State Consumer Disputes Redressal Commission
District Education Officer vs Baljit Sharma Through His Legal Heirs ... on 9 May, 2023
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.121 of 2021
Date of Institution : 07.04.2021
Date of Reserve : 28.04.2023
Date of Decision : 09.05.2023
District Education Officer Elementary Education Mansa, District
Mansa.
....Appellant/Opposite party No.4
Versus
1. Baljit Sharma, Peon, O/o District Education Officer (EE)
Mansa, District Mansa through its Legal Heirs:
i) Santosh Kumari Widow of Baljit Sharma S/o Babu Ram
ii) Gauri Sharma minor D/o Baljit Sharma S/o Babu Ram
through her guardian mother Santosh Kumari
iii) Darshana Kumari Sharma, mother of Baljit Sharma S/o
Babu Ram
All residents of Ward No.8, House No.82, Dheer Wali
Gali, Mansa.
......Respondent/Complainant
2. M.D.India Health Insurance (TPA) Pvt. Ltd., Mohali Tower, 1st
Floor, Phase-8B, Branch Mohali 160071 through its
Managing Director.
3. The Oriental Insurance Company Limited, Divisional Office,
Bank Street, Bathinda, through its Divisional Manager.
.....Respondents/Opposite parties No.1 & 2
4. Punjab Health System Corporation through its M.D. State
Institute of Health & Family Welfare, Phase -VI, Near Civil
Hospital, SAS Nagar, Punjab.
.....Proforma respondent/opposite party No.3
First Appeal No 121 of 2021 2
First Appeal under Section 41 of the Consumer
Protection Act, 2019 against the order dated
15.02.2021 passed the District Consumer Disputes
Redressal Commission, Mansa.
Quorum:-
Mr.Harinderpal Singh Mahal, Presiding Judicial Member
Mrs. Kiran Sibal, Member Present:-
For the appellant : Sh.Gurlabh Singh, Deputy D.E.O. For respondent No.1 : Sh.P.K.Kapila, Advocate For respondent No.2&3: Sh.Sahil Abhi, Advocate For respondent No.4 : Service dispensed with vide order Dated 28.09.2021.
HARINDERPAL SINGH MAHAL, PRESIDING JUDICIAL MEMBER This appeal has been preferred by the appellant/opposite party-D.E.O. Elementary Education, against the order dated 15.02.2021 passed by the District Consumer Disputes Redressal Commission (in short 'District Commission'), Mansa, whereby the complaint filed by the complainant under Section 12 of the Consumer Protection Act, 1986 (in short 'the Act') was partly accepted with costs and compensation of Rs.10,000/- against opposite party No.4. Opposite party No.4 was further directed to reimburse the amount of four bills sent by deceased Baljeet Sharma to opposite party No.4 by following the policy of the State Government along with interest @9% per annum from the date of filing of the complaint till realization. It was further directed that complainant No.3 (mother of the deceased) shall get ½ of the First Appeal No 121 of 2021 3 awarded amount and complainants No.1 & 2 shall share rest ½ of the awarded amount.
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.
