State Consumer Disputes Redressal Commission
Oic Ltd vs Rohan Arora And Another on 3 July, 2019
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.657 of 2018
Date of Institution : 20.11.2018
Order Reserved on: 04.06.2019
Date of Decision : 03.07.2019
1. The Oriental Insurance Company Ltd., Madan Mohan Malviya
Road, Amritsar through Branch Manager.
2. MD India Healthcare Services (TPA) Pvt.Ltd., 38-D, Industrial
Area, Phase-I, Mohali, Punjab through Principal
Officer/Chairman/ Managing Director.
Now both through their authorized signatory, Anita Gupta,
Regional Manager, Regional Office, SCO No.109-111, Sector
17-D, Chandigarh.
....Appellants/opposite parties No.3 & 1
Versus
1. Rohan Arora S/o Sh.Vijay Kumar aged 22 years R/o House
No.31, Prof. Colony, Tilak Nagar Shivala Temple Area, Amritsar
Mobile No.97798-93132.
....Respondent/complainant
2. Hargun Hospital Batala Road, Amritsar Phone No.0183-
2579001, 2579002, 9814104262 through Medical Director.
3. Secretary, Health and Family Welfare, Punjab, Chandigarh.
....Respondents/opposite parties No.2 & 4
First Appeal against the order dated
24.08.2018 of the District Consumer
Disputes Redressal Forum, Amritsar.
First Appeal No 657 of 2018 2
Quorum:-
Mr. Rajinder Kumar Goyal, Presiding Member
Mrs. Kiran Sibal, Member
Present:-
For the appellants : Sh.J.P.Nahar, Advocate
For respondent No.1 : Sh.Vijay Kumar, Auth. Rep.
For respondent No.2 : Sh.Sukhandeep Singh, Advocate
For respondent No.3 : Ex-parte
RAJINDER KUMAR GOYAL, PRESIDING MEMBER
ORDER
The instant appeal has been filed by the appellants/opposite parties No.1&3 against the order dated 24.08.2018 passed by District Consumer Disputes Redressal Forum, Amritsar (in short, 'District Forum'), whereby the complaint filed by the complainant was allowed by directing the opposite party No.2 to make the payment of Rs.9,869/- to the complainant and opposite parties No.1 & 3 were directed to make the remaining amount of Rs.95,378/- within one month, failing which opposite parties No.1 to 3 shall be liable to pay interest @ 9% per annum on the aforesaid amounts from the date of filing of the complaint till payment is made to the complainant. Opposite parties No.1 & 3 were further directed to pay Rs.5,000/- as litigation expenses to the complainant. The complaint against opposite party No.4 was dismissed.
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Forum. First Appeal No 657 of 2018 3
2. Brief facts, as averred in the complaint are that the opposite party No.4 implemented a scheme for medical treatment of the employees and pensioners of the Punjab Govt. The said scheme was adopted and implemented by way of its Insurance policies covering the family members. The complainant's father got health benefit mediclaim insurance for himself and his wife Asha Arora and son Rohan Arora vide policy No.231102/48/2016/769 for a total sum insured of Rs.3 lacs from opposite party No.3 by virtue of Punjab Government Employees and Pensioner Health Insurance Scheme covering the risk for the sum assured of Rs.3 lacs. During the policy period i.e. from 01.01.2016 to 31.12.2016, unfortunately on 24.11.2016 the complainant's foot got crushed injury and he was to be hospitalized at opposite party No.2-hospital and the complainant submitted his claim for cashless but opposite party No.2 asked the complainant to pay the entire bill from his own pocket as per instructions of opposite party No.1. An expenditure of Rs.2,20,460/- was incurred on his treatment. At the time of discharge, the complainant and his father requested to opposite party no.2 to hand over the entire medical record so that they can submit the same before opposite party No.1 which they refused to provide the same and assured that their claim would immediately be lodged with opposite party No.1 for reimbursement. It was further averred that all the original bills have been submitted to opposite party No.1 but no acknowledgment has been given. On inquiry, the complainant shocked to see that the opposite party First Appeal No 657 of 2018 4 passed less claim amount of Rs.1,20,778/- as per the status available on website of opposite party No.1. Thereafter, the complainant made regularly personal visits before the opposite parties about issuance of the claim and they put off the matter on one excuse or the other but till the filing of the complainant had not received any such claim amount. It was further averred that the terms and conditions were never supplied by the Insurance Company to the complainant. When the complainant did not hear anything from the opposite parties, he filed the consumer complaint before the District Forum and sought the following reliefs:-
i) to pay full claim amount of Rs.2,20,460/- along with interest @ 12% per annum from 24.11.2016 till realization;
ii) to pay Rs.50,000/- as compensation;
iii) to pay Rs.15,000/- as cost of litigation; and
iv) any other order which the District Forum may deem fit.
