New Complaint No.191 of 2023.
Date of Institution:25.10.2023.
Old Complaint No:34 of 2018.
Date of Institution: 19.01.2018.
Date of order:19.01.2024.
Anil Kumar Son of Sh. Bihari Lal, resident of Village Babowal, Jail Road, Gurdaspur, Tehsil and District Gurdaspur. …..........Complainant.
VERSUS
1. Principal, Pawan Kumar Govt. ITI, Gurdaspur, Tehsil and District Gurdaspur.
2. Director, Punjab State Board of Technical Education and Industrial Training Institute, Punjab, Chandigarh.
3. Govt. of Punjab Department of Health and Family Welfare (Health - V Branch), Punjab, Chandigarh, through its Secretary.
4. Oriental Insurance Company Limited, Branch Office Gurdaspur, Tehsil and District Gurdaspur, through its Branch Manager.
5. Oriental Insurance Company Limited, having its Registered Office: Oriental House, A-25/27, Asaf Ali Road, New Delhi – 110002, through its Managing Director.
6. The M.D. India Health Care Services TPA Limited. D - 38, Mohali, Near Max Pro Park, Industrial Area Chandigarh, through its Managing Director-cum-Authorized Signatory.
….Opposite parties.
Complaint Under section 12 of the Consumer Protection Act.
Present: For the Complainant: Sh.Amit Kashyap, Advocate.
For the Opposite Party No.1: None.
For the Opposite Party No.2: Sh.R.S. Goraya, Advocate.
For the Opposite Party No.3: Sh.Rahul Vashisht, Advocate.
For the Opposite Parties No.4 & 5: Sh.A.K. Joshi, Advocate.
Opposite Party No.6 exparte.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Anil Kumar, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of the Consumer Protection Act (here-in-after referred to as 'Act') against Principal, Pawan Kumar Govt. ITI Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the complainant was earlier serving as Allied Trade Instructor (ATI) in the Office of the OP No. 1. Now the complainant has been appointed as Electrician Instructor (EI), since the post of ATI has been removed. The complainant has been serving in the office of the OP No. 1 and also under the supervision of the OP No. 2. He is discharging his duties honestly, diligently and to the entire satisfaction of his higher superiors. It is pleaded that the complainant is employee of Punjab State Government. Earlier the Punjab Govt. has provided the medical facility to his Employees of State regarding reimbursement. Meaning thereby when any employee has become bed ridden due to some illness, he was to be admitted in the Hospital either in the Empanelled Hospital or other Hospitals and he has to spend amount on his/her ailment and afterward the State Government has to reimbursed his/her medical claim, on furnishing his medical bills and claim. It is further pleaded that the Govt. of Punjab through the office of the OP No. 3 i.e. Department of Health and Family Welfare has issued a Notification bearing No. 268 dated 20.10.2015 which is known by words "PGEPHIS" Punjab Government Employees and Health Insurance Scheme which introduces a Cashless Health Scheme. It is further pleaded that as per the said Notification, all the regular employees as well as retirees can avail the said Cashless Scheme, who will take benefit regarding Cashless Scheme. It is further pleaded that the said Scheme has been commenced with effect from 01.01.2016. The OP No. 1 has got furnished the Forms of the OP's No. 4 and 5 (Insurance Company) for getting Mediclaim Card of the OP’s insurance Company from all his employees. It is further pleaded that complainant has also furnished the said Form for getting Mediclaim Card. The Letter being issued by the OP No. 1 to the OP No. 4 regarding detail of his employees who are beneficiaries of the said Scheme and who have filled the said Forms bearing Memo No. 273 dated 15.12.2015. The name of the complainant is at Serial No. 12 of the said Letter. It is further pleaded that the complainant was in the age of 40 years approximately. He possesses good and robust health and he was in his prime and young age. It is further pleaded that unfortunately on dated 21.01.2016 the complainant has suffered an acute chest pain in his chest and as such he has been shifted by his family members to Arora Hospital, Gurdaspur at about 1 A.M. in the intervening night of 21/22.01.2016. The Hospital authorities have given treatment to the complainant and they have also injected one ANTEROLAT MI