Delhi

North East

CC/68/2015

Sh. Kapil Jain - Complainant(s)

Versus

Asstt. Dir/ Medical - Opp.Party(s)

09 Apr 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 68/15

 

In the matter of:

 

	Sh Kapil Jain House No. H-41 Naveen Shahdara Bird Hospital Wali Gali Delhi-110032	Complainant
	Versus
	Asst. Director (Medical) Employees State Insurance Co. ESIC HQ Office, Panchdeep Bhawan C.I.G. Marg New Delhi-110002	Opposite Party

 

DATE OF INSTITUTION:       JUDGMENT RESERVED ON:               DATE OF DECISION      :

20.02.2015 09.04.2019 09.04.2019

 

 

N.K. Sharma, President

Ms. Sonica Mehrotra, Member

Order passed by Ms. Sonica Mehrotra, Member

 

ORDER

1. Facts of the case, as emanating from the material on record, as concisely put are that the complainant is a beneficiary Employee State Insurance Company (ESIC) i.e. of OP vide ESIC IP/ Insurance No. 3304767708 which covers the complainant alongwith the dependents i.e. his family members including his mother (relevant for the purpose of complaint), his wife and his unmarried daughter. The complainant’s mother was a senior citizen aged 60 years and was suffering from cancer of cervix with hydronephrosis malignancy stage III and he was the sole bread earner in the family with limited and humble salary. On diagnosis of his mother’s critical ailment / disease, when she was shown at ESIC dispensary, the complainant admitted her at Shanti Mukand Hospital, Delhi on 30.01.2014, 20.02.2014 & 05.03.2014 and on respective dates bills of Rs. 33,112/-, Rs. 58,140/- & Rs. 2,01,533/- were raised by the said hospital and paid by the complainant.  The complainant raised a written request for reimbursement of said bills with OP. However, the OP only cleared / approved the second bill of Rs. 58,140/- on CGHS rate and issued a cheque no. 054723 of Rs. 39,477/- dated 15.10.2014 drawn on SBI Najafgarh Branch, Delhi in favour of the complainant. However, the OP, vide letter dated 05.02.2015 to the complainant rejected reimbursement of first and third bill of          Rs. 33,112/- & Rs. 2,01,533/- on grounds of having been declined by the committee with approval of competent authority with the reason that the patient should have attended ESI Hospital Basaidarapur for complaint and would have been referred to empanelled hospital from there as was planned procedure requiring prior permission. Therefore, feeling aggrieved by such arbitrary rejection of reimbursement by OP, the complainant alleging deficiency of service on the part of OP filed the present complaint praying for issuance of directions to OP to reimburse the first and third bill totaling Rs. 2,34,645/- alongwith interest @  10 % from issuance of bills till payment and compensation of  Rs. 20,000/- for mental, physical and financial hardship and Rs. 10,000/- towards litigation expenses.
2. The complainant had attached copy of ESIC ID alongwith list of dependents with respective UHIDs, copies of admission & treatment records of complainant’s mother at Shanti Mukand Hospital from 30.01.2014 to 07.05.2014 where she underwent chemotherapy and radiation for cancer of cervix stage III with the Department of Radiation Oncology and bills raised by the hospital dated 30.01.2014 for Rs. 33,112/-, on 20.02.2014 for Rs. 58,140/- and on 05.03.2014 for Rs. 2,01,533/-. The complainant had also attached the discharge summaries issued by the said hospital by Department of Obstetrics / Gynaecology and medical bills, copies of lab investigation expenses and other related medical documents of his mother undergoing treatment in the said hospital. The complainant has also attached copies of internal letters dated 28.08.2014, 30.09.2014 and 05.02.2015 written by Directorate (Medical) Delhi, ESI scheme to IMO incharge, ESI dispensary Seelampur, New Delhi informing of returning of bills of the complainant with remarks that the patient should have attended ESI hospital for her complaints located at Basaidarapur but she got admitted to private hospital without any prior intimation and therefore reimbursement was not permissible as per competent authority. The complainant has lastly attached the rejection letter no. DMU-16 / 51 / 38 / - Med-II dated issued by OP to him dated 05.02.2015 intimating rejection of approval / passing / payment of first and third bill of Rs. 33,112/- and Rs. 2,01,533/- respectively on grounds mentioned in the internal letters as aforementioned. The complainant filed authorization letter on behalf of his mother to pursue the present complaint due to his mother health issues being a cancer patient.
3. Notice was issued to the OP on 09.03.2015 and due to address being incomplete, fresh notice was issued vide order 27.04.2015 and as per track report, OP was served on 09.09.2015 and was granted last opportunity to appear on 12.11.2015. However, OP failed to appear on the said date and was therefore proceeded against ex-parte vide order dated 12.11.2015.
4. Complainant filed ex-parte evidence by of affidavit and written arguments on 18.12.2015 and 28.02.2018 respectively reiterating his grievance of non reimbursement of first and third bill by OP without any cogent reason in arbitrary manner.