3. Upon notice, opposite parties No.2,3 & 4 appeared and filed their separate replies, whereas opposite party No.1 did not appear before the District Forum despite service and, therefore, it was proceeded against ex-parte vide order dated 24.07.2017.
4. Opposite party No.2 filed its reply by taking preliminary objections that the complainant is not covered under the definition of consumer. The complaint is not maintainable either on the facts or under the law against opposite party No.2. The complaint is a gross abuse of the process of the Forum as the complainant has First Appeal No 657 of 2018 5 not approached the District Forum with clean hands. There is no evidence worth its name to show that there is any negligence or deficiency or delay in service on the part of opposite party No.2.
The purported complainant has absolutely no locus standi to file the present complaint under the provisions of the act ibid against opposite party No.2. The complaint is not properly verified. The complainant in his complaint has failed to prove by mentioning in his complaint that in what way opposite party No.2 was negligent or deficient with regard to treatment of the purported complainant or supply of documents for the settlement of the claim. The complaint is bad for mis-joinder/non-joinder of parties. The allegations levelled by the complainant in his complaint are false and frivolous. On merits, it is submitted that as per record of Hargun Hospital, the patient Mr.Rohan Arora was admitted in the hospital on 24.11.2016 vide registration No.8388 with alleged history of train accident with crush injury of left forefoot with near amputation of left fore foot. The patient was operated upon to save his complete foot and limb in the hospital by Dr.Gurinder Singh, plastic surgeon and initially the injured foot had fore foot amputation and then in the second surgery, full ALT Flap coverage was done for the purpose of giving shape to the foot. Most of the best treatment was given to Mr.Rohan Arora in the hospital. Since, most part of the treatment given to the patient was not covered under the policy, in question, there was no question of giving cashless treatment to the patient when major part of it was not going to be reimbursed by opposite First Appeal No 657 of 2018 6 party No.3, therefore, as per the understanding between complainant as well as the hospital, it was agreed that the patient would pay the full hospital bill and whatever claim is settled by opposite party No.1 & 3, the same shall be refunded to the patient. Also the claim of the patient was lodged by opposite party No.2 to opposite parties No.1 & 3, who were hesitant to pay the claim and after receiving the notice in the present complaint, on 05.07.2017, opposite party No.1 vide NEFT to the account of opposite party No.2, transferred Rs.89,713/- without any intimation to opposite party No.2 or without any detail. Thus, they tendered a cheque No.048537 dated 27.07.2017 of Rs.89,713/- in the name of patient. Rest all the averments as averred by the complainant in his complaint were denied and prayed to dismiss the complaint against it.
5. Opposite party No.3 filed its reply taking preliminary objections that there is no privity of contract between the alleged patient and opposite party No.3 since the said patient and his father were not a party to the contract of insurance. The complainant and his father neither got the insurance policy from opposite party No.3 nor paid the insurance premium relating thereto. The present insurance cover was taken by Punjab Govt. from opposite party No.3 for its employees collectively and hence the contract of insurance exists only between the Punjab Govt. and opposite party No.3. The complaint is technically defective as the same has not been filed in accordance with law. The complainant First Appeal No 657 of 2018 7 is estopped from filing the present complaint. The claim is not payable in the light of Notification No.21/28/12-5HB5/268 dated 20.10.2015. As per para No.4 of the said notification "The treatment can be taken by any enrolled beneficiaries in Govt. or in empanelled Hospitals in Punjab, Chandigarh and NCR Area (Gurgaon, Noida and Delhi). No reimbursement will be available to employee/pensioner in Punjab, Chandigarh and Panchkula, where cashless treatment is available.". The complainant himself failed to get the cashless facility. The opposite party-Insurance Company has issued the policy, subject to terms and conditions as envisaged in "The Punjab Government Employees and Pensioners Health Scheme" (in short 'PGEPHIS') by which all the parties i.e. Punjab Govt. Healthcare provider, TPA and Insurance Co. are bound to obey the terms and conditions of the said scheme. The claim of the complainant was non-payable in the light of para no.4 of Notification ibid. On merits, all the contentions were reiterated as detailed in preliminary objections. Rest all the averments as averred by the complainant in his complaint were denied and prayed to dismiss the complaint.
6. On the other hand, opposite party No.4 filed its reply by taking preliminary objections that the complaint is not maintainable before the Forum. The Government of Punjab as per notification dated 21.09.2016 has constituted Grievance Committee at District Level as well as at State Level Committee to redress grievance of the beneficiaries, service provider hospitals, Insurance Company First Appeal No 657 of 2018 8 and other stake holders and as per this notification the decision of the State Grievance Redressal Committee is final and binding on the stake holders. The complaint is bad for misjoinder of necessary parties as the replying opposite party has been unnecessarily impleaded without any cause of action. On merits, all the averments as averred by the complainant in his complaint were denied.
