DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT, AT AMRITSAR, PUNJAB.
Complaint Case No : RBT/CC/2018/241
Date of Institution : 04.04.2018/29.11.2021
Date of Decision : 04.08.2022
Mrs. Balbir Kaur wife of Sh. Vijay Partap Singh resident of H.No. 33, Labh Nagar, Ram Tirath Road, Amritsar.
…Complainant Versus
1.M.D. India Health Care Service Pvt. Limited, Maxpro Info Park, D-38, 1st Floor, Industrial Area, Phase-1 Mohali (Punjab), Through its Chairman/Managing Director/Principal Officer.
2.State of Punjab Through Principal Secretary, Department of Personnel, Civil Secteriat, Chandigarh.
…Opposite Parties
Complaint Under Section 12 & 13 of Consumer Protection Act, 1986. As Amended Upto Date.
Present: Sh. Deepinder Singh Adv counsel for complainant.
Sh. R.P. Singh Adv Proxy counsel for O.P-1.
Opposite party No. 2 exparte.
Quorum:-
1. Sh. Ashish Kumar Grover : President
2.Smt. Urmila Kumari : Member
(ORDER BY ASHISH KUMAR GROVER, PRESIDENT):
1. The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant has filed the present complaint Under Section 12 & 13 of the Consumer Protection Act, 1986 (as amended upto date) against M.D. India Health Care Service Pvt. Limited & others (hereinafter referred as opposite parties).
2. Brief facts of the case are that the complainant got Health Benefit mediclaim insurance for herself from the opposite party by virtue of the Punjab Government employee and pensioner health insurance scheme. It is alleged that the complainant unfortunately fell ill and was to be hospitalized at IVY Hospital, Amritsar from 19.10.2016 and discharge on 26.10.2016 and on the treatment of complainant the cost came more than Rs. 3 lacs and the opposite party No. 1 immediately informed about the above said hospitalization and all the treatment record alongwith medical bills were furnished to the opposite party No. 1. The complainant had to make the payment to the said hospital out of her own resources. It is further alleged that the sum insured for the medical benefit is for Rs. 3 lacs and the opposite party has not issued the insurance card to the complainant despite several requests but the complainant is entitled being Punjab Government pensioners and the opposite parties are bound to pay the insurance benefit to the complainant. But till today the opposite parties have failed to settle the genuine claim of the complainant and the conduct of the opposite parties amounts to deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
i)To pay the amount of Rs. 3 lacs alongwith interest @ 12% per annum from the date of payment till realization.
ii)To pay Rs. 50,000/- as compensation alongwith litigation expenses.
3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written reply by taking preliminary objections interalia on the grounds of maintainability, complaint is bad in law, act and conduct, complaint is frivolous and baseless, suppressed of material facts, jurisdiction etc. It is further alleged that as per Notification No. 21/28/12-5HB5/268 dated 20.10.2015 and as per Para No. 4 of the said notification “The treatment can be taken by any enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). No reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available.
4. On merits, it is submitted that the Punjab Government while launching the scheme providing this facility in the empaneled hospital fixed by the nodal department/state government on cashless basis, but as per the version of the complainant she got admitted in IVY Hospital Amritsar which is not on the empaneled list of hospitals/Nursing Home approved by the Nodal department/Government of Punjab, as such the claim of the complainant is not maintainable as per clause 4 of the Punjab Government Gazette Notification dated 20.10.2015. The Nodal department/ State Government has fixed the rates of all the medical facilities provided by the Hospitals and reimburse the same as per the rates fixed by the state government. It is denied that the complainant was having any insurance for the medical benefits up to Rs. 3 lacs. The complainant is not covered under the scheme because no premium has been paid by the complainant, as such no insurance card has been issued to her. All other allegations of the complainant are denied and prayed for the dismissal of complaint.
5. None appeared on behalf of opposite party No. 2, as such the opposite party No. 2 was proceeded against exparte vide order dated 15.7.2019.
