Punjab Health Systems Corporation V/S Ramesh Kumar Behal
Ramesh Kumar Behal filed a consumer case on 12 Dec 2022 against Punjab Health Systems Corporation in the Fatehgarh Sahib Consumer Court. The case no is RBT/CC/401/2018 and the judgment uploaded on 15 Mar 2023.
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.401/2018Complaint 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
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. .
The Oriental Insurance Company , through its Authorised Representative, Oriental House, A-25/27, Asaf Ali Road, New Delhi.
MD India Healthcare Services Pvt. Ltd., through its Authorised Representative, Mohali Tower, First Floor, F-539, Phase 8-B, Industrial Area, Mohali.
Max Super Speciality Hospital, through its Managing Director, Phase-6, Near Civil Hospital, Mohali.
..………....... Opposite Parties
Department of Industries and Commerce Punjab, through its Director, having its office at Bridge Market, Sector 17-D, Chandigarh.
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 .
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
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.
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.
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.
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
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.
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.
We have perused the complaint and heard counsel for parties and gone through the file.
Ld. Counsels for the parties have reiterated their stand as taken in their respective pleadings and as detailed above.
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
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.
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.
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.
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.
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 .
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.
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
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