil Hospital, Sahibzada Ajit Singh Nagar, Punjab, but the complainant has not impleaded it in the present complaint, therefore, the present complaint is liable to be dismissed; that claim of the complainant was repudiated under para 4 of the Notification dated 20.10.2015 of Government of Punjab, Department of Health and Family Welfare. In the said letter the Punjab Health Systems Corporation System has made clear that :

          "As per para 4 of the notification, it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh where cashless treatment is available. However, it is clarified that the bills pertaining to Government hospitals like, PGIMER Chandigarh, GMCH Sector 32, Chandigarh and General Hospital, Sector 16, Chandigarh will be reimbursed to the employees on submission of their bills to the insurance company. The bills can be sent for reimbursement to the Oriental Insurance Company c/o MD India Healthcare Services (TPA) Pvt. Ltd. Maxpro Info Park, D-38, 1^st Floor, Industrial Area, Phase-I, Mohali, Punjab."

                   Therefore, the claim of the complainant was repudiated and the complainant had taken the claim file from the TPA i.e. MD India Healthcare Services (TPA) Pvt. Ltd Maxpro Info Park, D-38, 1^st Floor, Industrial Area, Phase-I, Mohali, Punjab, as per the information received from the TPA. On merits, it is submitted that as per tender of Punjab Government, the insurance company issued a insurance policy namely Punjab Government Employee and Pensioner Health Insurance Scheme (PGEPHIS) w.e.f 1.1.2016 to 31.12.2016 as per terms and conditions framed and implemented by Punjab State Govt. The sum insured was Rs.3,00,000/- for family on floater basis. Claim of the complainant was repudiated under para 4 of the Notification dated 20.10.2015 of the Govt. of Punjab, Department of Health and Family Welfare. Further submitted that the Punjab Govt. floated a tender notice called Punjab Government Employees & Pensioners Health Insurance Scheme, Department of Health & Family Welfare, PHSC Government of Punjab which having specified conditions and the tender of Punjab Government was accepted by the Insurance Company which was effective from 1.1.2016 to 31.12.2016. As per clause 24 of the tender this Forum has got no jurisdiction to try and decide the present complaint as there is specific provision regarding dispute between beneficiary and Health Care Provider/Care Provider and the TPA/Insurance Company shall be referred to District Level Grievance Redressal Committee which is reproduce as under:-

"24 Dispute Resolution and Grievance Redressal.

If any dispute arises between the parties during the subsistence of the policy period or thereafter, in connection with the validity, interpretation, implementations or alleged breach of any provision of the scheme, it will be settled in the following way:

a)       Dispute between Beneficiary and Health Care Provider/Care Provider and the TPA/Insurance Company:

1.       District Level Grievance Redressal Committee

Grievance Redressal Committee shall be set up in each District for all possible Redressal of grievance of beneficiaries/Health provider by the Insurer. The Committee will constitute following member:

i)       Deputy Commissioner

ii)      Civil Surgeon

iii)     Deputy Medical Commissioner

iv)     Representative of Insurance Company

v)      Representative of TPA

          The committee will resolve the Grievance within 30 days from the date of receiving the application. Any party, if not satisfied with the decision of the committee, can reach to the State Level Committee. Therefore, as per above said condition of the tender, the present complaint is not maintainable under law. As per terms and conditions of the tender the company has no liability to pay more than PGEPHIS Schedule of rate. The beneficiary is entitled the cost of treatment as per PGEPHIS package rate with hospitals. Thus, there is no deficiency in service on the part of answering opposite party. Further submitted that in Punjab it has been specified in para no.4 of the Notification that no reimbursement will be available for the treatment in Punjab and Chandigarh, where cashless treatment is available. Only empanelled Hospitals, in Punjab, Chandigarh and NCR are eligible for treatment of the enrolled beneficiaries. Therefore, the claim was repudiated. All other allegations of complaint have been denied and a prayer for dismissal of the complaint with costs has been made. 

4.                Notice issued for the service of opposite partyno.3 was not received back either served or un-served. As such, after expiry of statutory period of 30 days, opposite party no.3 was ordered to be proceeded against ex-parte.

5.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit as Ex. C1 and copies of documents Ex.C-2 to Ex.C-30 and closed the evidence. 

6.                On the other hand, opposite party nos.1 & 2 tendered in evidence duly sworn affidavit of Sh.Jasvinder Singh, Sr. Divisional Manager, Oriental Insurance Co. Ltd. as Ex.OP-1 & 2/1, another affidavit of Dr.Geeta Bhardwaj as Ex.OP-1 & 2/2 and copies of documents Ex.OP-1 & 2/3 to Ex.OP-1 & 2/6 and closed the evidence.

7.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

8.                The case of the complainant is that he was a Govt. employee retired from Punjab Roadways, Patti Depot and now he is pensioner of Punjab Roadways. Punjab Government made a contract with opposite party nos.1 & 2 regarding the medical reimbursement of their employees, officials and pensioners and all the payment of medical bills of the employees, officials and pensioners of Punjab Government was to be made by opposite party nos.1 & 2. On 24.08.2016, the complainant got ill as his urine was stopped and due to which he was unconscious and immediately he was brought to Lajwanti Hospital and Nursing Home Pvt. Ltd. Jalandhar, where he was treated by the doctors for the disease of Post Tur (Residual Prostate) and due to emergency condition and unconsciousness of complainant, his operation was to be conducted immediately, as there was threat to his life and he was discharged on 25.08.2016. At that time the complainant was unconscious and attendants of the complainant were not aware about the empanelled hospitals under the scheme, as such, the treatment of the complainant taken from Lajwanti Hospital and Nursing Home, Jalanadhar. After discharge, the complainant lodged the claim for the reimbursement of his medical bills with opposite parties, who refused to payment of claim on the ground that he has not taken treatment as per terms of opposite party no.1. The complainant requested the opposite parties a number of times to release the claim amount, but to no effect. Due to these acts of opposite parties, the complainant has suffered mental tension, agony, harassment and financial loss.

