DebasisBhattacharya:- PRESIDING MEMBER
Being aggrieved by and dissatisfied with the service extended byCentral Government Health Scheme (hereinafter referred to as OP) of the address as mentioned above,in the matter of reimbursing of a claim for medical expenses related to the medical treatment of the Complainant himself, the instant case has been filed by the complainant, u/s 35 of the Consumer Protection Act 2019.
The brief facts of the case are as follows.
The complainant, being a retired Central Government employee and a pensioner, contributed an amount of Rs.39,030/- to avail medical services from the OP for the lifetime and thus became a beneficiary of Central Government Health Scheme (hereinafter referred to as CGHS) having a specific ID number.
However, having been severely indisposed, the Complainant had to take admission in a nursing home of Chandannagore Hooghly on 17.01.22, and the expenses the Complainant had to incur for the treatment undertaken by the said nursing home was to the extent of roundabout Rs.87,000/-. The Complainant was discharged from the nursing home on 23.01.22.
Being a beneficiary of CGHS, the Complainant submitted a Medical Reimbursement Claim of Rs.86,206/- and the same, primarily received by the concerned wellness centre of CGHS i.e. the first recommending authority bearing no.KO10 at BBD Bagh, Kolkata-700069 was forwarded to the concerned Additional Director of CGHS for further processing on 15th February 2022.
But allegedly the claim remained pending since the date of submission of the claim without any status, even after 65 days.
Here the Complainant refers to a judgment of the Hon’ble Apex Court where it was directed that Medical Reimbursement claim of pensionersshould be settled within thirty days.
Simultaneously the Complainant refers to Ministry of Health and Family Welfare’s office memo dtd 14.05.2018 which was issued in pursuance of the Hon’ble Apex Court’s directive as mentioned above in the WP (civil) No. 694 of 2015 in the case of Shiva Kant Jha vs. Union of India.
The Complainant considers this as disregarding of the order of the Apex Court.
Keeping the medical reimbursement claim of the Complainant pending for a substantial time in violation of the order of the Apex Court and the circular of the Department of Health and Family Welfare caused mental agony and harassment for the Complainant. Thus he has been compelled to approach to this Commission for admission and allowance of the Complaint.
Considering the treatment extended by the OP as deficiency of service, the complainant submits a prayer before this Commission to impose direction upon the OP to reimburse the claim in full, to pay Rs.15,000/- for sufferings and mental agony, Rs.10,000/- towards litigation costand ‘penalty’ @ Rs.3,000/- per day in respect of the period for which the claim was kept pending beyond the normal waiting period of 30 days.
However in the evidence on affidavit the Complainant admits to have received an amount of Rs.52, 535/- (Rs.47,050/- on 06.06.2022 and Rs.5485/- on 13.07.2022) against his original claim of Rs.86,206/-. The deduction is claimed to be unreasonable.
Balance claim of Rs.33,671/- is claimed to have been deducted by the OP unjustifiably.
The Complainant along with his petition has annexed copies of 1) evidence in support of payment of CGHS subscription of Rs.39,030/-, 2) relevant filled up medical reimbursement claim form, 3) SMS received from CGHS authority, 4) application under RTI Act dtd.22.02.2022, 5) judgment of the Hon’ble Apex Court as referred above, 6) Memorandum of Ministry of Health & Family Welfare and consequent office memo delegating powers for settlement of reimbursement claims, 7) Medical bill calculation sheet, 8) Discharge summary, 9) communication made to the Additional Director CGHS and 10) office memo of the Department on clarification regarding admissible/non-admissible itemsin respect of a particular claim.
In view of the above discussion and on examination of available records it transpires that the complainant is a consumer as far as the provisions laid down under Section 2(7)(ii) of the Consumer Protection Act 2019 are concerned.
The complainantis a resident within the district of Hooghly.
The claim preferred by the complainant does not exceed the limit of Rs.50,00,000/-Thus, this Commission has territorial as well as pecuniary jurisdiction to proceed in the instant case.
The issues related to the questions whether there was any deficiency of service and whether the complainant is entitled to get any relief, being mutually inter-related, are taken together for convenient disposal.
The OP has contested the case by filing written version, evidence on affidavit and brief note of argument.
In the first five paragraphs of the written version certain routine allegations have been made so far as the complaint petition is concerned.
To illustrate,
- The Complaint is not maintainable in its present form and prayer
- There is no cause of action
- The Complainant has got no right to file this Complaint
- The whole story of the Complaint is not tenable
- The case is defective for non-joinder and mis-joinder of parties and
- The Complainant has distorted and suppressed the material facts.
However, no clarification is furnished as to why these routine and somewhat irrelevant allegations are leveled.
Materials on records are perused.
Now the OP in their written version, evidence on affidavit and brief notes of argument repeatedly claim that CGHS facility is extended to pensioners on account of the Government service rendered and CGHS facility is not provided to any public on payment of CGHS contribution. Therefore the CGHS facility is service related matter and not a consumer related matter and therefore the complaint deserves dismissal.
As regards delay in reimbursement of the claim filed by the Complainant the OP explains that after receiving the claim documents on 14.02.2022 the same was forwarded to the Additional Director CGHS Kolkata on 22.02.2022 after provisional checking at the concerned wellness centre.
The OP further clarifies that the concerned medical reimbursement bill was duly put in the queue as medical reimbursement claims of pensioners are processed for payment serially as received and found correct. But against the backdrop the pandemic the number of such claims was increased manifold. Apart from this, a special relaxation was given to purchase medicines from outside CGHS and to get the same reimbursed. The OP claims that on account of receipt of such medicine purchase reimbursement bills to a great extent the processing of medical reimbursement claims was delayed. However the admissible amount of Rs.47,050/- was credited to the Complainant’s account on 06.06.2022. Subsequently a further amount of Rs.5485/- was credited to the Complainant’s account as per revised calculation.
