Punjab

Fatehgarh Sahib

RBT/CC/401/2018

Ramesh Kumar Behal - Complainant(s)

Versus

Punjab Health Systems Corporation - Opp.Party(s)

Siddharth Gulati

12 Dec 2022

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.

                                                              RBT. No.401/2018                                                                                        Complaint No. 401 of 2018                                                                                        Date of Institution:2.4.2018                                                                                  Date of Decision: 12.12.2022

 

Ramesh Kumar Behal ( now deceased) represented through legal heir Smt. Anuradha d/o Late Sh. Ramesh Kumar Behal S/o Sh. Ramji Dass R/o # 287, Phase-7, S.A.S. Nagar, Mohali

                                                                                                                     …………....Complainant

 

                                                Versus

1.   Punjab Health Systems Corporation , through its Secretary cum Managing Director, State Institute of Health and Family Welfare Complex,  Phase-6, Near Civil Hospital , SAS Nagar, Mohali. .
2. The Oriental Insurance Company , through its Authorised Representative, Oriental House, A-25/27, Asaf Ali Road, New Delhi.
3. MD India Healthcare Services Pvt. Ltd., through its Authorised Representative, Mohali Tower, First Floor, F-539, Phase 8-B, Industrial Area, Mohali.
4. Max Super Speciality Hospital, through its Managing Director, Phase-6, Near Civil Hospital, Mohali.

                                                                              ..………....... Opposite Parties

5.  Department of Industries and Commerce Punjab, through its Director, having its office at Bridge Market, Sector 17-D, Chandigarh.
6.  

 

Complaint under Section 12 of Consumer Protection Act 1986(Old)

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjeet Singh Bhinder, Member

Present: Sh. Anshul Jindal, counsel for complainant.

     Sh.K.G.Sharma, counsel for OPs no.1.

     Sh.J.P.Nahar, counsel for OPs no.2 and 3

      Sh.Shekhar Verma, counsel for OP.no.4

      Ms. Randeep Kaur , Senor Assistant on behalf of OP no.5

Order By

MS. SHIVANI  BHARGAVA, MEMBER

 

 The  complaint has been filed by the complainant  against the OPs (opposite parties),  Under Section 12 of Consumer Protection Act-1986(old) alleging deficiency in service with the prayer for giving direction to the OPs to reimburse  the incurred medical expenses on his  treatment i.e  Rs.1,62,435/-) alongwith interest @ 12% P.A  from the date of claim request for reimbursement  till the payment of claim  and   Rs.2,00,000/- as compensation  for mental and physical harassment  and Rs.22,000 as  litigation  expenses to the complainant .

