DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)

Consumer Complaint No.1180 of 2018

                                                Date of institution:  15.11.2018                                                  Date of decision   :  23.10.2019

Inder Jit aged about 62 years son of Gian Chand resident of House No. 23, Aman City, Kharar, District Mohali.

…….Complainant

Versus

1.     Managing Director, Punjab Health System Corporation, Phase-6, Mohali, Punjab.

2.     Oriental Insurance Company Limited, SCO No.109-110-111, Sector 17-D, Chandigarh through its authorised signatory/representative.

                                                         ……..Opposite Parties

Complaint under Section 12 of

the Consumer Protection Act.

Quorum:    Shri G.K. Dhir, President,

                Mrs. Natasha Chopra, Member.

Present:     Shri Rajan Bhateja, counsel for complainant.

                OP No.1 ex-parte.

                Shri Sudhir Gupta, counsel for OP No.2.

Order by :-  Shri G.K. Dhir, President.

Order

                Complainant, an Ex-Govt. employee retired as Additional Director (F&A) from the office of Director, State Transport Punjab, Chandigarh. During service of complainant, Punjab Govt.  issued cashless health insurance scheme vide notification dated 20.10.2015 for the Punjab Govt. employees. Name of that scheme was Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS). That scheme was to cover indoor medical expenses, specified daycare procedure and for treatment of chronic disease as specified by State Govt. This scheme was applicable to all serving Govt. employees and pensioners on compulsory basis. In view of this scheme, complainant was issued an identity card in his name for being beneficiary of above scheme. Complainant gave names of three beneficiaries namely Anita Soni (wife), Gian Chand (father), Raj Rani (mother). ID card to complainant even was issued. Shri Gian Chand father of complainant fell seriously ill on 07.01.2016 on account of severe chest pain and he was shifted to DMC, Ludhiana for treatment. Father of complainant remained admitted in DMC Ludhiana from 07.01.2016 to 18.01.2016. Amount of Rs.62,046/- was spent on his treatment and medical reimbursement certificate was issued to the complainant. Though the scheme provided for cashless treatment, but no amount sanctioned to the complainant because no e-card was issued by OP No.2. So complainant made payment of this amount from his pocket. Subsequently in October, 2016, mother of complainant Smt. Raj Rani fell  seriously ill due to sufferance from severe anxiety disorder with hypertension and as such she  had to be got admitted in Chaitanya Hospital, Pathankot on 23.09.2016. Mother of complainant was discharged from that hospital on 02.10.2016. An amount of Rs.37,390/- was spent by complainant from his pocket on treatment of his mother. On submission of medi claim form with OP No.2, reimbursement has not been done despite sending of representation and that is why by pleading deficiency in service on part of OPs, this complaint filed for seeking reimbursement of above referred medical expenses alongwith litigation expenses of Rs.11,000/- and compensation for negligence and deficiency in service of Rs.30,000/-.

2.             In reply filed by OP No.1, it is claimed that Punjab Health Welfare Corporation is the operating agency for PGEPHIS scheme formulated by Punjab Govt. vide notification dated 20.10.2015. That scheme was applicable to serving Govt. employees and pensioners on compulsory basis, is an admitted fact. However, this scheme was optional for All India Service Officers and Ex-MLAs, serving and Ex. Judicial Officers including Judges of Hon’ble High Court of Punjab and Haryana. Premium for the main member as well as dependant was paid by State Govt. and claim for medical reimbursement was to be settled by insurer i.e. OP No.2. This policy started w.e.f. 01.01.2016 and ended on 31.12.2016. Rs.53.00 crores was paid as premium to OP No.2 for insurance coverage, by State Govt. In case any bill for treatment prior to 01.02.2016 is submitted, then reimbursement of same to be done by Health & Family Welfare Department of Punjab as per State Services (Medical Attendant Rules) 1940.  So far as medical claim bills for period from 01.02.2016 to 31.12.2016 is concerned, reimbursements of same to be done by OP No.1 under PGEPIHS scheme. In case complainant has any grievance regarding his medical reimbursement, then he should approach the District Grievance Redressal Committee constituted by State Govt. vide notification dated 21.09.2016. Admittedly complainant after retirement as Additional Director is an Ex-employee of Punjab Govt. Admittedly Punjab Govt. issued cashless health insurance scheme vide notification dated 20.10.2015 as referred above and the said scheme was applicable to serving Govt. employees and pensioners on compulsory basis. Admittedly complainant gave names of three beneficiaries under the scheme. OP No.1 performed its role by informing OP No.2 to do the needful and as such there is no deficiency in service on part of OP No.1. No cause of action has accrued to complainant for filing this complaint against OP No.1 and as such prayer made for dismissal of same against OP No.1.