2. The facts of the complaint are that the Government of Punjab introduced a Cashless Work Insurance Scheme, vide its Notification dated 20.10.2015, Chandigarh, PGEPHIS and was compulsory to all the service employees and pensioners, who are covered under the existing Punjab Medical Attendant [CS(MA)] Rules 1940. As per the agreement between the Insurance Company and Government, the policy was to start from 01.01.2016 and initially upto 31.12.2016 and enrollment was to start from 31.12.2015. The complainant (now deceased), who was serving as Class IV employee in the office of District Education Officer (Ele. Edu.) Mansa, also sent his enrolment form along with other staff members. The Insurance Scheme was to provide coverage for meeting all expenses relating to the hospitalization of beneficiary member upto Rs.3 lacs per family per year in any of the empanelled hospital/nursing home and if the sum insured of Rs.3 lacs per family is exhausted, the coverage of the family shall be met from the sum insured of Rs.25 crore available to each and every beneficiary of the group on group floater basis, maintained by the Insurance Company. In May, 2016, the complainant (now deceased) got admitted in Amar Hospital, Patiala due to breathing disease, where he remained admitted from 19.05.2016 to First Appeal No 121 of 2021 4 06.06.2016, later on was admitted to Pragma Hospital, Bathinda and remained admitted there from 06.06.2016 to 18.06.2016. The doctor diagnosed his disease as bilateral Pneumonitis with type-II Respiratory failure, sepsis with septic shock, Generalized Anasarea seizure disorder. The patient was discharged on 18.06.2016 with the advise to follow up after 5 days. He again admitted to Pragma Hospital on 02.07.2016 and remained there upto 07.07.2016 and again re-admitted on 09.07.2016 upto 11.07.2016. Both the hospitals were empanelled under the scheme, but they refused to give cashless treatment due to which complainant spent Rs.5,26,000/-. Rs.1,01,389/-, Rs.60,302/- and Rs.10,193/- on his own. Later on, the complainant (now deceased) submitted his claim for the said amount to DEO (Ele. Education), Mansa for further submission to the competent authority for reimbursement on 23.08.2016, which was forwarded to Civil Surgeon, Mansa on 04.10.2016 but the same was returned with the remarks 'claim be reimbursed from Insurance Cashless Scheme'. The complainant submitted his claim to Insurance Company through registered post dated 08.03.2017 but the Insurance Company neither provided the cashless treatment nor reimbursed the expenses incurred on the treatment at the said hospitals, which compelled the complainant to file the complaint before the District Commission against the opposite parties and seeking the following reliefs:
i) to reimburse the total claimed amount i.e. Rs.6,97,884/-
along with interest @18% per annum and;
First Appeal No 121 of 2021 5
ii) to pay Rs.50,000/- as compensation for mental and physical harassment and expenditures incurred on the litigation.
3. Upon notice, opposite parties appeared and filed their replies separately.
4. Opposite parties No.1 & 2 filed their joint reply taking preliminary objections that the complainant is not consumer of the answering opposite parties, as there is no contract existed between the beneficiary and answering opposite parties. The agreement, if any existed with the Punjab Govt., who have not been impleaded as a party and the answering opposite parties has contractual liability towards the Punjab Govt. only. The complainant has no cause of action and locus standi to file the complaint and is bad for mis-joinder and non-joinder of the parties. The complaint is vexatious to the knowledge of the complainant. The complainant has suppressed the material facts from the District Commission and has not approached the Commission with clean hands. It is further pleaded that opposite parties No.1 & 2 have been impleaded just to create the jurisdiction, therefore, no cause of action has arisen at Mansa. As in PGEPHIS rules, it is provided in Para 21 of Dispute Resolution & Grievance Redressal that dispute between the beneficiary, TPA & Insurance Company is to be resolved by the District Level Grievance Redressal Committee comprising of Deputy Commissioner, Civil Surgeon, Deputy Medical Commissioner & Representative of Insurance Company. The complainant was not enrolled as a beneficiary with MD India First Appeal No 121 of 2021 6 and when he was not enrolled as a beneficiary, TPA was unable to register the claim, as such question of providing cashless card does not arise. The persons who could not enrolled themselves as beneficiary due to any reason whatsoever with the MD India till 31.12.2015, the Punjab Govt. vide Notification No.21/28/12- 5HS/758236/1 dated 20.05.2016 has extended the period for enrolment till 30.06.2016 and this was the last opportunity for them to get enrolled. The Punjab Government had also approved a scheme that beneficiaries were also entitled for medical treatment reimbursement as per the existing State Services Rules 1940 through treasury route. On merits, the opposite parties No.1 & 2 have reiterated all the submissions as detailed in the preliminary objections. It is further submitted that the complainant was not required to submit the bills as a beneficiary with the MD India (TPA) i.e. opposite party No.2 directly but through proper channel. The Insurance Company was not provide cashless treatment and the case firstly is to be scrutinized by opposite party No.1 and thereafter the claims is to be sent to opposite party No.2.
5. Opposite party No.3 filed its separate reply taking legal objections that the scheme was introduced for the welfare of employees. The Government has constituted a Grievance Redressal Committee at the District Level as well as the State Level and the complainant has not made any representation to the Committee. The employee has not sought necessary sanction from PHSC before filing the case. On merits, the opposite party No.3 reiterated all the contentions as averred in the legal objections First Appeal No 121 of 2021 7 and denied all the averments as averred by the complainant in his complaint. Lastly, the opposite party No.3 is praying for dismissal of the complaint.
