Order by:

Sh.Amrinder Singh Sidhu, President

1.           The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant Dr. Rajeev Kumar Gupta Sole Prop. of the firm running hospital under the name and style of Rajeev Hospital and he is practicing as Orthopedic Surgeon for earning his livelihood. The Opposite Party No. 3 had lodged a scheme in the Punjab Known as Bhai Ghanhya Sehat Sewa Scheme (hereinafter called as BGSSS Scheme) in which they provided the cashless insurance and treatment to the General Public of the Punjab and for this scheme they have purchased the insurance policy of one year period from opposite party no. 1 and the claims were settled through opposite party No. 2 as TPA. Under the aforesaid scheme, the opposite parties are nominated, recognized and empanelled the various hospitals and doctors in the Punjab from where the insured patient on cashless basis took the treatment under the BGSSS Scheme and the treatment expenses are directly paid to the concerned empanelled hospitals/doctors by the opposite party no. 1 and for this purpose the opposite parties took a fixed amount from the hospitals/doctors in advance for the policy period of one year. The complainant hospital was duly authorized and empanelled by the opposite parties for the BGSSS Scheme 2020-21 which starts from 16.03.2020 for one year and for this purpose they had taken the amount of Rs. 10,000/- from the complainant in advance vide DD No. 036810 dated 23.07.2019 of HDFC Bank in the name of Opposite Party No.3 as fee from the complainant hospital as per Cashless Insurance Scheme and recognized him under BGSSS Scheme. The opposite party No.2 is the 3^rd party administrator (TPA) on behalf of Opposite Parties no. 1 and 3, who gave the pre-authorization and clearance to the complainant from time to time for the treatment of the admitted patients and after the clearance, the complainant used to treat the concerned patients and submitted its bills along with claim forms and discharge report etc. to Opposite Party No.2 for reimbursement of the claim under the Cashless Hospitalization Scheme. Under the aforesaid scheme the complainant treated the patient Gurcharan Singh son of Jagir Singh who admitted on 09.11.2020 and after treatment discharged on 16.11.2020. Gurcharan Singh was duly insured under BGSSS Scheme Vide MD India ID No. MDI5-BGSSS-11304977-S with Opposite Parties. The total treatment charges of the patient Gurcharan Singh were Rs. 1,25,862/-. The Opposite Parties gave the pre-authorization to the complainant hospital regarding the treatment of Gurcharan Singh s/o Jagir Singh, in which it is clearly mentioned that the cashless treatment is valid for admission between 04.11.2020 to 03.12.2020. The said patient duly admitted & treated between this time frame i.e. 09.11.2020 to 16.11.2020. The amount of Rs.1,25,862/- as per medical bills is still pending with the Opposite Parties and the same has not been released by the Opposite Parties without any reason or any rule whereas, as per the directions of the Opposite Parties, the complainant prepared the Bills and demanded the charges as per rate list of the Opposite Parties, but the Opposite Parties deducted above said amount from the bill of the above said patients against their own rate list and rules which comes Rs.99,597/-. The complainant approached many times to the officials of the Opposite Parties and also wrote various emails, but nobody had listened the same and payment is still pending with the Opposite Parties till date. Finally on 14.12.2021, the complainant received an email from the Opposite Parties regarding rejection of the claim on the ground that "After approvals, policy lapsed on 31^st October, 2020. So, at the time of discharge, it is come to know that admissions are post lapse of policy. Hence cases denied at the same time. So, no such amount is pending under the same". This is gross violation of the terms and conditions of BGSSS Scheme 2020-2021 which was valid from 16.03.2020 to 15.03.2021. Regarding the lapse of policy before the policy period, the Opposite Parties never gave any prior intimation to the complainant neither send any email nor send any denial letter prior to this email dated 14.12.2021. The Opposite Parties no. 1 to 3 duly gave the pre-authorization of the aforesaid patient Gurcharan Singh s/o Jagir Singh for his treatment w.e.f. 04.11.2020 to 03.12.2020 and on the basis of the said pre-authorization, the complaint had treated the patient and now the Opposite Parties  are stating that the insurance policy is already lapsed on 31^st October 2020 before the policy period which is totally illegal and against the principal of insurance i.e. utmost good faith as per law settled by the Hon'ble Apex Court in Modern Insulator Vs. OIC. Till date the opposite parties neither a single word replied nor paid claim amount to the complainant against the above said re-imbursement of the Insurance Claim. Complainant also put reliance on judgement of Hon’ble National Commission, 2005 (1) CPJ 27 (NC) titled Harsolia Motors  Vs National Insurance, judgement of Hon’ble State Commission in case titled as Dharampal Vs New India Assurance-1999 (III) CPJ 25 another judgement of Hon’ble State Commission, Punjab in ICICI Lombard Vs Dr.Rajesh Jindal in FA no.1550/2014 decided on 17.11.2015, Judgement of Hon’ble Supreme Court-1996 (3) CPJ 8 (SC) titled as United India Insurance Co. Ltd. Vs.  M.K.J Corporation in para (ii) at page No.9, Judgement of Hon’ble State Commission, Chandigarh in 1998 (1) CLT 478 titled in Universal Process Vs Oriental Insurance Co. Ltd.  There is the clear deficiency in service on the part of the opposite parties. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay the claim amount of Rs.1,25,862/- alongwith interest @ 18% per annum from the date of admission till the date of payment.

