DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR
Consumer Complaint No.386 of 11.10.2017
Date of Decision : 23.02.2021
1. Janak Raj r/o House No. 4 E, New Baradari, Tehsil and District Jalandhar.
2. Kamlesh Rani w/o Sh.Janak Raj, r/o House No. 4-E, New Baradari, Tehsil and District Jalandhar.
….. Complainants
Versus
1. M/s Oriental Insurance Company Ltd., Regional Office SCO No. 109/111, Sector 17-D, Chandigarh, 160017 through its Manager.
2. M/s M.D India Insurance TPA Pvt. Ltd., Max Pro Park, D 38 , First Floor, Industrial Area, Phase 1, Mohali, Punjab through its Managing Director.
3. Punjab Government Employees and Pensioners, Health Insurance, Scheme Ministry of Health and Family Welfare, State of Punjab, Chandigarh.
4. Chawla Heart Care Centre, C/o Care Max Hospital, Guru Nanak Mission Chowk, Near Petrol Pump Jalandhar..
…Opposite parties
Complaint under the Provisions of Consumer Protection Act
QUORUM:
SH.KULJIT SINGH, PRESIDENT
SMT. JYOTSNA, MEMBER
ARGUED BY:
For Complainant : Sh.Vikas Kumar Gupta, Advocate
For OP No.1&2 : Sh.Brijesh Bakshi, Advocates
For OP No.3 : Summoned not required.
For OP No.4 : Exparte.
ORDER:-
KULJIT SINGH, PRESIDENT
The present complaint has been filed by complainant against the OPs on the averments that complainant no.1 is employee with Punjab Police having belt no. 2005/L Commissionerate Jalandhar and is posted a security in charge Commissioner office Jalandhar and his wife complainant no.2. Punjab Government Employee or Pensioner Health Insurance Scheme floated by State of Punjab through OP no.3 and they have paid requisite premium for the same and insured under insurance policy bearing no. 231102/48/2016/769 and same was valid from 01.01.2016 to 31.12.2016 issued by OP no.1. At the time of issuance of the said policy, it was intimated to them that insured persons are entitled for cash less treatment from empanelled hospitals/ network hospitals and all medical expenses will be reimbursed to insured persons. The details of insurance policy with terms and conditions are not provided to them. During the continuation of the insurance policy, complainant no.2 suffered heart blockage and she was immediately taken to one of the network/empanelled hospital i.e. OP no.4 but OP no.4 has refused to provide the cashless treatment despite providing the insurance card on the ground that earlier bills are not cleared under the scheme and complainant has to make the cash payment in case she required medical treatment. Since the complainant was in critical position and it was not possible to move to some other hospital as such complainant paid the entire dues from his own resources. The complainant has spent a sum of Rs.1,67,911/- on treatment and thereafter she filed claim for re-imbursement under claim no. MD10047513 with OP no.2. On 28.09.2016 OP no.2 had repudiated the genuine claim of the complainant on the ground that reimbursement is not provided under the policy and complainant is entitled to only cashless access. The complainants were highly surprised after hearing the response from the OP and requested them to pay the claim but OPs refused to listen the genuine problem of the complainants. At the time of issuance of the policy, it was intimated to complainants that insured persons are entitled to cashless treatment from the empanelled hospitals/network hospitals and all the medical expenses will be reimbursed to insured persons. The complainants also served a legal notice to OPs but of no use. Due to act and conduct of OPs, they filed the present complaint and prayed that OPs be directed to pay Rs.1,00,000/- as compensation for mental harassment and Rs.25,000/- as cost of litigation.
Upon notice, OPs no.1 and 2 appeared and filed joint written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. There is complicated question of law and facts involved in the matter and same cannot be adjudicated in summary proceedings. No amount of premium has been charged from the complainant and 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 of the complainant becoming a consumer of OPs. On merits, it was averred that as per tender of Punjab Government, the insurance company issued a insurance policy w.e.f 01.01.2016 to 31.12.2016 as per terms and conditions for sum insured of Rs.3,00,000/- for family on floater basis. No such intimation or assurance as claimed was given to the complainants and there is no provision for supplying any individual policy documents to complainants. The public domain publication was made regarding the policy and terms and conditions thereof with constructive notice to all beneficiaries. The reimbursement claim was raised before OP no.2 and on perusal of documents, it was found that complainant no.2 had ‘sick sinus syndrome’ and current illness was a complication thereof. The claim was rejected and repudiated on 28.09.2016 as per agreement of PGEPHIS. The complainant never informed or intimated OPs no.1 and 2 about admission or treatment till the raising of the aforesaid claim. Rest of the averments of the complainants were denied by OPs no.1 and 2 and they prayed for dismissal of the complaint.
Notice sent to OP no.3 not required by this Commission while notice sent to OP no.4 served but none has appeared on his behalf despite service, as such, OP no.4 is proceeded against exparte on 08.11.2017.
The complainant no.1 tendered in evidence his affidavit Ex.C-A along with documents Ex.C-1 to Ex.C-31. On the other hand, OPs no.1 and 2 tendered in evidence of Yash Paul Divisional Manager OIC along with copies of documents Ex.O-1 to Ex.O-5.
We have heard learned counsel for the parties and have also gone through the record of the case very carefully.
The glance at evidence is required by us to settle the controversy in this case. The complainant no.1 has tendered in evidence his affidavit Ex.C-A on the record. Ex.C-1 is copy of Punjab Government Employee and Pensioners Health Insurance Scheme card. Ex.C-2 is copy of acknowledgment receipt. Ex.C-3 is copy of claim detail. Ex.C-4 is copy of provider list. Ex.C-6 to Ex.C-9 are postal receipts thereof. Ex.C-10 is copy of hospital card issued in the name of complainant no.2 Kamlesh Rani. Ex.C-11 to Ex.C-29 are copies of payment receipts. Ex.C-30 is copy of discharge summary. Ex.C-31 is copy of cash memo. To refute this evidence of the complainant, OPs no.1 and 2 relied upon affidavit of Yash Pal Deputy Manager of OIC as Ex.O-A on the record. Ex.O-1 is copy of Punjab Government Gazette. Ex.O-2 is copy of form for Punjab Government Employee and Pensioner Health Insurance Scheme.
Ex.C-30 is discharge summary, which is the vital document on the record, from perusal of this document, it is clear that the complainant no.2 Kamlesh Rani admitted in the Chawla Hospital Guru Nanak Mission Chowk, Jalandhar on 17.05.2016 and discharged on 23.05.2016, where diagnosis of Non DM/Non HTN/Complete Heart Block is mentioned. The beneficiary shall avail this benefit of cashless basis from designated stores and hospitals in every District and Block of Punjab and Chandigarh. The scheme shall be provide coverage for meeting all expenses relating to hospitalization of beneficiary members up to Rs.3,00,000/- per family per year in any of the empanelled hospital. The benefit shall be available to each and every member of the family on floater basis i.e. the total cover of Rs.3 lakh can be availed by one individual or collectively by all members of the family. 10.2 Modus Operandi to be followed for treatment at various network hospitals for all types of treatment shall be as under:-
For private hospitals in Punjab, Chandigarh & Panchkula –Rates shall be determined in accordance with the PGEPHIS Schedule of Rates. For treatments that have not been mentioned in the PGEPHIS rates, the rates applicable shall be either CGHS Rates or negotiated rates with the hospital whichever is less. The rates shall be determined in accordance with the PGEPHIS Schedule of Rates, fixed by the Nodal Department/State Government.
The learned counsel for the complainant relied upon judgment in case titled as Ram Pal versus Central Administrative Tribunal and others reported in 2019(1) SCT 763 of Hon’ble Punjab & Haryana at Chandigarh that claim of reimbursement cannot be rejected solely on the ground that Hospital where he was treated was not included in Government order. In case a case authorities are bound to ensure as to whether claimant had actually taken treatment and factum of treatment is supported by records duly certified by doctor/hospital concerned. Once that is established, claim cannot be denied on technical grounds. The case law titled as Darshan Singh Rai vs. Union of India reported in 2008(2) SCT 242 of Hon’ble Punjab & High Court that all the rules and regulations regarding medical reimbursement are to be considered in favour of the government employee liberally and to his benefit. Further, case titled as Dr. Harinder Pal Singh vs. State of Punjab reported in 2014(3) SCT 483 that medical reimbursement policies are to be interpreted liberally and that reimbursement cannot be denied on the ground that the petitioner had not gone for treatment to the approved hospital.
8 On the other hand, counsel for OPs no.1 and 2 relied upon judgment titled as The Oriental Insurance Company & another versus Sukhwinder Singh and others of Hon’ble State Commission, Pb. Chandigarh reported in First Appeal No.556 of 2017 decided on 22.12.2017 & case titled as M.D India and others versus Sushil Dhawan and others reported in First Appeal No. 870 of 2017 of Hon’ble State Commission Punjab Chandigarh in support of his case.
9 It has been specified that as per notification no.21/28/12-5HB5/268 dated 24.10.2015 the treatment can be taken by any enrolled beneficiaries in Government or in empanelled Hospital in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). One side OPs no.1 and 2 pleaded in paragraph no.5 of their written submissions that complainant was diagnosed sick sinus syndrome which implies ailment caused by a malfunction of the sinus node, heart’s primary pacemaker and on the other hand, OPs no.1 and 2 pleaded in paragraph no.4 of their written reply that complainant never informed or intimated about admission or treatment till raising of the aforesaid claim much after the alleged payment thereof. In view of case law titled as Jawahar Lal Bohra Vs. State of Rajasthan (supra) the patient who had undertaken treatment from a hospital not specified was entitled to reimbursement at the rate applicable in the recognized hospital of the State Government. Further, government servant and retired pensioners was a beneficial and welfare legislation meant for the welfare of the Government servant and therefore a liberal, sympathetic and objective interpretation for the applicability of these rules has to made by the courts. The reimbursement of medical expenses to the patient at least to the extent of the rates applicable in the recognized hospital of the State Government. The State cannot refuse reimbursement of the expenditure incurred by a Government Servant for it is the bonafide duty of the Government to pay for the beneficial act of an employee as it is welfare State. The State cannot permitted to have an iron heart in such matters.
10. In the present case OPs no.1 and 2 are liable to pay expenses to complainant as per PGEPHIS rules for which he is entitled. According paragraph no.10 of the PGEPHIS Scheme in sub clause 10.2, Modus Operandi to be followed for treatment in various network hospitals for all types of the treatment under Punjab Government Employees & Pensioners Health Insurance Scheme, the rates shall be determined in accordance with the PGEPHIS Schedule of rates. The treatment provided shall be essentially on cashless basis, however in case where cashless services has not been rendered by the hospital, due to any reasons whatsoever, the beneficiary shall be eligible for reimbursement, subject to submission of claim to TPA within 30 days from the date of discharge of the hospital. In those hospitals where cashless treatment is not available then in that eventuality, OPs Hospital liable to pay the expenses as per PGEPHIS Schedule of rates to the government employees, for which he is entitled.
11. In the light of our above discussion, we partly allowed the complaint of the complainant and OPs No.1 and 2 are directed to pay the expenses as per PGEPHIS Schedule of rates to the complainant No.1 for which he is entitled.
12. The compliance of the order be made within 45 days from receipt of copy of this order.
13. Let copies of the order be sent to the parties of costs. under the rules.
14. File be indexed and consigned to the record room.
ANNOUNCED IN THE OPEN FORUM:
23rd Day of February, 2021
(Kuljit Singh)
President
(Jyotsna)
Member
