Date of Filing : 07.11.2013
Date of Order : 28.04.2016.
DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)
2nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3
PRESENT: THIRU. B. RAMALINGAM M.A.M.L., : PRESIDENT
TMT. K.AMALA, M.A. L.L.B., : MEMBER I
DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II
C.C.NO.346/2013
THURSDAY THIS 28TH DAY OF APRIL 2016
S. Suseela,
13/2, South Road,
West CIT Nagar,
Chennai 600 035. ..Complainant
..Vs..
M/s. Bharat Heavy Electricals Ltd (BHEL),
Power Sector – Southern Region,
Rep. by Senior Manager Personnel,
NO.190, Anna Salai,
Nandanam,
Chennai 600 035. ..Opposite party.
For the Complainant : M/s. Lavanya Shankar
For the Opposite party : M/s.S.Ramasubramaniam & Associates.
Complaint under section 12 of the Consumer Protection Act 1986. Complaint is filed seeking direction against the opposite parties to reimburse a sum of Rs.2,25,612/- towards medical expenses with interest and also to pay a sum of Rs.2,00,000/- as compensation and also to pay Rs.30,000/- as cost of the complaint to the complainant.
ORDER
THIRU. T.PAUL RAJASEKARAN :: MEMBER-II
1.The case of the complainant is in briefly as follows:
The complainant was a spouse of late C.R.Santhanam who predeceased her on 29.10.1995, retired as a Deputy Manager, in Power section (SR) is a member of Retired (24.7.1993) employees Contributory Health Scheme. After the demise of her husband she was continuing the membership with the opposite party (BHEL) and every year in January the retired employee and dependent should revalidate the membership with the employer, accordingly the validations was made by the complainant. The employee of the opposite party was a life member and a consideration for this scheme was accepted by the opposite party and revalidation also made by the complainant. The complainant also stated that every year she was subscribing the validation fee which was required to continue with the retired employees contributory Health scheme. The complainant further stated that she had a fall at her residence on the evening of 29.4.2013, resulting in fracture of her hip. The complainant was a member of retired employees’ Health Scheme provided by BHEL. The details of contribution of the Health scheme to be made by the members and also confirms the payment of fees paid by the complainant. The complainant having fell down from the house had a hip fracture and severe pain where she was residing at West C.I.T Nagar, and she was a senior citizen by age 74 years and having a fall and immediately she was taken to the nearest Apollo Specialty Hospital, Tenampet for immediate attention and treatment. Accordingly the patient was treated by the Apollo Specialty Hospital which is group of Apollo Hospitals and she was admitted on 29.4.2013 and underwent a surgery for Dynamic Hip screw fixation left hip because of “inter trochantric facture” in the left hip on 4.5.2013. When she filed her claim with the opposite party it was declined when she came to know that the opposite party will not reimburse of her claim for left hip fracture, she wrote a letter to the opposite party to reconsider her case, for reimbursement enclosing originals of the discharge summary, final bill and the item wise summary of the entire expense incurred by her at the Apollo Specialty Hospital on 10.5.2013. In the post operative period she took physiotherapy session between May 2013 to August 2013 as per the advice of the hospital authorities, when she claimed reimbursement for the physiotherapy sessions, the opposite party vide letter dated 11.6.2013 and 8.7.2013 repudiated both her hospitalization claim and reimbursement of physiotherapy expenses. The act of the opposite party amounts to deficiency in service which caused mental agony and hardship to the complainant. As such the complainant sought for claim a sum of Rs.2,25,612/- towards reimbursement of medical expenses with interest and also to pay a sum of Rs.2,00,000/- as compensation and also to pay Rs.30,000/- as cost of the complaint to the complainant. Hence the complaint.
Written version opposite party in briefly is as follows:
2. The opposite party denies all the averments and allegation contained in the complaint except those that are specifically admitted herein. The opposite party submit that the complainant cannot be considered as a consumer within the meaning of the C.P. Act 1986 as the present dispute revolves exclusively around employment related benefits and lack any element of a consumer service provider relationship between the complainant and the opposite party. Admittedly the grievances of the complainant stem from her claim that she is entitled to the benefits under the aforementioned health scheme only by virtue of her deceased spouse being a former employee of the opposite party’s company. The complaint is hopelessly non-maintainable and deserves to be dismissed at the very threshold of the basis of this short ground. The opposite party had submitted the Guide lines for beneficiary and retired employees contributory health scheme under para-3.2 hospitalization No.i) Admissble to both Annual and Life member, on referral by the company Doctor. Subject to the applicable Rules which follow hospitalization treatment can be taken at
a) Penal hospital i.e. company Approved hospitals
- CGHS Recognized Private Hospitals / Private Nursing home
- AIIMS / Govt. / PSU, / Defense / Railway hospital
At places where the company doesn’t have its own hospital / Company Approved Hospital and system of registration by Local Health Authorities also doesn’t exist, the retired employees can undergo inpatient treatment at Private Hospitals / Nursing Homes recognized by the State Govt. for the treatment of their employees. The names of Private Hospitals and Nursing Homes so recognized for the treatment of State Govt. employees should either appear in the order issued by the respective State Government or to be availed on their official website. Hence there is no deficiency in service on the part of the opposite party. Therefore this compliant deserve to be dismissed with costs.
