Chandigarh

DF-I

CC/748/2019

Uttam Kaur - Complainant(s)

Versus

Additional Director, Central Government Health Scheme, (Ministry of Health & Family Welfare, Govt. o - Opp.Party(s)

Devinder Kumar

03 Dec 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/748/2019
Date of Institution	:	24/07/2019
Date of Decision	:	03/12/2019

 

1. Uttam Kaur w/o Sh. Ravinder Singh, resident of #50, Good Earth Colony, Patiala (Punjab).
2. Ravinder Singh s/o Sh. Jaswant Singh, resident of #50, Good Earth Colony, Patiala (Punjab).

… Complainants

V E R S U S

Additional Director, Central Government Health Scheme (Ministry of Health & Family Welfare, Govt. of India), Kendriya Sadan, 4^th Floor, Sector 9-A, Chandigarh–160009.

… Opposite Party

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                

ARGUED BY	:	Sh. Devinder Kumar, Counsel for complainants
	:	Ms. Sharmila Sharma, Counsel for OP with Dr.Rajneesh Singhal, CMO (NFSG)(R&H), Authorised Representative of OP.

 

Per Rattan Singh Thakur, President

1.      The long and short of the allegations are complainants No.1 & 2 are wife and husband respectively. Complainant No.1 had retired from Punjab Govt. service while complainant No.2 had superannuated from CRPF. Complainant No.2 before superannuation had subscribed to membership of Central Govt. Health Scheme (CGHS) and paid lump sum amount of Rs.60,000/- for life membership.  Complainant No.1 was earlier drawing fixed medical allowance and later on gave up the said option alongwith complainant no.2 and enrolled themselves with the OP and as such they happens to be the consumers of the OP.

         The case of complainants is complainant No.2 on 22.3.2017 suffered stroke/cardiac arrest and approached the PGIMER Chandigarh as outpatient in the Department of Cardiology and was treated accordingly. Complainant No.2 again suffered cardiac arrest and under emergency was admitted in PGIMER, Chandigarh on 11.12.2017 and discharged on 17.12.2017. Under compelling circumstances he had to purchase medicines from the authorized medical store for treatment. He also took treatment for knee joint pain and skin allergy from Govt. Hospital, Sector 16, Chandigarh.

         Complainant No.1 also suffered from severe cardiac arrest and in emergency was admitted in PGIMER, Chandigarh on 6.3.2017 and after coronary angioplasty treatment discharged on 11.3.2017.  The case of the complainants is, complainant No.2 submitted different bills for medical reimbursement totaling Rs.44,642/- in respect of complainant No.1 and Rs.50,518/- in respect of himself. These were the genuine claims and besides it complainants also claimed other bills of treatment of Govt. Hospital, Chandigarh and the claim of medicines prescribed while she was abroad. The OP did not reimburse the bills being outdoor patient and was not reimbursable under the rules. Reference was made to various case laws. Hence, the present consumer complaint for directing the OP to pay total sum of Rs.1,04,543/- towards medical expenses alongwith compensation of Rs.1,00,000/- and Rs.25,000/- as litigation expenses. 

