Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.       Sh.Raj Karan Singh has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that  the complainant is pensioner of Government of Punjab and had retired as Inspector Food and Supplies department on 30.6.2006. Opposite Party No.1 Government of Punjab had formulated, The Punjab Government employees and Pensioners Health Insurance Scheme’ for giving cashless insurance of Rs.3 lacs to retired employees/ pensioners.  The complainant being a retired employee of Opposite Party No.1 is fully covered under the above said insurance scheme and hence he is a consumer within the meaning of Consumer Protection Act. Under the insurance policy, Opposite Party No.2 has been appointed as third Party Administrator (TPA) and complainant has been issued insurance card with Id No.MdId15-09417430234 by Opposite Parties. Opposite Party No.3 is the Modal Agency to implement the above said scheme, while the treatment was taken from Opposite Party No.4 which isempanelled hospital under the insurance scheme. Opposite Party No.5 is the concerned insurance company to grant insurance cover to the beneficiaries under the policy in dispute issued by it.  The complainant had developed shortness of breath on rest, palipation and chest pain and he was admitted in Fortis Escorts Hospital, Amritsar on 20.6.2016 and discharged on 24.6.2016. The complainant was diagnosed as 2 AV Block, Pulmonary Koch’s Type II DM, Hypertension. At the time of admission in the hospital, the complainant had disclosed that he is a pensioner of government of Punjab and covered under the insurance scheme with card in question.  Opposite Party No.4 Fortis Escorts Hospital had performed surgery and a pacemaker-double chamber (p) was implanted on the complainant. The hospital gave a  bill of Rs.294,848/- to the complainant inspite of the fact that he was covered under the cashless insurance scheme stated above. But Opposite Party No.4 did not provide the cashless insurance  as per the scheme and the complainant was compelled to pay cash payment of the bill. Thus the complainant under compelling circumstances had paid a sum of Rs.2,94,848/- in cash to Opposite Party No.4. the complainant was assured that the amount will be reimbursed to him by other Opposite Parties. Opposite Party No.4 had forwarded the insurance claim to Opposite Party No.2 alongwith all the necessary and required documents for settlement of the claim, which was acknowledged by Opposite Party No.2 and the Opposite Party No.2 had sent SMS to the complainant for additional documents requested from the hospital for cashless request of the complainant on 23.6.2016 and 24.6.2016 and the complainant had confirmed from Opposite Party No.4 that all the documents required by Opposite Party No.2 had been sent by Opposite Party No.4.  Thereafter, the complainant called on toll free number of Opposite Party No.2, but no response came through. The complainant is facing great harassment, mental agony and suffering financial loss at the hands of all the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties  may be directed to pay  the amount of cashless insurance incurred by him on his treatment i.e.Rs.2,94,848/- alongwith interest @ 12% per annum  and compensation of Rs.50,000/- on account of mental agony and harassment besides appropriate costs of litigation in the interest of justice, equity and fairplay.

Hence, this complaint.

2.       Upon notice, Opposite Party No.1 appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complaint against Opposite Party No.1 is not maintainable as Opposite Party No.1 is government service and as per the Consumer Protection Act , no complaint is maintainable against the government service, hence the present complaint is liable to be dismissed being not maintainable. On merits, the facts narrated  in the complaint  are matter of record, moreover, the complainant against Opposite Party No.1 being government servant is not maintainable.  Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made against Opposite Party No.1.

3.       None  appeared on behalf of Opposite Party No.2 despite due service, hence Opposite Party No.2 is proceeded against exparte vide order of this Forum.

4.       Upon notice, Opposite Party No.3 appeared through counsel and filed the written reply contesting the same taking preliminary objections therein inter alia that  the complaint is not maintainable before this Forum as under the law, there is a bar for filing case in any court against Punjab Health System corporation as per clause 15(1) of Punjab Government Gaz.(Extra) April, 18 of 1996 which is reproduced in para No.1 of the preliminary objections. The government of Punjab as per notification dated 21.9.2016 has constituted grievance committee at district level as well as at 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 deserves outright dismissal. On merits, the facts narrated by the complainant have been specifically denied being incorrect and a prayer for the dismissal of the complaint with costs was made.

