BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.262 of 2017

      Date of Instt. 28.07.2017

      Date of Decision: 05.01.2021

Ram Krishan aged 59 Years S/o Shri Dial Rattan alias Dial Chand, R/O Quarter No.-2, PWD Colony, Kapurthala

..........Complainant

Versus

1.       MD India Healthcare Services (TPA) Pvt. Ltd. (Punjab   Government Employees and Pensioners Health Insurance     Scheme (PGEPHIS)), MD INDIA HEALTH INSURANCE TPA           PRIVATE LIMITED Maxpro Info Park, D-38 Industrial Area,         Phae-1, Mohali, Punjab-160056 Through its Authorized      Representative.

2.       The Oriental Insurance Company Ltd, Regional Office, SCO NO      109, 110, 111 Surindera Building, Sector 17-D, Chandigarh       through it’s Regional Manager.

3.       Chawla Heart Care Center, Guru Nanak Mission Chowk,         Jalandhar.

4.       State of Punjab Department of Health and Family Welfare        Department through its Principal Secretary, Punjab, Civil       Sectretrate, CHANDIGARH (U.T)

                                                ….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Kuljit Singh             (President)

Smt. Jyotsna                   (Member)

Present:       Smt. Harleen Kaur, Adv. Counsel for the Complainant.

                   Sh. Brijesh Bakshi, Adv. Counsel for OPs No.1 & 2.

Sh. B. S. Bhatia, Adv. Counsel for the OP No.3.

OP No.4 DAW.

Order

Kuljit Singh (President)

1.                The instant complaint has been filed by the complainant, wherein alleged that the complainant is employed as SDO in PWD Branch in Punjab Government insured alongwith his family in a cashless Health Insurance Scheme (For Brevity PGEPHS) introduced by Government of Punjab to cover indoor medical treatment expenses, specified daycare procedures and treatment of chronic diseases as specified or to be specified by State Government OP No.4. This beneficial PGEPHS floated by OP No.4 was applicable to all Government serving employees and pensioners on compulsory basis with unique Nobel object Health for all its in service and pensioners. The premium as consideration of main member as well as dependents to cover risk under PGEPHS was to be paid by OP No.4 under policy bearing No.231102/48/2016/769. Master insurance policy for all insured was issued by OP No.2 to OP No.4 since they have had tendered into evidence up arrangement for reimbursement of mediclaim payment. The father of the complainant is also covered in PGEPHS. OP No.1 issued MIDID number MD 15-09855013845 and Claim Number (CCN) No.MD10005228 Member (CCN) to the complainant. The family members covered under PGEPHS scheme are the complainant, Dial Chand (alias Dial Rattan) Father, Mohinder Rattan- Mother, Kamal Rattan-Wife, Amandeep Rattan-Son, and Deepali Rattan-Daughter for the policy period for insurance risk cover from 01.01.2016-31.12.2016.

