Order dictated by:
Sh.S.S.Panesar,President.
- Mr.Mukhtar Singh complainant has filed the present complaint under section 12 & 13 of the Consumer Protection Act on the allegations that Punjab Government vide its Notification No. CHD/0092/2015-2017 dated 20.10.2015 has allowed cashless treatment upto Rs. 3,00,000/- to its employees and pensioners under Punjab Government Employees and Pensioners Health Insurance Scheme. This scheme is applicable to all the government serving employees ( whether covered under old or new pension scheme). In the said notification list of the hospitals is also attached in which name of opposite party No.2 hospital is also figures. The complainant is pensioner and he was also issued Identity Card No. MD 15-0987805686 of opposite party No.1 and policy period is from 1.1.2016 to 31.12.2016. Copy of the Identity card is enclosed. As such the complainant is the consumer of the opposite parties. The complainant suffered problem in his left eye and he was operated on 19.1.2016 in opposite party No.2 hospital. The complainant handed over the Identity card to opposite party No.2 but opposite party No.2 refused to accept the said Identity card of the complainant and denied the cashless treatment to him. As per notification of the Government and also Identity card issued by Insurance company, opposite party No.1, the complainant was entitled for cashless treatment but opposite party No.2 did not listen to his requests and as such charged a sum of Rs. 28,461/- on account of medical expenses from the complainant. The complainant having no alternative option paid the said amount to opposite party No.2 and opposite party No.2 also issued bill regarding the same. All the medical bills and record are enclosed. The complainant was issued Insurance policy as well as Identity card, as such he was entitled for cashless treatment. But in the present complaint, complainant was forced to pay the said charges to the tune of Rs. 28,461/- from his own pocket. As such he is entitled for reimbursement of the said amount . The complainant has sought for the following reliefs vide instant complaint:-
- Opposite parties be directed to reimburse the medical expenses amounting to Rs. 28,461/- alongwith interest @ 18% p.a. thereon ;
- Compensation to the tune of Rs. 25000/- may also be awarded to the complainant ;
- Opposite parties be also directed to pay cost of litigation to the tune of Rs. 5000/-.
Hence, this complaint.
2. On notice, both the opposite parties appeared and contested the claim of the complainant by filing separate written versions.
3. In written version on behalf of opposite party No.1 , certain preliminary objections were taken inter alia that 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. Hence, even otherwise the complainant is not covered under the definition of consumer to maintain the present complaint. As such the present complaint is liable to be dismissed on this ground alone ; that in the entire complaint the only grouse of the complainant is that he was admitted in the hospital of opposite party No.2 and informed them that he is a pensioner and covered under special scheme launched by the Punjab Govt and he has also been issued Identity Card under the said policy. But opposite party No. 2 did not consider the same and insisted the complainant to pay the charges for the treatment in cash . Opposite party No.2 has already filed written version in this regard in which they have specifically mentioned that complainant has never disclosed the said fact to the hospital authorities that he was covered under any scheme launched by the Punjab Govt nor produced any I.D. Card . Therefore , he was charged consultation fee as a general public for Rs. 230/- against the special consultation charges of Rs. 100/- if he had produced the said ID card for availing cashless facility ; that except the aforesaid allegations made out in the complaint, there is no allegation against opposite party No.1 nor the complainant ever raised any complaint that opposite party No.2 has not provided him cashless facility inspite of the fact that he was having ID card and covered as pensioner under the notification of Punjab Govt, rather has filed the present complaint directly which is not legally maintainable because there is set procedure that in case any cashless facilities are refused by the hospital authorities, the complainant should approach the concerned TPA appointed to deal with such type of cases and the said TPA has to consider on merits that whether any reimbursement can be made to him and also to call for explanation from the concerned hospital that why the cashless facility has not been provided ; that in the aforesaid preliminary objections , there is no question of any deficiency of service on the part of opposite party No.1 rather the entire complaint is related to opposite party No.2, who has already filed written version and as per said written version the complainant is estopped from his own act and conduct from filing the present complaint against any of the concerned parties. Hence, the name of opposite party No.1 has wrongly been impleaded in the present complaint as the same is without any cause of action or merit, therefore, the same is liable to be deleted from the array of opposite parties. On merits, facts narrated in the complaint have been specifically denied. It is further stated that no cause of action has arisen to the complainant to maintain the complaint u/s 11 & 12 of the Consumer Protection Act against opposite party No.1 because the complainant did not approach opposite party No.1 when opposite party No.2 allegedly denied him cashless medical aid as per notification of the Punjab Govt nor did the complainant applied for reimbursement of the medical expenses to TPA of opposite party No.1. As such the complaint against opposite party No.1 is liable to be dismissed being not maintainable.