3.             In separate reply filed by OP No.2, it is claimed that complainant has not approached the Forum with clean hands. Insurance is purely a matter of good faith. Complainant has not got enrolled himself under the scheme. Rather the policy period as per Ex.C-2 enclosed with the complaint, was for period from 01.02.2016 to 31.12.2016, but treatment got by complainant for his father in January, 2016, due to which coverage under the scheme not to be provided by OP No.2. Moreover, hospital from which patient got treatment was not authorised or empanelled one. No claim has ever been received by office of OP No.2. No enrolment proof or e-card has been placed alongwith complaint for enabling OP No.2 to look into the matter and as such OP No.2 not in a position to get the claim processed. If at all any claim is found payable, then it will be strictly payable as per terms and conditions of the scheme on rates approved as per rate list. Disputes involved in the complaint can be got adjudicated by leading elaborative evidence and as such matter should be got decided by complainant from civil court of competent jurisdiction. Complaint alleged to be drafted smartly because first claim lodged with respect to illness of Shri Gian Chand on 07.01.2016. Limitation to lodge complaint with respect to such claim expired on 06.01.2018 and as such this complaint is barred by limitation. Smt. Raj Rani, mother of complainant fell ill in October, 2016 and the claim with respect to her is also barred by limitation, more so when treatment not got by her from empanelled hospital and nor for any emergency. Complaint also alleged to be bad for non joinder of necessary parties because State of Punjab has not been impleaded as a party. In the absence of any documentary proof regarding submission of intimation given by State of Punjab or complainant, processing of claim could not have been done and as such prayer made for dismissal of the complaint. No intimation of any action was given to answering OP and as such by denying other averments of the complaint for want of knowledge or otherwise, prayer made for dismissal of the complaint.

4.             Appearing counsel claimed that evidence and documents already placed on record is the only evidence to be produced by them and no more documents to be produced and as such on their assertion and after hearing arguments of appearing counsel, this complaint decided.

5.             Issue of notification Ex.C-1 dated 20.10.2015 is not disputed by OP No.1 through written reply. Rather it is admitted in the reply filed by OP No.1 that facility of medical reimbursement under scheme PGEPHIS is available to pensioners and serving employees and their dependants.  The complainant retired from the post of Addl. Director (F&A) and as such certainly scheme was not optional for him. Rather scheme was compulsory for complainant. This PGEPHIS scheme to cover all the entitlements as specified under the State Services (Medical Attendant Rules) {CS (MA)} Rules, 1940. Even after going through Para No.3 of Ex.C-1, it is made out that the scheme will ensure cashless indoor medical treatment,  pre and post hospitalization. Coverage under the scheme was for amount of Rs.3.00 lakhs per family per year on floater basis as per para No.3 of this notification Ex.C-1. Treatment can be got by any enrolled beneficiary in Govt. or in empanelled hospital in Punjab, Chandigarh or NCR area. However, reimbursement can be taken by employee/pensioner for medical treatment taken in any other State in India in exceptional circumstances. All this is made out from Para No.4 of Ex.C-1. However, certain treatments are not covered under the scheme as per Para No.5 of Ex.C-1. Reimbursement of such exclusions will be made available to employee/pensioner as per existing policy and State Services (Medical Attendant Rules) {CS (MA)} Rules, 1940 as per Para No.5 of Ex.C-1. From all this, it is made out that the enrolled beneficiary entitled to cashless facility under the scheme for treatment through empanelled hospital or through hospital outside the State in exceptional circumstances. In case the case of beneficiary or pensioner or serving employee falls under the exclusions of the scheme, then reimbursement of same to be done as per existing policy as envisaged by Para No.5 of Ex.C-1. So if parents of complainant got treatment from the hospital not empanelled by OP No.2, then the case in hand will be covered by exclusion clause, due to which entitlement for reimbursement will be as per exisiting policy and State Services (Medical Attendant Rules) {CS (MA)} Rules, 1940.