6. Whereas, opposite party No.4 filed its reply and submitted that total 39 enrollment forms along with the complainant's form were sent to the company and the receipt C-1 dated 09.12.2015 is admitted as matter of record. The enrolment form of the complainant was sent to opposite party No.1 within the stipulated time. It was submitted that the answering opposite party on 04.10.2016 sent all 4 bills to Civil Surgeon Office Mansa but the bills were returned with the remarks that claim after 31.12.2015 be reimbursed from insurance cashless scheme, vide letter dated 04.12.2016 and the opposite party returned all the four claims to the complainant, vide letter dated 12.01.2017. The other averments as averred by the complainant in his complaint were denied and prayed for dismissal of the complaint.
7. The complainant filed rejoinder to the reply of opposite parties denying the contentions of opposite parties and reiterated all the averments as averred by the complainant in his complaint. Further, prayed for acceptance of the complaint.
8. The parties led their evidences in support of their respective contentions before the District Commission and after hearing learned counsel for the parties, the complaint was partly allowed, vide impugned order dated 15.02.2021.
First Appeal No 121 of 2021 8
9. Aggrieved by the said order, this appeal has been filed by the appellant/opposite party No.4 for setting aside the impugned order dated 15.02.2021 and to allow the appeal.
10. We have heard the contentions of the parties and have carefully gone through the record as well as written arguments filed by the parties. We have also given our thoughtful consideration to the same.
11. Vide, this appeal, the present appellant/opposite party No.4 has assailed the impugned order of the District Commission, Mansa, whereby the relief has been granted to the respondent/complainant against the appellant/opposite party No.4 and this appeal is levied with the prayer that they are not liable to pay all these expenses as ordered by the District Commission. It is argued that respondents No.2 & 3/opposite parties No.1 & 2 i.e. M.D. India Health Insurance (TPA) Pvt. Ltd. and the Oriental Insurance Company Limited are to reimburse the medical claim of the respondent/complainant. The respondents No.2 & 3/opposite parties No.1 & 2 have not come present to challenge the order of the District Commission, so the only question which survives at the moment is that who is to pay the amount claimed by the respondent/complainant in the complaint towards the reimbursement and what are the liabilities of the parties.
12. Admitted facts are that the Punjab Government has introduced a Cashless Work Insurance Scheme, vide notification No.21/28/12-5HB 5/268 dated 20.10.2015, Chandigarh, PGEPHIS, which was compulsory to all the Government Employees and First Appeal No 121 of 2021 9 Pensioners, who are covered under the Punjab Medical Attendant Rules. For that purpose, State Government selected the Oriental Insurance Company Ltd. i.e. respondent No.3/opposite party No.2 for the reimbursement of cashless medical treatment and as per the agreement between the two, the scheme was in operation from 01.01.2016 to 31.12.2016 and an enrolment for that said scheme was to start from 20.10.2015 and the same was completed on 31.12.2015. The complainant, Baljit Sharma (now deceased) who was at that time working as a Class IV employee in the office of DEO, Mansa and the present appellant said that his enrolment along with other staff members was submitted to the Insurance Company with the requisite documents within the stipulated period through their Drawing and Disbursing Officer, vide receipt C-1.
13. As per this Insurance Scheme, cover was to be provided for meeting all the expenses relating to hospitalization of beneficiary members upto Rs.3 lacs per family, per year in any of the Empanelled hospital, Nursing home and Government Hospitals. In case, the sum assured exceed Rs.3 lacs of the coverage then the remaining amount was to be made from Rs.25 crore stocked available in each and every beneficiary of the group 'on group floater basis' to be maintained by the Insurance Company i.e. respondent No.3/opposite party No.2. In case of serving employees and pensioners, the liability to pay the premium was of the State Government.
