Delhi

North

CC/154/2023

PRADEEP KUMAR SHARMA - Complainant(s)

Versus

CGHS - Opp.Party(s)

24 Jun 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No:154/2023

 

IN THE MATTER OF:

 

Sh. Pradeep Kumar Sharma

06 GF, Balaji Apartments,

Upkar Colony, Sant Nagar,

Burari, Delhi-110084.                                   …                          Complainant

 

Vs

 

Chief Medical Officer,

CGHS, KWC No.60,

New Police Lines,

Kingsway Camp, Delhi-110009.                     …                          Opposite Party

 

ORDER

24/06/2024

 

Ashwani Kumar Mehta, Member:

 

1.       The present complaint has been filed under Section 35 of the Consumer Protection Act, 2019. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that:-

 

1. The Complainant is a member of CGHS since 09.10.2014 by paying a sum of Rs.27,000/- vide DD number 253214 of 09.10.2014 for   life time duration. Copy of the slip for subscription to the CGHS Scheme has been annexed with the complaint as Annexure/Appendix ‘A’.
2. The Complainant has also surrendered the fixed medical allowance being a part of the central civil pension paid by the Govt. of India @ Rs.1,000/- PM to join CGHS.
3. The Complainant fell seriously ill on 04.07.2022 and keeping in view the emergency to save the life of the Complainant, Mrs. Sadhana Sharma, the wife of the Complainant took him to the hospital located near to the residence, i.e. Medlife Hospital, main road, Burari, Delhi-110084 where he was attended/admitted and treated forthwith because the CGHS Kingsway Camp Dispensary was about 07 Kms away from where the Complainant had to get referred for a CGGS empanelled hospital & the  Max Hospital was also 6.5 Km away therefrom. The complainant was discharged on 05.07.2022 (AN).
4. The Complainant submitted 03 sets of medical re-imbursement claim to OP for a sum of Rs.18,796/51p on 07.07.2022 which was received back by him after 38 days on 23.08.2022 with some observations which were replied and the claim was re-submitted to OP again on 24.08.2022. The copy of the bills submitted at CGHS has been annexed with the complaint as Annexure/Appendix ‘B’.
5. After issuing 64 reminders ending on 31.01.2023, a sum of Rs.5,465/- was paid on 03.02.2023 by deducting a sum of Rs.13,331/- without any justification. Copy of the bank statement has been annexed with the complaint as Annexure/Appendix ‘C’.
6. The Complainant further appealed to OP on 02.05.2023 for full reimbursement before the CGHS authorities in terms of Ministry of Health & Family Welfare Office Order No. H.11022/01/2014-MS of 15.07.2014, meant for the relaxations of provisions to be followed in considering requests for medical reimbursement claims in respect of CS (MA) beneficiaries with a copy to all concerned of CGHS for full reimbursement. Copy of the office memorandum of Ministry of Health and Family Welfare has been annexed with the complaint as Annexure/Appendix ‘D1 and D2’.
7. The request of the Complainant was summarily turned down without any speaking order of OP vide MRCEZ email of 22.05.2023. Copy of the email from Addl. Director CGHS, East Zone Delhi has been annexed with the complaint as Annexure/Appendix ‘E’.
8. Despite of repeated requests raised by the Complainant before OP at times in person & by notice, balance amount of Rs.13,331/51p  has not so far been paid. Copy of the request made by the Complainant has been annexed with the complaint as Annexure/Appendix ‘F’.

 

2.       The Complainant has referred a judgment of Supreme Court of India  in Writ Petition (Civil) No.694 2015 in the matter of Shiva Kant Jha V/s Union of India which is annexed with the complaint as Annexure/Appendix ‘G’. It has also been alleged that OP has inflicted enormous amount of mental agony and financial loss as well as the physical disorder on the Complainant and therefore, it has been prayed to pass directions to the OP to:-

1. Refund a sum of Rs.13,331/51p  with 18% interest;
2. Pay a sum of Rs.4,00,000/- as compensation towards the physical strain and mental agony suffered by the Complainant; and
3. Pay a sum of Rs.25,000/- towards cost of this petition.

 

3.       Accordingly, notice was issued to the OP to defend the complaint before the commission but the OP neither appeared nor did send any communication despite service of the notice. Since the OP has chosen not to contest the allegations levelled in the complaint despite service and has been proceeded Ex-parte, the allegations made by the Complainant have remained un-rebutted.