2.                The OP No.2 is insurer and OP No.1 Third Party Administrator (TPA) as per tendered into evidence up arrangement between OP No.4 and OP No.2. That the complainant’s father has become entitled to reimbursement of expenses incurred subject to peril covered under PGEPHS for medical expenses illness/and surgical operation to the extent of sum insured on the happening of contingency incorporated PGEPHS with OP No.2. That the father of the complainant 80 years old was admitted in Chawla Heart Care Center, Guru Nanak Mission, Chow, Jalandhar on 08.03.2016 and discharged on 20.03.2016 as inpatient diagnosis with complaint epigastric. He had undergone surgical operation as fully described in Discharge Summary. The said hospital being a penal Hospital sent a letter dated 12.04.2016 seeking approval for cashless sanction from OP No.1 and sent the same through TRACKON Courier on 12.04.2016. The complainant also sent a letter dated 28.02.2017 which was duly received on 06.03.2017 as per the stamp affixed on copy of the letter by OP No.1 and copy thereof was also sent to the OP No.2. That after covalence and discharge from O PNo.3, complainant preferred Mediclaim to OP No.1 for the reimbursement of medical and surgical operation expenses incurred and paid to OP No.3 since cashless was not sanctioned by O PNo.1. the complainant submitted original bills, receipts of payment, original reports, original discharge summary alongwith prescribed claim form duly signed and counter signed by O PNo.3 and also completed and complied with all the formalities and requirements which ever were asked for. That the medical expenses of the complainant have neither been reimbursed nor did his mediclaim settled till date despite his repeated follow up and protestations with OP No.1. The complainant has been put off on the pretext or the other that settlement of Mediclaim expenses amount is lying pending with OP No.1 and the complainant will get reimbursement of expenses in due course. The claim settlement status has not been made known to the complainant. The complainant has been running from pillar to post for the last over one year awaiting claim settlement and reimbursement of expenses but all in vain. All efforts made to convince persuade for reimbursement of expenses but there has been studied silence on the part of OP No.1 in this respect. The OP No.1 is required and duty bond to process, finalized and settle mediclaim expenses amount within 30 days of the receipts of prescribed claim forms with all supportive documents as per statutory and mandatory insurance regulatory and development authority of India (IRDAI) (Protection of Policy Holder’s Interests) Regulations, 2002. But IRDAI mandate has not been adhered to in the case of the complainant by OPs No.1 and 2 for the reason best known to them. Delay in settlement of PGEPHS mediclaim expenses per se is sufficient to saddle with charge of deficiency in rendering service and negligence on the part of the OPs NO.1, 2 and 4. That recently the Hon’ble Punjab and Haryana High Court in CWP No.13114 decided on 19.05.2017 by Hon’ble Meter reader. Justice Kuldip Singh has rapped OP No.4 for delay in settlement of Mediclaim expenses under PGEPHS and held one month as reasonable time to make payment after its sanction and also observed that scheme apparently collapsed. In the circumstances the Hon’ble High Court has directed OP No.4 to create mechanism in which after the submission of bills for medical reimbursement the movement of the same is mentioned and OP to issue necessary instructions as to how long particular authority can withhold/decide the medical bills and the employee who submits the bills, should have acess to the movement of bills so that he can oversee that his bills are properly dealt with and are processed and payment is made within reasonable time which could vary to three to six months and ensure that the employee/retired employee gets the payment to utilize the money for his further treatment for his personal use. That the act and conduct, behavior and approach on the part of the OPs No.1, 2 and 4 are unethical, unprofessional, callous and indifferent towards innocent insured covered under PGEPHS and cognizable under the provisions of the Consumer Protection Act, 1986 as amended upto date (for brevity the Act). The OP No.1, 2 and 4 have adopted unfair and deceptive trade practice as defined in the Act and are liable to be proceeded within the realm of said Act. That the harassed, fed-up and disgusted complainant is constrained and compelled to knock the doors of this Hon’ble Forum and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs No.1 and 2 be directed to reimburse Rs.1,52,000/- to the complainant alongwith interest @ 12% per annum from the date of payment to OP No.3 till actual realization since the complainant has been deprived of the beneficial use and advantage of this amount and further OPs be directed to pay compensation of Rs.30,000/- and litigation expenses of Rs.5500/-.

3.                Notice of the complaint was given to the OPs and accordingly, OPs No.1 & 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the above noted complaint is not maintainable under the law against the answering respondents. It is further alleged that the complainant has got no cause of action to file the present complaint against the answering respondent. There has been no default or undue delay, on the part of the answering respondent in processing the claim of the applicant. The respondent No.1 had received cashless request for the case of the complainant from the respondent No.3 Hospital which is a panel hospital and as per procedure the initial authorization approval of Rs.25,000/- was given by the respondent No.1 on the request of the respondent No.3 with claim/CCN MDI0005214. Thereafter as per procedure the panel hospital respondent No.3 was to provide the Final Diagnosis Reports, Medical Bills and Treatment Records and submit the claim for further processing. But the respondent No.3 failed to file any claim or submit any reports/medical records with regard to the MDI5-09855013845 with CCN No.MD10005214. In the absence of any claim the authorization of Rs.25,000/- also lapsed and the claim stood closed. Thereafter even the complainant did not approach the respondent No.1 and the payments of the respondent No.3 were settled in all cases as per their merits where the claims were filed by it. As regards the alleged letter purported to have been received in the office of Respondent No.1 on 06.03.2017 it may be seen that the same may have been got received at the receipt desk where the same is not checked and that too the letter/demand is almost one year after the patient/complainant was allegedly admitted. The said letter is not only very delayed but also it may be seen that the MDI Number is not clearly readable and even if the same was read there was no CCN Number mentioned regarding the alleged claim and already other payments of respondent No.3 had been settled. Even the hospital failed to submit any document from its side regarding any treatment given to the complainant and the respondent No.1 was constrained to close the claim for non-supply of documents for processing. As per law and policy conditions unless a legal and valid claim is raised to the respondent No.1 as per the policy conditions regarding the PGEPHIS Policy linked insured with proper CCN number and all requisite details the same cannot be considered and processed by the respondent No.1. Thus, the alleged claim and the present complaint is not maintainable and deserves to be dismissed. It is further allege that the complainant is barred by her own act, conduct, laches and negligence from filing the present complaint and claiming the relief as prayed herein. That the complainant is guilty of concealment of material facts and has not approached the Forum with clean hands and as such is not entitled to any relief. On merits, the factum in regard to purchase of the medical claim policy, is not denied and further submitted that the entitlement to reimbursement is subject to policy terms and conditions and processing requisites and cannot be claimed as a matter of right where either no claim or incomplete claims are raised. The panel hospitals in cashless cases has to file the claim with all requisite papers thereof to the respondent No.1 and secondly the same is subject submission of final claim as per CCN Number allotted and then to verification and claim settlement procedure to be adopted by the respondents No.1 and 2 as per law and policy terms and conditions and the respondent No.3 failed to raise any claim in CCN No.MDI0005214 and to provide any records of the same and hence the claim was closed and no claim is maintainable, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

