| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.133 of 07-05-2018 Decided on 18-12-2019 1.Dr.Rajesh Jindal Director of Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda. 2.Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda, thorugh its Director Dr.Rajesh Jindal. ........Complainants Versus 1.Reliance General Insurance Co. Ltd., SCO 147/148, 2nd Floor, Madhya Marg, Sector 9C, Chandigarh, 160009, through its Manager/Incharge. 2.MD India Healthcare Services (TPA) Pvt. Ltd., 539, Mohali Tower Building, Phase-8B, Mohali-160056, through its Manager/Regional Incharge. 3.Bhai Ghanhya Sewa Scheme Trust (BGSSS), Sector 34-A, Co-operative Bank Building, Ground Floor, Chandigarh-160022, through its Chief Executive Officer. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Smt.Manisha, Member. Present:- For the complainants: Sh.Naresh Garg, Advocate. For opposite party Nos.1 & 2: Sh.Vinod Garg, Advocate. For opposite party No.3: Sh.K.S Dabrikhana, Advocate. ORDER M.P Singh Pahwa, President This complaint has been filed by Dr.Rajesh Jindal and others complainants against Reliance General Insurance Co. Ltd. and others opposite parties under Section 12 of the Consumer Protection Act, 1986 (here-in-after referred to as 'Act'). Briefly stated, the case of the complainants is that Dr.Rajesh Jindal is practicing as D.M Cardiologist under the name and style of Jindal Heart Institution & Infertility Centre, Power House Road, Bathinda. He is owner of hospital and he is practising as Heart Specialist for his livelihood. Opposite party No.3 lodged a scheme in the Punjab known as Bhai Kanhiya Sehat Sewa Scheme (BGSSS) in which it provided cashless insurance and treatment to the general public of Punjab. The complainants have purchased insurance from opposite party No.1 and claims were settled through opposite party No.2 as TPA. Under this scheme, opposite parties also nominated and recognized the hospitals and doctors in the Punjab from where the patient can take treatment under BGSSS and treatment payment be reimbursed to the hospitals/doctors directly. For this, opposite parties also took a fixed amount from the hospitals/doctors annually. The complainants are duly authorized by opposite parties. Opposite parties took Rs.10,000/- from the complainants and recognized them under BGSSS scheme. It is alleged that opposite party No.2 is Third Party Administrator (TPA) on behalf of opposite party Nos.1 and 3. Opposite party Nos.1 and 3 also gave clearance to the complainants time to time for the treatment of admitted patients and after clearance, the complainants treated the concerned patients and submitted bills alongwith claim forms and discharge report etc., to opposite party No.2 for reimbursement of the claim under cashless hospitalization scheme. It is further alleged that under the scheme, the complainants treated Gurjant Singh S/o Gurnam Singh admitted on 31.3.2017 and he was discharged on 4.4.2017. Gurjant Singh is duly insured under BGSSS Scheme vide MD India with opposite parties. The claim of Rs.65,000/- is still pending with opposite parties. Cost of stent to the tune of Rs.29,600/- is also payable as per bill under agreement, but opposite parties did not pay the cost of stent. In this way, total amount of Rs.94,600/- is still pending with opposite parties. They treated Mejor Singh S/o Gurdev Singh admitted on 13.4.2017 and he was discharged on 17.4.2017. Mejor Singh is duly insured under BGSSS Scheme vide MD India with opposite parties. Cost of stent to the tune of Rs.31,689/- is also payable as per bill under agreement, but opposite parties did not pay the cost of stent. Opposite parties also paid less amount of Rs.15,000/- from the authorization i.e. Authorized amount Rs.82,850/-. Amount paid Rs.67,850/-. In this way, they paid less Rs.15,000/- from Pre Authorization and Rs.31,689/- for the stent cost. Total Rs.46,689/- is still pending with opposite parties. Opposite parties duly authorized the claims of the complainants to give the permission for treatment of patients for Rs.1,41,289/-. It is further alleged that the complainants many times approached the official of opposite parties and sent e-mails, but to no effect. On this backdrop of facts, the complainants have alleged deficiency in service on the part of the opposite parties. They have claimed Rs.1 lakh as compensation and Rs.50,000/- as cost of litigation in addition to reimbursement of insurance amont i.e. Rs.1,41,289/- with interest @ 18% per annum from the date of admission till payment. Hence, this complaint. Upon notice, the opposite parties appeared through their counsel and contested the complaint by filing their written version. opposite party Nos.1 and 2 in their joint written version raised the legal objections that the complainants are not 'consumers' of insurance company. The complainant No.1 is the owner of complainant No.2. Both the complainants deal in commercial transaction of treatment of people by charging fee in a form of money. It establishes that they are themselves service providers for offering medical services to the people. In fact, the services of hospital were hired by opposite party Nos.1 and 2 by signing MOU for taking cashless medical services in