Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.       Sh.Mukhtar Singh has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that Punjab Government vide its notification No.CHD/0092/2015-2017 dated 20.20.2015 had allowed cashless treatment upto Rs.3 lacs to its employees and pensioners under Punjab Government employees and Pensioners Health Insurance Scheme (PGEPHIS). This scheme is applicable to all the government serving employees (whether covered under old or new pension scheme). In the said notification, list of the hospitals is also attached in which the name of the Opposite Party No.2 hospital is also mentioned.  The complainant is a pensioner and he was issued identity card No.MD15-09878075686 of Opposite Party No.1 and the policy period is from 1.1.2016 to 31.12.2016. As such,  the complainant is a consumer of the Opposite Parties as defined under the Act and has a right to invoke the jurisdiction of this Forum. The complainant suffered problem in his left eye and he was operated on 19.1.2016 in the hospital of Opposite Party No.2. The complainant handed over his ID card to the Opposite Party No.2, but they refused to accept the same and denied to provide the cashless treatment to him and showed adamant  to charge the medical expenses.  The complainant requested to Opposite Party No.2 that as per the notification of the Punjab Government and as per the ID card issued by Opposite Party No.1, he is entitled for cashless treatment of his eye, but they did not listen his genuine and legitimate requests and rather, charged a sum of Rs.28,461/- from the complainant on account of medical expenses for the operation of his eye.  The complainant having no alterative option, had to pay the said amount to Opposite Party No.2 for which they issued the bill to the complainant. The complainant approached the Opposite Parties a number of times and requested them to reimburse the amount of Rs.28,461/-, but they did not pay any heed to the request  of the complainant.  Earlier, the complainant  also approached this Forum for the reimbursement of the amount and this Forum directed the complainant  to approach TPA of Opposite Party No.1 and apply for reimbursement of the insurance claim alongwith requisite documents. Accordingly, as per the directions of this Forum, the complainant approached TPA of Opposite Party No.1 and also submitted the original documents as per their requirement and lateron the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and failed to reimburse the full amount.  Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties be directed to reimburse the balance amount of Rs.22,461/- alongwith interest @ 18% per annum.

b)      Compensation of Rs.25,000/- on account of mental pain, agony. Harassment suffered by him.

c)       Costs of the proceeding of Rs.10,000/- to the complainant.

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 filed by the complainant is without any merits as far as Opposite Party No.1 is concerned because in the entire complaint, it does not disclose any cause of action against Opposite Party No.1. The entire allegations of the complainant are against Opposite Party No.2 hospital authorities. In the present case, the complainant alleged that inspite of showing I Card, the hospital authorities did not provide him cashless facility. To the said complaint written version was filed by said hospital that the complainant never showed his I Card and as such, the amount was charged directly from him.  As per the order of this Forum, the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and has settled the said claim being payable as per the terms and conditions of the policy  and arrangement made with the hospital authorities as per schedule rates as per Annexure XX. As per annexure XX which is a specific arrangement for making cashless payment to the listed hospital and according to the said scheduled rates, fixed amount for Cataract with IOL (P) of one eye is Rs.6000/- which is payable by the TPA to the hospital  and the same has been paid in the present case. On merits, the Opposite Party No.1 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.

3.       Opposite Party No.2 appeared and contested the complaint by filing  written statement and admitted to the fact that he was operated on 19.1.2016 as a general public and at no stage he provided any MD card which was not accepted by the hospital even he deposited the consultant fee of Rs.230/- as a general public whereas consultant fees  for Punjab Government servants/ pensioners is Rs.100/- . The reimbursement issue relates to insurance company and not the TPA for the general public for which the reimbursement bills duly verified was handed over to the patient for claiming from insurance company as desired by him.  Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

4.       In his bid  to prove the case, complainant tendered into evidence  affidavit Ex.CW1/A  in support of the allegations made in the complaint and also produced copies of documents Ex.C1   to Ex.C9  and closed his evidence.

5.       On the other hand, to rebut the evidence of the complainant, the Opposite Party No.1 tendered into evidence the affidavit of Sh.R.K.Sharma, Divisional Manager Ex.OP1/1  alongwith copies of documents Ex.OP1/2 to  Ex.OP1/10. Similarly, Opposite Party No.2 tendered into evidence the affidavit of Dr.Surinder Sharma, Medical Superintendent Ex.OP2/1 and thereafter, the Opposite Parties  closed the evidence on behalf of  the Opposite Parties.