9.                On the other hand, ld. counsel for opposite party nos.1 & 2 argued that complainant does not fall under the definition of consumer and the present complaint is not maintainable. The policy in question was issued in favour of Government of Punjab, Department of Health and Family Welfare. As per terms and conditions of the policy and as per para no.4 of the notification dated 20.10.2015 Government of Punjab, Department of Health and Family Welfare, the claim of the complainant was repudiated as per para no.4 of the notification, it is specified that no reimbursement will be available for the treatment in Punjab and Chandigarh, where cashless treatment is available. Only empanelled hospitals in Punjab, Chandigarh and NCR are eligible for treatment of the enrolled beneficiaries. The complainant has not taken treatment from empanelled hospital, so his claim is rightly repudiated. They argued that this Forum has no jurisdiction to try and decide this complaint, because as per contract with Punjab Government as per clause 24 of the tender there are District Level Grievance Redressal Committees are constituted and every dispute is to be settled by these committees and complainant did not approach to these committees and filed this complaint before Forum. So, this Forum has no jurisdiction to try this complaint.

10.              Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite party nos.1 & 2. Being the pensioner of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that the complainant took treatment from Lajwanti Hospital and Nursing Home from 24.08.2016 to 25.08.2016 and he lodged claim for the reimbursement of medical expenses borne by him with opposite party nos.1 & 2, which was repudiated by opposite party nos.1 & 2. Now, the first objection of opposite parties is that this Forum has no jurisdiction to try and decide the present complaint as under the scheme there was Dispute Resolution and Grievance Redressal Committees are constituted to settle the dispute, but the complainant did not approach to these committees and filed the present complaint before this Forum. It is settled principle of law that the remedy under Consumer Protection Act is an additional remedy other than available remedies. If there is any contract of arbitration or to  settle  any dispute by settlement committee under the scheme in that case also the complainant can approach to this Forum instead of arbitrator or dispute settlement committee. In that event the jurisdiction of this Forum is not barred and this Forum can entertain and decide the present complaint. Now, the second and main objection of opposite party nos.1 & 2 for non payment of medical expenses of complainant and for repudiation of the claim is that as per notification no reimbursement was available for the treatment in Punjab and Chandigarh, where cashless treatment is available and the beneficiary is entitled for the treatment under the scheme only from the hospitals which are empanelled under the scheme. The opposite party nos.1 & 2 argued that complainant did not claim cashless treatment as he did not get his treatment from empanelled hospitals under the scheme, so he is not entitled for any relief and cannot claim reimbursement of his medical expenses and his claim is rightly repudiated.

11.              On the other hand, ld. counsel for complainant argued that at that time his urine passing obstruct and due to which he was in unconscious condition and in emergency his attendants approached to Lajwanti Hospital and Nursing Home and due to emergency and threat of his life doctors advised immediate operation of the complainant to save his life and attendants of the complainant was not aware about the insurance in question and in emergency they do as per the advise of doctors to save his life only. After the treatment when he lodged the claim with opposite parties, now opposite parties cannot deny his genuine claim on the basis of certain terms and conditions, which were never explained or supplied to him. From the medical record of the complainant, it is clear that he was admitted in hospital in emergency conditions and in emergency doctors gave him treatment best available at that time to save his life. It is quite natural in the time of emergency where there is threat to the life of patient, the patient or his attendants immediately will approach to the nearest hospital or doctors and will take treatment as per the advise of doctors to save the life of the patient and not supposed to find the hospital or go for the treatment as per alleged terms and conditions of insurance company, which can be fatal for patient. Even as per notification date 20.10.2015 regarding said insurance scheme copy of which is Ex.OP-1,2/6 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 circumstances. In view of the above, we are of the opinion that it is generally seen that insurance companies rejected pre authorization for cashless treatment on various grounds and does not allow cashless treatment to patient or hospital, then in that case only the resources left for insured is to reimburse of his medical bills.

12.              From the above discussion, we are of the considered opinion that the complainant took his treatment in emergency conditions and at that time he cannot be supposed to approach any empanelled hospital of opposite parties and to wait for pre-authorization of insurance company for his cashless treatment before starting his treatment, which can threat to his life. The opposite party nos.1 & 2 wrongly and illegally repudiated the claim of the complainant for reimbursement of his medical bills, which amounts to deficiency in service on their part. Hence the present complaint is allowed against opposite party nos.1 & 2 and dismissed against opposite party no.3. So, opposite party nos.1 & 2 are directed to make payment of Rs.19,452/- i.e. claim amount borne by the complainant on his treatment alongwith interest @ 9% per annum from 29.12.2016, when they repudiated the claim of the complainant till realization. Further opposite party nos.1 & 2 are directed to pay Rs.3000/-(Three thousand only) consolidated as compensation and litigation expenses to the complainant. Compliance of the order be made within 30 days from the receipt of copy of this order, failing which, the complainant shall be entitled to initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of order be sent to the parties free of costs. File be consigned to record room.

Announced in Open Forum

Dated : 01.11.2017

 

                               (Bupinder Kaur)           (Vinod Bala)        (Ajit Aggarwal)

                                     Member                     Member                  President