3. Complainant has filed his Proof affidavit and Ex.A1 to Ex.A14 were marked on the side of the complainant. Proof affidavit of Opposite party filed and Ex.B1 was marked on the side of the opposite party.
4. The points that arise for consideration are as follows:-
1) Whether there is any deficiency in service on the part of the opposite party?
- Whether the complainant is entitled to the reliefs sought for?.
5. POINTS 1 & 2 :
Perused the complaint filed by the complainant and his proof affidavit and documents Ex.A1 to Ex.A14 were marked on the side of the complainant. Written version and proof affidavit filed by the opposite party and Ex.B1 was marked on the side of the opposite party and also considered the both side arguments.
6. The complainant was a spouse of late C.R.Santhanam who predeceased her on 29.10.1995 retired as a Deputy Manager, in Power section (SR) is a member of Retired (24.7.1993) employees Contributory Health Scheme. After the demise of her husband she was continuing the membership with the opposite party (BHEL) and every year in January the retired employee and dependent should revalidate the membership with the employer. Accordingly the validations was made by the complainant. The employee of the opposite party was a “life member” and a consideration for this scheme was accepted by the opposite party and revalidation also made by the complainant was shown in the Ex.B1 filed by the learned counsel of the opposite party. The revalidation includes the membership for their legal heirs and spouse of retired employee which is not in dispute. The complainant also stated that every year she was subscribing the validation fee which was required to continue with the retired employees contributory Health scheme.
7. It is stated that the complainant had a fall at her residence on the evening of 29.4.2013. It is proved by Ex.A3 that the complainant was a member of retired employees’ Health Scheme provided by BHEL. The details of contribution of the Health scheme to be made by the members were shown under Ex.A4 also confirms the payment of fees paid by the complainant which was shown and confirmed under Ex.A2. The complainant having fell down from the house had a hip fracture and severe pain where she was residing at West C.I.T Nagar, and she was a senior citizen by age 74 years and having a fall and immediately she was taken to the nearest Apollo Specialty Hospital, Tenampet for immediate attention and further treatment. Accordingly the patient was treated by the Apollo Specialty Hospital which is group of Apollo Hospitals and she was admitted on 29.4.2013 and underwent a surgery for “Dynamic Hip screw fixation left hip” because of “inter trochantric fracture” in the left hip” on 4.5.2013. The discharge summary Ex.A8 confirms that the patient had a fall at home and inability to walk and patient was evaluated and diagnosed there was a fracture and surgery was suggested.
8. During the course in the hospital “ a 74 year old female had an alleged history of fall was diagnosed to have left intertrochantric facture after thorough pre-operative evaluation DHS fixation done on 4.5.2013 and the patient was advised to come after one week for review”. The complainant had incurred an expense of Rs.1,88,738.36 which was claimed by the complainant from the opposite party. Because she was a continuous member of the BHEL retired employees contributory Health Scheme which was submitted to this forum under Ex.A1 and the complainant made a claim on 10.5.2013 by submitting all the bills to the opposite party to get it reimbursed. It was informed to the representatives of the complainant that medical reimbursement towards hospitalization will not be acceded because Apollo Specialty hospital is not in the list of approved hospital for Ortho treatment wherein complainant pleaded the opposite party to consider the reimbursement benefit which she is supposed to get it under Ex.A10. The complainant submitted all the relevant bills and prescriptions in Ex.A11 and Ex.A12 on receipt of the above cited documents the opposite party informed to the complainant, “the beneficiary of RECHS have to avail the treatment only from the Panel of doctors/ panel of hospitals / panel of laboratories” and the opposite party declined to give the approval for reimbursement of expenses incurred arising out of this accident. For emergency medical expense the opposite party had restricted Rs.1000/- every year stated in Ex.A14. Having aggrieved by the act of the opposite party the complainant filed this grievance petition before this forum on 7.11.2013 to redress which is within the jurisdiction and within the limitation furnished in the COPRA Act 1986. The complainant prays the forum to give direction to reimburse Rs.1,88,612/- from the opposite party with 9% p.a. interest from 10.5.2013 to till the date of realization and Rs.26,000 for post hospitalization along with interest and Rs.2,00,000/- for mental agony and Rs.30,000/- of cost of complaint.