Injection besides other treatment. It is further pleaded that but, the said Hospital located at Gurdaspur has failed to remove the chest pain to the complainant. It is further pleaded that they have charged Rs.50,000/- approximately from the complainant as medical expenses. But, afterward they have referred to the complainant to ESCORT, Amritsar due to critical condition of the complainant. On dated 22.01.2016, at about 6 A.M. the complainant was got admitted in the ESCORT Hospital, Amritsar, where the complainant has been fully diagnosed by the concerned Doctors. It is further pleaded that Hospital authorities have done Angiography of the complainant and found that the complainant has been suffering from acute chest pain due to Single Vessel Disease. It is further pleaded that PTCA to LAD was done on the same day. They have discharged the complainant on 25.01.2016 and has received Rs.2,25,702/- from the complainant. It is further pleaded that in total, the complainant has made the payment of more than Rs.2,75,000/- in both the Hospitals during the period of his admission. It is further pleaded that as and when the complainant was discharged from the Hospital and he approached the OP No. 1 firstly for getting reimbursement claim and he has filled the Reimbursement Claim Form and annexed the bills of the Hospital and requested the OP No. 1 to entertain the said Claim Form, but the OP No. 1 has flatly refused to entertain the same despite several requests being made by the complainant. It is further pleaded that thereafter, the complainant has also approached the OP No. 4 for getting Insurance claim, but of no use. It is further pleaded that firstly the complainant approached to the concerned authority of the OP No. 1 with the request to fill the Insurance Claim of the OP’s No. 4 and 5 for getting Insurance medical claim. But, the said concerned authority has refused to entertain the legal and genuine request of the complainant. It is further pleaded that officials of the OP No. 1 has firstly refused to entertain the request of the complainant on the ground that so far the Mediclaim Card of the OP’s No. 4 and 5 (Insurance Company) has not been issued in the name of the complainant and secondly, he has asked that since the Scheme is Cashless one, so reimbursement of Bills does not arise. It is further pleaded that the fact remains that the OP’s have denied making the payment of Insurance claim on arbitrary and vague grounds. It is further pleaded that at the time of filling papers of Insurance for getting Insurance Card, he has filled his Mobile Number as 95010-20571. It is further pleaded that the father of the complainant has retired from Education Department and he is also one of the beneficiary of the said Scheme. He has also furnished his Form for getting Insurance Card and he has filled his Mobile Number as 95010-20571 i.e. of his Son i.e. complainant, as the father of the complainant is not using separate Mobile Phone. It is further pleaded that non-issuance of the Mediclaim Card by the OP’s No. 4 and 5 on the false ground that two Forms contain one Mobile Number is vague, illegal, arbitrary, cryptic one. It is further pleaded that secondly the Hospital of the complainant where he got his treatment i.e. ESCORT HOSPITAL, AMRITSAR was earlier not in the list of Empanelled Hospital in the said Scheme and later on it has been added in the said List. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in services on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties No.4 and 5 to make the payment of Rs.2,75,000/- to the complainant, which the complainant has spent on his treatment along with traveling expenses, counsel fee and interest at the rate of 12 % Per Annum from the date of making payment i.e. 25.01.2016 till its actual realization. It is further prayed that all the opposite parties may also be directed to pay compensation amounting to Rs.1,00,000/- due to harassment being suffered by the complainant for physical harassment and mental agony and be directed to pay litigation expenses to the complainant on account of mental and physical harassment suffered by the complainant, in the interest of justice. The complainant may be granted any other relief to which he is legally and equitably entitled to as per the facts and circumstances of the case.
