Punjab

Ludhiana

CC/15/331

Surinder Singh - Complainant(s)

Versus

Chief Medical Supdt.Nr.Rly. - Opp.Party(s)

M.S.Sethi Adv.

06 Mar 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

                                                            Complaint No:  331 of 19.05.2015.

                                                            Date of Decision: 06.03.2017.

 

1. Surinder Singh aged 68 years S/o. Tara Singh, R/o. House No.5, Gali No.2, Bajrang Vihar, Manakwal Dhandra Road, Ludhiana.
2. Harmeet Kaur aged 63 years w/o. Surinder Singh, R/o. House No.5, Gali No.2, Bajrang Vihar, Manakwal Dhandra Road, Ludhiana.

                                                                                ..… Complainant

                                                  Versus

1. The Chief Medical Superintendent, Northern Railway, Ferozepur, Punjab.
2. The Divisional Railway Manager (P), Northern Railway, Divisional Office, Ferozepur Cantt., Punjab.
3. The Senior Divisional Medical Officer, Northern Railway, Ludhiana.
4. A.S.T.E (Works), Northern Railway, Ludhiana through authorized signatory
5. Northern Railway (Ferozepur Division), Ferozepur, through SR. Divl. Comml. Manager.

…..Opposite parties 

                              Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:

SH. G.K. DHIR, PRESIDENT

SH. PARAM JIT SINGH BEWLI, MEMBER

COUNSEL FOR THE PARTIES:

For complainants             :         Sh. M.S. Sethi, Advocate.

For OPs                           :         Sh. Iqbal Singh, Advocate.

ORDER

PER G.K. Dhir, PRESIDENT

1.                 Complaint under Section 12 of the Consumer Protection Act (hereinafter referred as Act) filed by complainant by pleading that he, a retiree in rank of TCM-1/SSE/Tele/UMB/Ldh w.e.f. 31.12.2016, availed the services of Ops under  liberalized health scheme known as RELHS for availing relief on medical expenses/treatment of self, wife and daughter. Ambala office of Ops issued a card bearing No.012742 dated 29.12.2006, which was later on registered with Ludhiana office. That card was renewed from time to time after making endorsement thereon. Ops charged necessary charges for providing its services in RELHS. Wife of complainant, a beneficiary under the scheme, fell down in bathroom on 16.12.2013 and suffered internal injuries, which caused severe pain. Wife of the complainant was unable to stand and move on account of these injuries. By watching condition of complainant no.2 serious, she was immediately brought to nearby Pahwa Hospital. She was admitted in emergency in CLU. There she was treated for fracture supracondyer femur left side with fracture superior public rami right side. Complainant No.2 underwent an open reduction and internal fixation for fractured femur. Claim for amount of Rs.54,892/- for this treatment during period from 16.12.2013 to 06.01.2014 at S.N.S. Pahwa Charitable Hospital, Ludhiana was submitted, but same was repudiated vide letter dated 28.10.2014. Repudiation took place on the ground that supracondylar femur is not life threatening condition. Besides it was held that open reduction internal fixation is not an emergency procedure. Reliance on Railway Board letter No.2005/H/6-4/Policy-11 dated 31.01.2007 was placed. That rejection of claim is unjustified, due to which complainant sustained mental tension, harassment and agony and as such, complaint filed for getting reimbursement of the claim amount of Rs.54,892/- with interest @18% till realization from the date of lodging of the claim. Compensation for mental tension and harassment due to adoption of unfair trade practices of amount of Rs.30,000/- and litigation expenses of Rs.5500/- more claimed. It is claimed that complainant No.2 had to be rushed to emergency at Pahwa Hospital because she was having non tolerable pain. Complainant was not in a position to contact the authorized medical office at Ludhiana for getting patient referred to Divisional Hospital, Ferozepur or to recognized private hospital at Jalandhar because pain being beyond control was unbearable.