accordance with certain terms and conditions of agreement. It establishes that complainants are not 'consumers' of insurance company. The complaint is liable to be dismissed. The complaint is not maintainable in absence of any consideration of amount, which is necessary transaction under 'Act'. The complainants have themselves alleged in contents of complaint that an amount of Rs.10,000/- was paid to Bhai Ghanhya Sehat Sewa Scheme towards registration of fee of scheme, but they did not pay any amount for consideration to the insurance company. The registration fee of scheme cannot be termed as consideration under 'Act'. It was a business transaction of hospital to earn more profit by offering medical services to beneficiary for consideration. Further legal objections are that the complainants are themselves service providers. Opposite party Nos.1 and 2 have already paid an amount of Rs.57,28,597/- to the hospital for treatment of 109 patients through NEFT transaction. It establishes commercial transaction of hospital. It does not fall under preview of Consumer Protection. It was agreed in Article 14 of MOU that in case of any dispute between parties, such disputes shall be finally settled through arbitration proceedings to be conducted under the provision of Arbitration and Conciliation Act 1996 as the complainants cannot make dispute of any condition of MOU before Consumer Court. For any dispute between parties, first option for settlement of dispute was Arbitration through Trust as per Article 14 of MOU and thereafter, remedy lies before civil court only. Moreover the intricate questions of law and facts are involved in the complaint. They requires voluminous documents and evidence to determine true facts of the case. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. It is further pleaded that as per MOU, the scheme was totally cashless and hospital had no authority to take any amount from customer, but hospital had charged money from customer just to earn more profit by violating agreed terms of MOU. An admissible amount of Rs.57,28,597/- has already been paid to hospital in 109 cases of treatment in accordance with agreed terms of MOU. It proves that all genuine and legitimate claims have already been paid to hospital. The complainants did not provide clarifications of queries of TPA for charging extra bill beyond package rate. The complainants have concealed the material facts and documents from this Forum. They have no locus-standi or cause-of-action to file the complaint. The complaint is bad for non-joinder of necessary parties. This Forum has no jurisdiction to try and decide the complaint. On merits, launching of scheme is not dispute. It is also mentioned that the hospitals were to provide cashless treatment to the patients against due authorization from Third Party Administrator (TPA)-opposite Party No.2 and were to claim reimbursement only at agreed rates and provisions terms i.e. Bhai Ghaniya Schedule Rates. It is admitted that opposite party Nos.2 and 3 nominated and empanelled various hospitals under the scheme wherein the hospitals agreed to provide cashless treatment to the patients and also agreed to charge/seek reimbursement at Bhai Ghaniya Schedule of Rates. A three party memorandum of understanding was also entered into between the complainants and opposite party Nos.1 and 2. It is denied that opposite parties took any fix amount from hospitals annually as alleged. Authorization of cashless treatment of various patients insured under the scheme is stated to be matter of record. It is denied that opposite party Nos.1 and 2 have not released full bill amount. It is further mentioned that amount under the scheme against patients Major Singh and Gurjant Singh on the basis of Bhai Ghaniya Schedule of rates has already been paid as per terms and conditions of the scheme. All other averments of the complainants are denied. In the end, opposite party Nos.1 and 2 have prayed for dismissal of complaint. Opposite party No.3 in its separate written version raised preliminary objections that the complaint against it is neither competent nor maintainable. The complainants are not 'consumers' of opposite party No.3. The hospital was the service provider under Bhai Ghanhya Sehat Sewa Scheme during the scheme period from 15.3.2017 to 14.3.2018. The complainants are not covered under the definition of 'Act'. As such, this Forum has no jurisdiction to entertain this complaint under 'Act'. The complaint is false, frivolous and vexatious. No cause-of-action accrued to the complainants for filing this complaint. Bhai Ghanhya Trust is a Trust registered with Registrar, of Firms and Societies with the object of formulating and administering the Bhai Ghanhya Sehat Sewa Scheme for the benefit of members and employees of the Cooperative Societies and Cooperative Department in the Punjab State. A service level agreement was entered in between the Bhai Ghanhya Trust (opposite party No.3), Reliance General Insurance Company (opposite party No 1) and MD India Health insurance TPA Pvt. Ltd (opposite party No.2) for implementation of the scheme. Opposite party No.2 was appointed as Third Party Administrator (TPA) by opposite party No.1 for the implementation