1.  The brief facts of the complaint are that complainant was a Punjab Government Employee and  served in the Department of Industries and Commerce, Punjab . The complainant being the Punjab Government Employee was the beneficiary of the Punjab Government Employees and Pensioners Health Insurance Scheme ( herein referred as PGEPHIS).  As per the terms of the PGEPHIS  every beneficiary  of this Insurance scheme was entitled for cashless treatment  up to Rs.3 Lakh in empanelled hospitals  with this insurance scheme.   The said cashless scheme was being implemented through Oriental Insurance Company and their TPA from 1.1.2016 to 31.12.2016.. The MDID card was being provided to the complainant being beneficiary of PGEPHIS.  On 27.7.2016 health of the complainant got worse and the family members of the complainant took him to the Max Super Speciality Hospital, Mohali empanelled with PGEPHIS. The cashless treatment was to be provided to the beneficiary of the PGEPHIS only after the empanelled hospital  receives the approval for the same from OP no.3. The family members of the complainant presented the MDID Card of the complainant to the doctors and they told the family members of the complainant to get the treatment done from them by  paying  cash  as the condition of the complainant was not good   and approval from insurance company will take time and on the assurance  from doctors that they can take the claim in respect of the same from OP no.3 afterwards.  For the benefit of the complainant,  the family members of the complainant agreed with the doctors  and they got the treatment of the complainant  done from OP no.4 by paying the cash. Complainant was admitted in the hospital  several times. Each time complainant was taken to OP no.4, they instead of making use of the MDID Card of the complainant, charged the complainant for the treatment. Complainant was chronic patient. The condition  of the complainant each time when he was taken to the hospital was very  serious and he was to be given treatment urgently due to which the family members were very helpless and they themselves made the payment to Op no.4. The complainant  sent the original medical bills along with  the claim  form  to OP no.3 for claim but the  claim  of the complainant was repudiated by stating that the  no reimbursement will be available to employee/Pensioners in Punjab, Chandigarh and Panchkula where cashless treatment is available. Reimbursement can be taken for medical treatment taken in any other state in India.  The complainant had sent the legal notices to the OPs regarding the same , but there has been no reply  to the legal notice  and neither  the complainant had been paid his Mediclaim amount till  date. Hence this complaint
2.          Notice of the complaint was given to the OPs no.1 to5 through registered Post, OPs no.1 to 5 appeared through their Counsels  and filed  their written version.
3.        The complaint has been contested by the OP no.1, who filed written version ,raised preliminary objections, that the complainant is not a consumer of OP no.1. The complaint is not maintainable . It is further alleged on merit that the  Punjab Health Systems Corporation is the operating agency for the Punjab Government employees & Pensioners Heath Insurance  Scheme (PGEPHIS) formulated by the Government of Punjab vide its notification dated 20.10.2015.  The said scheme was made applicable to all the Govt.  serving employees  and  pensioners on compulsory basis.  The premium of the main member as well as  dependent(s) (as defined in the State Services) (Medical  Attendant Rules) [CS(MA)] Rules, 1940 was paid by State Govt.  The claim for medical reimbursement  for the beneficiary was to be settled by the Insurance Company i.e  Oriental Insurance Company.   As per the report received from  TPA dated 19.11.2018 the Non-cashless claim filed by the petitioner have been paid.  In case the petitioner had any grievance regarding his claim for reimbursement, he could have approached the District Grievance Redressal Committee constituted by the Govt. of Punjab.  There is no deficiency on the part of OP no.1, as settlement of the claim or to repudiate any claim is the responsibility  of respondent no.2 & 3, as the policy in question has been  issued by the Oriental Insurance Company.  OP no.1 has no role in repudiation of claim, it is the sole responsibility of OPs no.2 and 3 Accordingly , OP no.1 prayed for dismissal of the complaint.