b)      To pay an amount of Rs.50,000/- as compensation on account of mental tension, agony and harassment suffered by complainant.

c)       To pay an amount of Rs.50,000/- as costs of the complaint.

d)      Any and other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and filed the written version taking preliminary objection therein inter alia that at the very outset it is submitted that the present application is false, bundle of lies, vexatious, vague and has been filed with ulterior motive against the opposite party No.1 for taking some undue benefit by humiliating, harassing and pressurizing the opposite party No.1, as such the present application is not maintainable and deserves dismissal by imposing exemplary costs. The Complainant has not come to this Commission with clean hands and has concealed material information and complete details regarding the facts of the captioned case. The claims have to be processed as per scheduled rates by MD India Health Insurance TPA Pvt. Ltd. and the same also have issued Initial Authorization Letter in this case on receiving Initial Request from Hospital but the Final Authorization have to be only issued after getting the Discharge Summary and Final Bills of the respective patient within stipulated period. The insurance policy is governed by the Service Level Agreement in such cases and as per the same, the validity of an Authorization Letter issued by the TPA shall be 30 days from the date of issuance of Authorization Letter, for all Network Hospitals, for admitting the beneficiary who has been authorized for cashless treatment under the Scheme. In case, there is no evidence of utilization of the authorized amount, the TPA cannot ascertain the utilization of the authorized amount. Auto cancellation of the issued authorization will be automated through system after 60 days from the date of issuance of Authorization Letter and the authorized amount will be credited to the Sum Insured, if after issuance of authorization, neither discharge submission is made by the hospital through pre-authorization module as well as nor the claim is submitted by the hospital. The insurance policy for all practical purposes has been stopped on 31^st October 2020 for non-payment of due installments of insurance premium by Bhai Ghanhya Trust. Due to the cancellation of the insurance policy for the non-payment of installment of premium for the 3^rd quarter, the Bhai Ghanhya Trust is solely responsible to the insured/complainant.

          As per Service Level Agreement Clause 6.4.6 and as per specimen of the Memorandum of Understating (MOU) Article 7, which describes the Billing Procedure and as per Article 7 7.4, the Hospital shall make online submission of the complete claim as per the checklist provided by the TPA preferably within 30 days from the date of discharge of the Beneficiary by the Network Hospital. The claims from the Network Hospitals received by the TPA after a lapse of 30 days, maximum up to 60 days from the date of the discharge of the Beneficiary shall be settled, with deduction of 10% of the due amount. The payment against such claims shall be accompanied with a letter from the TPA explicitly explaining the reasons of disallowances as late submission of claim, beyond stipulated time period of 30 days. The claims from the Network Hospitals submitted after a lapse of 60 days from the date of discharge of the Beneficiary may not be entrained by the TPA for processing and settlement. As such, the Discharge Summary and Final Bill of the respective patient has to be uploaded on portal of MD India TPA by the empanelled Hospital within 30 days, but in this case, these documents have not been uploaded by the Complainant Hospital with in stipulated period of 30 days after the discharge of the patient and not even within 60 days from the date of discharge of the respective patient which is mandatory as per Service Level Agreement and MOU as such the claim has been closed and cannot be processed as per insurance policy condition. On merits, it is submitted that there is certain procedure which has to be followed as per Service Level Agreement and MOU. The claims have to be processed as per scheduled rates by MD India Health Insurance TPA Pvt. Ltd. and the same also have issued Initial Authorization Letters in all these cases but the Final Authorizations have to be only issued after getting the Discharge Summary and Final  Bills of the respective patient within stipulated period. The insurance policy is governed by the Service Level Agreement in this case and as per the same, the validity of an Authorization Letter issued by the TPA shall be 30 days from the date of issuance of Authorization Letter, for all Network Hospitals, for admitting the beneficiary who has been authorized for cashless treatment under the Scheme. In case, there is no evidence of utilization of the authorized amount, the TPA cannot ascertain the utilization of the authorized amount. Auto cancellation of the issued authorization will be automated through system after 60 days from the date of issuance of Authorization Letter and the authorized amount will be credited to the Sum Insured, if after issuance of authorization, neither discharge submission is made by the hospital through preauthorization module as well as nor the claim is submitted by the hospital. The insurance policy for all practical purposes has been stopped on 31^st October 2020 for non-payment of due installments of insurance premium by the Bhai Ghanya Trust. The said patient was admitted after the cancellation of the insurance policy for non- payment of installment of the due premium. Further alleges that the said authorization is always subject to the terms and conditions of the insurance policy which in these cases stood cancelled on 31-10-2020, for non- payment of installment of the due premium. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint is made.

