PER:

Nidhi Verma, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant is a retired Government Teacher and he was covered under the Insurance Scheme of Punjab Government and as per which the policy holder shall be reimburse if the amount of expenses paid by him for his treatment after the treatment and after the lodging of the reimbursement claim. The complainant fell ill and was diagnosed with some Heart Problem and was advised for stent implant surgery by the Nayyar Hospital, Amritsar. The complainant got admitted in the Nayyar Hospital on 3.9.2016 and was operated upon for stent implant surgery and total paid Rs. 2,10,000/- to the hospital for the treatment received by him from his pocket and was discharged on 6.9.2016 by the hospital. The complainant being insurance policy holder of the opposite party through Punjab Government lodged reimbursement claim from the opposite party for Rs. 2,10,000/- immediately on discharge from the hospital and also sent the relevant documents to the opposite parties for getting the reimbursement.  The complainant was embarrassed when he received a letter dated 15.2.2017 from the opposite party qua which the opposite parties denied the reimbursement claim to the complainant by giving vague reason of non-enrolment with them. The complainant was actually enrolled and was covered under the Insurance Policy of the opposite parties through Punjab Government and as such, the reason for denying the reimbursement  is false and vague one, rather the Block Office of the elementary Division, Bhikhiwind, Tarn Taran had sent the reimbursement claim form through itself which also proves that the complainant had been enrolled with the opposite parties insurance policy. The complainant has been in correspondence with the opposite parties since the lodging of the claim and also after receiving the letter dated 15.2.2017. The complainant has prayed that the following reliefs may kindly be granted to the complainant.

1. The opposite parties may directed to make the reimbursement of Rs. 2,10,000/- to the complainant immediately.
2. The opposite parties may kindly be directed to pay Rs. 50,000/- as compensation and Rs. 30,000/- as litigation expenses.

Alongwith the complainant, the complainant has placed on record affidavit of complainant Ex. C-1, Self attested copy of patient Discharge Bill Ex. C-2, Self attested copy of performance for claiming medical reimbursement Ex. C-3, Self attested copy of letter dated 15.2.2017 Ex. C-4, Self attested copy of legal notice dated 23.4.2019 Ex. C-5 and self attested copy of postal receipt dated 23.4.2019 Ex. C-6.