5.       Upon notice, Opposite Party No.4 appeared through counsel and filed the written reply contesting the same taking preliminary objections therein inter alia that  the complaint is not maintainable against answering Opposite Party. There is no evidence worth its name to show that there is any negligence or deficiency or delay in service at the hands of the replying Opposite Party in providing the medical records required for seeking insurance clam and nor the same has ever been alleged. The assistance provided in seeking a cashless claim of insurance is without any consideration and does not make the complainant a consumer qua answering Opposite Party. On merits, the treatment availed by the complainant from Opposite Party No.4 is admitted and thereafter, all the documents for the claim of cashless insurance alongwith final bill of Rs.2,94,848/- were forwarded to Opposite Party No.2 for settlement of claim of complainant/ patient. The claim is under process as admitted by the complainant himself that he has received SMS from Opposite Party No.2. The hospital has nothing to do as far as approval of the cashless claim is concerned because there is no agreement of insurance between the complainant and Opposite Party No.4 from where the treatment has been taken by the complainant.   Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made against Opposite Party No.4.  

6.       Upon notice, Opposite Party No.5 appeared through counsel and filed the written reply contesting the same taking preliminary objections therein inter alia that  the complaint is without any merit as far as Opposite Party No.5  is concerned because in the entire claim, it does not disclose any cause of action against Opposite Party No.5 . As far as mediclaim policies are concerned, the same are government and followed by the independent TPA appointed in IRDA and in the present case the Opposite Party No.2 had been appointed as TPA to deal with the claims and as per the averments made out in the complaint, the entire correspondence regarding the matter in question was exchanged between the complainant and TPA and Fortis Hospital i.e. Opposite Party No.4.  However, as per the comments of the said TPA, it has been stated that the patient got admitted in Fortis Hospital and was referred implantation of Pace Maker and subsequently  request for authorisation 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 the TPA to the said hospital against which erring hospital did not reply 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 bee fetched by the said TPA through online system only.  In the light of these comments, it is apparent that 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. Hence the present complaint is also pre mature on this ground too because in the absence relevant documents as well as proper reply which was obligatory to be given by the hospital authorities to the said TPA, hence the present complaint is not legally maintainable. On merits, Opposite Party No.5  took almost same and similar pleas as taken by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made against Opposite Party No.5.           

7.       In his bid  to prove the case, complainant tendered into evidence  affidavit Ex.C1 in support of the allegations made in the complaint and also produced copies of documents Ex.C1  to Ex.C12  and closed his evidence.

8.       On the other hand, to rebut the evidence of the complainant, Opposite Party No3 tendered into evidence the affidavit of Dr.Rajinder Singh Arora Ex.OP3/1 and copies of documents Ex.OP3/2 to Ex.Op3/5. Similarly, Opposite Party No.4 tendered into evidence the affidavit of Dr.Pinka Moudgil Ex.OP4/1 alongwith documents Ex.OP4/2 to Ex.Op4/9. Similarly, Opposite Party No.5  tendered affidavit of R.K.Sharma, Divisional Manager Ex.OP5/1 alongwith documents Ex.Op5/2 to Ex.Op5/8 and closed the respective evidence on behalf of Opposite Parties No.3, 4 and Opposite Party No.5    