3.       Complainant has filed Replication to the Written Reply of Opposite Party No.1 stating that the patient Gurcharan Singh was admitted and treated within 30 days from the date of issuance of Authorization Letter. As per authorization letter issued by the Opposite Parties no.1 & 2, the complainant had treated the patient Gurcharan Singh. After the issuance of initial authorization letter, no intimation was given to the complainant by the Opposite Parties regarding cancellation of insurance policy. The Opposite Parties  gave the authorization letter to the complainant hospital regarding the treatment of the patient Gurcharan Singh s/o Jagir Singh, in which it is clearly mentioned that the cashless treatment is valid for admission between 04.11.2020 to 03.12.2020. The said patient duly admitted and treated between this time frame i.e. 09.11.2020 to 16.11.2020. Further submitted that the complainant hospital had made online submission of the complete claim as per the check list provided by the TPA on 16.11.2020 on the day of discharge of the patient Gurcharan Singh. Moreover, the discharge summary and final bill of the patient was uploaded on the portal of MD India by the complainant hospital on 16.11.2020 vide reference no.IN_161120_85. All other objections raised by the Opposite Party No.1 in the written version are denied.

3.       Upon service of notice, none has come present on behalf of Opposite Parties no.2 & 3, hence Opposite Parties no.2 & 3 were proceeded against exparte.

4.       To prove his case, complainant’s hospital tendered in evidence affidavit of Dr.Rajeev Kumar Gupta Ex.C1 alongwith copies of documents Ex.C2 to Ex.C30.

5.       To rebut the evidence of complainant, Opposite Party No.1 tendered in evidence copies of documents Ex.OP1/1 to Ex.OP1/4 and affidavit of Smt.Sunita Mahajan, Divisional Manager as Ex.OP1/5.

6.       During the course of arguments, ld. counsel for the parties have mainly reiterated the same facts as narrated in the complaint as well as written versions. We have perusal the rival contentions of ld. counsel for the parties and gone through the record. The case of the complainant is that complainant hospital was duly authorized and empanelled by the opposite parties for the BGSSS Scheme 2020-21 which starts from 16.03.2020 for one year. Under the aforesaid scheme the complainant hospital treated the patient Gurcharan Singh son of Jagir Singh who admitted on 09.11.2020 and after treatment discharged on 16.11.2020. Gurcharan Singh was duly insured under BGSSS Scheme Vide MD India ID No. MDI5-BGSSS-11304977-S with Opposite Parties. The total treatment charges of the patient Gurcharan Singh were Rs.1,25,862/-. The Opposite Parties gave the pre-authorization to the complainant hospital regarding the treatment of Gurcharan Singh s/o Jagir Singh, in which it is clearly mentioned that the cashless treatment is valid for admission between 04.11.2020 to 03.12.2020. To prove this facts complainant has placed on record copy of pre-authorization letter Ex.C24 and  copy of authorization letter dated 31.10.2020 which is Ex.C23. The said patient duly admitted and treated between the time frame i.e. 09.11.2020 to 16.11.2020. The amount of Rs.1,25,862/- as per medical bills is still pending with the Opposite Parties and the same has not been released by the Opposite Parties without any reason or under any rule. On 14.12.2021 the complainant received an email from the Opposite Parties regarding rejection of the claim on the ground that "After approvals, policy lapsed on 31^st October, 2020. So, at the time of discharge, it is come to know that admissions are post lapse of policy. Hence cases denied at the same time. So, no such amount is pending under the same". Ld. counsel for complainant further contended that regarding the lapse of policy before the policy period, the Opposite Parties never gave any prior intimation to the complainant neither send any email nor send any denial letter prior to this email dated 14.12.2021.