6.             It is admitted in Para No.4 of reply submitted by OP No.1 that Smt. Anita Soni, Shri Gian Chand and Smt. Raj Rani were three beneficiaries under the scheme due to which e-cards were issued in their names. In view of this admission suffered by OP No.1, there is no escape from the conclusion that in case treatment for any disease/aliment not covered by the Scheme, then reimbursement of same to be done by State Govt. under the existing policy. Though in Para No.1 of preliminary objections it is claimed that policy started from 01.01.2016 to 31.12.2016, but treatment for father of complainant got during period from 07.01.2016 to 18.01.2016 and as such it is obvious that OP No.2 as insurer not to provide reimbursement for this treatment because this treatment got for father of complainant prior to date of commencement of the Scheme i.e. 01.02.2016. Being so, reimbursement for this amount to be done by the State Govt. or its functionaries as per existing policy by keeping in view the State Services (Medical Attendant Rules) {CS (MA)} Rules, 1940.

7.             Perusal of copies of e-cards issued for Punjab Govt. Employees and Pensioners Health Insurance Scheme Ex.C-2 reveals that policy period with respect to the insurance cover to be provided by OP No.2 was for period from 01.02.2016 to 31.12.2016 and as such certainly OP No.2 was not liable to reimburse the treatment expenses for father of complainant during period prior thereto. That treatment was got for period from 07.01.2016 to 18.01.2016 even as per medical reimbursement certificate Ex.C-3 alongwith medical claim form Ex.C-4. So certainly liability of insurance company in this respect is not there at all.

8.             Complainant has produced on record medical reimbursement certificate Ex.C-5 for showing that mother of complainant Smt. Raj Rani got treatment from hospital at Pathankot for anxiety disorders and hypertension for period from 23.09.2016 to 02.10.2016. Perusal of  Clause-2 of this certificate Ex.C-5 itself reveals that the treatment was necessary and as such in view of contents of Ex.C-5, it has to be held that treatment by complainant for his mother  was obtained in emergent conditions from a hospital not empanelled by OP No.2 because list of empanelled hospitals produced by OP No.2 does not include the name of hospital, from where mother of complainant got treatment. So this treatment covered by exclusion clause of insurance policy, but in view of Clause 5 contained in Ex.C-1 and in view of necessity for such treatment, reimbursement bound to be made by State Govt. or its functionaries as per State Services (Medical Attendant Rules) {CS (MA)} Rules, 1940.