Thus, the OP assigns the reasons for delay in processing the claim of the Complainant to submissions of large number of claims against the background of Covid 19 pandemic, the policy of first come first serve and exhaustion of budget at the end of the financial year.
The OP asserts that there was no willful neglect in processing of the medical claims and there was no intention to disregard the order of the Hon’ble Apex Court.
The OP has annexed the calculation sheet and the revised calculation sheet in connection with the extent of entitlement of the claim filed by the Complainant.
As regardsthe deductions from the original claim, the OP clarifies that the calculation was done by designated Medical Scrutiny Committee as per extant rules and reimbursement was done as per CGHS rate.
Besides, it is further explained that the balance amount of Rs.33,6761/- could not be reimbursed as it included certain charges made by the hospital over and above the CGHS admissible rates and there were certain items reimbursement towards which was not admissible as categorized by CGHS. Moreover it is pointed out that the hospital in which the Complainant was treated was not a CGHS empanelled one and charges were much higher than CGHS admissible rates.
The Complainant on the other hand claims that there was baseless deduction of charges towards certain medical items by the OP while preparing the calculation sheet.
The Complainant has annexed office memorandum dtd.01.08.2013 on the subject ‘Clarification regarding admissible non-admissible items under CGHS’
Now the focus of the instant case lies on three issues. Firstly, whether the Complainant, as a retired Central Government employee as well as a pensioner, is entitled to file a complaint petition before this forum against CGHS, a Central Government organization. Secondly, whether the deductions from the original medical reimbursement claim was justified. And thirdly the delayed disposal of the Medical Reimbursement claim of the Complainant.
So far as the first issue is concerned, there was a unanimous decision of a full Bench of National Consumer Disputes Redressal Commission (NCDRC) comprising of its President Justice M. B. Shah, members Rajyalakshmi Rao, B. K. Taimni, Justice K. S. Gupta, Justice S. N. Kapoor and P.D. Shenoy in which retired Central Government employees were held consumers under the CGHS scheme and conferred a right on them to sue the Centre for damages in case of deficiency in health care provided to them and their dependents.
The question before the NCDRC was “whether a pensioner and beneficiary of the CGHS would be a consumer under the Consumer Protection Act 1986 for alleged deficiency in service by the CGHS Medical officer.
Answering in the affirmative, NCDRC said medical treatment facilities extended to a retired employee under CGHS could not be termed as “free service” as it was in consideration of service rendered by him to the Government till the age of superannuation, which conferred a right on him to get pension as well as other benefits, including medical treatment prescribed by various Rules or the schemes framed by the centre.
“Such employee would be a consumer as defined in Section 2(1)(d)(ii) of the Consumer Protection Act”, said Justice Shah writing for the bench.
In view of the above, this Commission is of the opinion that the Complainant had every right to file his Complaint before this Commission.
Since the treatment of coronavirus had not been included under the active products, these claims made by the subscribers were additional burdens on the books of CGHS especially when not treated at Government hospitals. CGHS had to recalibrate their finances as the number of claims for other diseases had also increased as people suffering fromcritical diseaseslike diabetes respiratory disorder etc were more prone to get diagnosed with coronavirus. Besides,these type of health insurance organizations had to face devastating liquidity challenges.
The health insurance sector faced certain challengesbut it continued to serve its subscribers with modesty and sincerity.
This is a hard reality that the pandemic was a colossal challenge to the entire human civilization and all sectors had to suffer from the impact of the pandemic in one way or the other. Healthcare sectors and health insurance sectors were no exceptions.
The particular juncture in which the claim was submitted before the CGHS authority was also a very sensitive one so far as the global impact of the pandemic was concerned.
Thus the reason assigned by the OP for delayed disposal of the claim of the Complainant is appreciable at least to some extent.
But keeping the verdict of the Hon’ble Apex Court and the circular of the concerned Department in mind, inference may be drawn that there was violation of the order of the Ld. Apex Court as well as the Consequent circular.
As regards the deductions made by the OP from the original claim amount this District Commission cannot be inclined to pass any directive to the OP specifying the quantum of the admissible claim. CGHS authority has to follow certain pre-determined norms and stipulations while deciding the extent to which a particular claim can be allowed. But the Complainant has every right to know the specific reasons for which and the particular heads under which the deductions have been made.
On meticulous scrutiny of all the aspects of the case, this Commission is of the view that there was deficiency of serviceto certain extent on the part of the OP in the matter of timely disposal of the Medical Reimbursement Claim of the Complainant.
Hence it is
ORDERED
that the complainant case no.70/2022 be and the same succeeds on contest but in part.
The opposite party i.e. the Additional Director CGHS (Kolkata) is directed to pay an amount of Rs. 3,000/- for causing mental agony and harassment and further Rs.2,000/- towards litigation cost.
Besides, the OP will also be liable to give an exhaustive and transparent clarification to the Complainant as to the deductions made by them from the original Medical Reimbursement Claim filed by the Complainant. In case of detection of any irregularity, the OP will reopen the claim and take action accordingly.
OP is directed to comply with this order within 45 days from the date of this order. In the event of failure to comply with this order, the opposite party will pay cost of Rs.5,000/- by depositing the same in the Consumer Legal Aid account.
Let a plain copy of this order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgment/sent by ordinary post for information and necessary action.
The final order will be available in the website www.confonet.nic.in