9. The opposite party is an employer of the complainant’s husband late C.R.Santhanam which was not disputed about the membership in the BHEL retired employees contributory Health scheme and did not dispute about the revalidation of the dependent of the retired / deceased employee of the opposite party. The opposite party had submitted the Guide lines for beneficiary and retired employees contributory health scheme under para-3.2 hospitalization No.i) Admissible to both Annual and Life member, on referral by the company Doctor. Subject to the applicable Rules which follow hospitalization treatment can be taken at
- Penal hospital i.e. company Approved hospitals
- CGHS Recognized Private Hospitals / Private Nursing home
- AIIMS / Govet. / PSU, / Defence / Railway hospital
At places where the company doesn’t have its own hospital / Company Approved Hospital and system of registration by Local Health Authorities also doesn’t exist, the retired employees can undergo inpatient treatment at Private Hospitals / Nursing Homes recognized by the State Govt. for the treatment of their employees. The names of Private Hospitals and Nursing Homes so recognized for the treatment of State Govt. employees should either appear in the order issued by the respective State Government or to be availed on their official website.
10. The contention of the opposite party in their written version and proof affidavit it is stated that the complainant had not taken treatment at the net work hospital provided by the opposite party. Hence the opposite party denied the claim that they have net work facilty with Apollo Hospital, Creams Road, Chennai (for heart ailment) but patient took treatment at Apollo Specialty Hospital, at Tenampet, for fracture in the hip which is an Ortho problem. The contention of the opposite party as per the scheme the beneficiaries should take treatment only to the “net work hospitals” recommended by the opposite party.
11. The opposite party had submitted a citation of NCRC, New Delhi Revision Petition NO.1786 / 2012
Yeshaswini Co-op. Farmers Health Care Scheme
..Vs..
Kuriakose and Ors.
Held that
Civil –Reimbursement – Whether reimburse medical expense of complainants was justified or not – Held, it is well known that ignorance of law,– It is bounded duty of the patient to approach the hospital, only if it is an approved hospital.
The reimbursement of medical expense of complainant was not justified or not ignorance of law was not an excuse it is bound duty to .. the only if it was an approved hospital. It is stated that in the order all the claims must be strictly determined but the cannons of fair play and justice. The issue cannot be ducked in the way, the complainants wants. This fact cannot obscure the fundamental fact that patient is bound to select one of the approved hospital.
12. Hence the opposite party pleaded the averments made by the complainant could not be accepted and pleading this forum that the repudiation of the complainant claim was unconscionable unfair and unlawful. The opposite party treats to dismiss the case with exemplary cost.
13. Pursuant of the complaint filed by the complainant along with proof affidavit , written version, proof affidavit, documents and the citations, filed by the opposite party on the thorough studying made in this case the learned counsel of the complainant argued and stated 1. the complainant was a senior citizen aged about 74 years who was a dependent from others for any execution of work or taking care of her physical movement. 2. The accident / fall in the residence of the complainant is not intentional, it is a furious, uneventful, unforeseen incident resulted in hip fracture. 3. There is no one to help at the time of accident and having received a call, by her son who was out of the residence and who was in employment rushed to the spot and took the patient to nearby hospital for immediate care and attention i.e Apollo Specialty Hospital, at Tenampet which is two to three kilometers away from her residence from where the complainant resides. 4) In the event of any emergency or accident the nomenclature of the human being will rush to the hospital and not searching for the documents where she has to be taken and what procedural aspect the patient has to adhered to 5) in this case, the attendant admitted his mother in the said hospital not aware of the procedure to be followed and after incurring heavy expense then at the later stage, he found out that his mother was covered by BHEL retired employees Health Insurance Scheme. After discharge of patient from the hospital, having came to know the details where the complainant has to file the medical reimbursement, her son took the step in submitting the bills to the employer of his father (BHEL) which was repudiated, based on the grounds’ the patient had not taken treatment with the net work hospital which could not be accepted for payment. 6) The learned counsel argued, at this old age we cannot expect the memory and mental status of the patient will go slow down. Accordingly where abouts of the paper kept in the house and the list of hospitals where she has to undergo treatment could not be remembered and it is not expected to have everything in remembrance. When the documents were in the control of Indian Husband normally the dependent children will take care of the issue. In the event of any uneventful / unforeseen accidents happen to mother. The complainant’s counsel gave a citation referring to VI (2015) CPJ 718 (NC) N.C.D.RC, New Delhi in the case of
RAJASTHAN STATE ROAD TRANSPORT CORPORATION & ANR.