7.       On the other hand, ld. counsel for the Opposite Party No.1 raised the plea that the insurance policy for all practical purposes has been stopped on 31^st October 2020 for non-payment of due installments of insurance premium by Bhai Ghanhya Trust. Due to the cancellation of the insurance policy for the non-payment of installment of premium for the 3^rd quarter, the Bhai Ghanhya Trust is solely responsible to the insured/complainant. We agree with the contention of the Opposite Party No.1 that policy has been stopped on 31.10.20220, but opposite party no.1 has not placed on record any document to prove that complainant’s hospital was timely informed about the lapse of the policy. The other plead of Opposite Party No.1 is that as per Service Level Agreement Clause 6.4.6 and as per specimen of the Memorandum of Understating (MOU) Article 7, which describes the Billing Procedure and as per Article 7 7.4, the Hospital shall make online submission of the complete claim as per the checklist provided by the TPA preferably within 30 days from the date of discharge of the Beneficiary by the Network Hospital. The claims from the Network Hospitals received by the TPA after a lapse of 30 days, maximum up to 60 days from the date of the discharge of the Beneficiary shall be settled, with deduction of 10% of the due amount. The payment against such claims shall be accompanied with a letter from the TPA explicitly explaining the reasons of disallowances as late submission of claim, beyond stipulated time period of 30 days. The claims from the Network Hospitals submitted after a lapse of 60 days from the date of discharge of the Beneficiary may not be entrained by the TPA for processing and settlement. As such, the Discharge Summary and Final Bill of the respective patient has to be uploaded on portal of MD India TPA by the empanelled Hospital within 30 days, but in this case, these documents have not been uploaded by the Complainant Hospital with in stipulated period of 30 days after the discharge of the patient and not even within 60 days from the date of discharge of the respective patient which is mandatory as per Service Level Agreement and MOU as such the claim has been closed and cannot be processed as per insurance policy condition. We do not agree with the aforesaid contention ld. counsel for the opposite party no.1 because in the replication complainant submitted that the discharge summary and final bill of the patient namely Gurcharan Singh had uploaded on the portal of MD India by the complainant’s hospital on 16.11.2020 and to prove this fact complainant has placed on record copy of document Ex.C30.

8.       On the other hand, Opposite Parties no. 2 & 3 did not opt to appear and contest the proceedings.  In this way, the Opposite Parties no.2 & 3 have impliedly admitted the correctness of the allegations made in the complaint. It also shows that Opposite Parties no.2 & 3 have no defence to offer or defend the complaint. We have perused the record placed on file. Before the treatment of patient Gurcharan Singh s/o Jagir complainant’s hospital has taken the pre authorization from Opposite Parties copy of which is Ex.C24 and they duly authorized the complainant’s hospital vide authorization letter dated 31.10.2020 Ex.C23 stating that payment valid for admission between 04.11.2020 to 03.12.2020. From it is evident that only after receiving pre-authorization from the Opposite Parties complainant started the treatment of patient Gurcharan Singh. Moreover the complainant came to know about the cancellation of the policy only on 14.12.2021, when they received email from the Opposite Party No.3 with remarks that “TPA given initial approval in these cases. After approvals, policy lapsed on 31^st October, 2020. So at the time of discharge, it is come to know that admissions are post lapse of the policy. Hence cases denied at the same time.” However, the complainant was never informed about lapse of the policy prior to this email dated 14.12.2021. If the complainant hospital was to be informed about the lapse of the policy prior to the treatment of patient Gurcharan Singh, it did not operate the patient on the basis of cashless treatment, rather it operated the patient on payment basis. Moreover, if there is dispute of any payment between Opposite Parties then what is the fault of complainant’s hospital and why the complainant hospital was not informed within time i.e. prior to lapse of the policy by the Opposite Parties. Thus, there is deficiency in service on the part of opposite parties.

9.       Keeping in view of the aforesaid facts and circumstances, we partly allow the complaint of the complainant. Opposite parties are, jointly and severally, directed to pay an amount of Rs.1,25,862/-(Rupees One lac Twenty Five Thousand Eight Hundred Sixty Two only) alongwith interest @ 8% P.A. from the date of filing of this complaint till its actual realization. The compliance of this order be made by Opposite Parties Insurance Company within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced in accordance with law. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.