Punjab

Fatehgarh Sahib

CC/80/2017

Ranbir Kaur - Complainant(s)

Versus

The EE Water Supply & Sanitation & others. - Opp.Party(s)

17 Jul 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

Consumer Complaint  No. 80 of 2017

                                                     Date of institution : 30.11.2017                          

                                                Date of decision    : 17.07.2018

Smt. Ranbir Kaur Wd/o Sh. Jaspreet Singh, residence of village Grangan, Tehsil Kharar, District SAS Nagar(Mohali)

……..Complainant

Versus

1. The Executive Engineer, Water Supply & Sanitation, Fatehgarh Sahib.
2. Superintending Engineer, Water Supply & Sanitation, Nabha Road, Patiala.
3. Secretary, Govt. of Punjab, Water Supply & Sanitation Department, Mini Secretariat, Sector-9, Chandigarh.
4. Secretary, Govt. of Punjab, Finance Department, Civil Secretariat, Punjab, Chandigarh.
5. Oriental Insurance Company, Regional Office, SCO 109-110-111, Surindera Building, Sector 17-D, Chandigarh.
6. MD India Health Insurance TPA Private Limited, D-38 Max-Pro Info Park, Industrial Area, Phase-1, SAS Nagar Mohali.
7. Oriental Insurance Co. CBO No.3, SCO No.37, Sector 30-C, Chandigarh.

 …..Opposite Parties

 

Complaint Under Sections 11-14 of the Consumer Protection Act.          

 

Quorum

Sh. Ajit Pal Singh Rajput, President                                

Sh. Inder Jit, Member

 

Present :        Sh. M.L.Sharma, Adv.Cl. for complainant.

                      Sh. Mohinder Singh SDE, for OPs No.1 to 4.

                      Opposite parties No.5 &6 exparte.

                      Sh.Amit Gupta, Adv.Cl. for OP No.7.

ORDER

 

