DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.783/2008
Sh. Ravinder Singh Pawar
R/o Flat No.A-4,
Shakti Aptts., Sector-9,
Rohini, Delhi-110085 ….Complainant
Versus
1. Central Government Health Scheme
Through Joint Director (Reimbursement)
D-Wing, Ministry of Health & Family Welfare,
Nirman Bhawan, New Delhi
2. Saroj Hospital and Heart Institute
Madhuban Chowk, Sector-14,
Rohini, Delhi
3. Delhi Police Headquarters ITO New Delhi | ……..Performa Party |
……Opposite Parties
Date of Institution : 2008 Date of Order : 07.06.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
S. S. Fonia, Member
O R D E R
Briefly stated, the case of the Complainant is that the Complainant was posted as Public Relations Officer with OP-3; that he suffered two heart attacks in the year 2003 & 2005; that he was suffering from left ventricle ejection fraction (LEVF) and the same being less than 20% he was advised by the doctors at the Escort Heart Institute to go to the nearest hospital in case of emergency for immediate medical attention. On the night of 20.09.2006 he suffered chest pain, palpitation and hot flushes over face and body and it was a continuous sign of heart problem. He was rushed to OP No.2 hospital which was near to his residence. Some investigations were conducted by the OP No.2 such as cardiac catheterization, angiography and after investigations OP No.2 had informed his wife that his life was in danger as his heart was very weak and not able to sustain pumping of the blood required for day to day activities and pace maker was required to be installed permanently. The OP No. 2 also convinced his wife that implantation of AICD which was a very expensive pace maker was required to be attached with the heart and the cost of that article was Rs.5 lacs. OP No. 2 advised that the same amount be deposited immediately for further action. They arranged the money and deposited Rs.5 lacs with the OP No.2 for operation. The operation was conducted and permanent pace maker was installed. The OP No.2 raised a bill of Rs.524135/- which was paid by the Complainant. He submitted the bills for reimbursement to OP No.3 for the repayment of entire amount. The OP No.3 forwarded the bill to Joint Director ( R & H), CGHS Ministry of Health and Family Welfare for approval. He waited for one year but no reply was received from OP No.3. On 23.04.08 he filed an application under RTI Act. On 13.05.08 he received a reply under RTI Act and he was informed that his case was under process. After that he approached the CMO (BRS) Nirman Bhawan, New Delhi through RTI application dated 07.07.08. The Joint Director, CGHS informed vide letter dated 24.07.08 that the Standing Committee of medical expert in the field for AICD implantation did not recommend the implantation and, therefore, the payment was not made to him. The Complainant has further stated that he filed another application under RTI Act on 09.08.08. The Complainant has stated that OP No.2 had advised him wrongly and implanted the pace maker by creating a panic and hence there is unfair trade practice, cheating and deficiency on the part of OP No.2. The OP No.1 or OP-2 is liable to reimburse the entire amount spent by him on his treatment. The Complainant has prayed as under:-
- Direct the OP No.1 or OP No. 2 to pay a sum of Rs.524135/- towards the reimbursement of the medical expense for the deficiency in service and unfair trade practice adopted by them.
- To award Rs.5 lacs on account of compensation for mental agony and trauma suffered by the Complainant.
- To award Rs.22,000/- as cost of litigation expenses.
