BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.295 of 2017
Date of Instt. 21.08.2017
Date of Decision: 06.06.2018
Malkiat Singh son of Mehnga Singh, presently posted as Excise & Taxation Officer (Excise), Jalandhar-I, Jalandhar.
..........Complainant
Versus
1. MD India Healthcare Service (TPA) Pvt. Ltd., Project Office Address, Maxpro Info Park D38, 1st Floor, Industrial Area, Phase I, Mohali through its authorized signatory.
2nd Add Tower Plot No.F 539, Phase VIII B, Industrial Area, Mohali Tower August Road, Mohali.
2. Oriental Insurance Company Ltd, 32, Amardeep Building, GT Road, near PNB Bank, Opp. Narinder Cinema Police Line Jalandhar through its authorized signatory.
3. Oriental Insurance Company Ltd., Surindra Building, SCO 109- 110-111, Sector 17D, Chandigarh through its authorized signatory.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. JJS Arora, Adv Counsel for the Complainant.
Sh. Brijesh Bakshi, Adv Counsel for OP No.1 to 3.
Order
Karnail Singh (President)
1. This complaint is filed by the complainant, wherein alleged that the complainant is working as an Excise and Taxation Officer, Jalandhar-1, in Government of Punjab and as such, the complainant is covered under the Punjab Government Employee & Pensioners Health Insurance Scheme, having ID No.MD 15-09872910089. That the complainant had gone to Amritsar on 06.07.2016, where unfortunately he got massive heart attack and was immediately taken to Carewell Hospital, Amritsar for initial treatment and remained admitted there for treatment till 09.07.2016, but on account of his serious condition, the complainant was shifted to Cardinova Hospital, Nakodar Road, Jalandhar, where he was hospitalized and operated upon. The complainant had paid a sum of Rs.90,606/- for his treatment at Carewell Hospital and Rs.3,48,460/- for his treatment at Cardinova Hospital.
2. That thereafter the complainant completed all the requisite formalities for insurance claim of the said treatment by submitting all the original bills and connected documents on 18.08.2016 alongwith claim form. The complainant also submitted all the investigating reports, cash receipts of the payments made by him, Barcode sticker of the stents inserted after operation as they were sticked with the bills, including discharge summary on 02.11.2016 as required by the officials of the OP. The claim of the complainant wrongly remained pending for long time without any solid reason, which forced the complainant to approach the officials of the OP time and again and also by writing letters from time to time. The complainant even visited the old office of the OP at Industrial area and also at new office at Mohali Tower to get the claim passed at the earliest, but with no positive result. Ultimately, after shifting of the office at Mohali Tower, one of the employee of the OP assured the complainant that his claim is going to be passed shortly and even amount will be deposited in the bank account of the complainant and accordingly, the complainant submitted all the details of the bank account for the said purpose. Inspite of said promise and passing of period of 1½ months, no further action was taken in the matter. The complainant again contacted the said official of the OP, who informed that the account number of the bank as supplied by the complainant is not legible, so advised the complainant to send copy of THE cheque along with account number thereof. Accordingly, the complainant sent the cheque No.698466 drawn over Punjab National Bank on 20.04.2017 on whatsup number of the said employee of the OP, but with no result whatsoever.
3. That the complainant was unnecessarily harassed without any fault on his part and he has been visiting the office of the OP time and again for his genuine claim and contacted the officials of the OP on telephone as well. The complainant has suffered a lot for not releasing of the due amount and he was in dire need of money and felt financial hardship. This is inspite of the fact that the complainant is a heart patient, but was being harassed without any fault. Ultimately, the complainant wrote letter No.1627 of 05.05.2017 asking the OP to clear the due amount, failing which he will be forced to approach the judicial Forum for redressal of his grievances, upon which a sum of Rs.2,13,254/- was deposited in the account of the complainant out of total claim amount of Rs.4,39,066/-. No explanation has been given till date by the OP as to why the remaining amount of Rs.2,25,812/- has not been paid or why the same has been declined. There was no reason to decline any portion of the claim amount as all required formalities of the genuine complaint was completed in all respects. It is a clear cut case of deficiency in service, unfair trade practice and negligence on the part of the OP and the complainant has been made to suffer without any fault on his part. Hence, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the balance amount of Rs.2,25,812/- along with interest @ 12% per annum from the date of lodging the claim till actual payment and further OPs be directed to pay Rs.1,00,000/- as damages on account of harassment, mental tension and torture being suffered by the complainant and further OP be directed to pay Rs.11,000/- as litigation expenses.
4. Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared and filed written reply and contested the complaint by taking preliminary objections that the complaint of the complainant is not maintainable under the law against the answering OPs and liable to be dismissed and further alleged that OP No.1 and 2 have been dragged into unnecessary litigation hence, they are entitled for special compensatory cost of Rs.20,000/- and further averred that there is complicated question of law and facts involved in the matter and the same cannot be adjudicated in summary proceedings, therefore, this Forum has got no jurisdiction to try and decide the present complaint and further stated that the allegations of the complaint the complainant does not fall under the definition of 'Consumer' under the 'Consumer Protection Act' and thus, the complaint is liable to be dismissed. No amount of premium has been charged from the complainant and the scheme was provided by the 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 as Health Benefit Scheme free of cost or any kind of charges to its employees and being a beneficial scheme there is no question of the complainant becoming a consumer of the OPs. It is further alleged that the policy was issued in favour of the Government of Punjab, Department of Health and Family Welfare, State Institute of Health and Family Welfare Complex, but the complainant has not impleaded it in the present complaint, therefore, the present complaint is liable to be dismissed and further alleged that it is the prerogative and right of the OP No.1 and 2 to process and verify the claim as per policy terms and conditions along with prescribed requisites and valuable right conferred by agreement between the parties i.e. the Government and the OP No.2 cannot be taken away by filing the instant complaint. On merits, the factum in regard to purchase of the medical claim policy, is not denied and further submitted that the medical claims filed by the complainant also not denied rather took a plea that as per agreement, the payment has been already released to the complainant. The remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
5. OP No.2 and 3 filed its separate joint reply, but took the same preliminary objections as well as same plea on merits and we do not find any justification to repeat the same and further OP No.2 and 3 stated that the complaint of the complainant is without merits and the same may be dismissed.
6. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA along with some documents Ex.C-1 to Ex.C-32 and closed the evidence.
7. Similarly, counsel for the OP No.1 to 3 tendered into evidence two affidavits Ex.OA and Ex.OB alongwith some documents Ex.O-1 to Ex.O-8 and closed the evidence.
8. We have heard the learned counsel for the respective parties as well as gone through the written arguments and also gone through the case file very minutely.
9. In nutshell, the case of the complainant to the extent that the complainant was working as an Excise and Taxation Officer, Jalandhar-I and being an employee got the benefit of the Government Scheme launched for the benefit of the employee known as 'Punjab Government Employee & Pensioners Health Insurance Scheme and under that Scheme, ID No.MD15-09872910089 was issued to the complainant. The complainant was got massive heart attack while he was present in Amritsar and accordingly, he got treatment from Carewell Hospital, Amritsar and there remained admitted and after that he was shifted to Cardinova Hospital, Nakodar Road, Jalandhar and thereafter, the complainant submitted two separate insurance claims for an amounting to Rs.90,606/- and other claim of Rs.3,48,460/- in regard to his treatment from both the hospitals and both the claims were considered by the OPs and claimed in regard to Carewell Hospital, Amritsar for amounting to Rs.90,606/- was repudiated, vide letter dated 06.10.2017 on the ground that the claim of the complainant is not admissible as per Policy Clause No.4, hence, the Insurance Company regret their inability to admit this liability under the present policy condition and the other claim of the complainant regarding treatment taken by the complainant from Cardinova Hospital, Jalandhar and submitted the said insurance claim for an amounting to Rs.3,48,460/- out of that amount, after making several written request only partly amount of Rs.2,13,254/- was paid to the complainant, but remaining amount of Rs.2,25,812/- have been withheld without any reason and rhyme by the OP, out of the total amount of Rs.4,39,066/- and upto this extent, the facts are not in dispute rather the OPs has not denied and thus, the complainant filed the instant complaint for recovery of the said remaining amount of the treatment i.e. Rs.2,25,812/- with interest as well as compensation and litigation expenses.
