2Nd ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.
First Appeal No.694 of 2017
Date of Institution: 06.10.2017
Order Reserved on : 25.01.2018
Date of Decision: 13.02.2018
The Oriental Insurance Co. Limited, SCO N.109-111, above Jimkhana Pub, Surendera Building Sector 17D, Chandigarh through the authorized Signatory.
Appellant/OP No.1
Versus
- Mukhtar Singh son of S.Sakattar Singh, resident of House No.3, Lane
No.1 Ranjit Vihar, Amritsar.
Respondent No.1/complainant
- Dr. Om Parkash Satyam Netralya, 117-A, The Mall, Amritsar through the Doctor in- charge/authorized signatory.
Respondent No.2/OP No.2
First Appeal against order dated 16.08.2017 passed by the District Consumer Disputes Redressal Forum, Amritsar.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Rajinder Kumar Goyal, Member
Present:-
For appellant : Sh.R.C. Gupta, Advocate
For respondent No.1 : Sh.H.Jeet Singh, Advocate for
Sh Gagandeep Singh, Advocate
For respondent No.2 : Ex-parte
RAJINDER KUMAR GOYAL, MEMBER
ORDER
The appellant/opposite party No.1 (hereinafter referred to as OP No.1) has filed the present appeal against the order dated 16.08.2017 passed in Consumer Complaint No.653 of 2016 by District Consumer Disputes Redressal Forum, Amritsar( herein referred as District Forum) vide which the complaint filed by the complainant was allowed and Opposite Party No.1- Insurance Company was directed to make the payment of balance bill amount i.e. Rs.22,461/- to the complainant, but however, the complaint against Opposite Party No.2 Hospital was dismissed. Compliance of the order was ordered to be made within 30 days from the date of receipt of copy of the order; failing which awarded amount shall carry interest @ 6% p.a from the date of the passing of this order until full and final payment.
2. Complaint was filed by the respondent No.1/complainant under Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averment that Punjab Government vide its notification No.CHD/0092/2015-2017 dated 20.20.2015 had allowed cashless treatment upto Rs.3 lacs to its employees and pensioners under Punjab Government employees and Pensioners Health Insurance Scheme (PGEPHIS). In the said notification, list of the hospitals was also attached in which the name of the Opposite Party No.2 hospital was also mentioned. The complainant is a pensioner and he was issued identity card No.MD15-09878075686 of Opposite Party No.1 and the policy period was from 1.1.2016 to 31.12.2016. The complainant suffered problem in his left eye and he was operated on 19.1.2016 in the hospital of Opposite Party No.2. The complainant handed over his ID card to the Opposite Party No.2, but they refused to accept the same and denied to provide the cashless treatment to him and . The complainant requested to Opposite Party No.2 that as per the notification of the Punjab Government and as per the ID card issued by Opposite Party No.1, he is entitled for cashless treatment of his eye, but they did not listened his genuine and legitimate request and rather, charged a sum of Rs.28,461/- from the complainant on account of medical expenses for the operation of his eye. The complainant approached the Opposite Parties a number of times and requested them to reimburse the amount of Rs.28,461/-, but they did not pay any heed to the request of the complainant. Earlier, the complainant also approached District Forum for the reimbursement of the amount and the Forum directed the complainant to approach TPA of Opposite Party No.1 and apply for reimbursement of the insurance claim alongwith requisite documents. Accordingly, as per the directions of the Forum, the complainant approached TPA of Opposite Party No.1 and also submitted the original documents as per their requirement and lateron the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and failed to reimburse the full amount. Vide instant complaint, the complainant sought the following reliefs.
a) Opposite Parties be directed to reimburse the balance amount of Rs.22,461/- alongwith interest @ 18% per annum.
b) Compensation of Rs.25,000/- on account of mental pain, agony. Harassment suffered by him.
c) Costs of the proceeding of Rs.10,000/- to the complainant.
3. Upon notice, Opposite Party No.1 appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complaint filed by the complainant is without any merits as far as Opposite Party No.1 is concerned because in the entire complaint, it does not disclose any cause of action against Opposite Party No.1. The entire allegations of the complainant are against Opposite Party No.2 hospital authorities. In the present case, the complainant alleged that inspite of showing I- Card, the hospital authorities did not provide him cashless facility. To the said complaint written version was filed by said hospital that the complainant never showed his I Card and as such, the amount was charged directly from him. As per the order of District Forum, the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and had settled the said claim being payable as per the terms and conditions of the policy and arrangement made with the hospital authorities as per schedule rates as per Annexure XX. As per annexure XX which is a specific arrangement for making cashless payment to the listed hospital and according to the said scheduled rates, fixed amount for Cataract with IOL (P) of one eye is Rs.6000/- which is payable by the TPA to the hospital and the same has been paid in the present case. On merits, the Opposite Party No.1 took almost same and similar pleas as taken by them in the preliminary objections. Remaining facts mentioned in the complaint were also denied and a prayer for dismissal of the complaint with cost was made.
