Order by:
Sh.Amrinder Singh Sidhu, President
1. This Consumer Complaint has been received by transfer vide order dated 26.11.2021 of Hon’ble President, State Consumer Disputes Redressal Commission, Punjab at Chandigarh under section 48 of CPA Act, vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 from District Consumer Commission, Ludhiana to District Consumer Commission, Moga to decide the same in Camp Court at Ludhiana and said order was ordered to be affected from 14th March, 2022.
2. The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that the complainant is employee of Punjab Government working in the courts at Ludhiana and Government of Punjab introduced the health insurance scheme for its employees and pensioners namely Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical diseases as specified or to be specified by State Government and said scheme applied to all the government serving employees and pensioners on compulsory basis. Accordingly, the complainant was also enrolled under the said scheme for the period 01.01.2016 to 31.12.2016 under ID card no.MD15-09780019924 issued by Opposite Party No.2. During said insurance period, the complainant was admitted in emergency in SPS Hospital, Ludhiana on 21.07.2016 to 24.07.2016 due to c/o fever (mid to moderate) x 5 days and he was diagnosed a ‘acute febrile illness with thrombocytopenia & hypertension. The complainant thereafter acknowledged from the family members that due to his admission in hospital, hospital expenses of Rs.26,633/- were paid by them because said hospital at the time of admission refused to provide cashless facility on the ground that they are not covered under the scheme for such treatment then after recovery, the complainant lodged his claim with Opposite Party No.2 and completed all the formalities and also submitted the duly signed claim form, discharge certificate, hospital certificate etc. however, the Opposite Parties rejected the claim of the complainant on 20.02.2017 on the ground that no reimbursement will be available for the treatment in Punjab & Chandigarh where cashless treatment is available. But however, the Opposite Parties before or after issuing policy card at any time nowhere disclosed issuing of any such notification denial of payment of claim. As such, the Opposite Parties not only rendered deficient/ negligent services, but also responsible for adopting Unfair Trade Practice.Vide instant complaint, the complainant has sought the following reliefs.
a) The Opposite Parties may be directed to pay the claim amount of Rs.26,633/- alongwith interest @ 12% per annum from 24.07.2016 as well as Rs.25,000/- for causing huge mental tension and physical agony costs of litigation amounting to Rs.5500/-.
3. Opposite Party No.1 appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. It is submitted that on the basis of notification No.21/28/12-5HB5/268 dated 20.102015 the policy in question was issued by Government of Punjab, Department of Health and family welfare from Oriental Insurance Company Limited for the benefits of Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) valid for the period 1.1.2016 to 31.12.2016 for a total sum insured of Rs.3 lakhs floater was issued subject to conditions, clauses, warranties and endorsements and the complainant was admitted in the emergency of SPS Hospital Ludhiana on 21.07.2016 for the treatment of fever (unspecified) and remained under the treatment of said hospital from 21.07.2016 to 24.07.2016. After the receipt of documents on perusal/ scrutiny of the said documents placed in the claim file of the complainant by MD India Health Insurance TPA Private Limited, a 3rd party administrator appointed under the Insurance Policy in question, the claim of the complainant was found to by said TPA not admission as per para No.4 of the notification dated 20.10.2015 wherein it has been specified that no reimbursement will be available for the treatment in Punjab and Chandigarh and as such, they have shown their inability to admit the liability under the policy conditions and informed the complainant vide letter dated 20.20.2017. On merits, Opposite Party No.1 took up the same and similar pleas as taken up by them in the preliminary objections. Hence, Opposite Party has rightly repudiated the claim of the complainant after application of mind and the complaint may be dismissed with costs.
4. Opposite Parties No.2 and 3 appeared and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission and filed almost the same and similar written version as filed by Opposite Party No.1-Insurance Company and prays for dismissal of the complainant with costs.
5. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.CA/1 alongwith copies of documents Ex.C1 to Ex.C8 and closed the evidence on behalf of the complainant.
6. On the other hand, to rebut the evidence of the complainant, Opposite Parties also tendered into evidence the affidavits Ex.RA and Ex.RB alongwith copies of documents Ex.R1 to Ex.R7 and closed the evidence.
7. We have heard the ld.counsel for the parties, perused the written submissions filed by the parties and also gone through the documents placed on record.
8. Ld.counsel for the parties have mainly reiterated the facts as narrated in the complaint as well as in written versions respectively and we have gone through the rival contentions of the parties. The question requires to be decided by this District Consumer Commission is whether the complainant is entitled for reimbursement of claim in view of the contents of the repudiation letter dated 20.02.2017 (Ex.C4) for not allowing the claim because cashless facility was not available for the treatment in Punjab and Chandigarh.
9. In the instant case, during said insurance period, the complainant was admitted in emergency in SPS Hospital, Ludhiana on 21.07.2016 to 24.07.2016 due to c/o fever (mid to moderate) x 5 days and he was diagnosed a ‘acute febrile illness with thrombocytopenia & hypertension. As per clause 12 (vi) of Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS), the expenditure is to be reimbursed by the Opposite Parties. The relevant clause 12 (vi) is reproduced hereunder:-
“(iv) in an event a Member goes to a Provider Hospital and inspite of showing his/ her ID card to the hospital authorities within stipulated time period, is denied cashless hospitalization by the hospital, for any reason whatsoever, including but not limited to, denial buy the Hospital at its own end without receiving any denial from the TPA or the wrongly denial by the TPA or delay in issuance of authorization by the TPA for any reasons or any other circumstances whatsoever and no fault lies with the Member, he/ she may submit his/ her claim to the TPA as per the check list for reimbursement within 60 days of date of discharge from the hospital. In such cases, the TPA/ Insurer shall extend full cooperation to the beneficiary and depending upon merit/ genuineness of the case, determine the admissibility of the claim within the purview of the scheme and settle the claim within 15 days of receipt of the claim, in accordance with terms and conditions of the scheme.”
In the similar facts and circumstances, Hon’ble State Consumer Disputes Redressal Commission, Punjab at Chandigarh in First Appeal No. 233 of 2020 decided on 02.12.2020 in case Managing Director, India Health Insurance TPA Vs. Som Pal Singh held that repudiation of the claim is not in order and the complainant is entitled to reimbursement of expenditure incurred on the treatment. In reference of Ex.C6 in reference of judgement on the notification Ex.C4 bearing No.21/2812-5HB5/268 dated 20.10.2015. In this regard, Hon’ble Punjab & Haryana High Court at Chandigarh in case Ram Pal vs Central Administrative Tribunal ... decided on on 14 January, 2019 in CWP-22482-2017 has specifically held that the Courts while dealing with medical reimbursement claims have repeatedly stressed that the applicable Instructions have to be liberally construed in favour of the beneficiaries. Not only this, in case Darshan Singh Rai v. Union of India , (P&H)(DB) 2008(2) S.C.T. 242, Division Bench of Hon’ble Punjab & Haryana High Court at Chandigarh has also held that all the rules and regulations regarding medical reimbursement are to be considered in favour of the Government employee liberally and to his benefit. The State cannot be permitted to have an iron heart in such matters. It was observed as under:
"7. 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. All the rules and regulations are to be considered in favour of the Government employee liberally and to his benefit. The State cannot be permitted to have an iron heart in such matters. It is not the plea of the respondents that the petitioner has not incurred the expenditure on his treatment. It is being noticed by this Court that quite often writ petitions are filed to obtain redress in the matter of reimbursement of medical expenses particularly by those who have retired from service, which is a sad commentary on the working style of the concerned departments and particularly of the head of those departments who must own responsibility for the indifference and delays in this regard."
In Dr. Harinder Pal Singh v. State of Punjab 2014 (3) S.C.T. 483 it was held that the 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 but had chosen to get himself treated abroad. The respondents were directed to process the claim made by the petitioner as per rates prescribed by Director, Health and Family Welfare, Punjab.
"15. The relationship of a doctor and a patient is a matter of confidence and trust. Any patient would like to go to the best doctor available. Even if the petitioner had not gone to any Government or any of the approved hospitals and had chosen to get himself treated from an hospital abroad, the liberty cannot be left with the Head of the Department to refuse reimbursement, once it is found that the patient had taken treatment. It is not that only medicines are to be taken orally. The rejection of the claim 10 of 20 CWP-22482-2017 [11] on these hypertechnical grounds, is totally arbitrary. The beneficial policies cannot be interpreted or kept in water tight compartment. These are to be interpreted liberally considering the facts and circumstances of the case. The fact that the petitioner had been operated upon in Prince Wales Hospital, Australia for his disease is not in dispute. Once that is so, the entitlement of the petitioner to reimbursement of the expenses incurred by him in terms of the rates prescribed by Director, Health and Family Welfare, Punjab cannot be denied."
