Sh. Inderjit Aggarwal son of Late Sh. Bal Mukund resident of House No.706, Sector 22-C, Chandigarh.

                                                                   ---Appellant/Complainant.

V E R S U S

Central Government Health Scheme, Inside Homeopathy Complex behind South Police Station, Sector 34, Chandigarh through its Joint Director.

Respondent/OP

Appeal under Section 15 of the Consumer Protection Act, 1986.

BEFORE:   HON’BLE MR. JUSTICE SHAM SUNDER, PRESIDENT.

                MRS. NEENA SANDHU, MEMBER.

S.  JAGROOP  SINGH   MAHAL, MEMBER.

Argued by: Sh. Munish Goel, Adv. for the applicant/appellant.

                    Respondent already ex parte.      

PER  JAGROOP  SINGH   MAHAL, MEMBER

          This is complainant’s appeal against the order dated 20.4.2011 passed by the learned District Consumer Disputes Redressal Forum-II, UT, Chandigarh (hereinafter referred to as the District Forum) whereby the complaint was dismissed.

2.                The brief facts of the case are that, the complainant retired as Senior Audit Officer from the office of AG Punjab on 31.01.1996. It was stated that, Government of India is having a scheme known as Central Government Health Scheme (in short CGHS) for retired officials of Central Government. The complainant after his retirement took a policy under the said scheme and he was issued an Identity Card bearing No.P-0827 and he had been paying the premium regularly. It was further stated that at the time of taking the policy, the complainant was told that he would get free medical treatment from any hospital alongwith medicines. The averment of the complainant was that on 10.04.2009, he was unable to speak and walk properly, therefore, he was taken to the clinic of Dr. Puneet Syal for checkup. Dr. Puneet Sayal advised MRI and other tests/investigations. After perusing the reports, he advised the complainant to approach Dr. Anupam Jindal, Neuro Surgeon at NINS Hospital for further treatment. Accordingly, the complainant visited the said hospital where Dr. Anupam Jindal advised various tests/investigations and after seeing the reports of those tests and investigations, he operated him on 18.04.2009. It was further stated that he remained hospitalized in the said hospital for a number of days and spent a sum of Rs.52,795/- on his treatment. Subsequently, the complainant submitted his claim alongwith all the required bills and other documents,  but to his utter surprise, his claim was rejected by the OP vide letter dated 23.7.2009 on the ground that he had received treatment from a private unrecognized hospital. It was alleged that repudiation of the claim, by the OP was illegal and contrary to the rules framed by the Government of India. It was stated that as per rules, the complainant was entitled to reimbursement even if he had taken treatment from a private unrecognized hospital. Therefore, repudiation of his claim amounts to deficiency in service on the part of the OP. Hence this complaint was filed.   

3.                          In its written reply the OP submitted that Central Government Health Scheme (CGHS) is not an insurance company, so, the question of issuance of policy does not arise. It was denied that the complainant had paid any premium for the alleged policy. According to the OP/respondent, the Central Government employees are entitled to medical facilities for which comprehensive provisions are contained in Civil Services (Medical Attendance) Rules, 1944. It was stated that CGHS was introduced to provide comprehensive medical care facilities to the Central Govt. employees to do away with the cumbersome and expensive system of reimbursement of medical expenses, that the complainant joined the said scheme on his retirement on payment of subscription at the prescribed rates, which were nominal charges. As per the said Scheme, the basic requirement for taking treatment was that the beneficiary must avail of all the medical facilities/treatment from the Central or State Govt. hospitals and the hospitals, which are fully funded by the Central Govt. or the State Govt. besides the private hospitals recognized by the government  under CGHS. As per instructions contained in letter dated 18.03.1992, CGHS does not reimburse treatment taken from private unrecognized hospitals, except, in cases where treatment had been taken in private unrecognized hospitals in an emergency. In the present case the complainant took treatment from NINS Hospital, Chandigarh which was an unrecognized private hospital. He remained admitted in the said hospital from 18.04.2009 to 21.04.2009 for (R) Fronto pariental Burrhole & Evaculation of ch. SDH. It was alleged that the complainant was well aware of his illness in the past as per submissions made by him in the complaint and after undergoing various tests/investigations he was got operated on 18.04.2009. Thus, the treatment was not emergency treatment, it was a well planned surgery. It was further stated that  as per instructions issued by the Central Government, a Local Level Committee was constituted to ascertain as to whether the treatment taken by the complainant was emergency treatment or not. The said Committee also opined that the treatment taken by the complainant was not emergency treatment. Thus the claim of the complainant was declined. It was further stated that there was no illegality in repudiation of the claim. Denying all other allegations of the complaint, the OP prayed for the dismissal of the complaint.

4.                          Parties led evidence in support of their case. 

5.                          After hearing the ld. Counsel for the parties and on going through the evidence on record, the ld. District Forum dismissed the complaint, as stated in the opening para of this order

6.                          Feeling aggrieved, the instant appeal has been filed by the appellant/complainant.

7.                          Despite due service neither the OP nor any legally authorized representative appeared on its behalf. Hence it was proceeded ex parte.  

