Delhi

East Delhi

CC/158/2014

DR. K.L SHARMA - Complainant(s)

Versus

CG.HS WEST ZONE - Opp.Party(s)

21 Feb 2014

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT OF NCT OF DELHI

                                                 CONVIENIENT SHOPPING CENTRE, SAINI ENCLAVE: DELHI-92

CC NO.158/2014
 

Dr. K.L. SHARMA

S/O LATE M.C.MISHRA

R/O FLAT NO. A-901,

PAVITRA COOPERATIVE GROUP HOUSING SOCIETY,

VASUNDHARA ENCLAVE,

DELHI-110096

 

Complainant

 

Vs

 

1. ADDITIONAL DIRECTOR,

CGHS, EAST ZONE,

LAXMI NAGAR,

DELHI

 

2. THE DIRECTOR

CENTRAL GOVT. HEALTH SERVICES,

NIRMAL BHAWAN,

NEW DELHI

 

3. THE SECRETARY,

 MINISTRY OF HEALTH & FAMILY WELFARE,

GOVT. OF INDIA, NIRMAN BHAWAN,

NEW DELHI-110001                       

Opposite Parties

 

                                                                                      Date of Admission - 11/03/2014

                                                                                    Date of Order          - 22/01/2016

ORDER

Dr. P.N.TIWARI-MEMBER.

This complaint has been filed with the allegation that the Complainant is a retired Govt. Servant having revised basic pension as per the 6^th pay commission of and is a beneficiary under the CGHS scheme. He was issued the CGHS Card No.1017825. He is entitled for treatment which are covered under the scheme and notified by the Government from time to time. The Medanta, the Medicity Hospital, Sector-38, Gurgaon (Haryana) is on the panel of the CGHS and Complainant is entitled for treatment. On 20/03/2013, in emergency, he was admitted at Medanta under the care of Dr. Balbir Singh and the emergency certificate UHID No.350735 was issued. He was treated up to 28/03/2013 and a bill of Rs. 1,78,021.91 was raised.

 Rs.37.131/- was paid by the CGHS and balance amount of Rs.1,40,890.91 was paid by the Complainant. He deposited an amount of Rs.1,50,000/-  vide receipt No. GHIPRC/13084573. Complainant was entitled for reimbursement of Rs.1,40,890.91. The claim was submitted to the Respondent, he has clarified that he has not taken any Mediclaim policy from any agency in his life and no medical insurance company will pay the amount of Rs.37,131/- on his behalf to the Hospital. His claim was rejected on 23/05/2013 alleging it to be as per terms and condition of agreement with the CGHS. The Respondent has paid of Rs.36,184/- directly in his bank account No.056300101005449. The said amount was not paid by the Complainant to the Medanta, the Medicity Hospital, Gurgaon. The entire exercise is adopted by the Respondent is illegal and arbitrary. The Complainant is entitled for the reimbursement of Rs.1,40,000/- which he has paid to the Hospital along with 18% interest with cost.

            Respondent No.1 & 2 filed their reply wherein they took the plea of Non joinder. They admitted Complainant being a beneficiary under the CGHS scheme and the CGHS Card No.101785 valid for his whole life and entitled for private wards. The Complainant is a known case of coronary Artery Disease with Rheumatic Heart Disease with post Mitral Valve Replacement (2006) and post PTCA (2012), it is also admitted that Medanta, Medicity Gurgaon, is a CGHS Empanelled superspeciality Hospital. He was admitted in emergency and was investigated, he underwent EPS and RFA for Left Atrial Techycardia. He was discharged in a stable condition on 28/03/2013. The Hospital raised the bill of Rs.1,78,021.91 out of which Rs.37,131/- was to be paid by the CGHS (UTI-TSL) and the Complainant paid Rs.1,40,890.91. The submission of the claim of Rs.1,40,000/- was also admitted after calculation as per the competent authority direction and amount of Rs.36,184/- was reimbursed to the beneficiary vide bill No.1865 dated 12/09/2013. The Hospital has charged more than CGHS rate, as such the amount is to be deducted more than the Hospital bill.

            Both the parties have filed on record their respective evidence in the form of affidavit.

            The short question which arises of our consideration is as to whether the Respondent was within his right to made the deduction from the Hospital bill and only an amount of Rs.37,131/- was to be paid or reimbursed. This is admitted to the respondent in their written statement that the Complainant has paid from his pocket an amount of Rs.1,40,000/-. The relevant rule which disentitles the Complainant from the reimbursement for the amount spent by him in his treatment has not been filed by the Respondent on record. It was for the Respondent to show that the expenses incurred by the Complainant were not allowed under the CGHS rule/scheme. In so far as the question of admission in emergency is concern the same cannot be considered as it is admitted that the Respondent Hospital is empanelled with the CGHS Scheme. The rule which permits the admission in emergency is only applicable to those Hospitals which are not empanelled with the CGHS and Government or department concerned. As such the plea raised by the Respondent is without any merit, the deduction made by the Respondents is illegal. The Complainant is entitled for reimbursement as per the entitlement under the CGHS rules and he should be paid in full accordingly. The total amount which is payable as per rules should be paid within 45 days after adjusting the amount already paid and if it is not paid in the time allowed the complainant shall be entitled for 9% interest from the date of the filling of this complaint till that amount is finally paid. We allow compensation and cost of litigation a sum of Rs.20,000/-.

Copy of this order be provided to both the parties.

 

 

 

(DR.P.N.TIWARI)                        (POONAM MALHOTRA)                                (N.A.ZAIDI)

         MEMBER                                          MEMBER                                        PRESIDENT