ORDER Date: 06-01-2017
Vikram Kumar Dabas, Member
The Complainant is an employee of DVB. It is alleged that OP has been entrusted with the task of providing free medical treatment to its employees and their family members on the analogy of CGHS scheme existing for Central Govt employees. It is alleged by the Complainant that as per DVB service/retirement rules he and his wife were entitled to avail medical benefit from nearby Govt. dispensary for which he had been issued with registration no. 296 at the Govt dispensary situated at Janak Puri. It is alleged by the complainant on 5th June 2012 he was detected as a case of prostate cancer. He had alleged that the disease/ailment was of such a nature which required forthwith examination & tests. He was therefore compelled to receive treatment from Adiva North Point Hospital at Green Park New Delhi where he had got admitted on 12/06/12 for evaluation of high PSA & prostatomegaly. He had submitted bills for reimbursement for the expenses incurred by him in this regard. The Complainant had also taken treatment at M/s BL Kapoor Multi Speciality Hospital, which was also not reimbursed to him. He has alleged deficiency in service on the part of the Ops. Hence the complaint.
The complaint has been contested by the OPs. OP-1 in its written statement has claimed that the complaint is not maintainable as all matters qua medical expense of retired employees of DVB are dealt with by OP 2. It has prayed that the complaint be dismissed.
OP - 2 has filed a separate written statement and has claimed that the present complaint is not maintainable and is liable to be dismissed. Para 3 to 9 of the reply of OP - 2 is relevant for the purposes of decision of this case and are reproduced as under :
3. Without prejudice to the above, it is most respectfully submitted that the facts of the case in brief are that Complainant Sh. Hardev Singh retired from the services of erstwhile DESU as Executive Engineer on 30th June, 1995 and drawing pension and other pensionary benefits from DESU/ DVB and now from DVB ETBF-2002 (Pension Trust) on unbundling of DVB on 01.07.02. The medical facility is provided to employee as part of welfare measures extended to employees and retirees by the employer. These benefits are provided without any contribution in the shape of one time or monthly basis from the beneficiaries Hence, the present issue is not a dispute between vendor and Consumer instead a dispute between the employer and employee on the facilities extended and claim settled as per the rules and procedure.
4. The complainant Sh. Hardev Singh approached the opted dispensary in Janakpuri in the routine manner on 12.06.20 12 and the Medical Officer of Janakpuri, BRPL dispensary referred his case to Govt./panel hospitals as per the procedure. Sh. Hardev Singh inspite of knowing the rules and procedures clearly and the availability of hospitals has opted for taking treatment from non-paneled hospitals at his Own will and choice. However Sb. Hardev Singh availed medical treatment from Adiva hospital and later from B.L Kapoor Hospital by diverting from the Prevailing procedures when facilities are available at
Govt, empanelled /listed hospital.
5. The panel hospitals except those mentioned as Premier Institution have given their consent that they will provide treatment as per CGHS Guidelines and they will charge CGHS approved rates for the patients referred by the designated dispensary. The category 2 hospitals, viz. Premier Institutions hospitals are either offering CGHS rates only for certain specified procedures or not offering it at all. In such cases where the beneficiary who wish to go to Category 2 hospitals Premier Institutions) as per their own choice/preferences the reimbursement is restricted to CGHS approved rates even if the hospital is charging their Own rates as indicated in the order dated 31.12.2013. The above order has been circulated widely
and is in the knowledge of all concerned.
6. That presently there are sixty hospitals empanelled for the DVB pensioners which includes hospitals specialized in Cancer Treatment also. In addition to above Rajiv Gandhi Cancer Institute, Rohini and AIIMS are exclusively earmarked for cancer treatment. In addition the beneficiaries can avail treatment for any type of disease from number of hospitals established by GNCTD at various location of Delhi. Further the beneficiaries can avail treatment from hospitals identified as premier hospitals with the condition that prior approval shall he obtained and all payments shall be limited to CGHS approved rates. Treatment for
cancer and related issues are available in these hospitals.
7. That the answering defendant is a Pension Trust, which has a fixed corpus and to pay within the permitted terms and conditions and no extra payment can be made at the cost of the Trust funds and other co beneficiaries. The Trust is thus a body with limited funding and not unlimited resources. The answering respondent cannot disburse in transgression of its charter and Trust Deed and Rules and the Trusts Act. The Hon’ble Supreme Court has even in a recent judgment in the case of State of Punjab & others Vs Ram Lubhaiya Bagga & Others 1998(4)SCCI 17 held regarding the primacy of availability of funds and resources being the most vital fact in matters even of medical reimbursement The claim of the claimant is thus liable to be rejected at the outset. In any case, without prejudice to the above, it is submitted, that as per K.R. Jam judgment (reported as 2010 (4) SCALE 546),
clarifies that entire liability of DVB has been transferred to DISCOMS / transferee.
8. No special dispensation against the rules and against what is applicable uniformly for thousands of beneficiaries can be carved out in this case. All legal and permissible claims have thus been charged. Rules cannot be molded/ broken to fit individual opinions and bad precedents cannot be permitted be set out in any case, especially at the cost of other co-members of the Trust, as any undue enrichment beyond the rules from the trust (which is a body with fixed/limited resources) would lead to loss of Trust Funds, contrary to the provisions of law and rules. The case has no merit and hence deserves to be dismissed as against the answering respondent.
9. That the complainant has not been able to show as to how he is entitled in excess of the CGHS guidelines and applicable rules. This is without prejudice to the submission of the Trust, that since unlike the CGHS Scheme, the present benefits are non contributory after the retirement, the dispute cannot be covered in any case under the Consumer Protection Act.
OP - 2 has contested the case on merit. It has stated that the complainant was reimbursed the expenses as per rules and nothing more is payable to him. It has prayed that this complaint be dismissed.
In the evidence the complainant has reiterated the content of the complaint by way of affidavit. The OPs in their evidence by way of affidavit have corroborated the contents of their written statement.
We have heard arguments advanced at the bar and perused the record. It is admitted by the complainant that he was an ex-employee of DVB and is getting benefits of the reimbursement of medical expenses from OP - 2 under the rules frames from time to time by it. In the present case as per the complainant he was detected as a case of prostate cancer on 05.06.2012. He had then got himself evaluated in a pvt. hospital i.e. Adiva North Point Hospital at Green Park Extension on 12.06.2012. It is therefore, clear that it was not a case of emergency and the complainant could have got his treatment from any empanelled hospital as per the scheme evolved by OP2. Similarly he had got himself treated at BL kapoor Multi Specialty Hospital where as he could visited the empanelled hospital for his treatment. It is therefore clear that the complainant had taken treatment at non empanelled hospital at his own choice without there being any case of emergency as alleged by him. The Ops have relied upon the judgment of the Hon’ble Supreme Court State Punjab and others V/s Ram Lubhaya Bagga and others which supports the case of the Ops. We are therefore of the considered opinion that there was no merits in this complaint which is hereby dismissed.
Copy of the order be sent to the parties as per rules. File be consigned to Record Room.
Announced on this ………………
