Punjab

Faridkot

CC/17/300

Anuradha Deora - Complainant(s)

Versus

Principal Secretary - Opp.Party(s)

In Person

22 Jan 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :          300 of 2017

Date of Institution: 4.09.2017

Date of Decision :  22.01.2019

 

Anuradha Deora w/o Deepak Kumar Deora r/o Mohalla Sethian, House No.B-II-36, Faridkot, District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1. Principal Secretary, Government of Punjab Department of Health + Family Welfare Punjab, Chandigarh, Sector-9, Mini Secretariat, Chandigarh.
2. Managing Director, Punjab Health System Corporation State Institute Health and Family Welfare Mohali Phase-6.
3. Director, Health Services Punjab, Sector-34A, Chandigarh.
4. M D India, Health Care Services TPA Pvt Ltd, Max Pro Info Park, D-38, Industrial Area, Phase-I, Mohali.
5. Oriental Insurance MD India, Health Care Services TPA Pvt Ltd, Max Pro Info Park, D-38, Industrial Area, Phase-I, Mohali (Pb
6. District Co-ordinator, Oriental Insurance Company, Civil Hospital Faridkot.
7. Nodal Officer, PGEPHIS, Sector 34-A, Chandigarh.

   .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

Present: Sh Madan Deora on behalf of Complainant,

   Sh Kashmir Lal, Ld Counsel for OP-1, 2 & 7,

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              Sh Vinod Monga, Ld Counsel for OP-4, 5 & 6.

              OP-3 Exparte.

 

ORDER

(Ajit Aggarwal, President)

                                                  Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against  OPs seeking directions to OPs to make payment of Rs.1,08,166/- on account of remaining reimbursement of expenses spent by complainant on her treatment with interest and for further directing OPs to pay Rs.50,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs11,000/-.

2                                              Briefly stated, the case of the complainant is that complainant is a Principal in Government Senior Seconday School, Quila Nau, Faridkot and being a government employee and as per Health Insurance Scheme for Pensioners, she is fully covered under Punjab Government Employees and Pensioners Health Insurance Scheme. The policy was valid from 1.01.2016 to 31.12.2016 and as per policy, complainant is entitled for cashless treatment and OPs are liable to pay the cashless insurance claim upto Rs.3,00,000/- and also reimbursement upto Rs.3 lacs. Premium for enrolment under scheme was paid by Punjab Government. OPs neither submitted any document nor explained any terms and conditions of policy in question to complainant. It is further submitted that during the subsistence of said policy complainant took treatment from Dayanand

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Medical College and Hospital, Ludhiana for her leg and total cost of treatment was Rs.1,40,989/-. Complainant submitted original bill for Rs.1,40,989/-to PGEPHIS, but they passed bill only for Rs.32,823/- and did not reimburse the remaining amount. Complainant requested the Company to review her case, but they did not give any reply. Complainant also made requests before Deputy Commissioner cum Chairman District Level Grievance Redressal Committee and State Level Grievance Committee, but she did not get any justice. Due to non payment of amount spent by her on her treatment, complainant has suffered financial loss as well as great harassment and this has caused mental agony to her. All this amounts to deficiency in service and trade mal practice on their part and she has prayed for accepting the present complaint alongwith compensation for Rs.50,000/-for harassment and mental agony suffered by her besides litigation expenses of Rs.11,000/-. Hence, the complaint.

3                                                   The counsel for complainant was heard with regard to admission of the complaint and vide order dated 11.09.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                                    On receipt of the notice, the OPs no.1, 2 & 7 filed reply taking preliminary objections that complainant has no cause of action to file the present complaint. It is averred that complainant has not mentioned the date of treatment in the complaint

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and moreover as per notification of Health Insurance Scheme launched by Punjab Government, Oriental Insurance Company/Op-5 has been selected as the insurer for implementing the scheme. The Insurance Company has appointed M D India i.e Third Party Administrator to deal with the approval of claims and State Government Punjab Health System Corporation as well as Nodal Officer, PGEPHIS is not liable for making any payment of medical claims for the period of treatment of complainant. However, on merits OP-1, 2 and 7 have denied all the allegations of complainant being wrong and incorrect and further averred that issue regarding claim of treatment is in between complainant and OP-5 i.e Oriental Insurance Company and there is no relation between complainant and answering OPs. Moreover, complainant has not produced on record any documentary evidence to prove that she submitted any request to Grievance Redressal Committee.

5                                          OP-4, 5 & 6 appeared in the Forum through counsel and filed written reply wherein they admitted the complainant  lodged the non cashless claim to the tune of Rs.1,40,989/- under the PGEPHIS Scheme for reimbursement. It is averred that complainant has no cause of action to file the present complaint as claim of complainant has already been settled on 18.04.2017 as per terms and conditions of scheme and as per PGEPHIS package rates, amount of Rs.32,823/-has been paid to her under non cashless scheme. There is no reason to review the claim of complainant as amount of Rs.32,823/- permissible under the said scheme has already been paid to her on 18.04.2017 with

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transaction date 25.04.2017. Claim filed by complainant for Rs.1,40,989/- is not permissible to her as per scheduled rates of PGEPHIS. It is reiterated that there is no deficiency in service on the part of answering OPs and they refuted all the other allegations alongwith allegations for relief sought by complainant and also prayed for dismissal of complaint with costs.

6                                    Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence her affidavit Ex.C-1 and documents Ex C-2 to C-6 and then, closed their evidence.

7                                        In order to rebut the evidence of the complainant, ld Counsel for OP-1, 2 and 7 tendered in evidence affidavit of Jagraj Singh as Ex OP-1, 2 & 7/1 and document Ex OP-1, 2& 7/2 and then, closed the same on behalf of OP-1, 2 & 7. Ld Counsel for OP-4 to 6 has tendered in evidence affidavit of Ashwani Kumar as Ex OP-1, documents Ex OP-4 to 6/2 to 4 and closed the same on behalf of OP-4 to 6.

8                                       We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.                            

9                                       The case of the complainant is that being a  Government employee, complainant was insured under the policy in question. She got conducted the treatment of her leg from Dayanand

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Medical College, Ludhiana and spent Rs.1,40,989/-on her treatment. She lodged claim with Ops, but Ops cleared the bill only Rs.32,823/-which is very less. Repeated requests made by complainant to revaluate her case for clearing the remaining claim amount bore no fruit. Requests made by complainant before Grievance Redressal Committee at the District Level and State Level went futile, which amounts to deficiency in service. Grievance of complainant is that despite repeated requests, Ops have refused to make payment of remaining claim amount to her which amounts to deficiency in service and trade mal practice. She has prayed for accepting the complaint. On the other hand, OPs no.1 2 and 7 have stressed mainly on the point that issue regarding claim of treatment is between complainant and OP-5 i.e Oriental Insurance Company and there is no relation between complainant and OPs-1, 2 &7 and even, complainant has not produced on record any documentary evidence to prove that she submitted any request to Grievance Redressal Committee. Plea taken by OP-4 to 6 is that claim of complainant has already been processed and cleared and nothing is due and payable by them to complainant. They also stressed that as per terms and conditions of scheme and as per PGEPHIS package rates, amount of Rs.32,823/-has been paid to her under non cashless scheme. Amount of Rs.32,823/- permissible under the said scheme has already been paid to her on 18.04.2017 with transaction date 25.04.2017. Claim filed by complainant for Rs.1,40,989/- is not permissible to her as per scheduled rates of

 

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PGEPHIS and there is no question of reviewing the same. They have prayed for dismissal of complaint with costs.

10                                          Now, it is admitted case of the parties that Punjab Government launched a scheme for the cashless medical treatment of their employees, officials and pensioners namely Punjab Government employees and pensioners health Insurance scheme and made a contract with opposite parties. Being employee of Punjab Government, the complainant was beneficiary under this scheme. It is further admitted that the complainant took treatment from DMC, Ludhiana during the subsistence of policy in question and spent an amount of Rs.1,40,989/-on her treatment and as per Cashless Health Insurance Scheme launched by Government of Punjab, complainant is entitled for reimbursement of expenditure spent by her on her treatment. She lodged claim for the reimbursement of medical expenses borne by her with OPs, but they cleared her bill only for Rs.32,823/- and they did not paid the remaining expenditure amount incurred by her on her treatment. The OPs argued that claim of complainant has already been passed and amount of Rs.32,823/- permissible under the terms and conditions and rules of policy in question stands paid to her and now, nothing is due to be paid. So, she is not entitled for any relief and cannot claim reimbursement of remaining medical expenses and her claim cannot be reviewed. There is no dispute that complainant got her treatment from hospital and spent Rs.1,40,989/-, which is duly proved from the bills. She lodged claim for reimbursement of this amount from

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OPs but the version of the OPs is that they settled the claim of complainant for Rs.32,823/- as per their own rates, but Ops failed to prove that how they fixed their own rates and on what basis. They deducted the remaining amount out of claim of complainant whereas complainant spent Rs.1,40,989/- for her treatment. This act of OPs amounts to deficiency in service and trade mal practice on their part. It is generally seen that Insurance Companies are only interested in earning the premiums and at the time of settlement, they find excuses to deny the   genuine claim of consumers.

11                                            From the above discussion, we are of the considered opinion that being a government employee, complainant was fully insured under the Punjab Government Employees Pensioner Health Insurance Scheme and is fully entitled to expenses incurred by her on her treatment. OPs No. 4 to 6 made part payment of only Rs.32,989/- for her entire claim of Rs.1,40,989/-and did not clear the remaining amount and OPs wrongly and illegally repudiated the remaining claim of the complainant for reimbursement of her medical bills, which amounts to deficiency in service on their part. Hence the present complaint is allowed against OP No. 4 to 6 and they are directed to settle the claim of complainant as per PGI rates and to pay the balance amount if any alongwith interest @ 9% per annum from the date of filing the present complaint till final realization. Further OPs No. 4 to 6 are directed to pay Rs.5000/- (Five thousands only) as consolidated compensation for harassment and litigation expenses to the complainant. Complaint

                                   cc no. 300 of 2017

 

against OP-1 to 3 and OP-7 stands dismissed. Compliance of the order be made within 30 days from the receipt of copy of this order, failing which, the complainant shall be entitled to initiate proceedings under Section 25 and 27 of the Consumer Protection Act. Copy of order be sent to the parties free of costs. File be consigned to record room.

Announced in Open Forum

Dated : 22.01.2019

 

(Param Pal Kaur)         (Ajit Aggarwal)

                                       Member                      President