By Inder Jit, Member

                      Complainant, Smt. Ranbir Kaur Wd/o Sh. Jaspreet Singh, resident of village Grangan, Tehsil Kharar, District SAS Nagar(Mohali), has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Sections 11 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.           The husband of the complainant, namely; Sh. Jaspreet Singh, who was an employee of OPs No. 1 to 3, got himself insured from Oriental Insurance Company as per notification No.21/28/12-5HB5/268 dated 20.10.2015 of Government of Punjab, Department of Health and Family Welfare(Health-V Branch) and was issued MD ID No. MD 15-09779722665 under the insurance policy. Under the said policy, treatment of the Punjab Government Employees was cashless in the listed hospitals. The husband of the complainant got his treatment from Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh (listed hospital) from 22.08.2016 to 28.09.2016, 30.09.2016 to 18.10.2016 and on 01.11.2016. The husband of the complainant died on 10.11.2016 due to illness. As per the said notification of Punjab government, the Ist bill of Rs.75,428/- for the treatment of Sh. Jaspreet Singh, submitted to OP No.6 by the PGI under the cashless scheme.  OP No.6 vide its letter dated 24.11.2017 repudiated the claim/liability of payment on the ground that the claim is not admissible as per policy clause and is within standard exclusion of IRDA.  After repudiation of claim, the complainant submitted an application along with aforesaid bill and two other Medical bills also amounting to Rs.75,428/-, Rs.54,464/- and Rs.53,214/- in the office of Executive Engineer, Water Supply and Sanitation at Fatehgarh Sahib( OP No.1) for reimbursement of medical expenses. OP No.1 forwarded the same, vide its letter No. 1709 dated 20.04.2017, to the Director, Health & Family Welfare, Punjab Chandigarh for verification/sanction for payment, who verified/sanctioned the same.  After getting verification/sanction of medical bills, OP No.1 forwarded the matter to Superintending Engineer, Water Supply & Sanitation, Patiala(OP No.2). But OP No.2, vide its letter No.19061 dated 07.07.2017, refused for reimbursement of bills by clarifying that the period of treatment is covered under PGEPHIS( Under Insurance) and returned all the original bills along with correspondence papers.  Thereafter, the complainant again made representation to OP No.1 but all in vain. The complainant further stated that in the said notification it is clarified in clause 5 that "since this cashless medical treatment is made available to employee/pensioner through insurance company there are certain treatments which are not covered under Health Insurance as per the Insurance Regulatory and Development Authority of India. Details of such exclusions are available in the scheme uploaded on the website of Health Department of Punjab. The reimbursement of such exclusions will be made available to employees/pensioners as per existing policy of the State Services( Medical Attendant Rules) {CS(MA)} rules1940 as amended from time to time through treasury route".  The complainant also served legal notice upon the OPs but of no avail. The act and conduct of the OPs amounts to deficiency in service on their part. Hence, this complaint for giving directions to the OPs to make the payment of three medical bills amounting to Rs.74,925/- + 53,924/-+ 52,979/- along with interest and further to pay Rs.2,00,000/- as compensation for mental agony and harassment and Rs.11,000/- as litigation charges.
3. Notice of the complaint was issued to the OPs, but OPs No. 5 & 6 chose not to appear to contest this complaint. Hence, OP No.5 & 6 were proceeded against exparte. 
4. Complaint is contested by OPs No. 1 to 4 and OP No.7. OP No.1 to 4 filed joint written reply. In reply to complaint, OPs No. 1 to 4 stated that three medical bills amounting to Rs.75,428/-, Rs.54,464/- and Rs.53,214/-  of late Sh. Jaspreet Singh, were received in their office, which were sent to Civil Surgeon, Fatehgarh Sahib for sanction vide office letter No.2272, 2273 and 2274 dated 18.05.2017.  The Civil Surgeon Fatehgarh Sahib sanctioned the bills to the extent of Rs.74,925/-, 53,924/- and 52,979/- respectively. Thereafter the sanctioned bills were forwarded to Superintending Engineer, Patiala(OP No.2) for administrative sanction but OP No.2 returned the said bills by mentioning that " Enrollment under this scheme will start from immediate effect and will be completed by 31.12.2015 and the benefits under this scheme will start from 01.01.2016 and will be available up to 31.12.2016 initially. Every employee/pensioner will ensure his/her enrollment along with dependents before 15.12.2015 enabling the Insurance Company to deliver the enrolled insurance cards up to 31.01.2015. No fresh enrollment of the serving Employees and Pensioners shall be allowed after the date of expiry of Enrollment Period except for any exceptional circumstances or in case of any employee who has joined the service after the enrollment period, under such circumstances, coverage as well as payment of premium of such employees/pensioners shall be allowed on prorate basis".  Therefore, the complainant has to submit the bills before M.D. India and claim the reimbursement of the bills from Insurance company.  Hence, there is no deficiency in service on their part.  The OPs No. 1 to 4 prayed for dismissal of the complaint qua them.
5. In reply to complaint, OP No.7 stated that the husband of the complainant, being the government employee, was covered under the Punjab Government Employees & Pensioners Health Insurance Scheme(PGEPHIS) and the insurance policy coverage has commenced from 01.01.2016 to 31.12.2016 subject to the terms and conditions of the policy and PGEPHIS Scheme. The coverage is specifically provided under Clause 10 of the said scheme. The rates applicable shall be PGEPHIS schedule of rates and for the treatments, where no rates have been mentioned, the rates shall be CGHS rates or negotiated rates with the hospital whichever are less, which is with regard to private hospital in Punjab, Chandigarh and Panchkula. While for government hospitals in Punjab and Chandigarh, the rates applicable will be PGEPHIS schedule of rates fixed by the Nodal Department and for the treatments which have not been mentioned shall be internal rates of the government hospital.  It is further stated that as per the claim papers it was observed that the claim arose out of alcohol abuse/drug abuse and as PGEPHIS is a public scheme, the claim is not admissible with the stands exclusion of IRDA. The claim was thus repudiated vide letters dated 20.01.2017 and 17.01.2017. There is no deficiency in service on the part of OP No.7. After denying the other averments made in the complaint, OP No.7 prayed for dismissal of the complaint.
6. In order to prove his case, the complainant tendered in evidence his affidavit Ex. C-1, attested copies of documents Ex. C-2 to C-21 and closed the evidence.  In rebuttal OPs No. 1 to 4 tendered in evidence affidavit of Balbir Singh Executive Engineer Ex. OP1, true copies of documents i.e. letter dated 24.04.2017 Ex. OP-2, letters dated 26.05.2017 and 30.05.2017 Ex. OP-3 to OP-5, letters dated 07.06.2017 Ex. OP-6 to OP-8, letters dated 07.07.2017 Ex. OP-9 to OP-11, letters dated 13.07.2017 Ex. OP-12 to OP-14 and closed the evidence.  OP No.7 tendered in evidence affidavit of Dr. S.K. Sharma Ex. OP7/1 and relies on Ex. C-2 tendered by complainant and closed the evidence.
7. Ld. counsel for the complainant argued vehemently that the payment of three medical bills, which were sanctioned by the Director Health & Family Welfare Department Punjab Chandigarh, has been held by the Water Supply & Sanitation Department officers illegally. He clarified on the subject by citing government of Punjab, Department of Health & Family Welfare( Health-V Branch) notification No.21/28/1.2-5HBS/268 dated 20.10.2015 (Ex. C-2), clause No.5 of which reads as under:-