3. Upon notice, the opposite party No.1 appeared through counsel and contested the complaint and filing their written reply, stating therein that the Govt. of Punjab through the Office of the OP No. 3 i.e. Department of Health and Family Welfare has issued a Notification bearing No. 268 dated 20.10.2015 which is known by words "PGEPHIS" Punjab Government Employees and Health Insurance Scheme which introduces a Cashless Health Scheme. It is pleaded that as per the said Notification, all the regular employees can avail the said Cashless Scheme which has commenced from 01.01.2016. The OP No. 1 has got furnished the Forms of the OP’s No. 4 and 5 and the name of the complainant figures at Serial No. 12 of the Letter issued by the answering OP No. 1 to the OP No. 4. It is further pleaded that the complainant has suffered a Heart attack and he remained admitted in Arora Hospital, Gurdaspur and Escort Hospital, Amritsar. It is further pleaded that answering OP No. 1 has got no concern with the claim of the complainant, as the same is to be given by the OP’s No. 4 and 5. It is further pleaded that the answering OP No. 1 has contacted the OP’s No. 4 and 5 with the request to receive the Claim Forms of the complainant and for submission of the same before the OP’s No. 4 and 5, but the OP’s No. 4 and 5 have refused to entertain the request of the answering OP No.1, the reasons are best known to them. It is further pleaded that the answering OP No. 1 has not repudiated the claim of the complainant and has not harassed the complainant.
On merits, the opposite party No.1 stated that there is no deficiency in service on the part of the opposite party. It is submitted that the answering opposite party No.1 has no objection if the complaint is allowed and the insurance claim is given to the complainant, in the interest of justice.
4. Upon notice, the opposite party No.2 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint is not maintainable against the answering OP No. 2 and the OP No. 2 has unnecessarily been dragged into unwanted litigation, as such the present complaint is not maintainable against the answering OP No.2 and same be liable to be dismissed. It is pleaded that the complainant is neither employee of the answering OP No. 2 and nor OP No. 2 has got any concern with the service conditions of the complainant and nor he is employer of the complainant. It is further pleaded that Job of the answering OP is only to conduct the exams of the students studying in the ITI’S. As such the complaint is liable to be dismissed on this score. It is further pleaded that the answering OP has got no knowledge about any alleged employees Health Insurance Scheme / Claim. The answering OP has got no concern with the alleged Health Insurance Claim. It is further pleaded that the answering OP has got no concern with the payment of the medical expenses allegedly born by complainant for his treatment. It is further pleaded that the complainant has filed a false complaint against the answering OP and has involved the answering OP into unwanted litigations.
On merits, the opposite party No.2 has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
5. Upon notice, the opposite party No.3 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complaint under reply is not maintainable against the opposite party No. 3 as the complainant had to take sanction first from the Corporation before initiating any legal proceeding against the OP No. 3 as per Section 15 of Punjab Health System Corporation Act, 1996 and the same is clear from the perusal of section 15 Punjab Health System Corporation Act, 1996 as follows:-
Section 15
- No suit or prosecution shall be entertained in any court against the corporation or against any officer or servant of the Corporation or person acting under the order or direction of the corporation for anything which is in good faith done or intended to be done under this Act or any regulation made there under.
- No suit, prosecution or other legal proceedings shall lie against any officer or servant of the corporation for any act done of purporting to be done under this Act or any regulation made there under without the previous sanction of the corporation.
It is pleaded that the present complaint under reply is also liable to be dismissed on the ground that the complainant has not made any representation to District Grievance Redressal Committee constituted vide notification dated 21.09.2016 by Govt. of Punjab in order to lay his claim, if any. It is further pleaded that no cause of action even arose to complainant for filing the present complaint. It is further pleaded that the Govt. of Punjab through the office of the opposite party No. 3 has issued notification bearing No. 268 dated 20.10.2015 which is known by words "PGEPHIS" Punjab Government Employees and Health Insurance Scheme which introduces cashless health scheme. It is further pleaded that neither any representation nor any requests were ever made by the complainant to District Grievance Committee nor to the opposite party No. 3 with regard to any alleged claim.