2        Notice of this complaint was sent to the opposite parties and opposite parties No. 2  and 3 appeared through counsel and filed written version by interalia pleadings that the present complaint is barred by law of limitation. The alleged treatment pertains to 30.9.2016 whereas the instant complaint has been filed after a long unjustified delay of more than 2 years and 8 months.  The present complaint is not maintainable. There is no valid contract of insurance between the insured and opposite party insurance company as far as the present claim is concerned, since the complainant never got himself registered under the Policy Scheme in question. As such, the opposite parties are not liable to pay any medical expenses allegedly incurred by the complainant. The opposite party insurance company has issued the policy subject to terms and conditions as envisaged in The Punjab Government  Employees and Pensioners Health Scheme, by which all the parties i.e. Punjab Govt. Healthcare provider, TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition no.8 of the scheme, “Every employee/pensioner will ensure his/her enrolment alongwith deponents 15.12.2015 enabling the insurance company to deliver the insurance cards upto 31.12.2015”. Furthermore, as per condition no.17 (a) of the scheme, "No fresh enrolment of serving employees or pensioners will take place after the date of expiry of Enrollment period". Even so, as per para 8 of Notification no. 21/28/12-SHBS/268 dated 20/10/2015 "No fresh enrolment of serving employees or pensioners will take place after the date of expiry of Enrollment period". The complainant is not covered under the Punjab Govt. Employee Pensioner Health Insurance Scheme as he failed to submit his enrollment form within the prescribed period. The complainant is estopped from filing the present complaint. That vide Notification no. 21/28/12-5H5/758236/1 dated 20/05/2016, the Govt. of Punjab had extended the enrollment period for employees and pensioners under PGEPHIS upto 30.06.2016. Despite the extension given by the Punjab Govt. to those who failed to enroll earlier, the complainant again failed to submit his enrollment form within the prescribed period. As such the complainant is not covered under the Punjab Govt. Employee Pensioner Health Insurance Scheme and he has himself waived off his entitlement as far as the present claim is concerned.  The complaint filed by the complainant is otherwise bad for mis-joinder and non- joinder of necessary parties and causes of action. The complainant having failed to implead State of Punjab, which is a necessary party to the present complaint, is not entitled to the relief claimed for. The present compliant is technically defective as the same has not been filed in accordance with the law. The complainant is not a party to contract of insurance. The present insurance policy is subject to terms and conditions as envisaged in "The Punjab Government Employees and Pensioners Health Scheme", by which all the parties i.e Punjab Govt., Healthcare provider TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition No. 21 of the scheme, the mechanism with regard to Dispute Resolution and Grievance Redressal has been set up by providing Grievance Redressal Committee in each District which will constitute the following members: (a) Deputy Commissioner, (b) Civil Surgeon, (c) Deputy Medical Commissioner, (d) Representative of Insurance Company. The said committee will resolve the Grievance within 30 days from the date of application. It has been further provided in the scheme that dissatisfied party may approach the State Level Grievance Redressal Committee whose decision shall be final and binding to all the parties. As such, in the light of above mentioned provision of the Scheme, this Commission has no jurisdiction to try and decide the present complaint. The complainant has got no cause of action to file the present complaint against the OPs. The complainant having failed to get himself registered under the Policy/Scheme in question, he is not entitled to the present claim and as such the complaint is liable to be dismissed. Even otherwise, if the complainant is able to prove before this Commission that he had duly enrolled himself in the present Scheme, the liability of the OP Ins. Co. has to be assessed in the light of PGEPHIS Schedule of rates. As per condition No.23 of the PGEPHIS scheme, "the reimbursement to the beneficiary against the claim of treatment availed in the private hospital shall be made in accordance with the PGEPHIS rates irrespective of the actual expenditure incurred by the beneficiary". Besides, as per para 4 of Notification no. 21/28/12-5HB5/268 dated 20/10/2015 "The Insurance co. will reimburse the bill of employee upto Rs 3 lacs as per the package rates defined under the scheme". Furthermore, as per para No.1 Annexure XX of PGEPHIS Schedule of rates, "In case of admission in semiprivate category of room, the rates will be 10% higher than the rates applicable to General Ward Category contained in the table" Hence, in the light of PGEPHIS Schedule of rates (Code 974, 992) and in accordance with terms and conditions of the policy, the competent authority of the OPs vide Email dated 04-06-2019 has assessed the maximum liability as Rs 1,09,254/-. Nevertheless, the OPs are not liable to pay any medical expenses allegedly incurred by the complainant since the complainant never got himself registered under the policy in question and is not covered under the PGEPHIS scheme. The complainant has not approached this Commission with clean hands and has concealed the material facts.  There is no valid contract of insurance between the insured and the OP Ins. Co. as far as the present claim is concerned, since the complainant never got himself registered under the Policy Scheme in question. The opposite parties No. 2 and 3 have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties No. 2 and 3 have placed on record affidavit of Sh. OP Dhawan Ex. OPs 2,3/1 alongwith documents i.e.  attested copy of Insurance policy Ex. OP2,3/2, Copy of PGEPHIS Scheme Ex. OP 2,3/3, Copy of notification Ex. OP2, 3/4, Copy of notification Ex. OP2, 3/5, Copy of schedule of rates Ex. OP 2, 3/6, copy of Judgment Ex. OP 2,3/7, Copy of email Ex. OP2,3/8.  

3        Notice of this complaint was sent to the opposite party No. 1 but no one appeared on behalf of opposite party No. 1 and consequently, the opposite party No. 1 was proceeded against exparte vide order dated 11.7.2019.

4        We have carefully gone through the record and heard the Ld. counsel the complainant and opposite parties No. 2 and 3.