4. The complaint has been contested by the OPs no.2 and 3, who filed jointly their written version and stated that  the cashless treatment is to be provided on receipt of authorization from TPA i.e OP no.3. However , the OP. 3 did not receive any request for cashless treatment from OP no.4. The complainant  has colluded with the Hospital so that Hospital can charge normal rates instead of the agreed rates between the empanelled hospitals, the TPA and the Punjab Government.  Op no.3  did not receive any request for cashless treatment  authorization  from OP no.4.  As per clause 4 of the Notification dated 20.10.2015 issued by the Government of Punjab, reimbursement of treatment is not allowed and  all  the empanelled hospitals are duty bound to provide cashless treatment on agreed rates.   No reimbursement will be available to employee/pensioner in Punjab, Chandigarh and Panchkula,  where cashless treatment is available. However,  reimbursement can be taken  by employees/pensioner for medical treatment taken in any  other State in India in exceptional circumstances.  In such circumstances, the insurance company will reimburse  the bill  of the employees up to Rs.3,00,000/-  as per the package rates defined under the scheme. There is no deficiency in service on the part of OPs no.2 and 3 as no intimation or request was ever received for cashless treatment. 
5. The complaint has been contested by the OP no.4, who filed written version and stated that all the allegations made in  the complaint are completely false, incorrect. The complainant never disclosed that he is a beneficiary of Punjab Government Employees and Pensioner Health Insurance  Scheme (PGEPHIS) .  The complainant did not produce any documents to claim the cashless Medi claim  for the treatment availed at the Hospital. The complainant visited OPD of the hospital multiple times, and had paid normal Hospital OPD charges, and never produced his MDID Card to claim the benefits of being the beneficiary of PGEPHIS.  In fact the complainant was provided senior citizen discount of 10% in  the OPD bills. Complainant took treatment for diabetic foot thrice, but he never disclosed his MDID Card to the concerned billing department to claim the cashless facility on account of being beneficiary of PGEPHIS. The Hospital  has been giving benefit of cashless Medi claim to beneficiaries of PGEPHIS  and gains nothing by denying the same to the complainant .  That acceptance/rejection of reimbursement claim under medical/health policies/schemes is a matter between the insured/beneficiary patient and the Insurance Company/TPA. The OP no.4 has absolutely no role or say or responsibility either in the sanction or rejection of the cashless Medi claim and/or reimbursement of the claim by the insurance companies. OP no.4 prayed for dismissal of the complaint
6. The complaint has been contested by the OP no.5, who filed written version and stated that OP no.5 is Proforma  OP. Complainant joined the Department of Industries, Punjab on 6.11.1963 and retired as Assistant from this Department on 31.1.1998. Since the matter pertains to the period between 1.1.2016 to 31.12.2016 whenPunjab Government Employees and Pensioners Health Insurance  Scheme  was inforce and Scheme was being implemented by OPs no.1 to 3. Therefore necessary action was to be taken by them.
7. The complainant in support of his complaint tender in evidence his  affidavit Ex.CW1/A and  documents EX.C1 to Ex.C.5.  In rebuttal the OP no.1  tendered affidavit of Dr.Rupinder Kaur Directior(Admn.) Ex.RW1/A along with documents Ex.R1/1 and Ex.R1/2, OPs no.2 and 3 jointly  tendered in evidence affidavit of Renu  Garg Divisional Manager Ex.OP2/1. OP no.5 tendered in evidence affidavit of Amit Narula Ex.OP5/1 along with document Ex.OP5/2. OP no.4 has filed documents along with version  as Annexure R-4/1 to Annexure R4/3.
8.                  We have perused the complaint  and heard counsel for parties  and gone through the file.
9.                  Ld. Counsels for the parties have reiterated their stand as taken  in their respective pleadings and  as detailed above.
10.               The complainant Ramesh Kumar Behal died on 18.12.2020 during the pendency of the complaint. So his wife Raj Dulari was impleaded as his Legal Heir. Unfortunately  she also passed away on 3.2.2022. Now their daughter  Anuradha is being impleaded as legal heir in the present complaint.  There is no dispute about the fact that the complainant (now deceased)  being a pensioner of Punjab Government was  covered under the PGEPHIS w.e.f. 01.1.2016  to 31.12.2016. Complainant  got admitted in Max Super speciality Hospital, Phase VI, Mohali  several times  in emergency.  Doctors told his family  members  that  patient needs treatment immediately  and authorization for cashless treatment from Insurance Company  will take time. So they  can  reimburse  claim later on  complainant’s family  agreed and they  paid the bills  themselves.  Complainant was treated  for different diseases on different times .  He spent Rs.1,62,435/- on his  treatment  but his claim was  rejected as motioned below  in claim file non cashless :-