2.                 In joint written statement filed by Ops, it is claimed that complaint is not maintainable in the present form; complainant has not approached this Forum with clean hands; intricate questions of law and facts are involved requiring elaborate evidence and as such, this Forum has no jurisdiction; complainants estopped by their act and conduct from filing this complaint. It is further claimed that Ops are not guilty of providing deficient service or of adopting unfair trade practice. Rather claim of complainants was rightly rejected as per rules and Railway Board’s letter No.2005/H/6-4/Policy-II dated 31.01.2007 as referred above. Condition of the patient at the time of admission in private non-recognized hospital is also not covered in the list of emergency conditions recognized by the Indian Railways. Admittedly, complainant retired on 31.12.2006 under RELHS. Basic pay of last month of the employee in service is deposited with Indian Railways for providing medical treatment to the employee and eligible dependents through existing infrastructure of Indian Railways from time to time. On becoming a member of RELHS, one does not become entitled to bear expenses against the procedure laid down by the Indian Railways. Reimbursement is awarded to RELHS beneficiaries only incase emergency is justified as per the Railway Board letter of 31.01.2007. Repudiation of the claim is as per rules and as such, by denying other averment of the complaint, prayer made for dismissal of the complaint. It is also claimed that the definite treatment in terms of open reduction and internal fixation was not available at Health Unit, Ludhiana, but said unit is competent to give first aid and provide pain relief and stabilize such cases. Even if the allegation by the complainants taken on its face value, then patient could have been referred to Divisional Hospital, Ferozepur or any other recognized private hospital at  Jalandhar. However, Railway Health System was bye passed by the complainants for getting treatment from a private non recognized hospital. Vitals of the patient were stable at the time of admission in the hospital and as such, emergency is not established. So reimbursement of the claim of the complainants was rightly rejected. Patient underwent open reduction and internal fixation for fracture femur and at the time of admission her pulse was 84/minute, BP 120/80 mmhg. Patient was conscious, oriented and there was adequate urine output. There was no active bleeding and as such, patient should have contact her authorized medical officer at health unit Ludhiana for getting referred to Divisional Hospital Ferozepur.

3.                 Complainants to prove their case tendered in evidence affidavit Ex. CA/1 of complainant No.1 along with documents Ex.C1 to Ex. C12 and thereafter counsel for complainants closed evidence.

4.                 On the other hand, counsel of OPs tendered in evidence affidavit Ex. RA of Dr. S.P. Sharma, Senior Divisional Medical Officer, Ferozepur along with documents Ex. R1 and Ex. R2 and then closed evidence.

5.                 Written arguments not submitted by any of the parties. Oral arguments heard and record carefully gone through.

6.                 It is not in dispute that complainant Surinder Singh owing to retirement and deposit of the necessary charges became entitled to avail services under liberalized health scheme known as RELHS for self as well as his wife i.e. complainant No.2. It is also not disputed that wife of complainant got treatment during period from 16.12.2013 to 06.01.2014 at S.N.S. Pahwa Charitable Hospital, Ludhiana by bearing expenses on such treatment by her husband. Treatment got was for fracture supracondylar femur left side with fracture superior pubic rami right side. Complainant No.2 underwent open reduction and internal fixation for fractured femur. At the time of admission pulse was 84 per minute, BP 120/80mmhg. Complainant No.2 was conscious and oriented. Adequate urine output was observed and no external wound or active bleeding was found at that time. Submission advanced by counsel for Ops in this respect certainly has force because the same borne from contents of discharge card Ex. C10 of S.N.S. Pahwa Charitable Hospital, Ludhiana. This treatment was got by complainant No.2 because she slipped in bathroom as per claim submitted through claim form Ex. C6. Distance of nearest Government hospital was 14 KM, but distance of nearest Railway hospital was 18 KM from the place, where this slipping resulting in sustenance of injury of fracture took pace is a fact borne from contents of Ex. C6. Intimation regarding treatment was given through proper channel to Senior DMO Incharge, Northern Railway, Ludhiana through letter Ex. C5 by claiming that amount of Rs.54,892/- incurred as expenses and the bills in that respect produced on record as Ex. C8. In admission details Ex. C7, it is mentioned by doctor of Pahwa Hospital that patient admitted in emergency services by providing ICU bed. So this certificate Ex. C7 issued by treating doctor establishes that on account of required emergent treatment, patient was admitted in ICU bed through emergency services. Even if pulse rate and BP or level of consciousness etc. may be showing normal condition of the patient as per contents of Ex. C7, but certainly patient on account of sustenance of injuries of fracture of femur referred above, was bound to remain in much pain because she was 60 years of age at the time of getting the treatment is a fact borne from contents of Ex. C6 and contents of Ex. C10 to Ex. C12. A person in age of 60 years by fall, if receives injury of fracture of femur of left side with fracture superior pubic rami right side, certainly bound to remain in much pain. If the treatment of open reduction and internal fixation provided immediately after fall that can reduce pain and even prevent occurrence of further complications of swelling or of stiffness of the surrounding tissues. As other hospitals were at distance of 14 KM and 18 KM from the place of slippage and as such, complainant No.1 and complainant No.2 being in old age, were bound to avail services from the nearby hospital, so that further complication may not arise. Besides the perusal of admission record Ex. C7 itself establishes that services were availed in emergency condition in ICU bed and as such, doctor of Pahwa Charitable Hospital, Ludhiana found it to be a case of emergent condition.