6. In order to prove the case the complainant tendered into evidence her own affidavit Ex.C-1, copy of discharge summary Ex.C-2, copy of the retirement order Ex.C-3, copy of medical bills Ex.C-4 consisting of 7 pages and closed the evidence.
7. To rebut the case of complainant the opposite party No. 1 tendered into evidence affidavit of Dr. Geeta Bhardwaz Ex.O.P1 and documents Ex.O.P2 to Ex.O.P7 and closed the evidence.
8. We have heard the Ld. Counsel for the parties and have gone through the documents placed on record by the parties.
9. Ld. Counsel for complainant argued that the complainant got Health Benefit mediclaim insurance for herself from the opposite party by virtue of the Punjab Government employee and pensioner health insurance scheme. It is further argued that the complainant unfortunately fell ill and was to be hospitalized at IVY Hospital, Amritsar from 19.10.2016 and discharged on 26.10.2016 and on the treatment of complainant the cost came more than Rs. 3 lacs and the opposite party No. 1 immediately informed about the above said hospitalization and all the treatment record alongwith medical bills were furnished to the opposite party No. 1 and the complainant had to make the payment to the said hospital out of her own resources. It is further argued that the sum insured for the medical benefit is for Rs. 3 lacs and the opposite party has not issued the insurance card to the complainant despite several requests but the complainant is entitled being Punjab Government pensioners and the opposite parties are bound to pay the insurance benefit to the complainant.
10. On the other hand, Ld. Counsel for opposite party No. 1 argued that as per Notification No. 21/28/12-5HB5/268 dated 20.10.2015 and as per Clause No. 4 of the said notification the treatment can be taken by any enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi) and no reimbursement will be available to employee/pensioners in the Punjab, Chandigarh and Panchkula, where cashless treatment is available. It is further argued that the Punjab Government while launching the scheme providing this facility in the empaneled hospital fixed by the nodal department/state government on cashless basis, but as per the version of the complainant she got admitted in IVY Hospital Amritsar which is not on the empaneled list of hospitals/Nursing Home approved by the Nodal department/Government of Punjab, as such the claim of the complainant is not maintainable as per clause 4 of the Punjab Government Gazette Notification dated 20.10.2015. It is also argued that the complainant was not having any insurance for the medical benefits up to Rs. 3 lacs.
11. Perusal of the record shows that on the following grounds the complainant is not entitled to medical reimbursement. Firstly, as per clause no. 4 of the Notification No. 21/28/12-5HB5/268 dated 20.10.2015 Ex.O.P4 which is as under;-
“The treatment can be taken by any enrolled beneficiaries in Government or in empaneled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). Further, details of the scheme can be seen on website www.pbhealth.gov.in. No reimbursement will be available to employee/pensioners in the 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, in such circumstances, the insurance company will reimburse the bill of the employee up to Rs. 3.00 lacs as per the package rates defined under the scheme”
12. Secondly, the complainant has alleged in her complaint that she got health benefit mediclaim insurance by virtue of Punjab Government Employee and Pensioner Health Insurance Scheme and the sum insured for the medical benefit is for Rs. 3 lacs but the complainant has failed to place on record any above said insurance card to indicate that the she is entitled for medical reimbursement for Rs. 3 lacs as alleged by the complainant.
13. Thirdly, the opposite party has placed on record copy of group medical insurance policy Ex.O.P5 of The Oriental Insurance Company Limited, which is in the name of Government of Punjab Department of Health & Family Welfare. But the complainant has failed to implead the above said Oriental Insurance Company as party in the present complaint. Therefore, the complaint is bad due to non-joinder of necessary party. So, we are of the view that the complainant is not entitled to reimbursement of above said amounts from the opposite parties.
14. In view of the above discussion, there is no merit in the present complaint and same is dismissed. However, no order as to costs or compensation. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
ANNOUNCED IN THE OPEN COMMISSION:
4th Day of August, 2022
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
