PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant got health benefit mediclaim insurance for himself from the opposite party by virtue of the scheme launched by the opposite party by name as AYUSHMAN BHARAT-PRIME MINISTER JAN AROGYA YOJNA, copy of the insurance card is Exhibit C-2 and took the treatment from opposite party No.2 from 1.1.2020 to till his discharge on 18.1.2020 and he is the consumer of the opposite party. The affidavit of the complainant is Exhibit C-1. The complainant unfortunately met with an accident and was to be hospitalized at AMANDEEP HOSPITAL, AMRITSAR i.e. Opposite Party No.2 and the treatment cost of the said hospitalization came to more than Rs 5 lakhs and the Opposite Parties were immediately informed about the said hospitalization and all the treatment record and bills were furnished and the treatment taken thereof. The sum insured for the medical benefit is for Rs 5 lakh, the copy of discharge card is Exhibit C-3 and medical bills are Exhibit C-4 to 0-6). The complainant is making futile calls after filing of claim form with opposite party No.2 who forwarded the same to the opposite party No.1 and visits to the opposite parties till the filing of the present complaint but the opposite parties has not settled the genuine claim of the complainant. The opposite party No.1 has introduced the said social welfare scheme for immediate disbursal of the medical expenses but the same has not been implemented in the case of the complainant who is very poor person belonging to the down trodden part of the society living in the miserable financial conditions. The aforesaid acts of the opposite parties in not settling the genuine claim of the complainant is an act of deficiency in services, malpractice, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant for which opposite parties are liable to pay the compensation of Rs 2 lakh to the complainant. The complainant prays for the following reliefs against the opposite party No. 1.
- The opposite party No. 1 be directed to pay the amount of Rs. 5 Lacs alongwith interest @ 12% from the date of filing of claim till realization.
- The opposite party No. 1 be directed to pay the compensation of Rs. 2 Lacs to the complainant.
- The opposite parties be directed to pay the adequate cost of the litigation.
2 Notice of this complaint was sent to the opposite parties and opposite party No. 1 appeared through counsel and filed written version by interalia pleadings that the complainant has concealed the true material facts from this commission and has not come to the court with clean hands, therefore, he is not entitled for any claim. There is no deficiency of service or unfair trade practice on the part of National Health Authority to invoke the Jurisdiction of this Commission. The complainant has filed frivolous complaint against the National Health Authority by making false claim and in order to extract illegal money which he does not deserve. The save and except the allegations which have been specifically admitted by these written version all other allegations of the complaint petition should be deemed to have been denied by the National Health Authority i.e. opposite party No. 1. The complainant got health benefit mediclaim insurance for himself from opposite party by virtue of the scheme launched by the opposite party by name as Ayushman Bhart- Prime Minister Jan Arogya Yojna and got his treatment from opposite party No. 2 from time period of 1.1.2020 till his discharge 18.1.2020. It is also admitted that the complainant unfortunately met with an accident and was to be hospitalized at Amandeep Hospital Amritsar i.e. opposite party No. 2. The sum insured for the medical benefit is on the record of opposite party No. 2 by which the opposite party No. 1 is not bound with. The real fact is that, the complainant is aware from the de-empanelment of Amandeep Hospital, Amritsar i.e. opposite party No. 2 from the Ayushman Bharat-Prime Minister Jan Arogya Yojna, vide month’s notice by opposite party No. 2 for the termination of agreement of Ayushman Bharat-Sarbat Sehat Bima Yojna, vide their letter dated 4th October, 2019 and by email dated 4th October 2019 which is Ex. OP1/1 and hence the same letter is being clarified by the Deputy Medical Commissioner, Amritsar on dated 10th October 2019 vide No. PHSC/ASR/DMC/19/3581 and that is approved by State Health Authority on dated 25th October 2019, vide ticket/ register Number: #RPI00021828, dated 25th October, 2019. The complainant has full knowledge regarding the de-empanelment of Amandeep Hospital from termination of agreement of agreement of Ayushman Bharat- Sarbat Sehat Bima Yojna on 25 October, 2019 and the complainant is getting his treatment from the opposite party No.2 from the time period 1 January 2020 till his discharge on 18th January, 2020. The opposite party No.1 National Health Authority (Ministry of Health and Family Welfare) has authorized State Health Authority, vide their Authority letter bearing number- DO.NO.8-12018/11/209-NHA, Dated: 4th September, 2020 (which is Ex-OP1/2) to appear before this commission on its behalf to urge the correct facts of the matter before the commission and the State Health Authority has authorized the District Nodal Officer Cum Deputy Medical Commissioner, Tarn Taran vide Authority Letter No. SHA/2020/7186-87, Dated: 4th September, 2020 (which is Ex- OP1/3). The Deputy Medical Commissioner, Tarn Taran has been authorized by State Health Agency, Punjab due to the jurisdiction of this present complaint, but the Deputy Medical Commissioner has not done any unfair trade practice as the reason that opposite party No.1 is being appeared before this commission to suppress the true material facts of this present case and denied the other content of the complaint and prayed for dismissal of the same. Alongwith the written statement, the opposite party No. 1 has filed affidavit Ex. OP1/4, Photostat copy of letter for termination Ex. OP1/1, Photostat copy of authority letter by NHA Ex. OP1/2, Photostat copy of authorization to Dr. Swaranjit Dhawan Ex. OP1/3