of the scheme. According to the provisions of the scheme, Third Party Administrator was responsible for issuing of identity cards to the beneficiaries and providing of a handbook containing policy instructions and list of network hospitals while issuing identity cards to the beneficiaries, for inspection of hospitals and thereafter recommend them to be taken on panel of hospitals, to grant authorizations, to settle the claims of hospitals and beneficiaries to make the payments to the empanelled hospitals. The complainants must have entered into an agreement with opposite party Nos.1 and 2 that they will provide cashless services to the members enrolled by them. Opposite party No.3 is neither necessary nor a proper party in this complaint. On merits, opposite party No.3 has reiterated its stand as taken in the preliminary objections and detailed above. In the end, opposite party No.3 has prayed for dismissal of complaint. Parties were afforded opportunity to produce evidence. In support of their claim, complainants have tendered into evidence affidavit of Dr.Rajesh Jindal dated 22.5.2018 (Ex.C1), affidavit of Major Singh dated 2.8.2018, (Ex.C2); affidavit of Gurjant Singh dated 1.8.2018 (Ex.C3); photocopy of show cause notice, (Ex.C4); photocopy of draft, (Ex.C5); photocopies of bills, (Ex.C6 and C7) and closed the evidence. In order to rebut this evidence, opposite party Nos.1 and 2 have tendered into evidence affidavit of Surya Deep Singh Thakar dated 26.11.2018, (Ex.OP1/1); photocopy of memorandum, (Ex.OP1/2); photocopy of agreement, (Ex.OP1/3); photocopies of letters, (Ex.OP1/4 and Ex.OP1/5); photocopy of case details, (Ex.OP1/6) and thereafter they failed to produce evidence. Therefore, their evidence was closed by order on 24.1.2019. The opposite party No.3 has tendered into evidence affidavit of Balbir Singh dated 29.5.2018, (Ex.OP3/1); photocopy of duty chart, (Ex.OP3/2) and closed the evidence. We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stqand as taken in their respective pleadings and detailed above. In support of his submissions, learned counsel for the complainants has cited the follwing case law :- (i) 2007(2) CPJ 3 case titled Alok Shanker Pandey Vs. Union of India; (ii) I (2007) CPJ 3 (NC) case titled Jmaya Appliances Pvt. Ltd Vs. United India Insurance Company Ltd.; (iii) Decision of Hon'ble State Commission, Punjab, Chandigarh rendered in First Appeal No.1550 of 2014, Decided on 17.11.2015 in case titled ICICI Lombard General Insurance Company Limited & Ors. Vs. Dr.Rajesh Jindal and Others; (iv) Decision of Hon'ble State Commission, Punjab, Chandigarh rendered in First Appeal No.1382 of 2016, Decided on 4.8.2016 in case titled ICICI Lombard General Insurance Company Limited & Other Vs. Dr.Kanwaljeet Deol and Other; (v) III (2018)CPJ 260 (NC) case titled Sr.Supdt. of Post Offices Vs. Sayyeda Madiha; (vi) IV (2007) CPJ 340 Punjab Metal Works (P) Ltd. Vs. Pareekh Marine Agencies Pvt. Ltd.; (vii) III (2007) CPJ 221 (NC) case titled Maharashtra Mathadi and Unprotected Labour Board Vs. Tata Iron & Steel Company; (viii) IV (2006) CPJ 144 (NC) case titled Container Corporation of India Ltd. Vs. U.K Paints Industries. We have given careful consideration to these rival submissions and gone through the case law cited by learned counsel for complainants. Since first objection of opposite party Nos.1 and 2 is that the complainants do not fall under definition of 'consumers' as provided under 'Act'. Therefore, before coming to the main controversy, it is to be examined that the complainants are covered under definition of 'consumers' or not. In case ICICI Lombard General Insurance Company Limited (Supra), Hon'ble State Commission examined this matter. Facts of the case were similar to the matter involved in this case and it was concluded that there is relationship of 'consumers' and 'service providers' between the complainants and opposite parties. Therefore, the contention of opposite party Nos.1 and 2 that the complainants do not fall under definition of 'consumers' is not acceptable. Now coming to the main controversy. The complainants have pleaded that under scheme launched by opposite parties, treatment was provided to Gurjant Singh S/o Gurnam Singh and Mejor Singh S/o Gurdev Singh. This fact is not disputed by opposite parties. Only controversy is regarding treatment charges. As per complainants, amounts mentioned in the complaint are still due, but version of opposite party Nos.1 and 2 is that authorized amount has already been paid to the complainants. It is also case of the complainants that authorization is sort of tentative decision. Thereafter the complainants were to submit the bills and opposite party Nos.1 and 2 were to honour the claim as per terms and conditions. Keeping in view the point involved in this case, the complaint is disposed of with the directions to opposite party Nos.1 and 2 to furnish detail of amounts paid to the complainants under different heads and if any further amount is payable as per terms and conditions, same be released to the complainants within 45 days from the 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. Announced : 18-12-2019 (M.P.Singh Pahwa ) President (Manisha) Member
| |
