The complainant Dr. Devinder Pal Bansal (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against Punjab Health System Corporation and others (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that the complainant is Retd. Medical Officer and got retired from C.H.C Bhagta Bhaika Disst Bathinda w.e.f 29 02 2016. On 30-06-2016, suddenly the complainant had felt severe chest pain and got admitted at Max Health Care Super Specialty Hospital Bathinda for treatment. After due care and diagnosis done by the doctor of said hospital, they concluded the diagnosis and told the family of complainant that the complainant is suffering from Major Heart Attack i.e Chronic Heart Disease and immediately stent had been placed in the body of complainant and after that, his treatment started under the care of Dr.Sharad Gupta, Global Healthcare Super Specialty Hospital Bathinda.
It is alleged that the complainant was covered under the Government Employee and Pensioners Heath Insurance Scheme(PGEPHIS) vide ID Card No. MDI5-09417430299 as per policy period from 01-1-2016 to 31-12-2016. The complainant was at bed rest approximately for one year as he was suffering from LVF too i.e Left Ventricular Failure too. Accordingly, the complainant had submitted his medical reimbursement Bills of Rs.16982.24 with Civil Surgeon Office Bathinda. The Civil Surgeon Office Bathinda had asked the complainant to submit the said bills with the office of opposite parties through proper channel for the purpose of reimbursement as per the policy and scheme of the Govt. The complainant had sent the said original bills for the period of 02-08-2016 to 18-12-2016 alongwith requisite request application to the opposite party No.1 office vide application dated 13-09-2017 via On Dot Courier and furnished the requisite formalities/documents including the entire treatment record and bills etc. The complainant alleged that he repeatedly approached the opposite parties and requested for payment aforesaid claim, but to no effect and rather the opposite parties kept on putting the matter off under one or the other false pretext.
The complainant alleged that even complainant had moved one RTI application to the opposite party No.1 to know the status of his said claim vide letter dated 18-01-2018, but no reply had been given to him for the same. Despite the repeated requests and lapse of considerable period, no action had been taken so far. The opposite parties kept the claim of complainant pending for more than 2 years and same is pending till date without any cause. In the meantime, wife of the Complainant had fallen serious ill in January 2019 and got admitted in Adesh Medical University Bathinda because of Left Side Paralysis Attack and Brain Stroke and she is also under treatment of Dr.Abhishek Bathinda as same is Chronic Disease. Even complainant got served legal notice dated 03-12-2019 upon the opposite parties and demanded his rights, but to no effect. Due to the aforesaid act on the part of the opposite parties, the complainant has suffered from the grave mental tension, agony, harassment and financial loss for which he claims compensation to the tune of Rs. 50,000/-.
On this backdrop of facts, the complainant has prayed for directions to the opposite parties to reimburse the entire amount of claim of Rs.16,982.28 with interest 12% p.a. w.e.f 13-9-2017 till its realization and Rs.50,000/- as compensation in addition to Rs.20,000/- as litigation expenses.
Upon notice, opposite party No. 1 filed written version. Learned cunsel for opposite parties No. 1 & 4 suffered statement dated 3-1-2022 that written version filed on behalf of opposite party No 1 may be read written version on behalf of opposite party No. 4.
Thus opposite parties No.1 & 4 contested the complaint by filing written reply raising legal objections that the opposite parties No. 1 & 4 have got no relationship with the present claim. That the application is not maintainable in its present form. The complainant does not fall under the definition of a consumer as he has not paid any premium for availing facility under the scheme. The complainant has no cause of action and locus standi to file the present claim and that this Commission has no jurisdiction to entertain and decide the present claim.
On merits, opposite party No.1 & 4 have pleaded that Punjab Government Employees and Pensioners Health Insurance Scheme (PGEPHIS) was a cashless health policy scheme for employees and pensioners of Punjab Government. The state government had issued a notification dated 21.09.2016 vide which District Grievance Redressal Committee (DGRC) were constituted at District level to settle the disputes between all the stake holders. The complainant has failed to make any representation before District Grievance Redressal Committee (DGRC).
Upon notice, opposite parties No. 2 & 3 also appeared through counsel and contested the complaint by filing separate written reply raising legal objections that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under C.P. Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed material facts and documents from this Commission as well as opposite parties therefore, the complainant is not entitled to any relief.
It has been pleaded that the complainant has concealed the fact that the complainant has violated the terms and conditions of the insurance and scheme. The treatment availed by the beneficiary under the scheme is on reimbursement basis i.e. subject to submission of claim to the TPA within 30 days from the date of discharge from the hospital. However, in this case the complainant got admission on 02.08.2016 and was discharged on 18.12.2016 whereas the claim file was submitted on 20.09.2017, i.e. after more than 9 months approximately, therefore, the claim was submitted for reimbursement in violation of terms and conditions of the scheme, hence no amount is payable.