3 The opposite party No. 2 appeared through counsel land has filed written objection by interalia pleadings that O.P. No-2 Hospital was an empaneled health care provider under Ayushman Bharat Sarbat Sehat Bima Yojna, but O.P. No-2 hospital terminated its agreement by giving one month notice on 4.10.2019 and as per Para No-2 of Section 12 of the agreement and thus after expiry of one month i.e. on 2.11.2019, the O.P. No-2 ceased to be the empaneled hospital of O.P. No-1. The complainant was admitted in the O.P. No-2 hospital on 1.1.2020 when O.P. No.2 was not an empaneled hospital and it was made clear to the complainant that on the relevant date O.P. No.2 being not an empaneled hospital was unable to provide sought for service to the complainant. The O.P. No. 2 could provide paid service to the complainant to which the complainant agreed and paid for his treatment. The complaint is not maintainable either on the facts alleged or under the Law against O.P. No-2, hence is liable to be dismissed on this score alone. The complainant does not disclose any cause of action against the O.P. No-2, hence is liable to be dismissed at least qua the replying O.P. No-2. The complainant has no complaint with the treatment given by the hospital but in so far as their claim with their insurer is concerned, the O.P. No-2 has no role to play in that. Thus this complaint is not maintainable qua O.P. No-2. The complainant is estopped from filing the complaint against O.P. No- 2. . The exorbitant amount of compensation has been claimed without any justification or rationale. The relationship between complainant and O.P. No-1 is not relevant in view of submissions made in Para No-1 of preliminary objections above. The complainant was admitted in O.P. No-2 hospital for his treatment from 1.1.2020 and was discharged on 18.01.2020 and he is a consumer qua the O.P. No. 1 But the complainant has no cause of action against the O.P. No. 2 The affidavit Ex. C-1 is denied and a counter affidavit is being filed in reply to that. So far as admission of complainant, his treatment and the bill paid are matters of record. There are different elements of the bills which include cost of medicines, cost of lab tests and other diagnostics procedures, visiting fees, theatre charges etc. So it is not the hospital bill exclusively. As already submitted when the complainant came for treatment, O.P. No-2 was not the empaneled hospital with O.P. No-1 and was not in a position to provide insurance benefits to complainant. It was made clear to the complainant and complainant agreed for paid treatment and he voluntarily paid for the treatment without any objection. Reimbursement of the bills is between O.P. No- 1 and the complainant and O.P. No-2 has nothing to do in that. It is for O.P. No-1 to settle the claim of the complainant. The complainant has no complaint about the treatment received in O.P. No-2 hospital. Besides, whatever is not specifically admitted, is denied. It is for O.P. No-1 to settle the claim of the complainant and O.P. No. 2 has nothing to do with this. When the complainant himself states not settling the claim of the claimant is an act of deficiency in service, malpractice etc., he admits that he has no cause of action against O.P. No-2 as the replying O.P. No-2 is not to settle the claim of the complainant. The opposite party No. 2 has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party no. 2 has placed on record affidavit of Dr. Amandeep Kaur Ex. OP2/1.
4 We have heard the Ld. counsel for complainant and have also carefully gone through the documents on the file.
5 From the combined and harmonious reading of documents and pleadings on record it is going to prove that the complainant got health benefit mediclaim insurance for himself from the opposite party by virtue of the scheme launched by the opposite party by name as AYUSHMAN BHARAT-PRIME MINISTER JAN AROGYA YOJNA, copy of the insurance card is Ex. C-2 and the complainant took the treatment from opposite party No.2 from 1.1.2020 to 18.1.2020 and he is the consumer of the opposite party. The affidavit of complainant is Exhibit C-1. The complainant met with an accident and was hospitalized at AMANDEEP HOSPITAL, AMRITSAR i.e. Opposite Party No.2. He spent more than Rs. 5,00,000/- for his treatment. The Opposite Parties were duly informed about the said hospitalization and all the treatment record and bills were furnished for the treatment taken thereof. The sum insured for the medical benefit was Rs 5 lakhs. The complainant submitted the claim form with the opposite party No. 2 who forwarded the same to the opposite party No. 1. But the opposite parties have not settled the genuine claim of the complainant.