10. The case of the complainant meeted out by the OP by taking a plea in the written reply that the complainant does not fall under the definition of the 'Consumer' of the 'Consumer Protection Act' and urged that the complaint of the complainant may be dismissed, the complainant has not paid any premium to the OP and thus, the complainant is not a consumer of the OPs and further took a plea that the Claim No.1 of the complainant was repudiated as per the policy terms and conditions and the notification itself i.e. provision Under Para No.4 and the Claim No.2 of the complainant was considered for reimbursement of Rs.3,84,460/- and as per the terms and conditions and compensation payable under the scheme, the same was approved of Rs.2,13,254/- and the payment was accordingly made through cheque dated 18.05.2017 and thus, the due amount has already been paid to the complainant and nothing more remains to be paid and the present complaint is liable to be dismissed. In view of the Para No.4 of the Notification as well as the Schedule Rates and further alleged that as per Clause 24 of the tendered 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 and the TPA/Insurance Company shall be referred to District Level Grievances Redressal Committee and thus, the complaint of the complainant on this score is also liable to be dismissed. It is further submitted by the OP that the said scheme was floated by the government for the benefit of the employee and pensioner under the Health Insurance Scheme w.e.f. 01.01.2016 to 31.12.2016 as per terms and conditions framed and implemented by the Punjab State Government. The sum insured was Rs.3,00,000/- for family on floater basis and further submitted in Para No.2 on merit in the written statement that the complainant was insured under the above said scheme and he went to Carewell Hospital, Amritsar for treatment as well as Cardinova Hospital, Jalandhar.
11. If we go through the written statement of the OP, then we can say without any hesitation that the OP has taken two contradictory plea in the written statement, on one side in the preliminary objection No.4, the OP itself alleged that the complainant is not a Consumer as he has not paid any premium of the insurance policy, but on the other hand, in Para No.2 on merit, the OP has categorically admitted that the complainant was insured under the above said scheme. So, the version of the OP itself created doubt that which one story propounded by the OP is true and which one is false. So, ultimately we conclude that the complainant took the insurance under the above said scheme for which the government had paid a premium to the insured company i.e. OP No.2 and 3 and as such, the complainant being a beneficiary of the government, become the Consumer, under the 'Consumer Protection Act'.
12. So, for the issue raised by the OP that this Forum has got no jurisdiction because if any dispute arises between the parties i.e. Beneficiary Health Care Provider, TPA/Insurance Company that will be referred to District Level Grievances Redressal Committee, but we do not agree with this version of the OP because as per Section 3 of the 'Consumer Protection Act', the complainant has additional remedy to approach this Forum apart from any other Redressal Forum. So, the version raised by the OP is not having any force in the eyes of law.
13. Now, coming to the main issue regarding alleged payment of the two insurance claim of the complainant, which are not denied by the OP rather the OP has categorically replied that the two insurance claim was submitted by the complainant and one was repudiated and in the other, an amount of Rs.2,13,254/- was paid full and final payment, but the complainant did not accept that amount as full and final payment and controverted that payment being a less amount of the total incurred on the treatment of the complainant. First of all, we have to consider whether the version of the OP that the sum insured was Rs.3,00,000/- for family on floater basis. In regard to this issue, we have to go through the notification, issued by the government on 20.10.2015 and copy of the same is available on the file Ex.O-8 and as perPara No.3 of the said Notification, it is categorically enumerated in Para No.3 as under:-
“The scheme will ensure cashless all indoor medical treatment, pre and post hospitalization, specified as defined, Day Care Procedures and OPD medical expenses relating to chronic diseases up to a sum of Rs.3 lacs per family per year on floater basis.”
