Punjab

StateCommission

A/262/2017

Oriental Insurance Company Ltd. - Complainant(s)

Versus

Raj Karan Singh - Opp.Party(s)

Jaswinder Kaur

06 Nov 2017

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION,     PUNJAB

          SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

 

                   First Appeal No.262 of 2017

 

 

                                                          Date of Institution: 17.04.2017

                                                          Order Reserved on : 03.11.2017    

                                                      Date of Decision  : 06.11.2017

 

The Oriental Insurance Company Limited Madan Mohan Malvia Road, Amritsar through its Branch Manager, through its authorized signatory Sh. B.S. Ahuja, Deputy Manager, Regional Office, Surendra Building, 109-111, Sector 17-D, Chandigarh.

 

                                                                Appellant/Opposite party no.5         

                   Versus

 

1.      Raj Karan Singh aged 69 years son of Sh. Didar Singh,           resident of 40, Lane No. 5, Green City, Amritsar.

 

                                                               Respondent no.1/Complainant

 

2.      State of Punjab, through its Deputy Commissioner, Amritsar.

 

3.      The Punjab Health Systems Corporation Limited, State Institute of Health and Family Welfare Complex, Near Civil      Hospital, Phase VI Mohali SAS Nagar, Punjab through its           Chairman/Managing Director/Principal Officer.

 

 

                       Respondents no.2 and 3/Opposite parties no.1 and 3

 

4.      Fortis Escorts Hospital, Verka-Majitha Bye Pass, Amritsar        through Medical Director.

 

5.      MD India Healthcare Services (TPA) Pvt. Ltd., 38-D, Industrial          Area Phase 1, Mohali Punjab through Principal Officer/         Chairman/Managing Director.

 

                                  Respondents no.4 &5/Opposite parties no.4&2

 

 

First Appeal against order dated 01.03.2017 passed by the District Consumer Disputes Redressal Forum,  Amritsar

………………………………………………………………………..

 

Quorum:-

 

          Shri J. S. Klar, Presiding Judicial Member.

            Smt.Surinder Pal Kaur, Member

 

Present:-

 

          For appellant                   : Sh.Satpal Dhamija, Advocate

          For respondent no.1      : Sh.Sukhandeep Singh, Advocate

          For respondents no.2&5  : Exparte

          For respondent no.3        : Sh.P.I.P Singh, Advocate

          For respondent no.4      : Sh. Munish Kapila, Advocate.

 

J.S KLAR, PRESIDING JUDICIAL MEMBER :-

         

          Challenge in this appeal by the appellant is to order dated 01.03.2017 of District Consumer Disputes Redressal Forum, Amritsar, directing the appellant and respondent no.5 of this appeal to make payment of the insurance claim amount of Rs.2,94,848/- to respondent no.1/Raj Karan Singh of this appeal, besides payment of Rs.5000/- as compensation and Rs.2000/- as costs of litigation. Respondent no.1 is complainant and respondent nos.2 and 3 are opposite parties nos.1 and 3 in the complaint and respondents no.4 and 5 are opposite parties nos.2 and 4 in the complaint before District Forum. Appellant of this appeal is opposite party no.5 therein and  they be referred as such, hereinafter for the sake of convenience.