2.     OPs contested the consumer complaint and furnished its reply. Its only defence is, per relevant rules and instructions, bills as OPD patient were not reimbursable. However, the items for Rs.9,792/- and Rs.646/- were passed and sent to the Pay and Accounts Office, New Delhi (CDDO) for payment.  Besides it, claimed complainant No.2 happens to be a Member of the District Forum, Chandigarh and should have been aware of the rules. On these lines, the cause is sought to be defended.
3.     Replication was filed and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the parties and gone through the record of the case. After perusal of record, our findings are as under:-
6.     Per pleadings of the parties and documents submitted, complainants had taken the membership of the OP on payment of Rs.60,000/-. As such, there is no dispute with respect to the fact of they being the consumers and the OP happens to be the service provider.
7.     Per pleadings of the parties, there is confusion in the allegations made in the consumer complaint whereby claim of the treatment in Govt. Multi Specialty Hospital, Chandigarh was also referred alongwith the treatment prescribed by the US doctor.  However, specific claim which was acceded to by the complainant as we could make out from the consumer complaint is Rs.44,642/- with regard to complainant No.1 and Rs.50,518/- in respect of complainant No.2. In the pleadings of the OP, it reimbursed or ordered reimbursement of bill No.1 in respect of complainant No.1 Rs.9,792/- and in respect of complainant No.2 Rs.646/-. Thus the amount which remains to be paid with respect to complainant No.1 is Rs.34,850/-(44642 – 9792) and Rs.49,872/- (50518 – 646) in respect of complainant No.2. We will confine the discussion and appreciation of the evidence with respect to these amounts only. 
8.     As per pleadings these bills were submitted and as per OP also the aforesaid amount was reimbursed and remaining was repudiated as being outdoor patient and was not reimbursable as per rules. This is what we could make out from the pleadings of the parties and we will confine our discussion to these amounts.  Other amounts were also referred, but, it seems not to have been submitted and if there were other amounts the cause of action was different. We hold so.
9.     The complainants are retired Government servants and pensioners and are in the autumn of their lives, being senior citizens. Complainant No.1 per record is 62 years old and the age of complainant No.2 is nearing 65 years. Offending reply was made in the written reply, of this is a welfare scheme for retired Government servants.  We do not agree with this contention as the complainants had rendered qualifying service minimum exceeding 20 years and, therefore, they were entitled to pension and medical reimbursement is also allowed to the pensioners. It is not for the welfare, but, in lieu of the untarnished qualifying service rendered, entitled them for the payment of the pension and medical reimbursement.
10.     The object behind the grant of medical reimbursement alongwith pension is during the discharge of public functions in the course of employment of government service, Govt. servant maintains the probity and honesty and works in the larger interest of the public on behalf of the society at large and need not to worry regarding the financial insecurity with regard to the medical treatment part in post retired life.  It appears with a view Government servant may not deviate to other ways to the detriment of public at large. It is a sort of security provided to the public servant so that he walks on right path in the betterment of the people at large on whose behalf they act for the society.
11.     Per pleadings of the parties, part amount of the two bills has already been ordered to be paid. This itself shows, the claim was genuine one and not only this the treatment was taken allegedly under compelled circumstances for her treatment as indoor patient and then post operative care.  A perusal of the few of the bills though not gives proper calculation reflects these were claimed as indoor patient and outdoor patient and few of the bills i.e. to say Annexure C-6/A was verified and countersigned by the Department of Cardiology, PGI, Chandigarh.  Annexure 6/B also countersigned by Prof. Yash Pal Sharma, Head, Department of Cardiology, PGI Chandigarh.  Annexure 6/C and 6/D signed by the Sr. Resident, Department of Cardiology, PGI, Chandigarh and there is reference of OPD as well as indoor treatment. The OP in its written reply had not clarified or to say that only indoor treatment medicines were reimbursed and not other medicines though it was connected with the indoor treatment of heart ailment which, if not treated on time, results could be fatal.
12.     Per pleadings of the parties and the evidence led, emphasis is on denial of claim due to the reason as per Rule, claim of OPD is not reimbursable. Reference could made to Annexure OP-1 i.e. circular, relevant portion of which is reproduced below :-  

         “…… Despite the instructions, this Ministry has been receiving number of requests for reimbursement of cost of medicines purchased by CGHS beneficiaries for OPD treatment. In order to avoid unnecessary reference to this Ministry it has been decided to reiterate that OPD medicines purchased by CGHS beneficiaries are not reimbursable and they should be got issued by the beneficiaries from the concerned CGHS dispensary.  This may be brought to the notice of all Govt. servants.”

 

13.     A mere perusal of the notification shows, there is a blanket ban and OPD medicines purchased by CGHS beneficiaries are not reimbursable and they should be got issued by the beneficiary from the concerned CGHS dispensary. On one hand, OP claims the defence of this rule and partly then reimburses the amount without clear cut segregation and its proved/admitted case being verified by PGIMER, Chandigarh an institute of repute that this was a genuine claim.  Assuming this rule is to be made applicable then in that eventuality even to an OPD patient medicine is to be issued, but, in the present case neither they passed the bill nor issued the medicines which the complainant had rightful claim so that they could have after taking the medicines as per their entitlement returned it to the chemist concerned and take the money back so that no loss is caused to them. Neither the bill was passed nor the medicines were issued so in the post retired life they were put to loss.
14.     Per reply furnished and arguments advanced, medicines which are recommended by Govt. hospital in the OPD are disbursed through the OP by taking it from the company or from the market at a discounted price.  Even no attempts were made to compare the price of the medicines after discount with the price which the complainant had spent from the local market so as to hold Govt. was being put to loss and deny the claim which is over and above the discounted price.
15.     Per pleadings of the parties and the evidence led, it has not been detailed in the reply, medicines which were prescribed by the PGI to the complainant were in their stock at the relevant point of time for disbursement.  Even the medicines were not supplied. In a similarly situated proposition, the Hon’ble Delhi High Court in case titled as Kamlesh Sharma Vs. Municipal Corporation of Delhi & Anr., 2003 (66) DRJ 237 under paragraph No.10 held as under :-