It has been pleaded that Punjab Government has entered into an agreement to provide cashless medical facility to its employees including pensioners under PGEPHIS (Punjab Government Employees and Pensioners Health Insurance Scheme) regarding which Punjab Government has issued notification to its employees also and Punjab Government along with Insurance Company and TPA i.e. opposite party No.2 has empanelled various hospitals to provide cashless treatment to employees of State Government and rates of each and every treatment/ operation have been finalized between empanelled hospital and TPA with consent of Punjab Government. The Insurance Company is only liable to pay the same to the employees of the Punjab Government as per aforesaid agreement/ insurance policy. Any treatment not provided in the agreement or mentioned in the exclusions is not payable at all.
It has been further pleaded that the Punjab Govt. floated a tender notice called Punjab Government Employees & Pensioners Health Insurance Scheme, Department of Health & Family Welfare, PHSC Government of Punjab which having specified conditions and the tender of Punjab Government was accepted by the Insurance Company which was effective from 1.1.2016 to 31.12.2016. As per clause 24 of the tender this Commision has got no jurisdiction to try and decide the present application as there is specific provision regarding dispute between beneficiary and Health Care Provider/Care Provider and the TPA/Insurance Company shall be referred to District Level Grievance Redressal Committee. Therefore, as per condition of the tender, the present complaint is not maintainable under law and hence liable to be dismissed.
Further legal objections are that the complainant has no locus standi or cause of action to file the present complaint and that the complaint is not maintainable in the present form and is liable to be dismissed.
On merits, the opposite parties 2 & 3 have reiterated their version as pleaded in legal objections and detailed above. After controverting all the averments of the complainant, the opposite parties No. 2 & 3 prayed for dismissal of complaint.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 22.1.2020 (Ex. C-1) and documents (Ex.C-2 to Ex.C-9).
In order to rebut the evidence of complainant, the opposite parties No.2 & 3 have tendered into evidence affidavit of Ashwani Kumar Dated 13.10.2020 (Ex. OP-2/3) and documents (Ex.OP-3/1 & Ex.OP-3/2 or Ex.OP-3/4).
Despite providing various opportunities, opposite parties No. 1 & 4 failed to produce any evidence. As such, evidence of opposite parties No. 1 & 4 was closed by order dated 7-7-2022.
The learned counsel for the complainant has argued that complainant is a government retired medical officer and on 30-6-2016, complainant felt severe chest pain and was admitted at Max Health Care Super Speciality Hospital, Bathinda and thereafter remained under treatment of Dr. Sharad Gupta, Global Health Care Super Speciality Hospital, Bathinda. It is further argued that complainant being government employee and pensioner was covered under PGEPHIS as per policy for the period from 1-1-2016 to 31-12-2016 Ex. C-3. Since the complainant was at bed rest, as such, later on complainant had submitted his medical bills of Rs. 16,982.24 for reimbursement with opposite party No. 4. On being contacted, the opposite party had demanded original bills which were supplied alongwith application dated 13-9-2017 through courier vide Ex. C-5 & Ex. C-6. Inspite of being repeatedly approached, opposite parties have not reimbursed the claim amount of Rs. 16,982.24 to complainant, which amounts to deficiency in service.
Learned counsel for complainant has further argued that the opposite parties cannot refuse to pay amount in dispute in respect of claim of complainant on the ground of alleged terms and conditions, which were never supplied or explained to complainant at the time of inception of insurance policy. In this regard, he placed reliance on citations :
(i) 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modem Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon'ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims.
(ii) 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein Hon'ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any Policy. The Insurance Companies in such cases rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining the policy.
(iii) 2012(1) RCR (Civil) 901 titled as IFFCO TOKYO General Insurance Company Ltd Vs Permanent Lok Adalat (Public Utility Services), Gurgaon and others, wherein Hon'ble Punjab and Haryana High Court held that Contract Act, 1872 - Insurance Act, 1938-contract among unequal Validity Mediclaim Policy -Exclusion Clause Pre Existing Disease - Exclusion Clause is standard form of contracts when bargaining power of the party is unequal and consumer has no real freedom to contract-Courts can strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. So deficiency stand proved and the opposite party Nos. 1 & 2 have incorrectly refused the payment of the claim.
On the other hand, learned counsel for opposite parties No. 1 & 4 has argued that as per copy of notification Ex. OP-3/2 and Salient Features of the Policy Ex. OP-1/1, the complainant was required to approach District Grievance Redressal Committee and since the complainant has not approached the said committee, as such, complaint is liable to be dismissed.
The learned counsel for opposite parties No. 2 & 3 has argued that treatment availed by the complainant under the scheme is on reimbursement basis subject to submission of claim to the TPA within 30 days from the date of discharge from the hospital but in the present case, complainant was admittedly discharged on 18-12-2016 and he submitted his claim file on 20-9-2017 after delay of nine months, as such, claim is not payable and has prayed for dismissal of complaint.
We have heard learned counsel for the parties and gone through the case law referred by learned counsel for the complainant and the file carefully.