In the written statement OP No.1 has stated that they had not provided recommendation for AICD implantation from the treating Govt. Specialist in support of his claim. The reasons for offering the treatment at private non empanelled hospital without recommendation of Govt. Medical specialists was not reasonable. Had the Complainant gone to some CGHS empanelled hospital he would have got the appropriate treatment on credit basis even by not paying any amount. If it was a real emergency, the treatment of AICD implantation provided by the OP No.2 was not justified. Had the Complainant availed appropriate treatment of some CGHS empanelled hospital as per the requirement of his medical condition instead of AICD he would have been reimbursed admissible amount as per CGHS rules. OP No.1 has further stated that since the Complainant firstly availed the treatment of an un-approved procedure and secondly, at a non empanelled hospital, thirdly without recommendation of Govt. Medical Specialist, it required the consideration by a standing committee of medical experts in the field and approval of the competent authority. The standing committee of experts consisting of Dr. Vimal Mehta, Assistant Professor Cardiology, GB Pant Hospital, Dr. Rakesh Yadav, Assistant Professor of Cardiology, AIIMS and Dr. Ranjit Kumar, Associate Processor Cardiology, Dr. RML Hospital considered the Medical papers of the Complainant in the meeting held on 10.06.2007 (Copy Annexure R-2) and came to the conclusion that AICD was not justified to be implanted in the Complainant. This was also communicated to the Complainant vide letter dated 22.08.2008. OP No.1 has prayed for dismissal of the complaint with cost.
In the written statement OP No.2 has stated that the complaint is not maintainable in as much as the Complainant had filed an application under RTI Act against his employers and he was not satisfied with the reply and not being reimbursed the amount, the legal practitioner guided him wrongly to file the case against OP No.2. The Complainant was guilty of his own wrong and OP-2 had given best treatment and charged reasonably. Moreover, the complaint contains various triable issues based on elaborate expert opinion and other ancillary tests etc. and, hence, this Forum is not competent to adjudicate upon the complaint.
It is stated that seeing the nature of disease and his condition it was mandatory on the part of OP-2 to treat the Complainant without any delay and as per the report and diagnosis, he was treated and best possible treatment was given to him and he had happily accepted and paid all the charges; now he is unnecessary dragging the OP No.2 in the litigation. It is denied that the report of the Standing Committee is fair or there is any lapse, negligence or deficiency in service on the part of OP No.2. It is also denied that the said treatment was done out of any greed of earning or for creating any panic. The sole responsibility for reimbursement was of OP No.1 & 3 and OP No.2 is not responsible. OP No.2 has prayed for dismissal of the complaint.
OP No.3 has been proceeded exparte vide order dated 20.08.09.
OP No.1 has been proceeded exparte vide order dated 08.03.13
Complainant has filed rejoinder to the written statement of OP No.2.
Complainant has filed his own affidavit in evidence while affidavit of Sh. Suresh Kumar Kangra, Manager Administration has been filed in evidence on behalf of OP No.2.
Written arguments have been filed on behalf of the Complainant and OP No.2.
We have heard the arguments on behalf of the Complainant and OP No.2. We have also gone through the record including original treatment file of the complainant prepared by OP-2 (retained on 1.10.2015) very carefully.
We straightaway come to the question, whether there was any necessity to install the pace maker in the body of the Complainant by OP No.2 and, if so, whether the Complainant is not entitled to any relief?
It is not in dispute that the Complainant was a known heart patient. He had already suffered two heart attacks in the past; he was admitted in OP No.2 Hospital on 20.09.2006 and thereafter one AICD was implanted in his body. He was discharged from OP No.2 hospital on 26.09.2006 and he paid an amount of Rs. Rs.5,24,135/- to OP No.2 towards bill amount. The Complainant submitted the bill to OP No.3 for reimbursement of the bill. The OP No.3 forwarded his case to the Joint Director, CGHS for approval of the bill. As the complainant had got the treatment from OP-2 hospital which was a non empanelled hospital and without recommendation of the Govt. Medical Specialist, Joint Director referred the matter to the Standing Committee of Medical Expert in the field and for approval of the competent authority. The standing committee of experts consisting of Dr. Vimal Mehta, Assistant Professor Cardiology, GB Pant Hospital, Dr. Rakesh Yadav, Assistant Professor of Cardiology, AIIMS and Dr. Ranjit Kumar, Associate Processor Cardiology, Dr. RML Hospital considered the Medical papers of the Complainant in the meeting held on 10.06.2007 (Copy Annexure R-2) opined as follows:-
“The patient has CAD with old anterior wall MI with L.V. dysfunction, Mild MR. He underwent PTCA on 13/07/2006. Late he was admitted on 20/09/2006 with complaint of Ghabarahat & Palpitation. The patient has no documented evidence of VT/VF. Even on Holter, there was no evidence of NSVT/VT. AICD is not justified is this patient.”
