JANGEER CHAND Vs. STATE OF PUNJAB AND OTHERS

JUDGEMENT

(1.) The petitioner is aggrieved against the decision of respondent No. 5 by which his medical claim has been negated on the ground that his claim documents have been received after 60 days from the date of discharge.

(2.) In brief, the Government of Punjab has issued a scheme called Bhai Ghanhya Sehat Sewa Scheme 2014-15. Under the said scheme, a tripartite agreement was executed on 13.11.2013 amongst United India Insurance Company Ltd. [UIIC], M.D. India Health Care Services (TPA) Pvt. Ltd. [TPA] and Bhai Ghanhya Trust [Trust] for the benefit of its members. A number of government and private hospitals were approved by UIIC or TPA by executing MOUs wherein the members of the Trust can have their cashless medical treatment or can get reimbursement after verification of documents through TPA. As per Clause 6.1.6 of the Agreement, TPA or UIIC is to settle the package rates with network hospitals as per Trust Schedule of rates and as per package code No. 990, Fortis Hospital is to conduct cashless bye-pass surgery at a prescribed rate. Respondent No. 4 to 6, in their reply, have reproduced Clause 6.1.6 of the agreement, which read as under:-

(3.) It is averred that the premium was paid by the Trust to UIIC and accordingly, insurance policy w.e.f. 16.5.2014 to 15.5.2015 was issued for the members of the Trust. The petitioner is also covered by the said medical insurance scheme during the period 2014-15. It is averred by the petitioner that on 30.11.2014, he suffered triple vessel disease and was in emergency admitted in Fortis Hospital, Mohali. He had a bypass surgery on 2.12.2014 and was discharged on 9.12.2014. At that time, the petitioner was covered by the medi-claim policy which was valid from 16.5.2014 to 15.5.2015. The petitioner paid medical expenses/bills of an amount of Rs. 3,63,583/- to the Fortis Hospital, Mohali. It is submitted that on 23.1.2015, while the petitioner was recovering from the earlier treatment mentioned here in above, suffered with Cholelithiasis (stones in gallbladder) for which the doctors at the Fortis Hospital put stunt in his gallbladder. The report of the medical treatment dated 23.1.2015 is also enclosed with the petition. The petitioner for the purpose of claiming reimbursement, as per the mediclaim policy, approached respondent No. 4 by submitting claim form but instead of accepting the same respondent No. 4 raised an objection regarding completion of documents but nothing was conveyed to the petitioner about the limitation. The petitioner, in compliance with the objections, submitted all the documents but again an objection was raised regarding compact disc of angiography. Ultimately, after completion of the documents, the form of the petitioner was accepted by respondent No. 4 on 28.2.2015 but vide letter dated 30.4.2015, the petitioner was informed that his case has been rejected by respondent No. 5 only on the ground that the documents submitted by him are after 60 days of discharge. The petitioner made a representation, served legal notice and finally filed the present petition for reimbursement of the medical claim.