4.                OP No.3 appeared through its counsel and filed separate written reply, whereby contested the complaint by taking preliminary objections that the complainant has suppressed and concealed the material facts from this Forum. The OP No.3 has been arrayed by the complainant in the present complaint just to harass it. It is further alleged that the answering OP is a reputed hospital of the city and followed by norms prescribed by the Govt. in respect of insurance of patients. The answering OP had conveyed to OP No.1 regarding the cashless insurance scheme of the patient namely Dayal Chand on the day of admission. However, the medical documentation of the patient has been submitted by the answering OP to the OP No.1 on 12.04.2016 for getting sanction of treatment of patient. On merits, it is admitted that the father of the complainant got treatment on 08.03.2016 and discharged on 20.03.02016, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

5.                Complainant does not want to proceed against the OP No.4, as such, he withdraw the present complaint against OP No.4, vide his separate statement dated 01.08.2017.

6.                In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and Ex.CB alongwith some documents Ex.C-1 to Ex.C-23 and  closed the evidence.

7.                In order to rebut the evidence of the complainant, the counsel for the OPs No.1 & 2 tendered into evidence two affidavit Ex.OA & Ex.OB alongwith some documents Ex.O-1 and closed the evidence.

8.                Counsel for the OP No.3 tendered into evidence documents Ex.OP3/1 to Ex.OP3/2 and closed the evidence.

9.                We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant and OPs No.1 & 2, very carefully.

10.              Precisely, the case set up by the complainant is that he being a pensioner availed the insurance facility provided by the Govt. under the scheme known as Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) and the claim of the complainant in regard to getting treatment by the father of the complainant, is admittedly received by the OP No.2, but the same was not entertained by the OP No.2 as the panel hospital respondent No.3 was to provide the final diagnosis reports, medical bills and treatment records and submit the claim for further processing. But the OP No.3 failed to file any claim or submit any reports/medical records with regard to the MDI-09855013845 with CCN No.MDI0005214. In the absence of any claim the authorization of Rs.25,000/- also lapsed and the claim stood closed. Even the hospital failed to submit any document from its side regarding any treatment given to the complainant and the respondent No.1 was constrained to close the claim for non-supply of documents for processing. As per law and policy conditions unless a legal and valid claim is raised to the OP No.1 as per the policy conditions regarding the PGEPHIS Policy linked insured with proper CCN number and all requisite details the same cannot be considered and processed by the OP No.1 and further submitted that the entitlement to reimbursement is subject to policy terms and conditions and processing requisite and cannot be claimed as a matter of right where either no claim or incomplete claims are raised and further the panel hospital in cashless cases has to file the claim with all requisite papers thereof to the OP No.1 and secondly, the same is subject submission of final claim as per CCN Number allotted and then to verification and claim settlement procedure to be adopted by the OP No.1 and 2 as per law and policy terms and conditions and the OP No.3 failed to raise any claim in CCN No.MDI0005214 and to provide any records of the same, hence the claim was closed and no claim is maintainable. Also the documents regarding admission and discharge of the father of the complainant and treatment or supportive tests of diagnosis not provided to the answering OPs i.e. OPs No.1 & 2. In the affidavit Ex.OA of Sandeep Thapa, Senior Divisional Manager of Oriental Insurance Company Ltd., it is submitted that the OP No.1 had received cashless request of the case of the complainant from the OP No.3 Hospital which is a panel hospital and as per procedure the initial authorization approval of Rs.25,000/- was given by the OP No.1 on the request of the OP No.3 with claim/CCN No.MDI0005214. Thereafter as per procedure the panel hospital O PNo.3 was to provide the final diagnosis reports, medical bill and treatment records and submit the claim for further processing.

11.               After considering the overall facts and circumstances, we came to conclusion that the complainant is failed to submit the requisite documents, which demanded by the OPs No.1 & 2. So, with these observations, the instant complaint of the complainant is disposed of with the direction to the complainant to submit final diagnosis reports, medical bills and treatment records with regard to the MDI5-09855013845 with CCN No.MDI0005214, whatsoever required to the OPs No.1 and 2, within 30 days from the date of receipt of the copy of this order and after receiving the required documents from the complainant, the OPs No.1 and 2 are directed to decide the insurance claim of the complainant within 30 days from the date of receipt of the documents, failing which the OPs No.1 and 2 will liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant will not satisfy with the settlement of the claim made by the OP, then complainant is at liberty to file a fresh complaint. This complaint could not be decided within stipulated time frame due to rush of work.

12.               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                                       Jyotsna                           Kuljit Singh

05.01.2021                              Member                          President