Punjab

Fatehgarh Sahib

RBT/CC/856/2018

Kiran Naval - Complainant(s)

Versus

Oriental Insurance Company Ltd. - Opp.Party(s)

Anita Ahuja

13 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.

                                                                             RBT/CC/856/2018

CC No. 856 of 2018

                                                                             Date of Institution: 16.08.2018

                                                                             Date of Decision:    13.09.2022

 

Kiran Naval now deceased represented by her LRS:-

a) Naresh Kumar age 65+ husband of Late Smt. Kiran Naval S/o Shri Sham Lal    R/o # 163, Anandpur Road, Deep Colony, Garh Shankar, Hoshiarpur.

b) Mrs. Nitika Pathak, age 35+ years D/o Late Smt. Kiran Naval W/o Shri Sumit Salgotra, #2995, Sector 42-C,Chandigarh.

c) Mrs. Swati Pathak Age 34 Yrs, D/o Late Smt. Kiran Naval W/o Shri Ashish Kumar Sharma, R/o #163, Ward No.11, Deep Colony, Garh Shankar, Hoshiarpur.

 

•  

                                                Versus

1. Oriental Insurance Company Limited, Regional Office, Surendra Building, SCO    No. 109-111, Sector 17-D, Chandigarh through its Regional Manager.
2. Oriental Insurance Company MAX Pro Info Park, D-38, 1st Floor, Industrial Area, Phase-1, Mohali.  
3. Manager, Punjab Government Employees and Pensioners Health Insurance, MD India Health Insurance TPA Pvt LTD, Max Pro Info Park, D/38, 1st Floor, Industrial Area, Phase-1, Mohali-160056, Punjab.
4. The Secretary to Department Chandigarh. Government, Punjab, Health Department, Chandigarh.
5. Director, Health and Family Welfare, Pariar Kalyan Bhawan, Sector 34-A, Chandigarh.        

       …………....Opposite Party(s)

Complaint under Section 12 of the Consumer Protection Act

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

Present:Ms. Anita Ahuja, Counsel for Complainant.

              Sh. Aman Sood, Counsel for OP No.1 and 2 (through VC)

              Sh. Ram Avtar, Counsel for OP No.3 (through VC)

