Complainant Arvind Kishore Puri has filed the present complaint U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the opposite party to make the payment of amount spent by him on his treatment immediately in terms of the Insurance Policy alongwith interest @ 18% P.A. from the date of due till actual realization. Opposite parties be further directed to pay Rs.30,000/- as compensation on account of mental agony, physical harassment and deficiency in service on their part alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he is member of Punjab Govt. Employees and Pensioners Health Insurance Scheme (PGEPHIS) as per policy of the Punjab Govt. i.e.  opposite party no.1 and he was insured for the period from 01.01.2016 to 31.12.2016.  He as well as his dependent family members were entitled for free treatment as per above mentioned policy. The opposite party no.2 is third party Administrator (TPA) as service provider and are responsible for providing the services to the insured as per the terms and conditions of the insurance policy and standing as  the privity of contract for both the opposite parties. On 27.12.2016, he suffered heart attack. He was rushed to Dr.R.S.Kalsi Clinic Simbal Chowk Batala, but in view of his serious condition he was taken to Nayyer Hospital Amritsar. He remained admitted from 27.12.2016 to 28.12.2016 and discharged at 10.28 AM on his request and thereafter he remained admitted at Ved Gupta Hospital, Mall Road Amritsar upto 31.12.2016. An amount of Rs.15,000/- was spent by him at Nayyer Hospital Amritsar and Rs.53,529/- at Ved Gupta Hospital which includes Hospital bills, Medicine bills and Lab tests etc. He is entitled for the refund as per policy of the Govt. He submitted his claim to the opposite parties, the opposite parties initially put the matter with one or other excuse but thereafter refused to entertain his claim on false and flimsy ground. This act of opposite parties of not entertaining his claim and not making payment of the amount spent by him on his treatment is illegal, null and void. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.           Upon notice, the opposite party no.1 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable. On merits, it was admitted that the opposite party no.2 is third party administrator as service provider and the TPA is responsible for providing the services to the insured as per the terms and conditions of the policy. Actually, the complainant has not submitted his claim for reimbursement alongwith the requisite documents to the MD India Health Insurance TPA Pvt.Ltd., Mohali, within stipulated period of 30 days from the date of discharge from the Hospital, which is the mandatory condition under the terms and conditions of the Punjab Govt. Employees and Pensioners Health Insurance Scheme (PHEHIS). Hence, the MD India Health Insurance TPA Pvt.Ltd., has rightly not entertained the claim under the terms and conditions of the PGEHIS. Hence the insurance company is not liable to pay the claim under the provisions of the scheme.  All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs. 

4.      The opposite party no.3 appeared through its counsel and filed its written version taking the preliminary objections that the complaint is not maintainable and in the notification issued by the Punjab Govt. Introduce cashless Health Insurance Scheme, thereafter referred as Punjab Govt. employee and pensioners Health Insurance Scheme ‘PGEHIS’ to cover indoor medical treatment expenses, specified day care procedure and treatment of chronic disease as specified or to all the Govt. serving employee and pensioners on compulsory basis. So, the complaint may be dismissed against opposite party no.3.  On merits, it was submitted that the opposite parties no.1 and 2 are fully responsible to release the re-imbursement bill of Rs.15,000/- and Rs.53,529/- to the complainant, under the Punjab Govt. notification dated 20.10.2015. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs. 

5.     Notice issued to the opposite party no.2 had not been received back. Case called several times, but none had come present on behalf of opposite party no.2, therefore, it was proceeded against exparte vide order dated 30.6.2017.  

6.       Counsel for the complainant tendered into evidence affidavit of complainant Ex.C-I, along with the other documents exhibited as Ex. C2 to Ex.C19 and closed the evidence.

7.        On the other hand, counsel for the opposite party no.1 tendered into evidence affidavit of Karam Singh S.D.M. Oriental Insurance Company Ex.OP-1/1 alongwith other document Ex.OP1/2 and closed the evidence.

8.       Dr.Sawinder Kumar Assistant Civil Surgeon tendered into evidence his own affidavit Ex.OP-3/1 alongwith other documents Ex.OP-3/2 and closed the evidence.

9.      We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants along with the scope of adverse inference that may be discretionarily/judicially drawn on account of the intentional non-participation/ex-parte proceedings by one of the titled opposite parties despite the proven service of the summons; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants.