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

7.       Ld.counsel for the complainant has reiterated the averments as made in the complaint and contended that Punjab Government vide its notification No.CHD/0092/2015-2017 dated 20.20.2015 had allowed cashless treatment upto Rs.3 lacs to its employees and pensioners under Punjab Government employees and Pensioners Health Insurance Scheme (PGEPHIS). This scheme is applicable to all the government serving employees (whether covered under old or new pension scheme). In the said notification, list of the hospitals is also attached in which the name of the Opposite Party No.2 hospital is also mentioned.  The complainant is a pensioner and he was issued identity card No.MD15-09878075686 of Opposite Party No.1 and the policy period is from 1.1.2016 to 31.12.2016. As such,  the complainant is a consumer of the Opposite Parties as defined under the Act and has a right to invoke the jurisdiction of this Forum. The complainant suffered problem in his left eye and he was operated on 19.1.2016 in the hospital of Opposite Party No.2. The complainant handed over his ID card to the Opposite Party No.2, but they refused to accept the same and denied to provide the cashless treatment to him and showed adamant  to charge the medical expenses.  The complainant requested to Opposite Party No.2 that as per the notification of the Punjab Government and as per the ID card issued by Opposite Party No.1, he is entitled for cashless treatment of his eye, but they did not listen his genuine and legitimate requests and rather, charged a sum of Rs.28,461/- from the complainant on account of medical expenses for the operation of his eye.  The complainant having no alterative option, had to pay the said amount to Opposite Party No.2 for which they issued the bill to the complainant. The complainant approached the Opposite Parties a number of times and requested them to reimburse the amount of Rs.28,461/-, but they did not pay any heed to the request  of the complainant.  Earlier, the complainant  also approached this Forum for the reimbursement of the amount and this Forum directed the complainant  to approach TPA of Opposite Party No.1 and apply for reimbursement of the insurance claim alongwith requisite documents. Accordingly, as per the directions of this Forum, the complainant approached TPA of Opposite Party No.1 and also submitted the original documents as per their requirement and lateron the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and failed to reimburse the full amount.

8.       On the other hand, ld.counsel for Opposite Party No.1 has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that  the entire allegations of the complainant are against Opposite Party No.2 hospital authorities. In the present case, the complainant alleged that inspite of showing I Card, the hospital authorities did not provide him cashless facility. To the said complaint written version was filed by said hospital that the complainant never showed his I Card and as such, the amount was charged directly from him.  As per the order of this Forum, the TPA of Opposite Party No.1 deposited Rs.6000/- in the account of the complainant and has settled the said claim being payable as per the terms and conditions of the policy  and arrangement made with the hospital authorities as per schedule rates as per Annexure XX. As per annexure XX which is a specific arrangement for making cashless payment to the listed hospital and according to the said scheduled rates, fixed amount for Cataract with IOL (P) of one eye is Rs.6000/- which is payable by the TPA to the hospital  and the same has been paid in the present case. Similarly, ld.counsel for Opposite Party No.2 has repelled the contention of the complainant on the ground that  the complainant was operated on 19.1.2016 as a general public and at no stage he provided any MD card which was not accepted by the hospital even he deposited the consultant fee of Rs.230/- as a general public whereas consultant fees  for Punjab Government servants/ pensioners is Rs.100/- . The reimbursement issue relates to insurance company and not the TPA for the general public for which the reimbursement bills duly verified was handed over to the patient for claiming from insurance company as desired by him.  Perusal of the pleadings and averments of the file shows that the Opposite Party No.1 has failed to produce any policy terms and  condition under which they have deducted the bill amount and paid a meagre amount of Rs.6000/- out of the total amount of Rs.28,461/-. The complainant has duly proved  his case beyond any shadow of doubt while appearing himself in the witness box as his own witness and tendering his duly sworn affidavit and his evidence remained unrebutted and unshattered. He has duly proved the relevant and material documents on the file such as Punjab Government Gazette Extra ordinary dated 20.10.2015 published by the Department of Health and Family Welfare bearing notification No.21/28/12-5HB5/268 s Ex.C1, list of the hospitals Ex.C2, ID card Ex.C3, certificate issued by the hospital authorities of Opposite Party No.2 Ex.C4 showing the payment of Rs.28,461/- by the complainant, cash receipt Ex.C5, certificate issued y Opposite Party No.2 regarding  total hospital expenses Ex.C6, another certificate issued by Opposite Party No.2 Ex.C7, another  certificate showing the payment of Rs.500/- to the hospital authority Ex.C8. in view of the above submissions and facts, circumstances and the documents, the case of the complainant is duly proved as per which, the complainant is legally entitled to g rant of aforesaid reliefs.  

9.       In view of the aforesaid facts and circumstances of the case, we direct Opposite Party No.1- Insurance Company to make the payment of balance bill amount i.e. Rs.22,461/- to the complainant, but however, the complaint against Opposite Party No.2 Hospital stands dismissed.            Compliance of this order be made within 30 days from the date of receipt of copy of the order; failing which awarded amount shall carry interest @ 6% p.a from the date of the passing of this order until full and final payment. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated: 16.08.2017.