9.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

10.     Ld.counsel for the complainant has reiterated the facts narrated in the complaint and submitted that the complainant is pensioner of Government of Punjab and had retired as Inspector Food and Supplies department on 30.6.2006. Opposite Party No.1 Government of Punjab had formulated, The Punjab Government employees and Pensioners Health Insurance Scheme’ for giving cashless insurance of Rs.3 lacs to retired employees/ pensioners.  The complainant being a retired employee of Opposite Party No.1 is fully covered under the above said insurance scheme and hence he is a consumer within the meaning of Consumer Protection Act. Under the insurance policy, Opposite Party No.2 has been appointed as third Party Administrator (TPA) and complainant has been issued insurance card with Id No.MdId15-09417430234 by Opposite Parties. Opposite Party No.3 is the Modal Agency to implement the above said scheme, while the treatment was taken from Opposite Party No.4 which is empanelled hospital under the insurance scheme. Opposite Party No.5 is the concerned insurance company to grant insurance cover to the beneficiaries under the policy in dispute issued by it.  The complainant had developed shortness of breath on rest, palpation and chest pain and he was admitted in Fortis Escorts Hospital, Amritsar on 20.6.2016 and discharged on 24.6.2016. The complainant was diagnosed as 2 AV Block, Pulmonary Koch’s Type II DM, Hypertension. At the time of admission in the hospital, the complainant had disclosed that he is a pensioner of government of Punjab and covered under the insurance scheme with card in question.  Opposite Party No.4 Fortis Escorts Hospital had performed surgery and a pacemaker-double chamber (p) was implanted on the complainant. The hospital gave a  bill of Rs.294,848/- to the complainant inspite of the fact that he was covered under the cashless insurance scheme stated above. But Opposite Party No.4 did not provide the cashless insurance  as per the scheme and the complainant was compelled to pay cash payment of the bill. Thus the complainant under compelling circumstances had paid a sum of Rs.2,94,848/- in cash to Opposite Party No.4. The complainant was assured that the amount will be reimbursed to him by other Opposite Parties. Opposite Party No.4 had forwarded the insurance claim to Opposite Party No.2 alongwith all the necessary and required documents for settlement of the claim, which was acknowledged by Opposite Party No.2 and the Opposite Party No.2 had sent SMS to the complainant for additional documents requested from the hospital for cashless request of the complainant on 23.6.2016 and 24.6.2016 and the complainant had confirmed from Opposite Party No.4 that all the documents required by Opposite Party No.2 had been sent by Opposite Party No.4.  Thereafter, the complainant called on toll free number of Opposite Party No.2, but no response came through. The complainant is facing great harassment, mental agony and suffering financial loss at the hands of all the Opposite Parties. It is further contended that the complainant being old man having age of 68 years is wandering pillar to post to redress his grievance, but none of the Opposite Parties is bothering to settle the claim of the complainant despite fulfillment of all the formalities. 

11.     On the other hand, none appeared on behalf of Opposite Party No.2 to defend its case  and hence Opposite Party No.2 was proceeded against exparte, but however,  ld.counsel for the Opposite Party No.5  has specifically  repelled the aforesaid contention of the ld.counsel for the complainant on the ground that in the present case the Opposite Party No.2 had been appointed as TPA to deal with the claims and as per the averments made out in the complaint, the entire correspondence regarding the matter in question was exchanged between the complainant and TPA and Fortis Hospital i.e. Opposite Party No.4.  However, as per the comments of the said TPA, it has been stated that the patient got admitted in Fortis Hospital and was referred implantation of Pace Maker and subsequently  request for authorisation 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 the TPA to the said hospital against which erring hospital did not reply 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 bee fetched by the said TPA through online system only.  In the light of these comments, it is apparent that 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. Hence the present complaint is also pre mature on this ground too because in the absence relevant documents as well as proper reply which was obligatory to be given by the hospital authorities to the said TPA.. But on the contrary, the hospital authority of Opposite Party No.4 has submitted that  all the documents for the claim of cashless insurance alongwith final bill of Rs.2,94,848/- were forwarded to Opposite Party No.2 for settlement of claim of complainant/ patient. The claim is under process as admitted by the complainant himself that he has received SMS from Opposite Party No.2 and the now hospital has nothing to do as far as approval of the cashless claim of the complainant.  As such, the contention of the Opposite Party No.5  that the claim of the complainant is pre mature, is not tenable because all the relevant documents for the settlement of the claim has already been submitted by Opposite Party No.4 to Opposite Party No.2 as confirmed by Opposite Party No.2  through SMS to the complainant.

12.     Hence, in view of the aforesaid facts and circumstances of the case, we direct the Opposite Parties No.2 and  5 to make the payment of claim amount of Rs.2,94,848/- to the complainant within 30 days from the date of receipt of copy of order, failing which the complainant shall be entitled to the interest @ 9% per annum on the awarded amount from the date of order till realization. The complaint is disposed of accordingly. However, the complaint against 1, 3 and 4 stands dismissed. Opposite Parties No.2 and 5 are also directed to pay Rs.5,000/- to the complainant on account of compensation for causing mental tension and harassment besides Rs.2,000/- as costs of litigation. Copies of this order be supplied to the parties free of cost and the file be consigned to record room after compliance.

Announced in Open Forum

Dated: 01.03.2017.