“10. Let me now analyze and consider the present case in the light of the foregoing judicial pronouncements and principles as enumerated. The petitioner being a retired employee was entitled to avail of medicines and diagnostic facilities, free of charge at the hospitals and dispensaries. The office order also provided for specialised treatment on priority basis from hospitals. It is not in dispute that in the instant case the treatment was obtained from the prescribed and recognised hospitals and dispensaries. This is apparent from the essentiality certificates issued by the Hindurao Hospital and the Post Graduate Medical Institute of Sciences, Rohtak, and the AIIMS. The question with which we are faced is of reimbursement of the cost of medicines prescribed by the Doctors of recognised hospitals, where the petitioner's deceased husband was receiving treatment. The medicines were not available in stock and were considered essential and required for treatment. The hospital and medical authorities had the obligation to purchase/provide the medicines within a reasonable time as per office order. Reasonable time would depend upon the exigency of requirement. In case it is an emergency, then the patient is certainly not expected to wait for a reasonable time as per the usual procedure. In such situations, the attendants of the patients or family members are not expected to follow the procurement procedure and are left with no option but to purchase the same. Reference is invited to the observations of the Supreme Court in Surjit Singh v. State of Punjab noted earlier. In the instant case, the hospital authorities have certified that the said medicines were not available and had recommended the bills for reimbursement. The respondents have not paid the same on account of Clause 2, I am of the view that Clause 2, which puts an absolute ban on reimbursement of expenditure incurred by a pensioner on treatment is arbitrary, irrational and liable to be struck down, as violative of Article 14 and 21 of the Constitution of India. The said clause is wholly inconsistent with other provisions and seeks to negate the obligation on the part of the MCD as provided for in the office order, namely to provide treatment and medicines free of charge and especially the obligation to purchase medicines, if not available in the hospital stock within a reasonable time. Once the obligation to purchase the medicines, not available in the stock and to provide them to the patient within a reasonable time is there, the said right cannot be taken away by providing a ban on reimbursement. The said clause is wholly arbitrary and irrational. Accordingly Clause 2 of the office order is struck down, in so far as it imposes a complete ban on reimbursement of medical expenditure. By striking down Clause 2 of the aforesaid office order, it should not be understood as whittling down the right of the respondents to frame or formulate a policy including one providing a restriction or ceiling on reimbursement of expenses as long as the said policy is not violative of Article 14 and 21 of the Constitution of India.”

 

As such, a complete ban was held to be unconstitutional. This ratio is being made applicable to the present case. Even the medicines were not given by the OP to the complainants so that they could return it to the chemist and taking the money back, if they so desired.

16.     Not only this, even in the case titled as Shiva Kant Jha Vs. Union of India, II (2018) CPJ 19 (SC) in the case of Central Govt. Health Scheme under paragraph No.13 at page 23 it was held as under :-

          “13) It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/ Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.”

 

The Hon’ble Apex Court had held the only criteria is pensioner or Government servant ought to have taken treatment and the claim should not be denied merely on technicalities of rule or law.

17.     Furnishing a reply that at one point of time, complainant No.2 happened to be a Member of the District Forum will not disentitle him from his claim particularly for the reasons that even for a Member/staff of the Consumer Forum, legal recourse is to be taken i.e. the District Forum or the civil court wherever the remedy lies and there is no special Tribunal established for a Member/ staff of District Forum to make such a legitimate claim before that Tribunal. Hence, we are least influenced by this argument and we have to strike a balance even in the case of a Member/staff of a District Forum. Hence, we conclude deficiency in service on the part of OP.
18.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under :-

1. to reimburse the amounts of Rs.34,850/- and Rs.49,872/-, as detailed above, to complainants No.1 & 2 respectively alongwith interest @ 9% per annum from the date of denial of claim till realization.
2. to pay an amount of Rs.15,000/- to the complainants as compensation for causing mental agony and harassment to them;
3. to pay Rs.10,000/- to the complainants as costs of litigation.

19.     This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
20.     The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
03/12/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President