On merits, the opposite party No.3 has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
6. Upon notice, the opposite parties No.4 and 5 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the present complaint of the complainant against the replying OP’s No.4 and 5 is not maintainable, as the complainant is not insured with the replying OP’s insurance company under the Punjab Government Employees and Health Insurance Scheme. It is pleaded that the complainant is neither insured with the replying OP’s insurance company, nor any Insurance Card ever issued to him, hence, replying OP’s insurance company is not liable to pay any claim. It is pertinent to mention here that the replying OP’s insurance company had filed an application for production of Insurance Card of the complainant, which would have been issued at the time of insurance to the complainant if he is insured under the scheme, but the complainant did not produce the same. It is further pleaded that the replying OP’s insurance company is not in a position to give the proper and complete reply of the complaint in absence of insurance card of the complainant or other particulars of the insurance. It is further pleaded that the present complaint is not maintainable against the replying OP’s insurance company, as there is no insurance contract exists between the complainant and the replying OP’s. Hence, there is not any contractual liability of the replying OP’s against the complainant under the Consumer Protection Act. It is further pleaded that Punjab Government has sponsored this scheme to its Employees and Pensioners and no insurance consideration is deducted from their salaries, hence, if there is any insurance contract even then the replying OP’s insurance company has contractual liability towards Punjab Govt. only, not against the complainant, as the complainant is not covered within the definition of 'Consumer' under Consumer Protection Act. It is further pleaded that no cause of action has accrued against the replying OP’s. Hence, the present complainant is liable to be dismissed on this score only and the present complainant is bad for mis-joinder and non-joinder for all the necessary parties. The M.D. India Health Care Services TPA is the necessary parties for the complete and effectual adjudication of the matter.
On merits, the opposite parties No.4 and 5 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
7. Opposite party No.6 did not appear despite the service of notice and was proceeded against exparte vide order date 31.12.2018.
8. Learned counsel for the complainant has tendered into evidence affidavit of Anil Kumar, (Complainant) as Ex.C-1 alongwith other documents as Ex.C-2 to Ex.C-10.
9. Learned counsel for the opposite party No.1has filed reply.
10. Learned counsel for the opposite party No.2 has filed reply.
11. Learned counsel for the opposite party No.3 has tendered into evidence affidavit of Dr. Maninder Singh, (Deputy Medical Commissioner, Gurdaspur) as Ex.OP-3/1 alongwith other document as Ex.OP-3/2 alongwith reply.
12. Learned counsel for the opposite parties No.4 and 5 have tendered into evidence affidavit of Sh. Karam Singh, (Senior Divisional Manager, Oriental Ins. Co. Ltd., Pathankot) as Ex.OP-4,5/A alongwith reply
13. Written arguments filed by the opposite parties No.3, 4 and 5, but not filed by the complainant and opposite parties No.1 and 2.
14. Counsel for the complainant has argued that complainant was earlier serving as Allied Trade Instructor in the office of opposite party No.1 and now the complainant is appointed as Electrician Instructor. It is further argued that Govt. of Punjab has provided medical facility to its employees regarding reimbursement of medical bills and hospitalization. It is further argued that Govt. of Punjab through office of opposite party No.3 department of Health and Family Welfare has issued notification dated 20.10.2015 which is known by words "PGEPHIS" which introduced a cashless health scheme as per which all the regular employees as well as retirees can avail said insurance scheme which commenced w.e.f. 01.01.2016. Opposite party No.1 got furnished the forms of opposite parties No.4 and 5 for getting mediclaim cards of insurance for all the employees and the complainant also furnished the said form for getting mediclaim card. It is further argued that unfortunately on 21.01.2016 complainant suffered chest pain and was hospitalized with Arora Hospital Gurdaspur where Arora Hospital gave some treatment and charged Rs.50,000/- and thereafter complainant was referred to Escort, Amritsar in critical condition where complainant had spent Rs.2,25,702/- on his treatment. Complainant had approached the opposite parties alongwith record for reimbursement of the medical bills but opposite parties flatly refused to reimburse the medical claim. It is further argued that failure to make payment of Rs.2,75,000/- spent by the complainant on his treatment amounts to deficiency in service on the part of the opposite parties.
15. On the other hand none has appeared on behalf of opposite party No.1. However, it has been pleaded by the opposite party No.1 that he has no objection if the complaint is allowed.
16. Counsel for the opposite party No.2 has argued that complainant is not employee of opposite party No.2 and the job of answering opposite party is only to conduct exam of students in the ITIs and as such complaint is liable to be dismissed.