2.      The complainant has filed complaint U/s 12 of Consumer Protection Act, 1986 (in short, "the Act") against OPs on the averments that he is a pensioner of Government of Punjab and retired as Inspector Food and Supplies Department on 30.06.2006. OP no.1/Government of Punjab had formulated 'The Punjab Government Employees and Pensioners Health Insurance Scheme' for  cashless insurance of Rs.3 lac to pensioners/retired employee. OP no.2 has been appointed, as Third Party Administrator (TPA) and complainant has been issued insurance card with ID No. "MDID15-09417430234 by the OPs. OP no.3 was appointed, as nodal agency to implement the scheme. The complainant took treatment from OP no.4, which is empanelled hospital under the above insurance scheme. OP no.5 is insurance company, which granted insurance cover to the beneficiaries under policy no. 231102/48/2016/769 issued by it. The complainant had developed shortness of breath and chest pain and was hospitalized in OP no.4 Hospital on 20.06.2016 and discharged therefrom on 24.06.2016. He was diagnosed as '2 AV Block Pulmonary Koch's, Type II DM, Hypertension'. He disclosed that he was pensioner of Government of Punjab and was, thus, covered under the scheme with above referred card issued to him. Surgery was performed by OP no.4 and  pacemaker-double chamber (P) was implanted upon him. The hospital raised bill of Rs.2,94,848/- from him, despite the fact that he was covered under Cashless Insurance Scheme, as referred to above. OP no.4 had not provided cashless insurance, as per scheme and complainant was forced to pay cash amount of the bill. OP no.4 forwarded the insurance claim to MD India Healthcare /OP no.2 along with all the necessary and required documents for settlement of the  claim, which was acknowledged by OP no.2 and claim ID No. MD10030742 was given to him. The complainant received SMS from OP no.2 on 22.06.2016 at 6.23 PM on his phone no. 09417430234 for processing his claim and additional documents required from hospital for his cashless request by OP no.2 on 23.06.2016 and 24.06.2016. The complainant got confirmed from OP no.4/Hospital that all documents required by OP no.2 had been sent by the hospital. The complainant called on toll free no.1800-233-5557 of OP no.2, but no response was given thereto. He also contacted District Coordinator of OP no.3 Gurmit Singh by visiting his office at Mohali, but of no use. The complainant has, thus, alleged deficiency in service on the part of OPs and prayed that OPs be directed to pay insurance claim of Rs.2,94,848/- incurred by him on his treatment with interest @ 12% p.a and Rs.50,000/- as compensation for mental harassment.

3.      Upon notice, OP no.1 appeared and filed its separate written reply and contested the complaint of the complainant. It was averred that OP no.1 is a government sector and as per the Consumer Protection Act, no complaint is maintainable against the government sector, hence the present complaint is liable to be dismissed. OP no.1 prayed for dismissal of the  complaint.

4.      OP no.2 was set exparte before District Forum vide order dated 2010.2016.

5.      OP no.3 appeared and filed its separate written reply and contested the complaint of the complainant. It was averred that the Government of Punjab, vide notification dated 21.09.2016 has constituted Grievance Committee at District Level as well as State Level Committee to redress grievance of the beneficiaries, service provider hospitals, insurance company and other stake holders and as per this notification, the decision of the State Grievances Redressal Committee is final and binding on the stake holders and once he has not availed of this legal remedy, the present complaint is not maintainable and hence deserves to be dismissed. Rest of the averments were denied by OP no.3 and it prayed for dismissal of the complaint.

6.      OP no.4 appeared and filed its separate written reply by raising preliminary objections that complaint is not maintainable. The complaint is gross abuse of process of law. The complaint is bad for mis-joinder of the  parties. No cause of action accrued to complainant to file the  present complaint. On merits, it was averred that complainant was admitted in the hospital of OP no.4 on 20.06.2016, as he complained of shortness of breath on rest, palpitation and chest pain since December 2015 and was discharged on 24.06.2016 after implantation of Pacemaker-Double Chamber (P).  All documents for claim of cashless insurance along with final bill of Rs.2,94,848/- were forwarded to MD Insurance India for settlement of insurance claim of complainant. The claim is under process, as admitted by complainant himself and he has received SMS from MD India in this regard. The hospital has nothing to do as far as approval of the cashless claim is concerned, because there is no agreement of insurance between complainant and OP no.4,         fromwhere the treatment has been taken by him. The complainant at the time of admission has signed an undertaking that in case of non-payment of hospital bill by TPA or insurer, he would clear the total medical bill before discharge. Rest of the averments were denied by OP no.4 and it prayed for dismissal of the complaint.       

7.      OP no.5 appeared and filed its separate written reply and contested the complaint of the complainant. It was averred that complainant is not covered under the definition of consumer to file the present complaint and as such, present complaint is liable to be dismissed. Medical policies are governed and followed by the independent TPA appointed under the  IRDA and in the present case, OP no.2 had been appointed, as Third Party Administrator to deal with the claims. The entire correspondence regarding the matter in question was exchanged between the complainant and TPA and Fortis Hosptal i.e. OP no.4. As per comments of TPA, it has been stated that the patient got admitted in Fortis Hospital and was referred to implantation of Pacemaker and subsequently request for authorization was sent to TPA against CCN No. 30742. Subsequently, said TPA referred the case to Freedom Software Authorities for their final opinion over it. Freedom Software raised on CCN No. 30742 and consequently an ADR was raised by TPA to the said hospital against which erring hospital had not replied and charged full amount from the said patient. In the same remarks, the said TPA further confirmed that the physical claim file of the said case has not been received by them either through hospital or through the patient. The aforesaid details have been fetched by the said TPA through online system only. The complainant as well as concerned hospital authorities have failed to supply the requisite documents as well as failed to give reply to the query raised by said TPA. Rest of the averments were denied by OP no.5 and it prayed for dismissal of the complaint.

8.      The complainant tendered in evidence his affidavit Ex.C-1 along with copies of documents Ex.C-2 to Ex.C-12. As against it; OP  No.3 tendered in evidence affidavit of Dr. Rajinder Singh Arora Deputy Medical Commissioner, PHSC Amritsar Ex.OP-3/1 along with copies of documents Ex.OP-3/1 to Ex.OP-3/4. OP no.4 tendered in evidence affidavit of Dr.Pinak Moudgil Facility Director of Fortis Escorts Hospital Amaritsar Ex.OP-4/1 along with copies of documents Ex.OP-4/2 to Ex.OP-4/9. OP No.5 tendered in evidence affidavit of Mr. R.K. Sharma Divisional Manager Ex.OP-5/1, affidavit of Ms. Geeta Bhardwaj General Manager Operations MD India Health Ins. TPA Ex.OP-5/2 along with copies of documents Ex.OP-5/3 to Ex.OP-5/8 and closed the evidence. On conclusion of evidence and arguments, the District Forum Amritsar accepted the complaint of the complainant by virtue of order dated 01.03.2017. Dissatisfied with the order of the District Forum Amritsar, opposite party no.5 now appellant, carried this appeal against the same.

9.      We have heard learned counsel for the parties at considerable length and have also examined the record of the case.  Pleadings of both the parties have been carefully evaluated by us on the record. Evidence on the record has also appraised by us. The complainant tendered his affidavit Ex.C-1 on the record in support of his case. Ex.C-2 is insurance card issued by OP no.5 to complainant as pensioner Ex.C-3 is cashless policy. Discharge summary of the complainant issued by OP no.4 is Ex.C-4. Ex.C-5 is test reports of the complainant/insured. Ex.C-6 is the bill raised by OP no.4/Hospital amounting to Rs.2,94,848/- for treatment cost of the complainant. Ex.C-7 has proved that OP no.4 received Rs.1,50,000/- from complainant and Ex.C-8 has further proved that OP no.4/Hospital received additional amount of Rs. 1,44,848/- from the complainant. The entire money has been paid by the complainant from his own pocket, as is evident by documents Ex.C-7 and Ex.C-8 on the file. Ex.C-9 is the claim form for Punjab Government Employee and Pensioner Health Insurance Scheme and Ex.C-10 is clinical report of the  complainant. The complainant served legal notice Ex.C-11 upon OPs. Ex.C-12 is certificate issued by District Controller Food & Supply, Amritsar regarding pension PPO no. 200677 Pb of complainant. The OPs also led evidence consisting of affidavit of Dr. Rajinder Singh Arora Deputy Medical Commissioner PHSC, Amritsar Ex.OP-3/1. He stated that Punjab Health System Corporation is not accountable under Section 15(1) of the Act. The complaint is not maintainable against it. The complainant has not approached either  District Grievance Redressal Committee or State Grievance Redressed Committee and hence no deficiency in service or imperfection is discernible on the part of the OPs in this case. Punjab Government Gazette is Ex.OP-3/2 placed on the record. Ex.OP-3/3 is notification issued by Punjab Government on 21.09.2016 constituting the Grievances Cell. Ex.OP-3/4 is the notification issued by the Punjab Government constitution of Grievance Redressal Committee at State level. Ex.OP-3/5 is notification no.21/28/12-5HB5/263 dated 20.10.2015 of Punjab Government for introducing a cashless Health Insurance Scheme for Punjab Government employees and retires/pensioners. Affidavit of Dr. Pinak Moudgil Director of Fortis Escorts Hospital Amritsar is Ex.OP-4/1. He deposed about illness of the complainant and treatment provided to him. He further stated that medi-claim cashless policy is an agreement of complainant with OPs no.2 and 3 and terms and conditions whatever  are known to the parties. OP no.4 is not a part of agreement. He denied any deficiency in service on its part. The general consent given by the complainant for treatment is Ex.OP-4/2. Similarly, affidavit of R.K Sharma Divisional Manager Oriental Insurance Co. Ltd is Ex.OP-5/1 on the record. He stated that certain queries were raised from the hospital to which no reply was given by the hospital and requisite documents not submitted by the complainant to the said TPA. The affidavit of Ms. Geeta Bhardwaj General Manager Operations is Ex.OP-5/2 on the record. She stated that in the absence of any reply received from the concerned hospital, the matter was referred to the panel of doctors, who opined that in the absence of uploading of the ECG by the concerned hospital, PPI is not recommendable. The matter was referred to Freedom Software Authorities for their opinion over it and objection was raised that given ECG has been reported by the Cardiologist as AF with controlled ventricular rate in his note and patient has been described cardivas on the same day.  She stated that query was raised from the concerned hospital authorities to upload the ECG Report, but to no effect. Other documents placed on the record by OPs have been considered by us.