..Vs..
ISHWAR SINGH RATHORE
Under sec 21(b) - the petitioner took just technical ground and without considering the seriousness of patient / complainant repudiated reimbursement of claim - Better health facilities and treatment is fundamental right of each person.
14. It is further stated that if the complainant undertakes indoor treatment of life threatening disease like kidney, heart and some sudden accident in a private hospital outside the State, without reference in case of emergent circumstances, Government may allow reimbursement of the medical expenses incurred upto the cost of treatment, that would have been incurred ..
“The petitioner took just technical ground and without considering seriousness of patient / complainant repudiated reimbursement of claim – Better health facilities and treatment is fundamental right of each person. Hence we take a realistic and not a technical or pedantic view. “
15. Considering the facts and circumstances of the case filed by the complainant, we are of the considered view that the complainant is a senior citizen where she had accident fall resulting in life saving action, the complainant brought to notice of nearby hospital which is Apollo Specialty Hospital, a subsidiary of Apollo Hospitals. The repudiation of opposite party’s decision could not be accepted. It is a fundamental right under article 21 of the Indian constitution where the patient or an individual has got the right to claim right full demands, when they were unfortunate event. The opposite party without considering the seriousness of the patient for complainant repudiated the reimbursement of claim on technical grounds cannot be accepted.
16. We hereby direct the opposite party not by evade, the treatment should have at Apollo Hospital (Heart Treatment only) to have ortho treatment the Apollo Specialty hospital could not be accepted. Considering the age, the dependency, the merit, the genuineness of the claim made by the complainant and the complainant had not received any advance from the opposite party and the repudiation on mere technical grounds will not be accepted. Therefore, we are of the considered view that the opposite party is directed to pay a sum of Rs.2,25,612.05 rounded to Rs.2,25,612/- towards reimbursement of medical expense, with interest at the rate of 9% p.a. from the date of complaint i.e. 7.11.2013 to till the date of payment and also to pay a sum of Rs.5,000/- as litigation charges to the complainant. Considering the facts and circumstances of the case we are not inclined to award any compensation.
In the result, the complaint is partly allowed. The opposite party is directed to pay a sum of Rs.2,25,612/ (Rupees two lakhs twenty five thousand six hundred and twelve only) towards reimbursement of medical expense with interest at the rate of 9% p.a. from 7.11.2013 to till the date of realization and also to pay a sum of Rs.5,000/- (Rupees five thousand only) as litigation charges to the complainant within six weeks from the date of this order.
Dictated directly by the Member-II to the Assistant, transcribed and computerized by her, corrected by the Member-II and pronounced by us in the open Forum on this the 28th day of April 2016.
MEMBER-I MEMBER-II PRESIDENT.
Complainant’s side documents :
Ex.A1- - - Copy of booklet issued by the opposite party.
Ex.A2- - - Copy of Statement of Account reflecting the amount paid
For evalidating the membership.
Ex.A3- - - Copy of Membership card issued under BHEL retired
employees health scheme.
Ex.A4- 22.9.1999 - Copy of Corporate personnel circular No.22 of 1999 issued
By the opposite party.
Ex.A5- 26.7.2000 - Copy of circular recognizing additional hospital for Chennai
Based division issued by the opposite party.
Ex.A6- 29.4.2013 & - Copy of receipts issued by Apollo Hospital.
3.5.2014
Ex.A7- 29.4.2013 to - Copy of inpatient bill break up issued by Apollo Hospital.
9.5.2013.
Ex.A8- - - Copy of discharge summary issued by Apollo Hospital.
Ex.A9- 10.5.2013 - Copy of claim form submitted by the complainant.
Ex.A10- 10.5.2013 - Copy of communication addressed by complainant.
Ex.A11- 10.5.13 to – Series of prescriptions issued by opposite parties.
15.7.13
Ex.A12- 11.6.2013 - Copy of letter of repudiation sent by the opposite party.
Ex.A13- 5/13 to 8/13- Copy of receipts issued by the Physiotherapist.
E.A14- 8.7.2013 - Copy of letter by the opposite party refusing
reimbursement for physiotherapy.
Opposite party’s side documents:
Ex.B1- - - Copy of BHEL Retired Employees’ Contributory Health
Scheme.
MEMBER-I MEMBER-II PRESIDENT.