5        In the present complaint, the complainant is a retired Government teacher and he was covered under the Insurance Scheme of Punjab Government and as per which the policy holder shall be reimburse if the amount of expenses paid by him for his treatment after the treatment. On dated 3^rd Sept, 2016 the complainant got admitted in the Nayyar Hospital and was operated upon for Stent Implant Surgery and paid Rs. 2,10,000/- to the hospital for the treatment received by him from his pocket and was discharged on 6^th Sept, 2016.  The complainant being Insurance Policy holder of the OP through Punjab Government lodged reimbursement claim from the OP for Rs 2,10,000/- and also sent the relevant documents to the OP for getting the reimbursement.  On dated 15^th Feb 2017 received the letter from the OP  , in which OP denied the reimbursement claim to the complainant by giving vague reason of non – enrolment with them. The complainant has been in correspondence with the Ops and also send legal notice on dated 23.04.2019. OP No. 2 & 3 stated in their written version that the present complaint is barred by law of limitation. The alleged treatment pertains to 3.9.2016 whereas the instant complaint has been filed after a long unjustified delay of more than 2 years 8 months . Hence, the present complaint is not maintainable. Moreover, there is no valid contract of insurance between the insured and the OP Ins. Co. , Since the complainant never got himself registered under the policy/Scheme in question.

6        The OP insurance Co. has issued the policy subject to terms and conditions as envisaged in “the Punjab Government Employees and Pensioners Health Scheme”, by which all the parties i.e. Punjab Government, HealthCare provider, TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. As per condition no.8 of the scheme,” every employee/pensioner will ensure his/her enrolment alongwith dependents before 15.12.2015 enabling the insurance company to deliver the insurance cards upto 31.12.2015”. Furthermore , as per condition no 17 (a) of the scheme , “ No fresh enrolment of serving employees or pensioner will be taken after the date of expiry of enrolment period”.  The complainant is not covered under the Punjab Government Employee Pensioner Health Insurance Scheme as he failed to submit his enrollment form within the prescribed period . However, vide notification no 21/28/12- 5H5/758236/1 dated 20/5/2016 , the Government of Punjab had extended the enrolment period for employees and pensioners under PGEPHIS upto 30.06.2016 , that despite the extension given by the Punjab Government to those who failed to enroll earlier, the complainant again failed to submit his enrolment form within the prescribed period .As such the complainant is not covered under the Punjab Government Employee Pensioner Health Insurance Scheme and he has himself waived of his entitlement as far as the present complaint is concerned.

7        Further, As per condition number 21 of the scheme, the mechanism with regard to Dispute Resolution and Grievances Redressal has been set up by providing Grievance Redressal Committee in each district which will constitute the following members:-

• Deputy Commissioner
• Civil Surgeon
• Deputy Medical Commissioner
• Representative of Insurance Company