It is admitted fact that complainant was government employee and was fully covered for cashless treatment under PGEPHIS scheme of the government. It is further admitted fact that opposite party No. 1 had got its employees insured with opposite parties No. 2 & 3 for cashless treatment under insurance.
The only objection of opposite parties No. 1 & 4 is that complainant had not approached District Grievance Redressal Committee. However, this Commission is of the view that since the claim of the complainant was denied by the opposite parties without any reasonable ground, as such, it is constitutional right of the complainant to approach appropriate court/Forum for redressal of his grievances.
The objection of opposite parties No. 2 & 3 is only regarding delay of nine months in submission of claim file. However, this Commission is of the view that complainant has specifically mentioned in para No. 5 of the complaint that complainant was at bed rest approximately for one year as he was suffering from LVF too and as such, became late in submission of claim file. This Commission is of the view that opposite parties have not in any manner challenged the genuineness of the claim and only were interested in finding one excuse or the other to deny the claim. Moreover, it is not the case of the opposite parties that complainant was not entitled to reimbursement of the claim amount. Further more, the Insurance Company was engaged by Punjab Government only with aim to provide benefit of medical reimbursement on its behalf. The State of Punjab was under obligation to provide medical reimbursement to its employees/pensioners.
Hon'ble State Commission, Punjab, Chandigarh in First Appeal No. 262 of 2017 decided on 06-11-2017 case titled The Oriental Insurance Co. Ltd., Vs. Raj Karan Singh and others has observed that :-
“The complainant is covered under the policy taken by the Punjab Government for benefits of its government employees and pensioners. The complainant suffered from ailment and was treated at OP No.4 hospital, as is proved on the record by his affidavit as well as record of OP No. 4/Fortis Hospital, as referred to above. Even there is no specific denial to this treatment received by the complainant from OP No. 4/hospital. We are not obivious of this fact that insurance company and TPA appointed as nodal agency as well as hospitals are frequently violating the cashless policy to derprive the employees of their entitlement of cashless treament. Right of good health is ones fundamental right enshrined in Airticle 21 of Constitution of India. The innocent people, who suffered from ailments and are duly covered under the cashless policies are denied the benefits on sheer technical matters and are being harassed. If complainant is covered under the cashless insurance policy issued by the Punjab Government, then the claim should have been allowed without any hitch on the part of the OPs. This dual function of the TPA and hospital is to take up the matter and to settle it immediately without any detriment and harassment to the insured. The complainant has been issued cashless insurance card by OP No. 3. Nodal Officer has also failed to supervise the matter in this regard. The purpose of cashless insurance should be hassle-free service, so that the aggrieved parties should not suffer at all. The complainant being beneficiary is covered upto Rs.3.00 Lac amount for ailments under the cashless policy. It is really pathetic that complainant has to give money for his treatment from his own pocket, due to sheer deficient act of other OPs.”
In First Appeal No. 625 of 2017 decided on 20-11-2017 case titled Oriental Insurance Co. Ltd., Vs. Puran Chand & Ors, it has been held :
“The claim documents submitted by complainant were not honoured by opposite party No. 1 who took over the responsibility on the basis of agreement entered into with Punjab Government Cashless Scheme for Reimbursement of the treatment expenses of retired employees and their dependants after taking premium from Punjab Government on behalf of them. The claim cannot be denied to complainant on this hyper-technical matters only, when it is fundamental right of the complainant enshrined in Article 21 of the Constitution of India for reimbursement for the treatment of his health from the State Government. OP No. 1 has taken the premium from State Government and it cannot deny the claim to complainant being beneficiary of this scheme on this technical point.
It has been further observed that :-
“ It is the duty of the State Government, which has been delegated to opposite party No. 1 by giving premium to take this responsibility of this reimbursement of the claim to its retired employees and serving employees.”
Thus, from the above discussion and evidence on record, the complainant and fully proved deficiency in service on the part of the opposite parties and refusal to pay the claim by the opposite parties amounts to deficiency in service.
Now the question is regarding amount for which the complainant is entitled. Although the complainant has made prayer for reimbursement of the entire amount of Rs. 16,982.28. However, in case of treatment of government employees from private hospitals, reimbursement is under policy and regulations of the government.
Accordingly, complainant is partly allowed and opposite parties No. 2 & 3 are directed to reimburse the expenditure made by complainant on his treatment against claim amount of Rs. 16,982.24 as per respective hospital rate in accordance with PGIMER, rate Chandigarh, mentioned in Ex. OP-3/1. The complainant is also held entitled to receive interest on the reimbursement amount @9% p.a. from the date of filing of complaint till realization. The complainant is also held entitled to compensation of Rs. 5,000/- on account of mental tension and harassment and cost of litigation.
The compliance of this order be made by the opposite parties No. 2 & 3 within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced:-
21-6-2023
- (Lalit Mohan Dogra)
President
(Shivdev Singh)
Member