14. The true and actually sense of the above said wording of Para No.3 is interpreted by us as under that the said para relates to medical expenses to cronic disease up to Rs.3,00,000/- not like a treatment took by the complainant. Further, we go through Para No.4 of the said Notification, wherein the word used as the enrolled beneficiaries can get treatment from empanelled hospital in Punjab, Chandigarh and NCR Area, no reimbursement will be available to employee/pensioner in 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 and in such circumstance, the insurance company will disburse the bill of the employee upto Rs.3,00,000/- as per the package rate defined under the scheme and further, we like to refer Para No.7 of the said notification, wherein is defined as under:-
“The insurance company will make the buffer of Rs.25 crores for meeting out expenses over and above Rs.3 lacs and cashless insurance to any employee/pensioner will be available beyond Rs.3,00,000/- subject to the availability of the buffer. On the exhaustion of the buffer, the cashless reimbursement more than Rs.3,00,000/- will not be available to any employee/pensioner. In such circumstances, the insurance company will inform the employee/pensioner that further treatment shall not be on cashless, but reimbursement basis as per the existing pattern at PGI/AIMS rates. The concerned DDO will seek the reimbursement from concerned Civil Surgeon/ Directorate of Health & Family Welfare as per the State Services (Medical Attendant Rules) 1940”.
15. We have analyze the above said para of the Notification Ex.O-8 and find that the complainant got the treatment from the hospitals i.e. Carewell Hospital, Amritsar and Cardinova Hospital, Jalandhar, but it is not the case of the OP that the aforesaid hospitals are not empanelled. So, accordingly, we do not find any dispute to this extent.
16. So for the concern of not availing the facility of cashless treatment by the complainant, for that the complainant has categorically alleged in the complaint as well as in his own affidavit Ex.CA that he applied for ID Card in the month of December, but till the date of taking treatment, he was not provided the ID Card by the OP and in the absence of ID Card, he was not allowed to get cashless treatment from any hospital because the said card is very much necessary to prove that he is an insured under the said policy of the government i.e. Punjab Government Employee and Pensioner Health Scheme. The version of the complainant seems to be true because the OP has brought on the file copy of an agreement Ex.O-5 and we go through the said agreement, wherein Clause 2.8 (A) is incorporated in regard to providing cashless treatment to the Card Holder and it is categorically mentioned in the aforesaid para that it is obligatory and responsibility of the hospital to ask for ID Card, before rendering cashless treatment to the beneficiary, if the complainant was not provided the said ID Card by the OP then how he can get cashless treatment and as such, we find that there is no fault on the part of the complainant for not getting cash less treatment and therefore, the complainant is entitled for reimbursement of the amount spent by him on his treatment.
17. Further, the question remains in regard to the value of the insured is hing in the air, which required deep consideration and accordingly, we again revert back to Para No.4 and 7 of the Notification Ex.O-8 and find that there is no specifically and categorically barred imposed by the said notification for not reimbursement of amount more than Rs.3,00,000/- rather in para No.4, it is clearly described that under exceptional circumstances, the reimbursement can be taken by the employee/pensioner and further the matter is resolved in Para No.7 of the said notification by elaborating that the insurance company will make the buffer of Rs.25 Crores for meeting out expenses over and above Rs.3,00,000/- and cash less insurance to any employee/pensioner, who will be available beyond Rs.3,00,000/- subject to availability of the buffer. The wording of the above para itself gave impression that the employee/pensioner is entitled for reimbursement of the treatment amount of rupees more than 3 lacs, subject to the availability of the buffer, means if the amount is available in the buffer, then the employee/pensioner can get reimbursed more than Rs.3,00,000/-, but in this case, the first claim of the complainant in regard to Rs.90,606/- was repudiated by the OP on the basis of the Para No.4 of the said notification that no reimbursement will be available to employee/pensioner in Punjab, Chandigarh and Panchkula, where cashless treatment is available, but we came to conclusion the case of the complainant is not fall under this definition because the case set up by the complainant is on different footing, he alleged that the ID Card, which is very much necessary/required for getting cashless treatment, was not issued to the complainant, till the date of his treatment rather the same was issued later on and photostat copy of the said card is available on the file Ex.C-1. So, accordingly, we are of the considered opinion that the first claim of the complainant in regard to treatment taking from Carewell Hospital, Amritsar for amounting to Rs.90,606/- has been illegally and wrongly repudiated by the OPs.