8.                          We have heard the ld. Counsel for the appellant/complainant and have perused the record carefully.

9.                          The learned Counsel for the complainant/appellant has argued that in fact it was a case of emergency, which has not been appreciated either by the OP or by the learned District Forum and that the complainant was entitled to the reimbursement of the medical expenses incurred by him on his treatment. On the other hand the case of the OP/respondent is that a Member of the Central Government Health Scheme (CGHS) is entitled to reimbursement for the treatment taken in Central or State Govt hospitals and in the hospitals approved by the Centre or State Governments. According to the OP/respondent there is an exception to this Rule as contained in Annexure OP-1, that where treatment had to be taken in private unrecognized hospitals in an emergency, the reimbursement could be allowed. Annexure OP-2 is the order vide which Heads of Departments were empowered to decide the cases of reimbursement of medical claim in respect of treatment obtained in emergency at private hospital/private nursing home/private clinic. It was further decided vide Annexure OP-3 that, if there is any doubt as to whether a particular case constituted an emergency, a local level Committee of Medical Officers should be set up to ascertain the same. Further case of the OP/respondent is that in the present case neither the Head of the Department considered it as an emergency nor the said Committee. Annexure OP-4 contains the minutes of meeting of the said Committee and the name of the complainant/appellant is at serial No.4. After seeing the entire documents submitted by the complainant it was observed that it was not a case of emergency. This decision of the local level Committee cannot be discarded on the basis of Annexure A-5, which was procured by the complainant on 10.8.2011 from NINS Brain and Spine Hospital after his complaint was dismissed by the learned District Forum. This document never existed and was never produced either before the HOD or before the local level Committee or before the learned District Forum. Such like documents, which had been procured after the decision of the case, cannot be taken into consideration to upset the decision already reached at by the Consumer Fora. Otherwise also in our opinion the document Annexure A-5 cannot overrule the opinion of the local level committee, given vide Annexure OP-4.

10.                       The fact and circumstance leading to the treatment of the complainant also do not make it a case of medical emergency, where the complainant had to get treatment from a private hospital. There is no dispute about it that the complainant is resident of Sector 22-C, Chandigarh. It is not his case if State and Central Govt. Hospitals or fully funded and approved hospitals are not located in Chandigarh.  It was mentioned by him in para No.3 of the complainant that he was in a state of confusion since 10^th April, 2009. He was unable to speak and walk properly. He was taken to Dr. Puneet Syal for check up on 16.4.2009. Why he was taken to Dr. Puneet Syal for check up instead of taking him to a Central or State Government hospital or any hospital recognized by the Centre or State Governments is not explained. Dr. Puneet Syal advised MRI alongwith other tests and sent him to Dr. Shamer
Singh Memorial Radio Diagnostic Centre. He got the various tests conducted on 16.4.2009. The MRI of brain was got conducted on 17.4.2009. He again went back to Dr. Syal with the result of the various tests but did not approach the approved hospitals for the reasons best known to him. It is then mentioned in para No.6 of the complaint that Dr. Syal told him that it was an emergency and needed immediate      surgery.  He  referred  the complainant to  Dr. Anupam  Jindal, where the

complainant appeared on 17.4.2009 in the evening. When it was case of surgery, why the complainant went to Dr. Anupam Jindal instead of going to a Central or State Hospital as required under the CGHS, is again any body’s guess. The complainant was not operated upon on 17.4.2009 but the surgery was conducted on 18.4.2009. There was therefore, ample time at the disposal of the complainant to reach the recognized hospital, if he wanted to get the reimbursement of the expenses incurred by him but he did not.  

11.                     In view of the above facts, we cannot hold it to be a case of emergency. In fact the complainant had sufficient time at his disposal to choose a recognized hospital but instead of approaching a recognized hospital, he went to a private unrecognized hospital, as per his own plan. The OP is bound to reimburse him only, if he satisfies the conditions set out in the scheme for reimbursement. There is no dispute about it that the complainant did not satisfy the said conditions and obviously he would not be entitled to get reimbursement of the medical expenses. We are therefore, of the opinion that the decision of the OP in not allowing the medical reimbursement is based on solid facts, which cannot be assailed by the complainant.

12.                     As a member of the scheme it was necessary for the complainant to comply with the various terms and conditions to get reimbursement of medical expenses incurred by him. If the treatment taken by the complainant is beyond those parameters set up by the OP, the complainant would not be entitled to the medical claim. The learned District Forum therefore, rightly upheld the decision of the OP and dismissed the complaint. We are also not inclined to accept the contention of the complainant and hold that the impugned order passed by the learned District Forum is perfectly legal and valid and does not suffer from any defect. There is no merit in this appeal and the same is accordingly dismissed. Parties are left to bear their own costs of litigation.   

                    Copies of this order be sent to the parties free of charge.

Pronounced.

9.1.2012                                                                       sd/-

[JUSTICE SHAM SUNDER]

PRESIDENT

                                                        Sd/-

[NEENA SANDHU]

MEMBER

                                                                        Sd/-

[JAGROOP SINGH MAHAL]

MEMBER