Delhi

East Delhi

CC/1088/2014

NIRUPUMA - Complainant(s)

Versus

CGHS WILLNESS - Opp.Party(s)

23 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO.  1088/14

 

Mrs. Nirupama Biswas

W/o Dr. S.K. Biswas

R/o Flat No. 342, Nirman Apartment

Mayur Vihar, Phase-I Extn

Delhi – 110 091                                                                    ….Complainant

 

Vs.

 

CGHS Wellness Centre – 77

Through Director/Chairman/Principal Officer/

Company Secretary

Mayur Vihar, Delhi – 110 091

 

The Secretary

Ministry of Health & Family Welfare

Government of India, Delhi – 110 001                     …Opponent

 

 

Date of Institution: 27.11.2014

Judgment Reserved on: 23.10.2017

Judgment Passed on: 24.10.2017

 

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Mrs. Nirupama Biswas against CGHS Wellness Centre-77 (OP-1) and Ministry of Health & Family Welfare (OP-2), under Section 12 of the Consumer Protection Act, 1986. 

2.       The facts in brief are that husband of the complainant            Dr. S.K. Biswas, who was a beneficiary of CGHS, was attacked with stroke on 13.01.2013 and admitted at Escort Hospital at Okhla,

New Delhi.  Surgery of his left side brain skull was carried out on 14.01.2013.  An amount of Rs. 7,43,156/- was paid to Escort Hospital for the period 13.01.2013 to 30.01.2013 by the complainant.   

          Further an amount of Rs. 2,03,514/- spent for Metro Hospital for the period 30.01.2013 to 18.02.2013 was directly reimbursed from CGHS. 

          The complainant made the claim for Rs. 7,43,156/- from government under Central Govt. Health Scheme (CGHS) under which the husband of the complainant was registered.  Out of Rs.7,43,156/-, CGHS approved only Rs. 1,47,334/- without giving any reason for non-approval of rest of amount.  The said approved amount was deposited in the account of the complainant in Corporation Bank, Mayur Vihar, Phase-I.  Since CGHS did not approve rest of claimed amount of Rs. 5,95,822/-, the complainant has prayed for directions to OP to release the balance claimed amount of Rs. 5,95,822/-. 

3.       In the reply, OP have stated that the complainant has submitted that she took her husband to Fortis Escorts Hospital believing it to be on the panel of CGHS and when the patient’s condition improved slightly, he was shifted to CGHS empanelled Metro Hospital, Noida.  The complainant made a claim of Rs. 7,43,156/- on 05.04.2013 vide claim no. 15/2013/DEL/EZ/D77, out of which Rs. 1,74,334/- was reimbursed to beneficiary vide bill no. 357 dated 25.04.2013.  Escorts hospital was on the panel of CGHS w.e.f. 07.10.2010 and was removed from the list of empanelled hospital w.e.f. 13.02.2013. 

          It was stated that the patient spent an amount of Rs. 7,43,156/- out of her pocket, but did not put up the claim for treatment in Metro Hospital for Rs. 2,03,514/- as she got the credit for this part of the treatment. 

          They have stated that the information was given to the beneficiary regarding the admissible amount and as per OM number S.11011/23/2009-CGHS D.11/Hospital Cell dated 16.11.2010, reimbursement has been made to the beneficiary as per package rate admissible under CGHS.

          They have further stated that the patient had to spend           Rs. 7,43,156/- out of his own pocket because the hospital which was on CGHS panel till 12.01.2013 did not extend the credit facility to the CGHS pensioner beneficiary and misled the beneficiary by informing that it was not on the panel. The hospital did not charge the beneficiary as per the CGHS rates. Other facts have also been denied.     

4.       In support of its complaint, complainant have examined herself.  She has deposed on affidavit and have narrated the facts stated in the complaint.  She has also got exhibited documents such as copy of letter issued from Ministry of Rural Development regarding the details of pension of Dr. S.K. Biswas (Ex. PW-1/1), medical certificate from the doctor        (Ex. PW-1/2 colly.), bill of the hospital (Ex. PW-1/3 colly.), claim dated 23.03.2013 (Ex. PW-1/4), calculation sheet dated 12.04.2013 (Ex. PW-1/5), letter issued by CGHS/respondent no. 1 (Ex. PW-1/6) and advice from the Escort Hospital Physiotherapist (Ex. PW-1/7).   

          No evidence has been led on behalf of OP. 

5.       We have heard Ld. Counsel for complainant and have perused the material placed on record as none has appeared on behalf of OP. 

It has been argued on behalf of complainant that CGHS Wellness Centre and Ors. have not reimbursed the total amount, which he spent on the treatment of his husband Dr. S.K. Biswas at Escort hospital. 

          It is admitted case of both the parties that bill for an amount of Rs. 7,43,156/- was submitted with OP for reimbursement, out of which an amount of Rs. 1,47,334/- was paid.  The stand taken by OP has been that the amount of Rs. 1,47,334/- was reimbursed as per CGHS rules.  The complainant took the treatment from Escorts hospital which was on the panel of CGHS and was removed from the panel on 13.02.2013.  The complainant took the treatment when the hospital was on the panel of CGHS, however, the hospital have not charged CGHS rates as they shown their unwillingness to continue their empanelment under CGHS.  From the letter of Ministry of Health & Family Welfare vide no. S11031/CGHS(HEC)/2012-13-CGHS(P) dated 13.02.2013 (R-12), it is evident that Escorts Hospital and Research Centre remained on the panel of CGHS till February 13, 2013.  The husband of the complainant took the treatment from the Escorts hospital during its empanelment.  They have not given the credit facility and charged their own rates not CGHS rates, though, they remained on the panel of CGHS.  This has been reflected by OP in their WS. CGHS Wellness Centre have paid the amount to the complainant as per his eligibility under CGHS rules.  Thus, by not reimbursing the total amount claimed by the complainant for the treatment of her husband and reimbursing the amount as per his entitlement, it cannot be said that there has been deficiency on the part of OP.  The deficiency, if any, may be of Escorts Hospital who have given the treatment to the husband of the complainant and have not charged the rates of panel hospital, though, they remained on the panel of CGHS till 13.02.2013.

          Though, no case of deficiency on the part of OP is made up, however, from the discharge summary of Escorts Hospital, it is noticed that husband of the complainant was admitted in emergency in unconscious condition.  The fact that husband of the complainant was admitted as an emergency case, the hospital being on CGHS panel should have extended the credit facility and charged CGHS panel hospital rates.  The complainant was compelled to pay the hospitalization charges which have not been reimbursed by CGHS Wellness Centre.  Though we are conscious of the fact that we cannot issue directions, but to impart justice and avoid further litigation, we direct CGHS Wellness Centre (OP) to take up the matter with Escorts Hospital for getting the bill of Dr. S.K. Biswas revised as per CGHS panel rates and the revised bill be processed and the amount admissible under the rules be paid to       Dr. S.K. Biswas, husband of the complainant.  This process be completed within a period of 3 months from the date of receipt of the order by CGHS Wellness Centre (OP).    

          As there is no deficiency on the part of CGHS Wellness Centre (OP), the complaint of the complainants deserves its dismissal and the same is dismissed with above directions.  There is no order as to cost.   

          Copy of the order be supplied to the parties as per rules.

          File be consigned to Record Room.

 

(DR. P.N. TIWARI)                                                             (SUKHDEV SINGH)

     Member                                                                                   President