10.     We observe that the prime dispute that had prompted (affidavit Ex.C1) the present complaint pertained to the alleged non-settlement of the complainant’s hospitalization claim by the OP1 insurers at the behest of the OP2 TPA who had preferred to suffer the ex-parte proceedings. Further, the OP1 insurers admit having rightly repudiated the insurance claim (in question) vide its written statement per the affidavit (Ex.OP1/1) since the same was not submitted within the stipulated period of 30 days from the date of discharge from the Hospital in conformity with the terms of the applicable policy and thus was not payable.

11.    We find  refusal by the OP2 Hospital to provide cashless medical-treatment (free of cost) to the patient/complainant despite its being one of the Network Hospitals as designated vide Punjab Government Employees & Pensioners Health Insurance Scheme (PGEPHIS) and secondly upon refusal to entertain the reimbursement claim by the OP1 TPA (Third Party Administrators) who have preferred to suffer ex-parte proceedings that also gives rise to the judicial presumption that they do not have any defense to plead before the forum.

12.     We find that the complainant had been a State Govt. Employee working as a process-server with the local civil courts at Batala and thus a member of the PGEPHIS (Punjab Govt. Employees and Pensioners Health Insurance Scheme) vide Punjab Govt. Notification dated 20.10.2015 by virtue of which he was also entitled for cash-less medical-treatment in the OP1 insurers net-work Hospitals. However, the OP1 insurers had been also liable to refund the incurred hospitalization expenses to the insured but at their network-hospital contracted-rates against those incurred/ paid at other than network Hospitals for treatment in urgent emergency situations.

13.     We get firm support to the above proposition/finding in the light of the judgment of the honorable State Consumer Commission, Punjab; in FA # 1100 of 2010 titled Fortis Hospital, Mohali vs. Medsave Healthcare (TPA) Ltd. & Ors; wherein, paragraph ‘22’ reads as: “After producing the ID Card, respondent no. 6 was to get cashless treatment but that was not provided for the reasons known to the appellant hospital or the insurance company (appellant in other appeal). The appellant Hospital has given the treatment and obtained the expenses for the treatment and the insurance company was liable to reimburse the same, but the District Forum held the appellant hospital liable to pay the expenses, compensation and costs jointly and severally and the said order is required to be modified”.      

14.     Although, the OP2 TPA has preferred the ex-parte proceedings to participation and not to plead its defense but we understand that the PGEPHIS membership eligibility covers (confines itself) to ‘cashless hospitalization/treatment in Network Hospitals, only and medical reimbursement for treatment at Government Hospitals or at those rates only.       However, in the light of the recent ruling by the honorable State Consumer Commission, Punjab in FA # 1105 of 2014 titled: Sukhdev Singh Nagpal vs. New Karian Pehalwal Co-op Ag Service Society & Ors., the insurers are liable to reimburse but only up to the standard-expenses fixed with the network hospitals for that particular medical treatment.

15.     Further, we find that then insurance claim has been duly filed by the complainant (Ex.C3) with the competent authority CJSD, Batala who had further forwarded the same (Ex.C2) to the District Authority (Dist. & Sessions Judge, Gurdaspur), thus there had been no delay in submissions at the complainant’s end.

16.     We also find that the terms and conditions of the related policy as exhibited here (Ex.OP1/2) has been an IOCM (inter office communication memo) and it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured and in the absence of the same these cannot enforced upon them at the stage of settlement of reimbursement claim(s).         

17.     Finally, the OP3 Health Department vide its affidavit (Ex.OP3/1) have duly deposed on the strength of the Govt. Notification (Ex.OP3/2) that the complainant’s claim had been eligible for reimbursement under the rules as disclosed by the OP1 (and the OP2 TPA) insurers to the insured through the various Punjab Govt. Departments.

18.     In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party1 insurers to reimburse the medical expenses incurred by the complainant but only up to the Standard-Expenses settled with the Network Hospitals for the treatment of the ailment suffered/ treatment undergone by the complainant within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment. The parties here shall themselves bear their costs. 

19.     Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.

                                                                           (Naveen Puri)

                                                                                   President.                                                                                               

ANNOUNCED:                                               (Jagdeep Kaur)

February 07, 2018                                                             Member.

*MK*