6 Ld. Counsel for the opposite party No. 1 contended that the complainant has concealed the true material facts from this commission, as such he is not entitled for any claim. He further contended that there is no deficiency of service or unfair trade practice on the part of National Health Authority. The complainant got health benefit mediclaim insurance for himself from opposite party by virtue of the scheme launched by the opposite party by name as Ayushman Bhart- Prime Minister Jan Arogya Yojna and got his treatment from opposite party No. 2 from time period of 1.1.2020 till his discharge 18.1.2020. It is also admitted that the complainant met with an accident and was hospitalized in Amandeep Hospital Amritsar i.e. opposite party No. 2. The complainant was very much aware from the de-empanelment of Amandeep Hospital, Amritsar i.e. opposite party No. 2 from the Ayushman Bharat-Prime Minister Jan Arogya Yojna, vide one month notice by opposite party No. 2 for the termination of agreement of Ayushman Bharat-Sarbat Sehat Bima Yojna, vide their letter dated 4th October, 2019 and by email dated 4th October 2019 same letter was being clarified by the Deputy Medical Commissioner, Amritsar on dated 10th October 2019 vide No. PHSC/ASR/DMC/19/3581 and that was approved by State Health Authority on dated 25th October 2019, vide ticket/ register Number: #RPI00021828, dated 25th October, 2019.
7 The counsel for opposite party No. 2 contended that the O.P. No-2 Hospital was an empaneled health care provider under Ayushman Bharat Sarbat Sehat Bima Yojna, but the said hospital terminated its agreement by giving one month notice on 4.10.2019 and as per Para No-2 of Section 12 of the agreement. Thus, after expiry of one month i.e. on 2.11.2019, the O.P. No-2 ceased to be the empaneled hospital of O.P. No-1. Further it was admitted by O.P. No 2-that the complainant was admitted in hospital on 1.1.2020 and on such date, Amandeep Hospital was not an empaneled hospital as such opposite party No. 2 could not provide the treatment to the complainant under the Aushman Bharat Sarbat Sehat Bima Yojna.
8 The opposite party No. 1 has taken the specific objection that the complainant was not entitled for the treatment in Amandeep Hospital i.e. opposite party No. 2 under Aushman Bharat Sarbat Sehat Bima Yojna because the said hospital was de-empaneled from the list of the hospitals under Aushman Bharat Sarbat Sehat Bima Yojna vide one month notice by opposite party No. 2 vide their letter dated 4th October, 2019 and by email dated 4th October 2019 same letter was being clarified by the Deputy Medical Commissioner, Amritsar on dated 10th October 2019 vide No. PHSC/ASR/DMC/19/3581 and that is approved by State Health Authority on dated 25th October 2019, vide ticket/ register Number: #RPI00021828, dated 25th October, 2019. It is pertinent to mention here that the complainant was not aware of the fact that the said hospital was de-empaneled from the list of the Aushman Bharat Sarbat Sehat Bima Yojna. Neither the opposite party No. 1 has sent any intimation regarding the de-empanelment of hospital nor the opposite party No. 2 has intimated the complainant in this regard. It was the duty of the opposite party No. 1 to intimate all the beneficiary under the Aushman Bharat Sarbat Sehat Bima Yojna to supply the list of hospitals which are empaneled as well as de-empaneled from time to time.
9 The opposite parties have to ensure as to whether, the complainant has taken the treatment and if the treatment taken by the complainant is duly supported by the necessary documents like discharge card, medicine bills any surgery performed by the doctors etc. the opposite parties cannot refuse to settle the genuine claim under the said scheme. The complainant is entitled for reimbursement under the said scheme irrespective of the fact that whether he has taken the treatment from the empaneled or de empaneled hospital. The opposite parties have to ascertain that the complainant has actually taken the treatment from any of the hospital. Reliance has been placed on Writ Petition (Civil) No. 694 of 2015 D/d 13.4.2018 Shiva Kant Jha Vs Union of India of Supreme Court of India and W.P.(C) 10684/2022 & CM Appl. 31035/2022 titled Union of India & Anr Vs Sh. Joginder Singh” of High Court of Delhi at New Delhi
10 The opposite party No. 1 has not placed on record any terms and conditions with list of empaneled hospitals from where the patient can avail the facility of treatment under the policy in question. In case, if there is medical emergency a person has not to see whether the hospital on the list of empaneled hospitals under the policy. His priority is to get the treatment as soon as possible from the best hospital. The purpose of the Aushman Bharat Sarbat Sehat Bima Yojna is to ensure the health benefits to the general public at large. Preservation of human life is of paramount importance and state is under obligation to provide the timely and necessary medical treatment to a person as the said right is a fundamental right under article 21 of the constitution of India. The opposite parties should not adopt the technical ground to settle the genuine claim of the complainant. By not reimbursing the amount to the complainant regarding his treatment, it amounts to deficiency in service and unfair trade practice on the part of the opposite party No. 1.
11 In view of the above discussion, the present complaint is allowed and the opposite parties No. 1 is directed to make the payment of Rs. 5,00,000/- (Rs. Five lacs only) to the complainant. Complainant is also entitled to Rs. 25,000/- as compensation on account of harassment and mental agony and 11,000/- as litigation expenses. Opposite party No. 1 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. The present complaint against the opposite party No. 2 is dismissed. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission.
31.05.2023