Thus, it is evident that the OP No.1 enquired into the matter and constituted a Standing Committee of Medical Expert for Cardiac Device Implantation on 10.06.07. The committee opined that the patient had no documented evidence of VT/VF. Even on Holter, there was no evidence of NSVT/VT, AICD was not justified in the patient.
In our considered opinion, a beneficiary of CGHS is entitled to the treatment even from non-empanelled hospitals in case of emergency and it is the duty of non-empanelled hospitals to check, verify and certify that the patient had been given treatment under emergent condition or emergency in order to save his life and that in case the required treatment was not given to him his life would have been in danger. However, in the present case, we have gone through the original medical treatment record of the complainant prepared by OP-2 hospital and we do not find even a single document which may even throw light that the condition of the complainant was bad or he was required to be given the treatment in emergency and, therefore, the implantation of AICD in his body was necessary in order to save his life. Therefore, in these circumstances, it was the duty of the OP-2 to give to the complainant primary medical aid and then to refer him to a government recognized empanelled hospital for further treatment and management. OP-2 has not filed any expert opinion to the contrary. On the other hand, an application for obtaining independent medical expert Committee’s opinion has been filed on behalf of the OP-2 on 8.6.2015 i.e. after a lapse of about 7 years from the date of filing of the complaint. OP-2 could have easily obtained some medical expert opinion itself and file the same on the record. The Standing Committee of Experts consisting of 3 Cardiologists of the highly reputed Government Hospitals of Delhi considered the case of the complainant on the basis of his medical papers prepared by OP-2 and concluded that the implantation of AICD in the complainant was not justified. Therefore, we cannot easily brush aside or ignore the said report based on cogent evidence. Therefore, we hold that OP-2 had implanted the AICD in the complainant without there being a need to do so only with a view to earn profits. Not only this, the OP-2 also implanted an unnecessary AICD (which must be a metal in the body of the complainant) which in the facts and circumstances of the case was against all medical ethics.
In view of above discussion, it is crystal clear there was no need for implantation of Cardiac Device to the Complainant/patient at least by treating his case not in an emergent condition or emergency. The OP No.2 was not empanelled hospital under CGHS (i.e. OP No.1). If the patient was serious, they should have given first aid treatment and referred him to some other empanelled hospital for further treatment. The treatment of AICD implantation was not required as emergency operation. Therefore, we are of the opinion that the OP No.2 is guilty of unfair trade practice.
We dismiss the complaint against OP-1 & 3 and allow the complaint against OP-2 and direct the OP-2 to pay Rs.524135/- towards the reimbursement of medical expenses alongwith interest @ 6% per annum from the date of filing of the complaint till its realization to the complainant. OP No.2 is also directed to pay Rs.2,00,000/- (Rupees Two Lacs only) as compensation for causing mental agony and harassment to the Complainant including cost of litigation.
Original Medical record be retained.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(S. S. Fonia) (Naina Bakshi) (N. K. Goel)
Member Member President
Announced on 07.06.16.
Case No. 783/08
07.06.2016
Present – None.
Vide our separate order of even date pronounced, we dismiss the complaint against OP-1 & 3 and allow the complaint against OP-2 and direct the OP-2 to pay Rs.524135/- towards the reimbursement of medical expenses alongwith interest @ 6% per annum from the date of filing of the complaint till its realization to the complainant. OP No.2 is also directed to pay Rs.2,00,000/- (Rupees Two Lacs only) as compensation for causing mental agony and harassment to the Complainant including cost of litigation. Let the file be consigned to record room.
(S. S. Fonia) (Naina Bakshi) (N. K. Goel)
Member Member President