18. From the second claim, whereby the complainant demanded treatment charges of Rs.3,48,460/-, but out of that the OP paid part payment of Rs.2,13,254/-, the total amount claimed by the complainant is Rs.4,39,066/-, which is over and above the insured amount of Rs.3,00,000/- as alleged by the OP, for that purpose, Para No.4 of the said Notification Ex.O-8 itself make clear that the pensioner/employee is entitled to avail the treatment charges beyond Rs.3,00,000/-, subject to availability of the buffer, but in the second insurance claim, the OP has not mentioned or informed to the complainant that there is no further amount is available in the buffer, if so then, the complainant is entitled for more than Rs.3,00,000/- as per Para No.7 of the Notification Ex.O-8, if there was no over and above Rs.3,00,000/- available in the buffer, then it is the duty of the OP No.1 to inform the complainant or the employer of the complainant that the remaining amount be got reimbursed as per the existing pattern of said State Services Medical Attendance Rules, but the OP No.1 did not bother to take the case of the complainant seriously, which is apparently negligence on the part of the OP for not taking the case of the complainant seriously and as such, we are of the considered opinion that the complainant is entitled for the treatment amount of rupees over and above 3 lacs as per Section 7 of the Notification.
19. Coming to next question whether the OP has rightly make part payment of Rs.2,13,254/- out of the total amount Rs.4,45,066/-. The said part payment, have been made by the OP on the pretext that the same is disbursed to the complainant as per the PGEPHIS Schedule of rates, which is Ex.O-4 and also made a reliance upon a Tender Notice Ex.O-3. We have gone through the Tender Notice Ex.O-3 and find there is no restriction imposed upon the expenditure on treatment of the heart, simply rate is fixed for making payment of room charges or general ward, which is not a big issue because the charging of the room is provided of Rs.1000/- per day as per the said Tender Notice, in the written statement, the OP calculated the amount by taking into consideration two stent inserted by the doctor at the time of operation of the complainant, but virtually three stent was inserted as per bills Ex.C-16, Ex.C-18 and Ex.C-19 and the amount calculated by the OP, where is Rs.52,000/- per stent and two stent including other charges equal to Rs.2,13,254/-, but as per schedule of rate Ex.O-4, there is no condition imposed for decreasing the price of stent rather as per para No.4 of the Schedule of Rate, it is categorically mentioned that the cost of stent is reimbursable in addition to package rates to the provider/hospital, cost of implantes is payable in addition to package rate as per Punjab Medical Attendance Rules and the rate of the stent is mentioned in the last page of the said Schedule of Rates Ex.O-4, wherein the category of the stent is divided in two types i.e. 992 and 993. The complainant alleged that the stent used by the doctor in his case is having 993 number and cost of the one stent is to be paid to the OP or concerned hospital is upto Rs.1,17,000/-, but the OP has calculated the said price of Rs.52,000/-, which is absolutely wrong against the said schedule of rates and further the complainant has brought on the file bills and cash memo of medicines of the Carewell Hospital, Amritsar, which are Ex.C-7 to Ex.C-11 and Ex.C-13 and further the purchase bills of the stent are Ex.C-16 and Ex.C-18 and Ex.C-19 and the cost of two stent is mentioned therein Rs.75,000/- each and the cost of third stent is Rs.40,000/-, the other bills of the Cardinova Hospital, Jalandhar are proved on the file by the complainant Ex.C-16 to Ex.C-31 and the complainant also made sincere efforts to get the insurance claim from the OP and sent letters Ex.C-2 to Ex.C-4 and discharge summary Ex.C-12 and claim form of both the insurance claim are Ex.C-10 and Ex.C-14 and insurance policy has been brought on the file by the OP Ex.O-7. So, from the over all circumstances as discussed above give impression to us that the OP has illegally and wrongly repudiated the first insurance claim of the complainant regarding Rs.90,606/- and further with malafide intention just to harass the complainant make a part payment of Rs.2,13,254/- instead of Rs.4,39,060/- and as such, we find there is unfair trade practice and deficiency in service on the part of the OP and therefore, we find much force in the argument put forth by the learned counsel for the complainant and therefore, we conclude that the complainant is entitled for the relief.
20. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the balance amount of medical treatment of Rs.2,25,812/- along with interest @ 12% per annum from the date of lodging the claim, till realization of the same and further the OPs are directed to pay compensation to the complainant for mental and physical harassment, to the tune of Rs.20,000/- and further OPs are also directed to pay litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
21. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
06.06.2018 Member President
