This is an application u/s.12 of the C.P. Act, 1986.
Complainant by filing this complaint has submitted that he is an employee and working for gain with Ikya Human Capital Solution Pvt. Ltd. having its office at 181/1, A.J.C. Bose Road, Kolkata – 700 014 where complainant was working as driver and he is covered under ESI Scheme under ESI Act, 1948 and he has one insurance policy no.4113732060 of ESI Scheme under ESI Act, 1948 and employer of the complainant pays the premium for such insurance scheme, whereas OP is the administrative head and medical officer for such ESI insurance scheme. That apart from having the aforesaid Insurance policy under ESI Scheme the complainant also purchased one separate insurance policy for mediclaim with National Insurance Company Ltd. having policy no.100701/46/11/ 8500000013 for Rs.50,000/-.
Employer of the complainant provides drivers employed by them to various companies who are the clients of the said employer Ikya Human Capital Solution Pvt. Ltd. and for which the complainant was assigned the duty as a car driver by his employer for Microsec Capital Ltd., having its office at Karaya P.S. jurisdiction and on the night of 06-03-2012 when the complainant was asleep, he suffered massive heart pain and he was rushed to B.M. Birla Heart Research Centre at Alipore, Kolkata and was admitted there at about 3.24 a.m. and was diagnosed with Angina Pectoris and on the next date on 07-03-2012 the OP was contacted for providing the name and address of the Government Hospital covered under the ESI Scheme for transferring and admitting the complainant for the said ailment when OP conveyed that no bed is available at that time and also no such medical facility is available for a patient of Angina Pectoris and a patient may be treated at any other hospital and/or any other Nursing Home.
Since the charges of B.M. Birla were exorbitant considering that fact the complainant was admitted on 06-03-2012 and discharged on the same day at 4.45 p.m. when B.M. Birla Heart Research Centre charged Rs.14,744-42 and, thereafter, complainant was shifted to Anandlok Hospital for continuation of treatment and he was released from Anandlok Hospital on 12-03-2013 and for his treatment at Anandlok Hospital he spent Rs.1,22,220/- and also spent Rs.14,744-42 at B.M. Birla Heart Research Centre and total he spent Rs.1,36,964/-. Being cured complainant submitted his claim with National Insurance Company who disbursed only Rs.37,350/- out of which Rs.35,000/- was cashless claim and the remaining Rs.2,350/- was received by cheque.
For getting such benefit of mediclaim from National Insurance Company complainant sent relevant documents to TPA namely Genins India T.P.A. Ltd. at 19, R.N. Mukherjee Road, Kolkata-1.
Subsequently, complainant lodged his claim with the OP for reimbursement balance amount of Rs.99,614/- along with all the documents but no response was received from the OP and also the employer of the complainant wrote a letter to the OP with a request to reimburse the claim but OP remained silent and finding no other alternative complainant through his Ld. Lawyer sent a notice dated 20-11-2012 to the OP calling upon him to settle and reimburse the claim and that was duly served on the OP and thereafter another notice was sent again to the OP on 22-08-2013 but OP did not respond. But as per provision of ESI Scheme complainant is a consumer under the OP but OP failed, refused and neglected to admit and reimburse the claim of the complainant what he is legally entitled to under the said scheme and for causing harassment, mental pain and agony complainant filed this complaint for proper relief.
On the contrary OP by filing written statement submitted that the entire allegation is false. No assurance was given by the OP to the complainant that he may be treated in the hospital and same shall be disposed etc. but it is submitted that no such application for claim of the complainant is available in their office so it can safely be said that complainant did not submit any such claim in proper form before the OP but it is specifically mentioned that if complainant submits the relevant papers of his claim before the Review Committee what efficiently runs for settlement of such reimbursement claims and the review committed will take immediate action for settlement of the claim within the frame work of reimbursement rules. But complainant has failed to make any such claim in proper form to the proper authority for which the entire allegation of the complainant is false and for which the complaint should be dismissed.
Decision with Reasons
On meticulous study of the complaint including the written version and also considering the documents as submitted by the complainant including the admission of the OP it is clear that complainant is covered under Employee State Insurance Scheme and no doubt his Employer-s Code No. is 53000254880001001 and no doubt Jamuna Prasad is the employee of Ikya Human Capital Solutions Pvt. Ltd. But considering the material papers it is found that complainant has failed to prove that he submitted such application along with such materials before the ESI Authority and fact remains complainant himself failed to produce original documents along with the claim form. So, considering that fact and also the version of the OP it is clear OP has stated very rightly that complainant never produced original documents before the OP authority for considering his case for review in view of the fact that he already enjoyed mediclaim for such ailment. So, such a claim can only be decided by Review Committee as per scheme but complainant did not file all these original documents to the Review Committee and or did not file such application properly duly endorsed by the employer.
Considering the above facts we have gathered that there is or was no deficiency on the part of the OP and OP is willing to dispose the same subject to decision of the review committed in respect of his entitlement of claim whether as per law he is entitled to get the same when he has already enjoyed another insurance policy claim from insurance company. Considering the above facts we are directing the complainant to submit fresh application along with documents to the OPs 1 and 2 authority for reviewing his case for consideration and in this regard invariably OP1 shall have to help the complainant so that complainant may file the fresh application along with all documents to the OPs1 and 2 for reviewing the claim of the complainant in respect of disbursement and OP shall take such immediate step in this regard.
In the result, the final order is passed along with this complaint directing the OP to settle the claim of the complainant with all morality and as per provision of ESI Rules and Regulations.
In the result, the case succeeds.
Hence,
Ordered
That the case be and the same is allowed on contest but without any against the OPs.
Complainant is directed to visit the office of the OPs1 and 2 and to file an application afresh for reimbursement of his claim along with all documents for considering his claim by the Review Committed as per ESI Regulations and invariably on receipt of the said application along with all connected medical document papers OPs1 and 2 shall have to take such positive steps immediately for settlement of the claim of the complainant without any further delay and it must be done within 2 months from the date of receipt of such application made by the complainant to the OPs1 and 2.
For any reasons original documents in support of treatment cannot be filed by the complainant in that case OPs shall have to verify the Xerox copy in support of treatment cost etc. with the authority who issued the original of the same or the GTA who already received the original documents in support of his treatment and it shall be the duty of the OPs in this regard not to claim original document from the complainant but to collect it from the GTA or from Anandlok or from B.M. Birla Heart Research Centre.
Complainant is directed to file fresh application along with all copies of medical treatment sheets at once and OP shall have to help him to fill up the application form properly so that no error shall be there in the application and on receipt of the same OP shall have to settle the claim of the complainant within two months from the date of receipt of the complainant-s application and OPs1 and 2 are hereby directed to submit report about the final result of the settlement of the claim of the complainant as per direction of the Forum and after two months if it is not complied in that case penal action shall be started against the OP and in that case penalty and other fine may be imposed and even this Forum shall have its power to direct the OP to pay certain amount as final settlement of claim. Total matter shall be under the control of this Forum for giving further direction and order if required. OPs to report to the Forum if OPs faces any problem for settling this matter within stipulated period.