CLAIM FILE- NON CASHLESS
Name of Patient	Ramesh KumarBahal	Ramesh KumarBahal	Ramesh KumarBahal	Ramesh Kumar
Control No.
		Urinary tract Infection	Type 2 diabetes mellitus with diabeticFOOT	Septic shock
Hospital Name	MAX HOSPITAL	MAX HOSPITAL	MAX HOSPITAL	MAX HOSPITAL
Date ofAdmission	August 29,2016	July 27,2016	September 22,2016	November 21,2016
Date ofDischarge	August 30,2016	July 27,2016	September 22,2016	November 21,2016
Lodged Amount
Final Status
	Para 4	Para 4	Para 4	Para 4

 

 

11.              The Ops argued  that this Commission  has no jurisdiction to entertain  the  complaint. It is settled Principle of Law that remedy  Under Consumer Protection Act  is  an additional  remedy  other than  available remedies. Under Section 100 CPA 2019 provisions of the act shall be  in  addition to  and not in  derogation of the provisions  of any other  law for the  time being in force.
12.              OP no. 1 filed in reply that settlement of claim or repudiation  of claim is responsibility of OPs no.2 and 3. Claim of the complainant  when he was  admitted in hospital in Oct. 2016 was paid in Nov., 2016 through Cheque.
13.           OPs no. 2 and 3 argued that they did not receive any request for cashless treatment  and complainant  had not followed the procedure for cashless Medi claim  under Policy. Complainant had filed medical reimbursement  bills with OPs no.2 and 3, which were repudiated on different dates with  remarks as per PGEPHIS  notified by Punjab Government that No reimbursement will  be available  to employee/Pensioner in Punjab, Chandigarh  and Panchkula where cashless treatment is available. Reimbursement can be taken for medical treatment  taken in any other state in India in exceptional circumstances. 
14.            OP no.4 filed in reply that complainant never disclosed that he was  beneficiary of PGEPHIS.  He never showed his MDID card while getting treatment from hospital.
15.           OP no.5 filed in reply that  complainant, got retired  as Assistant from this Department  on 31.1.1998. Since the matter pertains to the period between 1.1.2016 to 31.12.2016, when PGEPHIS  was inforce and scheme was implemented by OPs no.1 to 3 .
16.                 From the perusal of the record on the file  We find  that  complainant  ( now deceased)  who was then 78 years old had lodged  his claim with  oriental Insurance Company being Punjab Govt. Pensioner. The cashless Medi claim is to be reimbursed by Oriental Insurance Company  i.e OP no.2  assisted by OP 3 i.e TPA . OP no.4 stated  in reply that  complainant did not disclose that he is beneficiary of PGEPHIS. It is admitted by OPs no.2 and 3  themselves that Hospital authorities i.e OP 4 did not  send them documents for  cashless treatment  .  OP no.2 repudiated his claim  thrice on ground that  no  reimbursement will be  available for the treatment  in Punjab, Chandigarh, Panchkula where cashless  treatment is available   and once  on ground that requested claim  documents  not received.
17.  

In view of ourabove discussion, thepresent complaint is partly allowed.The claim is to besettled by insurer i.e OP no.2notby claim processing agencyi.e OP no.3.This is so because liability of reimbursing the incurred medicalexpenses remains of the insurer and not of the agentwho is just to process the claimat theasking of theinsurer . OP no.2 i.e Oriental Insurance Company is directed to reimburse the amountpaid by the complainant toMax Hospital , Phase6, Mohali for treatment as per the bills producedsubject to the terms and conditions of policy. The Op no.2 is also directed to payRs.25,000/- ascompensationfor mental and physicalharassmentand Rs.10,000/- as litigation expenses.OP no.4 is directed to compensatecomplainant’s Legal heir for Rs.20,000/- for misguiding thecommission by lying that complainant did not disclose that he was beneficiary of PGEPHIS. The compliance of this order be made by the OPs within a period 45 days from the date of receipt of certified copy of this order. Thereafter it shall be liable foran interest @ 6% P.A on the amount from the date of filing complaint, failing which the complainant shall be entitled to recover the above said amount through legal process. The complaint could not be decided within a specific period as provided by the statute due to rush of work and large pendency. Copy of this order be sent to the complainant and the OPs as per rules. File be consigned to record room.

 

Announced 12 December 2022

                                                           

                                                                      (Pushvinder Singh)

                                                                              President

                                                                    

    

                                                                                   (Shivani Bhargava)

                                                                              Member

 

                                                                                    (Sh. Manjeet Singh Bhinder )

                                                                                             Member