5. On hearing held on 23.05.2018, this Forum had directed the complainant to place on record the list of empanelled hospitals with OP for the period 2014 since the rejection of payments of bills by OP was on the ground of treatment taken in unempanelled hospital for the relevant period. In compliance of the said order, the complainant filed list of empanelled centers for oncology treatment with Directorate (Medical) Delhi in which list at serial no. 5 the name of Shanti Mukand Hospital appears with period of empanelment 14.08.2011 to 31.03.2013 with medical facility of medical oncology, surgical oncology and radiation therapy and the said hospital shall offer all such facilities to the ESI beneficiaries at its Diagnostic Centre at CGHS rates. It was also mentioned in the terms of agreement that the validity of contract will be for 2 years from 01.07.2013 to 30.06.2015 and the empanelled centers shall provide service on cashless basis to referred ESI beneficiaries at ESI rates. The complainant also placed on record, the copy of print out of the list of empanelled hospital for super specialty treatment under ESI scheme featuring Shanti Mukand Hospital at serial no. 1 for Oncology specialty with validity up to 30.06.2015 alongwith copy of circular no. 111-U/ 17/11/15/SST/Med-II dated 13.04.2016 issued by Additional Director, Directorate (Medical), featuring Shanti Mukand Hospital at serial no. 24 on the said circular for Oncology and Oncosurgery as Selected Specialty Service. Complainant also filed additional written arguments submitting that ESIC Act has been made to provide medical care to its beneficiaries and dependence but due to non cooperation of OP and rejection of valid and legal bills of the complainant, the complainant was made to suffer and in the intervening period, also lost his mother on 19.09.2016 and filed her death certificate issued by MCD.
6. OP entered appearance on 12.09.2018 alongwith letter dated 04.12.2017 issued by Director (Medical), ESI’s Dispensary with instruction to appear in the present complaint and prayed for setting aside ex-parte order. However, in view of this Forum not having power to review its own order, the plea was not entertained and OP prayed for time to approach Hon'ble State Commission for seeking appropriate relief. The matter was posted for oral argument on 07.12.2018 on which date none appeared on behalf of OP and the matter was posted for ex-parte final argument to be addressed by the complainant on the next date i.e. 09.04.2018.
7. We have heard the arguments addressed by the complainant and have thoroughly perused the documentary evidence placed on record before us. The OP had reimbursed the second bill of Rs. 58,140/- on CGHS rate vide cheque of Rs. 39,477/- issued on 15.10.2014 for the complainant’s mother’s cancer treatment expenses and pertinently, the complainant’s mother had undergone her entire cancer treatment at Shanti Mukand Hospital from January 2014 till May 2014 and all three bills were raised by the same hospital. We see no reason why the OP passed one bill of the said hospital and rejected the other two bills of the same hospital on ground of it being unempanelled and no prior permission sought for taking treatment and instead the patient should have been taken to ESI Basaidarapur Hospital. The said defence / ground taken by the OP is falsified / negated by the documents placed on record by the complainant before this Forum on 27.07.2018 regarding Shanti Mukand Hospital being duly empanelled with ESIC under the Directorate (Medical) Delhi for relevant period 2014. Therefore in our considered view, the rejection of the first and third bills by OP was arbitrary, illegal, unjustified, whimsical, unsubstantiated and without any cogent reason and such action amounts to deficiency of service and unfair trade practice on the part of OP. The conduct of OP of willful abstention from proceedings for three years and suddenly appearing on 12.09.2018 with a department letter seeking reinstatement of defence and again disappearing thereafter does not inspire confidence and speaks volume of its lackadaisical approach and sheer dereliction of duty and callousness and lack of right earnestness of purpose despite having been given sufficient time by this Forum to approach Hon’ble State Commission to get its defence reinstated which it failed to avail of or act upon.
8. We therefore allow the present complainant on merits and direct the OP to refund / reimburse Rs. 2,34,645/- towards first and third bills alongwith interest thereon @ 9% p.a. from the date of filing the complaint till realization. We also direct the OP to pay a sum of Rs. 7,000/- as compensation for mental, physical and financial harassment and Rs. 3,000/- towards cost of litigation. Let the order be complied within 30 days by OP from the date of receipt of copy of this order.
9.  Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
10.   File be consigned to record room.
11.   Announced on  09.04.2019

 

(N.K. Sharma)      President

(Sonica Mehrotra)  Member