4. Opposite Party No.2 appeared and contested the complaint by filing written statement and admitted to the fact that complainant was operated on 19.1.2016 as a general public and at no stage he provided any ID card which was not accepted by the hospital. Even he deposited the consultant fee of Rs.230/- as a general public whereas consultant fees for Punjab Government servants/ pensioners is Rs.100/- . The reimbursement issue relates to insurance company and not the TPA for the general public for which the reimbursement bills duly verified was handed over to the patient for claiming from insurance company as desired by him. Remaining facts mentioned in the complaint were denied and a prayer for dismissal of the complaint with costs was made.
5. In his bid to prove the case, complainant tendered into evidence affidavit Ex.CW1/A in support of the allegations made in the complaint and also produced copies of documents Ex.C1 to Ex.C9 and closed his evidence.
6. On the other hand, to rebut the evidence of the complainant, the Opposite Party No.1 tendered into evidence the affidavit of Sh.R.K.Sharma, Divisional Manager Ex.OP1/1 alongwith copies of documents Ex.OP1/2 to Ex.OP1/10. Similarly, Opposite Party No.2 tendered into evidence the affidavit of Dr.Surinder Sharma, Medical Superintendent Ex.OP2/1 and thereafter, the Opposite Parties closed the evidence on behalf of the Opposite Parties.
7. After going through the allegations as alleged in the complaint, written version filed by OPs evidence and documents brought on record the complaint filed by the complainant was partly allowed as referred above.
8. Aggrieved with the order passed by the learned District Forum the appellant/OP No.1 has filed the present appeal.
9. We have heard the learned counsel for the parties and have perused the record carefully.
10. It was argued by the counsel for the appellant that the patient has been rightly paid Rs.6000/- as per PGEPHIS schedule of rates (Ex.OP1/9). The charging of Rs.28,461/- by OP No.2-Dr. Om Parkash Satyam Netralya has no relation whatsoever with the OP No.1 i.e. The Oriental Insurance Company. Therefore, the impugned order passed by the District Forum is liable to be set aside.
11. Counsel for respondent No.1/complainant argued that complainant is a Punjab Government Pensioner, as per Punjab Government Notification dated 20th October, 2015 Ex.C-1 and I-card issued to him, he is entitled for cashless treatment from the notified empanelled hospitals wherein Dr. Om Parkash Satyam Netralya is included. As such he is not liable to pay any cash amount to the hospital whereas he was forced to pay Rs.28,461/- to the hospital/OP No.2. He is entitled for the reimbursement of Rs.28,461/- as per scheme of the Punjab Government. He further requested to upheld the order of the District Forum.
12. During the arguments counsel for the appellant was asked to go through the details of items charged in the bills Ex.C-6 to Ex.C-8 issued by the hospital viz-a-viz provision in the PGEPHIS schedule of rates. It is found as under:-
Items | Amount Charged | Provision as PGEPHIS Schedule of rates | Remarks |
Operation fee | 8600 | 6000 | Payable as per item No.79. |
IOL cost | 5900 | 5900 | As per para-3 (cost of implants) |
Theatre fee | 8500 | 8500 | As per 2(XI) OT charges |
Assistant fee | 1500 | 1500 | As per 2(XVIII) |
Room rent | 1000 | 1000 | As per 2(II) |
Drugs used in OT | 1000 | 1000 | As per 2(XV) |
Lab tests | 500 | 500 | As per 2(XII) |
| 27000 | 24400 | Rs.6000/- already paid by Op1 |
From the above, it is evident that balance Rs.18,400/- out of Rs. 24400/- is payable to the complainant by the insurance company Op1 whereas Rs.2600/- is payable to the complainant by Op 2-hospital as they have charged in excess of the packaged rates at serial No.79 of PGEPHIS, schedule of rates. The hospital Dr. Om Prakash Netralaya is an empanelled hospital so they cannot charge more than the packaged rates agreed with the Punjab Govt.
13. The District Forum while awarding Rs. 22461/- has not appreciated the excess amount charged by the hospital from the complainant. As per evidence Ex. C-5 the complainant has paid Rs. 27000/- after discounts & not Rs. 28461/- as alleged in the complaint. Only Rs. 6000/- has been paid by Op1 to the complainant. So, there is deficiency in service on the part of both the opposite parties.
14. Sequel to above, the appeal is partly allowed to the extent that the amount awarded by the District Forum is reduced from Rs. 22461/- to Rs.18,400/- to the complainant alongwith 6% interest from the date of lodging the claim against Op No.1. Opposite party No.2 i.e. Dr. Om Prakash Netralaya is also directed to pay Rs.2,600/- to the complainant alongwith 6% interest from the date of payment for charging excess amount than the agreed rates with the Insurance Company. Rest of the order passed by the District Forum be treated as it is.
It is further directed that order be complied within 30 days from the date of receipt of the copy of the order, failing which, the awarded amount shall carry interest @ 6 % p.a. until full and final payment.
15. The appellant had deposited an amount of Rs.11250/- with this Commission at the time of filing of the appeal. This amount with interest accrued thereon, if any, be remitted to the concerned District Forum, after the expiry of 90 days, from the dispatch of the certified copy of the order to the parties; subject to stay, if any, by the higher For a/Court for release of the above amount and the District Forum may pass the appropriate order in this regard.
16. The appeal could not be decided within the statutory period due to heavy pendency of the Court cases.
(Gurcharan Singh Saran)
Presiding Judicial Member
(Rajinder Kumar Goyal)
Member
February 13 , 2018
PK/-