7. The contesting parties produced the evidence in support of their respective averments before the District Forum, which after going through the same and hearing learned counsel appearing on their behalf, allowed the complaint against opposite party No.1 to 3 and dismissed against opposite party No.4, vide impugned order. Hence, this appeal by the appellants/opposite parties No.3 & 1.
8. Notice of this appeal was issued to respondents being complainant and opposite parties No.2 & 4 (respondents No.2 & 3).
9. We have heard learned counsel for the appellants and the respondents No.1 & 2 as respondent No.3 did not appear despite service and was proceeded against ex-parte vide order dated 06.03.2019. We have carefully gone through the records of the case.
10. Learned counsel for the appellants/opposite parties No.1& 3 argued that the order passed by the District Forum is wrong, illegal and against the actual facts of the case. The District Forum has wrongly and illegally directed the opposite parties that opposite party No.2 Hospital will pay Rs.9,869/- and opposite parties No.1 & First Appeal No 657 of 2018 9 3 will pay Rs.95,378/- to the complainant despite the fact that opposite party No.2 did not provide the cashless treatment and submitted a final bill of Rs.1,30,665/- only which was processed and paid for Rs.99,682/-. Opposite party No.2 -Hospital knowingly charged excess amount for the treatment given to the complainant. The opposite party No.2 did not even send pre-authorization request for cashless treatment to opposite party No.1. Opposite party No.2 being an empanelled hospital, was under an obligation to provide cashless treatment to the complainant and should not have charged anything from the complainant. Also, to make wrongful gain from the appellants/opposite parties No.1 & 3, opposite party No.2 provided treatment on higher rates other than the agreed rates between the Hospital, Govt. of Punjab and the Insurance Company and compelled the complainant to take the reimbursement. There is no deficiency in service or unfair trade practice on the part of the appellants. It is prayed that the appeal be allowed and the order passed by the District Forum be set aside.
11. On the other hand, learned counsel for the respondent No.2/opposite party No.2 argued that best treatment was given to the patient/complainant in the hospital. As most of the treatment given to the patient was not covered under the policy, in question, so cashless treatment was not given to the complainant. As per understanding between the complainant and the hospital, it was agreed that the patient would pay the entire hospital bill and First Appeal No 657 of 2018 10 whatever claim is settled by the opposite parties No.1 & 3, the same shall be refunded to the patient. Accordingly, claim was lodged with opposite parties No.1 & 3 and after the institution of the complaint on 05.07.2017, opposite party No.1 vide NEFT transferred a sum of Rs.89,713/- in its account which was in return immediately paid to the complainant. Therefore, there is no deficiency in service on the part of the opposite party No.2.
12. On the other hand, learned counsel for the respondent /complainant argued that there is no illegality in the order passed by the District Forum and it needs no interference. The District Forum has passed the order in favour of the complainant after completely gone through the evidence and material on record. There is no merit in the appeal and prayed to dismiss the appeal with costs.
13. Admittedly, the father of the complainant being Punjab Government Employee, was insured under the Punjab Government Employees and Pensioners Health Insurance Scheme, for cashless treatment upto Rs.3,00,000/-, along with his wife Mrs.Asha Arora and son Rohan Arora, as per ID Card No.MDI5-09779893132, Ex.C-2, for the period 01.01.2016 to 31.12.2016. On 24.11.2016, the left forefoot of respondent/complainant was crushed injury and he was to be hospitalized at the hospital of respondent No.2/opposite party No.2. As alleged by the respondent/ complainant in the complaint that cashless treatment was not provided by the treating hospital and he was forced to pay the First Appeal No 657 of 2018 11 entire bill from his own pocket. The complainant paid a total amount of Rs.2,20,460/- though proved on record Rs.1,95,060/-. It is well observed by the District Forum that the complainant has not produced any receipt showing cash payment of Rs.20,000/- on 24.11.2016 as well as Rs.5,400/- paid to opposite party No.2. Therefore, the complainant has credited Rs.1,95,060/- in the account of opposite party No.2 for his treatment. After the treatment, the claim of the complainant was lodged by opposite party No.2 to opposite parties No.1 & 3 i.e. TPA and Insurance Company along with hospital final bill, medicines and blood test bills as well as admission and discharged card, amounting to Rs.1,30,665/-, whereas the complainant had paid Rs.1,95,060/- as stated above.
14. During the pendency of the complaint in the District Forum, the appellant/opposite party No.3, vide Ex.C-7 settled the claim amount as Rs.99,682/- through opposite party No.2 against the final bill submitted by opposite party No.2 for Rs.1,30,665/-. Whereas the Hospital -opposite party No.2 paid only Rs.89,713/- vide cheque No. 048537 dated 27.07.2017 to the respondent/complainant.
