Chandigarh

DF-II

CC/268/2016

Tarsem Singh - Complainant(s)

Versus

Addl. Director, Central Government Health Scheme - Opp.Party(s)

R.P.Sharma Adv.

08 Feb 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	268 of 2016
Date  of  Institution	:	21.04.2016
Date   of   Decision	:	08.02.2017

 

 

 

Tarsem Singh, Sr.Citizen, aged 77 years, resident of House No.4144, Sector 56, Chandigarh.  

             …..Complainant

Versus

 

1]  Addl.Director, Central Government Health Scheme, Kendriya Sadan, 4^th Floor, Sector 9-C, Chandigarh.

 

2]  Silver Oaks Hospital, Phase-IX, Mohali.

 

….. Opposite Parties  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH             MEMBER 

        

 

Argued by:-

            Sh.R.P.Sharma, Counsel for the complainant.

            None for OP No.1.

            OP NO.2 exparte.  

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant, a Senior Citizen and Central Government Pensioner, became member of Central Government Health Scheme (hereinafter referred to as ‘CGHS’ for short) and was issued CGHS Card NO.P-1673 entitling him and his wife CGHS benefits valid for whole life (Ann.C-1).  It is averred that on 3.1.2013, the wife of complainant Late Smt.Pushpa Kaur remained admitted in Silver Oaks Hospital (OP No.2) from 3.1.2013 to 8.1.2013 where she was operated upon for cataract and discharged in stable condition on prescribed medication.  It is averred that again she was got admitted in OP NO.2 Hospital on 11.1.2013 under proper sanction of the CMO In-Charge and remained admitted as an indoor patient from 11.1.2013 to 29.1.2013 and after proper medical treatment, she was discharged in a stable condition on prescribed medication. It is submitted that on completion of medical treatment, two medical bills dated 27.1.2013 and dated 14.2.2013 for Rs.38,269/- and Rs.1635/- respectively (Totaling to Rs.39,904/- ) were submitted for re-imbursement with OP NO.1 (Ann.C-2 & C-3). However, the wife of the complainant unfortunately expired on 2.2.2013.  The Opposite Party NO.1 after scrutinizing the bills, passed the medical reimbursement for Rs.19,268/- after deducting a major amount of Rs.20,636/- (Annexure C-4). Thereafter, the complainant made representation to the OP No.1 for wrongful deduction of Rs.20,636/- and sent reminders dated 26.7.2013 and 19.8.2014 under registered post, but to no avail.  The complainant also issued legal notice dated 17.10.2014 in this regard to Opposite Party No.1 and to Secretary to Govt. of India, Ministry of Health & Family Welfare. When the grievance of the complainant remained unaddressed, the complainant filed the present complaint.

 

2]       The OP No.1 has filed reply stating that the case of the complainant relates to Department of Neurology, as per Discharge Summary, for which the OP No.2 was not empanelled under CGHS at that time.  It is stated that Smt.Pushpa Kaur (wife of the complainant) was admitted in Silver Oak’s Hospital from 3.1.2013 to 8.1.2013 under the consultant Dr.Sanjay Mishra, Neurophysician for the treatment of Epileptic attack. It is also stated that the Hospital charged non-CGHS rates from the complainant and the complainant at his own will paid the charges in cash.  It is further stated that it is nowhere mentioned in the discharge summary that the wife of the complainant was a CGHS beneficiary. It is submitted that the medical reimbursement claim for Rs.38,269/- was processed and passed for payment of Rs.18,056/- as per CGHS rates/rules.  It is also submitted that the admissible amount, as per CGHS Rates, was paid to the complainant.

        It is pleaded that Smt.Pushpa Kaur was again admitted in Silver Oak’s Hospital from 11.1.2013 to 29.1.2013 and the hospital gave him credit facility for treatment.  It is also pleaded that complainant submitted a medical bill for Rs.1635/-, which was processed and payment of Rs.1212/- was made as per CGHS Rules/Rates. It is further pleaded that the medical claims of the complainant were processed and reimbursed as per admissible CGHS Rates/Rules. Pleading no deficiency in service and denying rest of the allegations, the OP No.1 has prayed for dismissal of the complaint.

         The Opposite Party No.2 did not turn up despite service of notice through regd. post, hence it was proceeded exparte vide order dated 6.6.2016.

 

3]       Parties led evidence in support of their contentions.

4]       We have heard the ld.Counsel for the complainant and have also perused the entire record.

 

5]       The coverage of the complainant & his wife (now deceased) under Central Government Health Scheme (hereinafter referred to as ‘CGHS’ for short) valid for whole life, is duly proved on record. The present case pertains to two claims raised by the complainant for the reimbursement of the expenses incurred by the complainant for the treatment undergone by his wife on two different occasions i.e. from 3.1.2013 to 8.1.2013 and from 11.1.2013 to 29.1.2013 for which he paid an amount of Rs.38,269/- and Rs.1635/- respectively.  The complainant in the present complaint disputed about the less settlement of the above claims by OP No.1, claiming that the treatment was taken in an empanelled hospital i.e. OP No.2 under the Central Govt. Health Scheme of OP No.1 and thus entitled to full claim.