Similarly, the Rajasthan High Court in Jawahar Lal Bohra v.State of Rajasthan (Rajasthan) 2014(3) S.C.T. 242 held that medical attendance Rules providing for reimbursement of the medical expenses to the Government servant and retired pensioners, was a beneficial and welfare legislation meant for the welfare of the Government servants and, therefore, a liberal, sympathetic and objective interpretation for the applicability of these Rules, has to be made by the Courts. The Court noted that specifying a very limited of number of hospitals at a few places only where treatment could be availed of could only be construed as making the applicability of the said Rules ineffective. The Court held that the petitioner who had undertaken treatment from a hospital not specified was entitled to reimbursement at the rate applicable in the recognised hospital of the State Government The relevant observations of the Court are as under:
"13. The recognition given to only 3 hospitals of Delhi for the purposes of Rule 6, while specifying 11 hospitals for Rule 7 at Delhi and Mumbai, also does not have any logical reasoning or rational nexus behind it. If the contingency of taking the 11 of 20 CWP-22482-2017 [12] treatment outside the State of Rajasthan, for the reasons beyond the control of the Government servant or in any emergency is duly recognised as a fact entitling the Government servant for such reimbursement, the specification of different set of hospitals for two different rules, and that too to a very limited extent of number of hospitals at a few places only viz. Delhi or Mumbai, can only be construed as making the applicability of the said Rules ineffective even though the purpose of these Rules is to make the reimbursement of expenses subject to fulfilment of other conditions. For this reason on a harmonious construction of both these Rules 6 & 7 of the Rules of 1970, this Court may have to even invoke and apply even the Appendix-11, list of hospitals, for the reading the same with the Rule 6 of 1970 Rules, and not restricting the same for Rule 7 only. Even though, the petitioner took his treatment in the Asian Heart Institute, Mumbai, and not in the Bombay Hospital, Bombay, which is included in the Appendix-11 of the Rules of 1970, which is to be read with both Rule 6 & 7, the purpose of the aforesaid harmonious construction is to allow the reimbursement of medical expenses to the petitioner at least to the extent of the rates applicable in the recognised hospital of the State Government at Mumbai, namely, Bombay Hospital, if not, the actual expenses incurred by him in the Asian Heart Institute, Mumbai. Not doing so would obviously render the petitioner remediless and without any reimbursement in the present case, which will defeat the purpose and objective of the 1970 Rules.
Apparently and avowedly, these medical attendance Rules providing for reimbursement of the medical expenses to the Government servant and retired pensioners, is a beneficial and welfare legislation meant for the welfare of the Government servants and, therefore, a liberal, sympathetic and objective interpretation for the applicability of these Rules, has to be made by the Courts and not a pedantic or narrow approach of the matter would subserve the interest of justice."
Hon'ble the Supreme Court in Shiva Kant Jha Vs. Union of India AIR 2018 SC 1975 considering this question has held that a Government employee during his life time or after retirement is entitled to get the benefit of medical facilities and that no fetters can be placed on his rights. It was further held that the claim of reimbursement cannot be rejected solely on the ground that the Hospital where he was treated was not included in the Government Order, It was held that in such a case the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once that is established, the claim cannot be denied on technical grounds. The relevant observations are as under:
"13. It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would 14 of 20 CWP-22482-2017 [15] deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court."
10. On the other hand, the rulings citied by the Opposite Parties are not applicable to the facts of the present case and the same are distinguished.
11. In the present view of the matter, we are of the considered opinion that the Opposite Parties have wrongly and illegally rejected the claim of the complainant.
12. Now come to the quantum of compensation. The complainant in his complaint has claimed the reimbursement of his medical bill upto the extent of Rs.26,633/- and this amount spent by the complainant on his treatment has nowhere denied by the Opposite Parties by filing any cogent and convincing evidence and hence, the claim of the complainant to that amount is genuine and we allow the claim of the complainant accordingly.
13. In view of the aforesaid facts and circumstances of the case, we allow the complaint of the Complainant and direct the Opposite Parties joint and severally to reimburse the medical bills of the complainant amounting to Rs.26,633/- (Rupees twenty six thousands six hundred thirty three only) alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 13.11.2017 till its actual realization. Opposite Parties are also directed to pay compensation to the complainant for causing him mental tension and harassment to the tune of Rs.10,000/- (Ten thousands only). The compliance of this order be made by Opposite Parties jointly or severally within 45 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced in accordance with law. Copies of the order be furnished to the parties free of cost by District Consumer Commission, Ludhiana and thereafter, the file be consigned to record room after compliance.
Announced in Open Commission at Camp Court, Ludhiana.
Dated:28.04.2022.