14. In the case in hand, Baljit Sharma, Peon (now deceased), was enrolled under the scheme and was getting treatment. He First Appeal No 121 of 2021 10 hospitalized from w.e.f. 19.05.2016 to 06.06.2016 in Amar Hospital, Patiala and then from 06.06.2016 to 18.06.2016 in Pragma Hospital, Bathinda, he again was admitted from 02.07.2016 to 07.07.2016 and then from 09.07.2016 to 11.07.2016 in Pragma Hospital, Bathinda, which was empanelled under the said scheme. Sh.Baljit Sharma, who was insured under this scheme, lodged his claim on 23.08.2016 after getting stable from the disease. The appellant/opposite party No.4 has placed his file with the list of serving employees of DEO, Mansa under the Cashless Scheme for the year 2015, whereas his name figures at Sr.No.7 and the appellant/opposite party No.4 i.e. DEO, Mansa, vide letter Ex.OP- 4/2 requested to respondent No.3/opposite party No.2 - Insurance Company for issuance of card in respect of cashless scheme for taking medical reimbursement. All these facts are also not denied by respondents No.2&3/opposite parties No.1 & 2, while filing their written statement before the District Commission in the corresponding paras of on merits. Meaning thereby, they admitted the fact that they were engaged by the State Government for the PGEPHIS Scheme, which was otherwise compulsory for all the Government employees and pensioners. Though, the contention is raised by respondents No.2 & 3/ opposite parties No.1 & 2 that the claim was not submitted within the stipulated period, which is totally baseless because earlier Sh.Baljit Sharma (now deceased), during his life time lodged the claim on 23.08.2016 with the appellant/opposite party No.4, which is also admitted and this claim was to be paid by respondent No.2/opposite party No.1 as per the First Appeal No 121 of 2021 11 policy as the Punjab Government was under obligation to reimburse the medical claim to its employees and pensioners and employees cannot be made to suffer merely on the ground that the claim was not received within the time. A reference is made to the findings recorded by the Division Bench of the Hon'ble Punjab and Haryana High Court in the case of Waryam Singh Vs. State of Punjab 1996(2) SCT 495 wherein it is held that right to life is not only to protect citizens from being killed, except in due course of law. The State cannot backtrack and deny the benefit of State Policy, providing medical assistance, which forms part of the right to life enshrined under Article 21 of Constitution of India. In the said case, an objection was taken by the respondent that before getting the treatment, prior approval was not taken nor the treatment was taken from the approved hospital and the reimbursement of medical expenses was declined. The Division Bench held that the petitioner is entitled to medical expenses, as are being charged by the Government and approved hospitals.
15. In view of the law laid down and the authority referred Waryam Singh (supra), it is clear that even if the claim is not lodged well within the stipulated period, even then the genuine claim cannot be denied, as State Government back track and deny the benefit of the State Policy, providing medical reimbursement to its employees, this also burdened on the Insurance Company to reimburse the medical claim of the employees of the State Government who are enrolled under the scheme if they are without any deficiency and if any deficiency is occurred that has to be First Appeal No 121 of 2021 12 looked into by the parent department. Even, the State Government provided some buffer insured amount which lies with the Insurance Company to the extent of Rs.25 crore of every group in a case where the claim filed by employee exceeds more than Rs.3 lacs.
16. With regard to the status of the respondent No.1/complainant (now deceased) being a consumer and the complaint filed under the Consumer Protection Act, it is an admitted fact that the respondent/complainant was working as Class IV employee with the appellant/opposite party No.4, and was enrolled under the PGEPHIS scheme as a government employee, which was compulsory for all the Government Employees, who are covered under the Punjab Medical Attendants Rules, 1940. Since the scheme was for the benefit of all the employees and pensioners of Punjab Government so the Sh.Baljit Sharma/respondent No.1 (now deceased) being beneficiary certainly falls in the definition of Consumer Protection Act, as defined under Section 2(7) of the Act.
17. In view of the above discussions, this appeal is partly allowed and the impugned is modified to the extent that firstly the Insurance Company shall reimburse the medical claim of respondent No.1/complainant within 30 days of the receipt of certified copy of the order, thereafter, if any deficiency remains the other opposite party i.e. appellant/opposite party No.4 will make good the same. The remaining part of the impugned order is upheld.
First Appeal No 121 of 2021 13
18. The appellant/opposite party No.4 had deposited a sum of Rs.5,000/- at the time of filing of the appeal. This sum, along with interest accrued thereon, if any, shall be remitted by the Registry to the District Commission after the expiry of 45 days of the sending of certified copies of the order to them. The concerned party may approach the District Commission for the release of the above amount to the extent of their/its entitlement and the District Commission may pass the appropriate order in this regard, in accordance with law.
19. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(HARINDERPAL SINGH MAHAL) PRESIDING JUDICIAL MEMBER (KIRAN SIBAL) MEMBER May 09th ,2023 parmod