15. Now there are two issues to be decided;
1) Whether opposite party No.3 has settled the claim amount for Rs.99,682/- but paid Rs.89,713/- against the bill raised by opposite party No.2-Hospital for Rs.1,30,665/- is as per PGEPHIS rates/policy or not? First Appeal No 657 of 2018 12
2) Is there any deficiency in service and unfair trade practice on the part of opposite party No.2-Hospital for charging Rs.1,95,060/- and submitting final bill of Rs.1,30,665/- to the opposite parties No.1 & 3 for reimbursement?
16. On perusal of the final bill submitted by opposite party No.2/respondent No.2, claim of Rs.1,30,665/- was to be paid to the complainant as the hospital is an empanelled hospital, therefore, the bill amount of Rs.1,30,665/- is as per the PGEPHIS rates. The table mentioned below shows amount settled by the opposite party No.3 and amount payable by the opposite party No.3 against bill of Rs.1,30,665/-:-
Sr.No. Item Bill raised Bill Payable as Remarks Description by reimbursed per opposite by Opposite PGEPHIS party No.- party No.3- rates 2 - Insurance Hospital Company
1. Room Rent 17000/- 15000/- 17000/- As per ID Card entitlement is for Single AC room
2. Consultation 22440/- 3000/- 22440/-
3. Medicine 64545/- 58478/- 64545/-
Payable
4. Lab 2550/- 2550/- 2550/- as per
5. X-ray 230/- 154/- 230/- PGEPHIS
6. Code 1459 4000/- 4000/- 4000/- scheme
7. Code 1459 4000/- 4000/- 4000/-
8. Code 2061 12500/- 12500/- 12500/-
8. Diet +Bio 3400/- 0 3400/-
Medical Waste Charges Total 1,30,665/- 99,682/- 1,30,665/-
First Appeal No 657 of 2018 13
17. During the arguments, the counsel for the opposite party No.3-Insurance Company agreed to pay the balance amount of Rs.40,952/- (Rs.130665-89713/-) but stated that they cannot pay the excess amount i.e.Rs.64,395/- (Rs.1,95,060-1,30,665/-) as the opposite party No.3-Hospital has not submitted bill for Rs.1,95,060/-, for the reasons best known to opposite party No.3- Hospital. The counsel further stated the opposite party No.2 did not provide the cashless treatment being an empanelled hospital and provided treatment on higher rates other than the agreed rates between the Hospital, Govt. of Punjab and Insurance Co.
18. From the above, it is clear that the complainant/respondent No.1 was charged Rs.1,95,060/- for the treatment, whereas opposite party No.2 presented a final bill of Rs.1,30,665/- to opposite parties No.1 & 3 for reimbursement of claim, which shows that despite being empanelled hospital - opposite party No.2 has committed a gross unfair trade practice with the complainant / respondent No.1 in charging excess amount than rates approved by PGEPHIS. If opposite party No.2 charged Rs.1,95,060/- from the complainant/respondent No.1 then they should have submitted the final bill for the same amount and it is for the TPA and Insurance Company to settle the payable amount.
19. The District Forum while awarding Rs.95,378/- to be paid by opposite parties No.1 & 3 has ignored the fact that when final bill of amount Rs.1,30,665/- was sent to the opposite party No.3 then First Appeal No 657 of 2018 14 how the opposite party No.3 can give the claim amount above the bill submitted to them.
20. In view of the above discussions, the appeal is partly allowed and order of the District Forum is modified to the extent that the appellants/opposite parties No.1 & 3 are directed to pay the balance amount of final bill submitted by opposite party No.-2 i.e. Rs.40,952/- (Rs.1,30,665-89,713 = Rs.40,952/-), whereas opposite party No.2 is directed to refund the excess amount charged i.e. Rs.64,395/- (Rs.1,95,060-1,30,665 = Rs.64,395/-) charged from the respondent/complainant.
21. Both the parties are directed to pay the said amount to the respondent/complainant within a period of one month, failing which, the amount shall attract interest at the rate of 9% per annum from the date of receipt of order passed in the appeal. Rest part of the order passed by the District Forum is upheld.
22. The appellants/opposite parties No.1 & 3 had deposited a sum of Rs.25,000/- at the time of filing of the appeal. They deposited another amount of Rs.50,000/- in compliance of the order dated 19.12.2018. Both these sums, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the District Forum, after the expiry of 45 days of the sending of certified copy of the order to them. The concerned party may approach the District Forum for the release of the above amount to the extent of his entitlement and the District Forum can pass the appropriate order in this regard, in accordance with law. First Appeal No 657 of 2018 15
23. Arguments in this appeal were heard on 04.06.2019 and the order was reserved. The certified copies of the orders be communicated to the parties, as per rules.
24. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(RAJINDER KUMAR GOYAL) PRESIDING MEMBER (KIRAN SIBAL) MEMBER July 03,2019 parmod