The said committee will resolve the Grievance within 30 days from the date of application.  It has been further provided in the scheme that dissatisfied party may approached the State Level Grievance Redressal Committee whose decision shall be final and binding to all the parties.   However, if the complainant is able to prove his enrollment himself in the present Scheme, the liability of the OP has to be assessed in the light of PGEPHIS schedule of rates . as per condition No.23 of the PGEPHIS Scheme, “ the reimbursement to the beneficiary against the claim of treatment availed in the private hospital shall be made in accordance with the PGEPHIS rates irrespective of the actual expenditure incurred by the beneficiary”. Besides , as per para 4 of notification no. 21/28/12-5HB5/268 dated 20/10/2015 “the Insurance co. will reimburse the bill of employee upto Rs 3Lacs as per the package rates defined under the Scheme”. Further more, as per para No. 1 Annexure XX of PGEPHIS schedule of rates, “In case of admission in semi-private category of room, the rates will be 10% higher than the rates applicable to general ward category contained in the table”. Hence, in the light of PGEPHIS schedule of rates( code 974,992) and in accordance with terms and conditions of the policy, the competent authority of the Ops vide Email dated 04.06.2019 has assessed the maximum liability as Rs 1,09,254/-  Nevertheless, the Ops are not liable to pay any medical expenses allegedly incurred by the complainant since the complainant never got himself registered under the policy in question and is not covered under the PGEPHIS Scheme. However, after going through the facts and circumstances of the case we are of the considered opinion that the Ld. Counsel for the complainant has submitted that the main controversy involved in the present case is that Ops had repudiated the claim of the claimant vide letter dated 15.02.2017 ( Ex.C-4 )  by stating that Tara Singh is not covered under Punjab Government Pensioner Health Insurance Scheme , as non- enrolment with them. Punjab Government has sponsored the Scheme to it’s employees and pensioners and no insurance consideration is deducted from their salaries. It is provided free of costs. The scheme was started from 01.01.2016 upto 31.12.2016 and enrolment under the scheme was to start from 20.10.2015 and was to be completed by 31.12.2015.  (Ex.OP2,3/3) As per the terms and conditions of the said scheme,  condition No. 8 of the scheme stated that “Every employee on pensioner will ensure his her enrollment along with dependents before 15^th of December 2015 enabling the insurance company to deliver the insurance card up to 31^st December 2015”. Furthermore as per condition number 17 of the scheme “No fresh enrollment of serving employees or pensioners will take place after the date of expiry of enrollment.”  Furthermore, (Ex .Op 2,3/5) vide notification no. 21/28/12-5h5/7582361 dated 20/05/2016 , the Govt. Of Punjab had extended the enrolment period for employees and pensioners under PGEPHIS upto 30.06.2016 . As per the terms and conditions of the said Scheme the enrolment of the employees and pensioners should be must ,as Government has sponsored the Scheme to it’s employees and pensioners and no insurance consideration is deducted from their salaries. It is provided free of costs. After gone through the evidence placed on the record the fact that there is no valid contract of insurance between the insured and the OP Insurance Co. The complainant failed to prove their enrolment with the Punjab Government. The complainant has not placed any Insurance Card Number or form that can prove that he submit his enrolment form within the prescribed period. the complainant has not arrayed the name of concerned department from where he has obtained the policy. Concerned department could have supplied the necessary information regarding his enrolment with them. The complainant has placed in evidence on record Discharge Bill Ex. C-2, Copy of performance for claiming medical reimbursement Ex. C-3, Copy of letter dated 15.2.2017 Ex. C-4, Copy of legal notice dated 23.4.2019  Ex. C-5 and Copy of postal receipt dated 23.4.2019 Ex. C-6.  But has miserably failed to submit the mandatory document i.e. insurance card Number which proves his enrolment / registration Number with the Punjab Government Employees Pensioner Health Insurance Scheme.  Hence , the complainant is not entitled to get the relief claimed for , because he failed to submit his enrolment form within the prescribed period and in despite of the extension given by the Punjab Government to those who failed to enroll earlier i.e. 15.12.2015 , the complainant again failed to submit his enrollment form upto 30.06.2016 . As such the complainant is not covered under the Punjab Government Employees Pensioner Health Insurance Scheme and he has himself waived off his entitlement by not completing the enrolment within prescribed period.  If Punjab Government started said Scheme to facilitate his/her employees and pensioners without any costs but only required to registered their enrolment within prescribed period. It was the duty of the employees and pensioners to get the benefits as per the terms and conditions of the said Scheme – where enrolment was must but the complainant failed to do so . Hence there is no valid contract of insurance between the insured and the OP  insurance Co. as far as the present claim is concerned, since the complainant never got himself registered under the Policy/Scheme. Moreover, the complaint is time barred as it has been filed after the lapse of two years from the date of cause of action. As such the Opposite Parties are not liable to pay any medical expenses allegedly incurred by the complainant.  Therefore, there is no deficiency or delay on the part of the Opposite Parties.

8        In view of the above discussion, we do not find any merit in the complaint and the same is hereby dismissed. The parties are left to bear their own costs.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission.

27.02.2023