4.       The complainant has filed evidence by way of Affidavit.  Therefore, the complaint has been examined on the basis of the documents/evidences and material available on records. Since the OP has chosen not to contest the allegations levelled in the complaint despite service, it is considered as deemed acceptance of the allegations of deficiency of service and harassment to the complainant by the OP. However, a thorough examination of the allegations were required to be examined by the Commission on the basis of the available records, for redressal of the grievance of the consumer judiciously. As such,  on the perusal of the allegations levelled in the complaint and the material available on records, it has been found that the Office Memorandum dated 15.07.2014 issued by Ministry of Health and Family Welfare (GoI) for relaxations of provisions to be followed in considering requests for medical reimbursement claims in respect of CS (MA) beneficiaries has laid down the procedure for considering such cases in para 3 which is reproduced as under:-

“ 3. All cases involving requests for relaxation of rules for reimbursement of full expenditure will henceforth be referred to the Technical Standing Committee, to be chaired by the DGHS/Spl. DGHS and Specialists of concerned subject as members. Addl. DDG (MG-Section), Dte. GHS shall be member secretary for organizing the meetings of Technical Standing Committee. If Technical Standing Committee recommends the relaxation of rules for permitting full reimbursement of expenditure incurred by the beneficiary, the full reimbursement may be allowed by the Secretary (Health & Family Welfare) in consultation with IFD. A check list for consideration of requests for reimbursement in excess of the approved rates may include:

a. The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and the patient was admitted by others when the beneficiary was unconscious or severely incapacitated and was hospitalized for a prolonged period;

b. The treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency and was admitted for prolonged period for treatment of Head injury, Coma, Septicemia, Multi-organ failure, etc.;

c. Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency for treatment of advanced malignancy:

d. Treatment was taken in a private hospital not empanelled under CS(MA)/ CGHS under emergency in higher type of accommodation as rooms as per his/her entitlement was not available during that period;

e. Treatment was taken in higher type of accommodation under specific conditions for isolation of patients to avoid contacting infections;

f. Treatment was obtained in private hospital not empanelled under CS(MA)/ CGHS under emergency while on official tour to another city:

g. Treatment was obtained in a private hospital not empanelled under CS(MA)/ CGHS under emergency when there is a strike in Govt. hospitals;

h. Approval for air-fare with or without attendant on the advice of treating doctor for treatment in another city even though he is not eligible for air travel/treatment facilities are available in city of residence and

i. Any other special circumstances.”

5.       The complainant’s case is covered in the cases mentioned at sr. no.3 (c) of the Office Memorandum dated 15.07.2014 issued by Ministry of Health and Family Welfare and the OP has not considered and decided the case accordingly. Besides, the complainant/beneficiary of the scheme has also not been communicated about the recommendations of the committee in his case in detail which amounts to deficiency of service on the part of the OP.

 

6.       The Complainant has also relied on the judgment of Hon’ble Supreme Court in the matter of Shiva Kant Jha Vs. Union of India in WP (C) No.694 of 2015 wherein it has been observed that:-

“15) In the present view of the matter, we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and well being of the central government employees and pensioners. In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-State to pay the balance amount of Rs. 4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only.

16) Further, with regard to the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which shall meet every month for quick disposal of such cases, We, hereby, direct the concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days. We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible. Further, the above exercise would be futile if the delay occasioned at the very initial stage, i.e., after submitting the relevant claim papers to the CMO- I/C, therefore, we are of the opinion that there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. In this view, we are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month.

7.       The above observations of the Hon’ble Supreme Court also appear relevant in the complainant’s case and have been followed in this case.

8.       In view of the above observations, we are of the considered view that the complainant has suffered directly due to deficient service and unfair trade practice on the part of the OP  in terms of the deficiency defined in the Act which includes any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. Besides, by following the observations of the Hon’ble Supreme Court, we also hold that the OP has caused unnecessary harassment to Complainant/pensioner who is senior citizen, affecting him mentally, physically and financially.

9.       Therefore, we feel appropriate to direct the OP to pay the complainant:-

1.  a sum of Rs.13,331/51p (Rupees Thirteen Thousand Three Hundred Thirty-One and paise Fifty One Only) within thirty (30) days from the date of receipt of this order, with interest at the rate of 9% p.a. from 24-09-2022 (the date of re-submitting the re-imbursement claim by the complainant after clearing the objections to the OP) till the date of the payment to the complainant;
2.  a sum of Rs.25,000/-(Rs. Twenty Five Thousand Only) as compensation for causing unnecessary harassment to Complainant who is senior citizen and also affecting him mentally, physically and financially
3. Pay a sum of Rs.10,000/- (Rs.Ten Thousand Only) towards litigation expenses.

 

10.     It is clarified that the aforesaid ordered amount shall be paid by the OP, within 30 days as directed above at para 9(a), (b) & (c). In case, the aforesaid ordered amount is not paid by the OP to the Complainant within the period as directed above, the OPs shall be liable to pay interest @12% per annum on the entire awarded amount from the date of expiry of 30 days period.

11.     Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

                  ASHWANI KUMAR MEHTA                                              HARPREET KAUR CHARYA

                                        Member                                                                          Member                

                               DCDRC-1 (North)                                                              DCDRC-1 (North)

                           DIVYA JYOTI JAIPURIAR

                            President 

                                  DCDRC-1 (North)