10.    The submission of counsel for appellant is that complainant is not a 'consumer' of OP no.5 and as such, the order of District Forum is erroneous. We find no substance in this submission raised by counsel for the appellant. The Punjab Government took the insurance policy for its employees and for the retirees. The employees and retirees have been rendering or rendered the services to Punjab Government, which is consideration and government employees are the beneficiaries of this policy. Consequently, they are covered under the definition of 'consumer' under Section 2(1)(d) of the Consumer Protection Act being beneficiaries of this policy with express approval of Punjab Government for availing this service. This contention of counsel for the appellant is, thus, repelled on this point. The next submission of counsel for the appellant  is that Grievance Cell has been constituted by the Government of Punjab by issuing notification. The complainant has not knocked the door of Grievance Cell as constituted by State Government firstly and hence complaint is not maintainable. We find no force in this submission raised by counsel for appellant. At the first blush, it is clear that Section 3 of the Consumer Protection Act gives an additional remedy to the Consumer Forum and it is the option of the party either to approach Grievance Cell or the Consumer Forum. The remedy of the  complainant cannot be curtailed by means of notification of Punjab Government in view of statutory provision of Section 3 of the CPA, which is  special enactment for the protection of consumers by Parliament, The contention of the appellant is, thus, rejected.

11.    The next submission of counsel for the appellant is that the hospital is at fault, because it has not uploaded the ECG and has not supplied the documents. We have gone through the evidence on the record. 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 oblivious of this fact that insurance company and TPA appointed as nodal agency as well as hospitals are frequently violating the cashless policy to deprive the employees of their entitlement of cashless treatment. Right of good health is ones fundamental right enshrined in Article 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 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 up to Rs.3 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.

12.    In this view of the matter, we find that District Forum has taken correct view of the matter in this case. The order of the District Forum does not suffer from any illegality or material infirmity and is affirmed in this appeal. The appeal is without merits and is hereby dismissed.

13.    The appellant had deposited the amount of Rs.25,000/-with this Commission at the time of filing of the appeal and further deposited Rs.1,94,187/-. Both these amounts with interest, which accrued thereon, if any, be remitted by the registry to respondent no.1/complainant of this appeal by way of a crossed cheque / demand draft   after the expiry of 45 days. Remaining amount as per order of the District Forum, if any due, shall be paid by the appellants/OPs to the complainant with 45 days from receipt of copy of this order.

14.    Arguments in this appeal were heard on 03.11.2017 and the order was reserved. Certified copies of the order be communicated to the parties as per rules.

15.    The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                                          (J. S. KLAR)

                                                          PRESIDING JUDICIAL MEMBER

                    

 

                                                               (SURINDER PAL KAUR)

                                                                               MEMBER

November, 6  2017                                                             

(ravi)