7.                 Emergent conditions are enumerated in Ex. R1, but case of complainant No.2 does not fall in any of the specified condition enumerated in Ex. R1 and as such, it is vehemently contended by counsel for Ops that availing of the services by complainant No.2 for treatment from unrecognized private hospital exonerates the Ops from liability. List of emergency conditions given in Ex. R1 cannot be termed as exhaustive. After going through letter Ex. R2 of 31.01.2007 relied upon by both parties, it becomes obvious that emergency means any condition or symptom resulting from any cause, arising suddenly and if not treated at the early convenience, then same will be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples of those emergencies are given as injuries sustained in road accident or other type of accident like acute heart attack etc. In case the injury of fracture of femur would not have been attended to immediately in emergency services by the nearest hospital, then certainly complications bound to aggravate because the swelling may have taken place and treatment of internal fixation at later stages even would not have been as affective as would have been on providing of immediate treatment. Tissues and limbs of a person of age of 60 years bound to be somewhat weak as compared to the tissues and limbs of a young person in the age of 20-30 years. The internal fixation and application of open reduction alone would have provided strength to the surrounding tissues at earliest resulting in further damage to other tissues and as such, in case the services at earliest availed from Pahwa Hospital for treatment, then those were availed in emergent conditions, otherwise health of complainant No.2 due to injury to other tissues may have more deteriorated. So certainly it is a case in which the treatment in emergency at ICU bed got from nearest hospital for saving further detriment to the surrounding tissues and limbs of complainant No.2. So this case falls in the emergent condition mentioned in letter Ex. R2.

8.                 Record of admission details as well as record of pulse rate, BP etc. and of the provided medicines has been produced by complainant in this case and as such, they have complied with the conditions mentioned in letter Ex. R2 in so far as the same provides that for establishing the emergency condition, production of such record is required. In such circumstances rejection of the claim on account of getting treatment from unauthorized hospital is quite improper because after submission of intimation through letter Ex. C5, specific opinion of the authorized Railway medical officer for specifying reasons for treatment being not obtained in emergent condition could have been obtained and produced on record. However, no such record produced by Ops. By keeping in view the nature of injuries and required emergency for immediate treatment, we are of the opinion that repudiation of the claim is improper. As repudiation is improper and as such, the same is an act of unfair trade practice or of deficiency in services. Circular Ex. R2 itself provides that if treatment taken in non recognized private hospital, then reimbursement should be made at the  CGHS rates of tht city or nearest city. CGHS Rates means the rates specified under Central Government Health Scheme. Approval can be assessed by Ops alone as per guidelines of sub clause (c) of main clause-II of Ex. R2. Entitlement of the complainants for treatment from non recognized private hospital will be as per CGHS rates only and as such, complainants not entitled for the total amount of incurred expenditure. So Ops must assess the payable amount as per rules contained in Ex. R2 and thereafter, make payment of the same within specified time of 40 days after receipt of copy of this order. As repudiation of claim is unjustified and as such, complainants entitled for compensation for mental harassment of somewhat reasonable amount and also to litigation expenses.  

9.                 As a sequel of above discussion, complaint allowed with directions to Ops to pay due amount as per rules to complainant within 40 days after receipt of copy of this order. In case payment within this specified time not made after assessing the same as per rules, then complainant will be entitled to interest on the payable amount @8% per annum w.e.f. today till payment. Compensation for mental harassment of Rs.7,000/- (Rupees Seven Thousand only) and litigation expenses of Rs.3,000/- (Rupees Three Thousand only) more allowed in favour of complainant and against Ops, whose liability held as joint and several. Payment of these compensation and litigation expenses be made within 30 days from the date of receipt of copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

                                         (Param Jit Singh Bewli)                      (G.K. Dhir)

                                         Member                                              President

Announced in Open Forum.

Dated:06.03.2017.

Gobind Ram.