17. Counsel for the opposite party No.3 has argued that present complaint is not maintainable as the complainant has not approached the District Grievance Redressal Committee constituted by the Govt. However, it is admitted by the counsel for the opposite party No.3 that notification dated 20.10.2015 was issued which introduced cashless health scheme for Pb. Govt. employees.
18. Counsel for the opposite parties No.4 and 5 has argued that complainant is not insured with opposite parties insurance company and no cashless card was ever issued by the insurance company. Even the insurance company had moved application for production of insurance card but no such card was produced by the complainant. It is further argued that the scheme has been introduced by the Govt. of Punjab and Punjab Govt. sponsored this scheme to its employees and pensioners and no insurance consideration is deducted from their salaries and the contract if any is towards Govt. of Punjab and not with the complainant and as such present complaint is liable to be dismissed.
19. Opposite party No.6 remained exparte.
20. We have heard the Ld. counsels for the complainant and opposite parties No.2 to 5.
21. To prove his case complainant has placed on record his affidavit Ex.C1, copies of bills of treatment Ex.C2, copy of prescription slip of Arora Hospital Ex.C3, copy of coronary angiography report Ex.C4, copy of coronary angiogram Ex.C5, copy of discharge summary Ex.C6, copy of acknowledgment Ex.C7, copy of notification Ex.C8, copy of memo No.273 Ex.C9 and copy of letter dated 15.12.2015 Ex.C10.
22. It is admitted fact that the complainant was earlier serving as Allied Trade Instructor with Govt. ITI Gurdaspur and thereafter was appointed as Electrician Instructor. It is further admitted fact that Govt. of Punjab had issued notification dated 20.10.2015 known as "PGEPHIS" which had introduced a cashless health scheme for the Govt. employees which commenced on 01.01.2016. It is further admitted fact that complainant remained admitted at Arora Hospitral Gurdaspur and thereafter at Escort, Amritsar and had to bear the expenses of treatment from his own pocket. It is further admitted fact that complainant has not been reimbursement the charges of medical treatment. The only disputed issue for adjudication before this Commission is whether the complainant is entitled to receive the treatment expenditure from the opposite parties.
23. Perusal of notification Ex.OP-3/2 shows that State Government had started scheme PGEPHIS for providing cashless indoor health insurance and chronic disease reimbursement upto Rs.3.00 Lacs per family per year and accordingly Government had issued notification on 20.10.2015. Perusal of file further shows that the process for obtaining health benefit was started by the department vide memo No.273 dated 15.12.2015 Ex.C9 was issued to Oriental Insurance Company wherein name of the complainant is mentioned at serial number 12. The plea of the counsel for the opposite parties No.4 and 5 is that since no amount has been deducted from the salary of the complainant as such complainant does not fall under definition of Consumer Protection Act, 1986. The definition of said section read as under:-
"(ii). Definitions. - (hires or avails of) any services for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any beneficiary of such services other than the person who 'hires or avails of the services for consideration paid or promised, or partly paid and partly promised, or under any system of deferred payment, when such services are availed of with the approval of
the first mentioned person 2(but does not include a person who avails of such services for any commercial purpose)".
Admittedly in the present case also Govt. of Punjab has also not deducted any amount from the salary of the complainant and as such we have no hesitation in holding that no relationship of consumer and service provider is established between the complainant and opposite parties No.4 and 5. Moreover, complainant has not placed on record any insurance card or copy of any contract having been entered into between the Govt. and the insurance company. As such non reimbursement of the medical claim by the opposite parties does not amount to deficiency in service. Accordingly, we are of the view that as per the definition of consumer as mentioned in the Consumer Protection Act, 1986, the complaint does not fall within the ambit of consumer as per the Act.
24. Accordingly, without going into merit of the case the present complaint is disposed off with the directions to the complainant to approach the appropriate Forum for redressal of his grievance. Complainant can also take benefit of Section 14 of Limitation Act.
25. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
26. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
(Lalit Mohan Dogra)
President
Announced: (B.S.Matharu)
Jan. 19, 2024 Member
*YP*