4. In his separate written statement, opposite party No.2 also took preliminary objection to the effect that Dr. Om Parkash Satyam Netralaya, Amritsar has nothing to say except that the complainant was treated in this hospital as one of the general patients. On merits facts narrated in the complaint have been specifically denied. It is admitted to the extent that Mukhtar Singh was operated for Cataract Surgery on 19.1.2016 as a general public as he first visited on 12.1.2016 and paid consultation fee as general public of Rs. 230/-, whereas the consultation charges for Punjab Government employees/pensioners are Rs. 100/- only. At no stage complainant showed any ID card for availing cashless facilities as per Punjab Government notification for treatment of Punjab Government employees/pensioners. It is admitted to the extent that the complainant was issued a detailed expenditure of Rs. 28,461/- on DHS 47 form which was required by him for reimbursement from the concerned Insurance company. The Punjab Government notification is being implemented for Government employees and pensioners who visit this hospital with proper identity card and a prayer for dismissal of the complaint with cost has been made.
5. In his bid to prove the case Sh.Amanjot Hundal,Adv.counsel for the complainant tendered his duly sworn affidavit Ex.C-1, copy of notification Ex.C-2, copy of list of hospitals Ex.C-3, copy of identity card issued by Punjab Govt. Ex.C-4, copy of form DHS 47 Ex.C-5, copy of receipt dated 19.1.2016 Ex.C-6, copies of certificate issued by Dr.Om Parkash Eye institution Ex.C-7 to Ex.C-9 and closed the evidence on behalf of the complainant.
6. To rebut the aforesaid evidence Sh.P.N.Khanna,Adv.counsel for opposite party No.1 tendered into evidence affidavit of Sh.R.K.Sharma,Div.Manager Ex.OP1/1, certified copy of Insurance policy alongwith relevant Punjab Govt. Gazette Ex.OP1/2 and closed the evidence on behalf of opposite party No.1.
7. On the other hand Dr.Surinder Sharma, Medical Superintendent on behalf of opposite party No.2 tendered into evidence his duly sworn affidavit Ex.OP2/1 and closed the evidence on behalf of opposite party No.2.
8. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
9. In his bid to prove the case complainant himself has made into witness box as his own witness and filed his duly sworn affidavit Ex.C-1. Copy of Punjab Govt.notification Ex.C-2 has also been pressed into service for stressing the point that complainant was entitled to cashless facility for his treatment in the hospital. The complainant has also adduced on record copy of Identity card Ex.C-4 and copy of form DHS Ex.C-5 from which it transpires that complainant remained admitted in opposite party No.2 hospital for the period w.e.f. 19.1.2016 to 20.1.2016 for Cataract Surgery for left eye. The complainant has also adduced on record the medical bills Ex.C-6 to Ex.C-9 and a perusal whereof shows that the complainant incurred an expenditure of Rs. 28,461/- on his treatment. But , however, the complainant did not apply for reimbursement of the medical expenses with opposite party No.1 for the reasons best known to him. The only grouse of the complainant is that the opposite party No.2 had charged an amount of Rs. 28,461/- and insisted upon the complainant to pay the amount in cash ,whereas he was entitled to cashless facility at the end of opposite party No.2. As a matter of fact when cashless facility was denied to the complainant, he was supposed to approach opposite party No.1 for reimbursement of the medical expenses incurred by him on his treatment. But that not being the case , the instant complaint filed by the complainant against opposite party No.1 is premature. As a matter of fact, opposite party No.2 has treated the complainant as a general public patient and it is their case that the complainant has not produced any Identity card at the time of either obtaining consultation nor at the time when operation was conducted on him. Whatever the case may be, at the stage when the complainant was compelled to pay the amount of Rs. 28,461/- by opposite party No.2, remedy open to the complainant was to approach TPA of opposite party No.1, for reimbursement of the medical expenses incurred by him on his treatment. The complainant could not rush to this Forum directly before approaching the TPA of opposite party No.1 with a request for reimbursement of the disputed amount. As such we hold that instant complaint is premature . Therefore, complainant is directed to approach TPA of Insurance company i.e. opposite party No.1 and apply for reimbursement of the Insurance claim alongwith requisite documents within 15 days of the receipt of copy of this order , which shall dispose of the claim of the complainant within a further period of one month therefrom. The complaint stands disposed off accordingly. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 15.09.2016