              OP No.4 and 5 ex parte

Order by

Pushvinder Singh, President

1.                  The present complaint has been filed by the complainant (hereinafter referred to as ‘CC’) against the opposite parties (hereinafter referred to as “OPs”) with a prayer to direct the OPs to reimburse the payment of Rs.4,28,161/- with interest @ 18% per annum and a compensation of Rs.2,00,000/- towards physical and mental harassment. CC also seeks Rs.50,000/- for litigation expenses.
2.                   The CC stated she retired while serving as S.S. Mistress from the Government Senior Secondary School, Garhshankar, Hoshiarpur. She allege that Punjab Government introduced a Cashless Health Insurance Scheme known as the Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) to cover indoor medical diseases and made it applicable to all Government serving employees as well as pensioners compulsorily w.e.f. 01.01.2016, as per its Notification dated 20.10.2015, though it was liable on its own to reimburse all such medical bills under statutory rules known as the Punjab Medical Attendant Rules, 1940 by ensuring that it was a cashless scheme and they will not be required to pay any money while getting treatment from empanelled hospitals and for rest, payments to be reimbursed at the PGIMER/AIIMS rates by OP Nos.1 & 2 through OP No.3. CC was also insured/covered under aforesaid scheme by opposite parties which was operative/valid w.e.f. 01.01.2016 to 31.12.2016.
3.                  CC got some heart problem she got treatment from Fortis Hospital, Mohali, an empanelled hospital and remained under treatment for coronary angiography, coronary angioplasty, stent coronary etc. as an indoor patient from 22.08.2016 to 30.08.2016. The scheme is called as Cashless but she had to pay entire expenses of her treatment amounting to Rs.4,28,161/- from her own sources. After treatment CC submitted her bills for reimbursement to her school for onward transmission to competent authorities and Principal of her school vide letter dated 23.02.2017 sent her bills to DEO(Secondary) Hoshiarpur for reimbursement. However, the same was returned to her by the office of DEO(Secondary), Hoshiarpur with remarks that as per Government Scheme she was covered under aforesaid insurance policy and her payment would be made by the respondent-Insurance Company.
4.                     After that CC mailed on 26.09.2017 to OP No.3 and requested to reimburse payment of her medical bill but all in vain. A legal notice dated 02.12.2017 was also sent by her counsel but remained unresponded. CC alleged that the bill submitted by her through her school-Principal was wrongly returned to her by OP Nos.4 & 5. CC further alleged that the OP/Insurance Company had failed to make payment to the hospital, being a cashless policy because under the Constitution of India as also under statutory Punjab Medical Attendants Rules, 1940, OP Nos.4 & 5 are legally bound to make her payment of medical bills to its employees/pensioners and thereafter, should claim reimbursement from OP-Insurance Company. CC alleged that OPs have caused her unwarranted physical and mental harassment.
5.                     Notice of the complaint was given to the OPs and Sh. Ram Avtar, Adv. appeared and filed reply/version on behalf of the OP Nos.1 to 3. However none has appeared on behalf of the OP Nos.4 and 5. In reply, OP Nos.1 to 3 stated that the complaint is not maintainable as there is no deficiency or illegality in denying the reimbursement of medi-claim as per terms and conditions of the insurance policy issued to Government of Punjab, Department of Health and family Welfare. OP Nos.1 and 3 further stated that the CC had sent a cashless request through hospital at the time of admission , but the hospital had not given any reply for uploading of PTCA clips, hence the claim file was closed due to pending of IRC query. OP Nos.1 to  submitted that the answering OP Nos.1 to 3 cannot be held responsible for the payment of medical expenses incurred on treatment. The cashless request is concerned for the treatment, the OP No.3 had referred the case to Teleread and as per Teleread status was EQUIVOCAL, therefore OP No.3 further requested the hospital for uploading the PTCA clips, but no reply has been given by the hospital in this regard and after lapse of policy during pending of IRC query the file was closed. The cashless request was not accepted due to non-corporation of the hospital. OP denied all other allegations and prayed for dismissal of the complaint with cost.
6.                   CC in his evidence has furnished his affidavit in support of the complaint and reiterating the facts contained in the complaint as Ex.C-1/A and he also produced the copy of Notification dated 20.10.2015 as Ex.C-1, copy of ID Card as Ex.C-2, copies of bills and receipts as Ex.C-3, copy of sent reimbursement bills through letter dated 23.02.2017 as Ex.C-4, copy returned back bills through endorsement dated 06.03.2017 as Ex.C-5, copy of letter  dated 25.09.2017 mailed on 26.09.2017  as Ex.C-6, copy of legal notice as Ex.C-7, District Forum’s order dated 03.05.2018 as Ex.C-8. On the other hand OP Nos.1 to 3 produced the evidence by way of affidavit as Ex.OP-1/A, copy of notification as Ex.OP-1, copy of insurance policy as Ex.OP-2, copy of salient features of PGEPHIS as Ex.OP-3, copy of claim scrutiny sheet for not accepting cashless request as Ex.OP-4.
7.                   We have heard the counsels for the parties and have gone through the file carefully.
8.                  The CC has filed this complaint for reimbursement of medical bills amounting to Rs.4,28,161/- along with interest and also for compensation for mental & physical harassment and also for litigation expenses. Admittedly, CC was a government employee and she retired as S.S. Mistress from Govt. Senior Secondary School Garhshanakar, Hoshiarpur. It is also admitted that a cashless insurance policy was taken by the CC from the OP Nos.1 and 2 for amount of Rs.3,00,000/-. The period of said policy on the basis of government scheme was 01.01.2016 to 31.12.2016. It is also not disputed that CC remained under treatment as indoor patient in Fortis Hosptial Mohali for the treatment of coronary angiography, coronary angioplasty and stent coronary etc. It is also not disputed that the amount of Rs.4,28,161/- was paid by the CC to the Fortish Hospital and the copies of the bills are already on the file. CC was insured under cashless health insurance scheme known as the Punjab Government Employees and Pensioners Health Insurance Scheme(PGEPHIS) and during the period of said scheme CC got heart problem and got treatment from Fortis Hospital, Mohali. But the benefit of cashless treatment was not given to the CC as such after treatment she approached the OP Nos.1 to 3 but they did not accept the request of CC. In the present complaint OP No.1 to 3 has admitted all facts and has stated that the CC has sent a cashless request through hospital at the time of admission but the hospital had not given any reply for uploading of PTCA, IRT so the claim file was closed due to pending IRC query. It is also been stated by the OP Nos.1 to 3 that cashless request was not accepted due to non-cooperation of hospital who by not giving reply of Precise Tele Radiology 365 Pvt. Ltd. query. In these all circumstances we find that the OP Nos.1 to 3 have failed to disclose any valid reason for non-reimbursement of the medical bills and accordingly CC is entitled to reimbursement of the amount of Rs.3,00,000/- from the OP Nos.1 to 3 as insurance policy was of the amount of Rs.3,00,000/- only. The CC is also entitled to interest and we feel that interest @9% per annum shall be the reasonable rate of interest. The CC is also entitled to the compensation for physical and mental agony and in this regard we find that she is entitled for the amount of Rs.30,000/-. She is also entitled for Rs.20,000/- for litigation expenses.                  
9.                      In view of our aforesaid discussions, the present complaint is allowed partly and OP Nos.1 to 3 are directed to reimburse the payment of Rs.3,00,000/- out of payment of medical bills subject to terms and conditions of policy along with interest @9% per annum from the date of bills till the date of payment. OP Nos.1 to 3 are also directed to pay compensation of Rs.30,000/- towards mental and physical harassment and also directed to pay Rs.20,000/- for litigation expenses. The liabilities to pay the abovesaid amount shall be of all the OPs jointly and severely. The compliance of this order be made by the OPs within a period of 45 days on receipt of certified copy of this order. Copy of this order be provided to the CC and the OPs as per rules. This complaint could not be decided within a specific period as provided by the statute due to rush of work and large pendency.  File be returned back to the District Consumer Commission, Mohali for consignment.

    Pronounced:-

    13.09.2022                                                      

       

                                                                      (Pushvinder Singh)

                                                                                     President

 

 

 

    (Manjit Singh Bhinder)

                                                                                                     Member

 

 

               

                                                                            (Shivani Bhargava)

   Member