" Since this cashless medical treatment is made available to employee/pensioner through Insurance Company, there are certain treatments which are not covered under Health Insurance as per the Insurance Regulatory and Development Authority of India(IRDA). Details of such exclusions are available in the scheme uploaded on the website of Health Department of Punjab i.e. WWW.punjabhealth.gov.in. The reimbursement of such exclusions will be made available to employees/pensioners as per existing policy and State Services(Medical Attendant Rules) [CS(MA)] Rules, 1940 as amended from time to time through Treasury route".

Ld. counsel further argued that as per this clause, the payment of all the pending medical bills is to be made by the XEN, Water Supply and Sanitation Division, Fatehgarh Sahib. These medical bills already stand approved/sanctioned by the Health Department. He prayed for directing the concerned officer to release the payment immediately along with interest and heavy compensation/litigation charges.

8. On the other hand Sh. Mohinder Singh, SDE, representing OP No.1 to OP No.4, submitted that the payment of medical bills is to be made by the Insurance Company. Ld. counsel for OP No.7 argued that the Oriental Insurance Company is not liable to make the payment of the said medical bills under the rules.
9. We have gone through the written arguments, evidence produced, oral submissions and the material placed on record. We are of the opinion that OP No.1 and 2 have committed deficiency in service. We agree with the pleadings of Ld. counsel for the complainant. As per aforesaid Government of Punjab notification dated 20.10.2015(clause-5) the payment of medical bills duly approved/sanctioned by the Health Department amounting to Rs.74,925/-, Rs.53,924/- and Rs.52,979/- is to be made by the XEN Water Supply and Sanitation, Fatehgarh Sahib( OP-1). Hence, we accept this complaint and direct OP No.1 to make the payment of aforesaid medical bills to the complainant alongwith compensation together with litigation charges to the tune of Rs.20,000/-(lump sum) for the mental agony and harassment etc. This order be complied within 45 days from the date of receipt of certified copy of this order. In case OP No.1 fails to comply with the order within the stipulated period, OP No.1 shall pay interest @ 9% p.a. from the date of payment of aforesaid bills became due to the complainant till its realization. The aforesaid medical bills be submitted to OP No.1, within 10 days from the date of receipt of certified copy of this order, if the bills are in possession of the complainant.
10. The arguments on the complaint were heard on 10.07.2018 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated: 17.07.2018

(A.P.S.Rajput)            

    President

 

(Inder Jit)          

   Member