9.             As per instructions issued vide letter No.12/193/94-5HBV-5/5251-54 dated 13.02.1995, issued by Govt. of Punjab under Punjab Services (Medical Attendance) Rules, 1940, in case treatment got from other than the hospitals of Govt. of Punjab, then District Civil Surgeon will be competent to grant permission for a particular disease for the purpose of reimbursement of incurred expenditure. As per Clause 1 (b) of these Govt. instructions of 1995, if treatment in any private hospital in the country got, then reimbursement of expenses incurred on such treatment permissible to the level of extent as per rates fixed by Director Health and Family Welfare, Punjab for a similar treatment package or actual expenditure, whichever is less. Virtually through this Clause 1 (b) of this notification freedom has been given to pensioners and Govt. employees to get treatment in any private institution/hospital of their own choice in the country provided undertaking is given that the concerned will get reimbursement of expenses to the level of extent as per rates fixed by Director Health and Family Welfare, as referred above. In view of freedom of choice for treatment in any private institute/hospital, certainly State Govt. or its functionaries cannot deny reimbursement of incurred medical expenses for treatment of parents of complainant as per these instructions. So even if OP No.2 may not be liable for reimbursement of expenses because of treatment being not got from an empanelled hospital, despite that liability of OP No.1 remains because it has been admitted in written reply filed by OP No.1 that Punjab Health System Corporation is operating agency under the PGEIPHS Scheme formulated by Govt. of Punjab through notification Ex.C-1 dated 20.10.2015. As Managing Director, Punjab Health Systems Corporation, being operating agency to guide the pensioners/employees properly and as such it was under obligation either to act its own for reimbursing the incurred medical expenses or to forward the case to the concerned for such reimbursement, more so when letter Ex.C-7 dated 09.12.2017 was received by ASC of Punjab Health Corporation, Mohali as revealed by endorsement on the foot of Ex.C-7 itself. In view of this letter Ex.C-7 it is obvious that complainant lodged the claim with appropriate authority i.e. Punjab Health Systems Corporation, Mohali within period of limitation i.e. within 2 years of getting of treatment by complainant for his parents, but that claim not reimbursed and as such fault lays with OP No.1 or its functionaries. So deficiency in service is on part of OP No.1.

10.            Submission advanced by counsel for OP No.2 has force that complaint is barred by limitation in so far as non submission of reimbursement claim with OP No.2 within period of two years from the date of getting of treatment for parents of complainant is concerned. This complaint was filed on 15.11.2018, but claim with OP No.2 not shown to be lodged at all within period of two years from the date of treatment referred above and as such certainly complaint against OP No.2 is barred by limitation.

11.            Clause-13 of terms and conditions of the Scheme placed on record Ex.OPR-2/2 lays that for reimbursement of cost of treatment under the Scheme as per which treatment must be got from the empanelled hospital. Insurances Company will settle the claims of the hospitals/nursing homes within 15 days of receipt of complete details alongwith discharge summary of the patient. That treatment for parents of complainant not got from the empanelled hospital because the name of hospital from where mother of complainant got treatment is not at all mentioned in the list of empanelled hospitals annexed with this Ex.OPR-2/2. Moreover, there is nothing on record to suggest that insurance company was approached by complainant or his parents or the hospital/nursing home concerned, for reimbursement of claim. As complete details alongwith discharge summary of parents of complainant not shown to be submitted with OP No.2 at any time and as such question of reimbursement of incurred medical expenses by OP No.2 does not arise. So long as claim with insurer not lodged, insurer not bound to process the claim and as such there is no deficiency in service on part of OP No.2. Rather that deficiency in service is on part of OP No.1 because even after receipt of letter Ex.C-7 as referred above, intimation to complainant was not given for taking appropriate action by way of approach to OP No.2 or to concerned authorities. Complaint is not bad due to non joinder of Punjab State because as per contents of written statement by OP No.1, Punjab Health Systems Corporation is the operating agency for PGEIPHS Scheme. Inaction on part of OP No.1 or its functionaries made the complainant to suffer and as such complainant entitled to compensation for mental agony and harassment and also to litigation expenses from OP No.1 and not from OP No.2. However, entitlement of complainant for reimbursement will be as per terms and conditions of the circular refereed above. 

12.            As a sequel of above discussion, complaint allowed against OP No.1 only, but same dismissed against OP No.2. OP No.1 is directed to get the process of payment initiated for reimbursement of expenses and arrange to pay the due amount of incurred medical reimbursement expenses on treatment of parents of complainant to the level of expenditure as per rules fixed by Director, Health and Family Welfare, Punjab for similar treatment package or actual expenditure, whichever is less. Compensation for mental agony and harassment of Rs.15,000/- and litigation expenses of Rs.10,000/- more allowed in favour of the complainant and against the OP No.1. Payment of these amounts of compensation and litigation cost be made within 30 days from the date of receipt of certified copy of order. Certified copies of the order be supplied to the parties as per rules. File be indexed and consigned to record room.

Announced

October 23, 2019.

                                                                (G.K. Dhir)

                                                                President

(Mrs. Natasha Chopra)

Member