 

6]       In nutshell the main issue for discussion is whether the complainant is entitled for full refund of the amount, he spent on the treatment of his wife or not?

         It is duly admitted by Opposite Party NO.1 that the Hospital-Opposite Party NO.2, wherefrom the wife of the complainant undergone treatment on two different occasions, as mentioned above, is duly empanelled under CGHS, Chandigarh, vide Govt. of India, Ministry of Health and Family Welfare, vide Office Memo NO.S11011/23/2009-CGHS-D.11/Hospital Cell/Part-IX, dated 1st Nov., 2011.

 

7]       The only stand of OP No.1 is that the reimbursement claims raised by the complainant were duly processed and passed as per CGHS Rates/Rules and thus, are not deficient in service. Opposite Party NO.1 also claimed that Opposite Party No.2 was empanelled for ‘General Purpose including Cardiology, Cardiovascular & Cardiothoracic, Surgery and Joint Replacement.’ and as the case of the wife of the complainant related to the department of Neurology (as per the Discharge Summaries) for which the OP NO.2 was not empanelled under CGHS at that time.    

 

8]       In order to clarify the stand of Opposite Party NO.1, we have gone through the annexures referred by it and from the bare perusal of the same, it is nowhere established that OP NO.2 was only empanelled for providing treatment for cardiology, cardiovascular, cardiothoracic and joint replacement and thus cannot be interpreted in the sense that OP NO.2 is not empaneled for treatment of ailments relating to Neurology.  

 

9]       The Opposite Party NO.1 has failed to place on record any of the document revealing that the documents annexed were ever brought into the notice of the complainant i.e. beneficiary under the CGHS.    Also the OP No.1 failed to place on record the copy of an agreement entered into between Director, CGHS and OP No.2 to justify its stand. It is added that the complainant is otherwise also entitled for the full reimbursement as per the rules of CGHS, as on both the occasions, the wife of the complainant was admitted in the Hospital i.e. OP NO.2 under emergency condition and for such view, we are guided by the following judgments, placed on record:-

a)  Inderjit Aggarwal Vs. CGHS – 2010(1) CLT 432 (Chandigarh State Commission)

b)  Dr.D.K.Jain Vs. UOI, decided on 6.3.2099 by Central Administrative Tribunal (Principal Bench)

c)  District Project Coordinator Vs. Vidhya Devi – 2014(1) COJ 384 (NC).

 

10]      From the above findings as well as settled law, we safely conclude that the complainant is entitled for full reimbursement of the claims and OP NO.1 is duty bound to pay the balance amount, which it deducted wile reimbursing the amount claimed under two valid claims. 

 

11]      Although we have decided the core issue with regard to the less settlement of the claim, but at the same time we cannot ignore and left the issue undecided relating to the deficient services rendered and unfair trade practice resorted to by Opposite Party NO.2, which forced the CGHS beneficiary to pay over and above the package rates.  This factum of overcharging by Opposite Party NO.2 got disclosed vide Ann.C-9 dated 24.10.2014, when in response to the legal notice dated 17.10.2014 issued by the complainant, he was disclosed that the reimbursement claims raised for Rs.38,269/- and Rs.1635/- respectively (Totaling to Rs.39,904/-), were settled for Rs.19,268/- stating that the claims of the complainant were processed as per admissible CGHS Rules/Rates.  This clarifies that the Opposite Party NO.2 charged an excessive amount than the package rates fixed under the CGHS. 

 

12]      Furthermore, the absence of OP No.2 draws an adverse inference that despite having knowledge of the dispute in question, it chose not to appear and it did not come forward to defend the claim of the complainant for the simple reason that either it admits the claim of the complainant or left with nothing to contradict the claim raised by the complainant. Hence, the allegations of the complainant supported by duly sworn affidavit goes unrebutted and unchallenged from the side of OP No.2.

       

13]      In the light of above observations, the present complaint of the Complainant is allowed against the OPs. Accordingly, the OPs are directed as under:-

[a]      The Opposite Party No.1 shall refund the balance amount of Rs.20,636/- to the complainant against his claims;

             However, the OP NO.1 shall have the right to recover the balance amount of Rs.20,636/- from OP NO.2, who charged in excess from the complainant than the package rates and is also at liberty to initiate an appropriate action against it, as deem fit;

 

[b]      The Opposite Party No.2 shall pay Rs.15,000/- to the complainant as consolidated amount of compensation for causing mental agony and harassment for the deficiency in service as well as for resorting to unfair trade practice, including the cost of litigation.

 

         The above said order shall be complied within 45 days of its receipt by the Opposite Parties; thereafter, they shall also be liable to pay interest @9% per annum on the awarded amount from the date of filing this complaint till realization.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

8^th February, 2017                                                                           Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER