ORDER

Mrs. Manju Bala Sharma, Member

1. Instant complaint has been filed by the complainant on 16/03/2016.  It is alleged by the complainant that he was an employee of OP No.  1 & 2 on the post of A.T.I. and retired from the services of the OPs in the year 2014.    The OP3 is the hospital where the complainant has taken treatment of his disease.    It is alleged that  on 29.12.2011 the complainant received a severe heart attack when he was at home and thereafter he was immediately admitted in the Max Hospital, Gurgaon (Haryana) for his treatment but unfortunately the said Hospital denied him to admission as  the said hospital lacked necessary infrastructure for heart treatment.  The information  about illness was given to the Depot , the OP2 through telephonic message and the same was recorded in the D.O. registrar on  29.12.2011 itself and is  Annexure C. After that the family members of the complainant took him to Paras Hospital, Sushant Lok, Gurgaon, the OP3 as no panel Hospital was available nearby.       The complainant was discharged on 01/01/2012 at 2.30 PM.  The information about the treatment of the complainant in the said hospital was not communicated to OP1 / OP2 as the family members of the complainant were not aware of the service rules.  The complainant informed the OP NO. 1 and 2 after discharge and submitted bill of Rs. 1,33,748 spent on his treatment.  The copy of discharge summary and final bill  of the Paras Hospital and other Bills are annexed with the complainant as Annexure – D (colly).  It is further alleged that it was an emergency case the family members had no time to search the panel Hospital of the D.T.C.   The OP No. 3 was the nearest hospital.  The OP No. 2 has sent a letter on 11.02.2013 to Max Hospital to confirm the same but as complainant was not admitted in the Max Hospital  so there was no entry in the said Hospital.  The complainant was firstly taken to Max Hospital Gurgaon and on its refusal he was got admitted in Paras Hospital Gurgaon Haryana.  Copy of letter dated 11.02.2013 issued by DTC to the Max Hospital Gurgaon (Haryana) is Annexure – E.     It is further alleged that OP1 and OP2 have confirmed the fact of the treatment from the Hospital but no payment towards the reimbursed  was disbursed to the complainant despite several representations made by the complainant to the OP1 and OP2 .The complainant was shocked when he was informed vide letter dated 05.02.2014 that his claim was rejected by the department. After rejection of the claim of the complainant a legal notice was served through his counsel on 09.08.2014.   It is also alleged by the complainant that despite service of legal demand notice, the OP No. 1 & 2 have not paid the amount incurred on account of medical expenses by the complainant.  Pleading deficiency in service on the part of OP1 to OP3  complainant prays that OP1 & OP2 be directed to reimburse the claim  of Rs. 1,33,748/- along with interest @ 18% p.a. along with Rs. 50,000/- towards loss of money , mental torture and other expenses.
2. O.P1 and OP2  appeared and filed their reply taking preliminary objections inter-alia  that  the medical reimbursement  facility provided by the OP1 and OP2 as per rules and regulations of the medical scheme is a statutory benefit to the employees of the DTC which does not mean the services hired or availed or agreed to be hired or availed of by the employee. It is denied that the MAX Hospital Gurgoan has denied the complainant to admit in the Hospital as they do not have the facility of heart diseases. It is  also denied  that there was no   panel hospital near the said hospital and moreover the complainant has not informed to the unit for admission in the Paras Hospital.  It is alleged that the complainant  willfully  ignored the Panel Max Hospital and  got  admitted in  Paras Hospital , Gurgoan and the reimbursement of the bills is to be made only against the treatment taken from  the Panel Hospital as per procedure of Medical Scheme of DTC.   In reply OP3  alleged that there was no cause of action against it hence complaint be dismissed against it.
3. Complainant and OP1 & OP2  has filed their  affidavits in evidence testifying all the facts stated in the complaint and written statement respectively their supportive documents.   Sh. Kapil Choudhary. Authorised Representative of OP3  has filed his affidavit in evidence on behalf of OP3. Written submissions have also been filed by both the parties.
4. We have heard learned counsel for the parties and gone through the relevant record and written submissions.
5. The main question for disposal of this complaint is as to whether the complainant has taken the treatment from other than the panel hospital of OP1 /OP2 and whether  intimation was sent to OP1 /OP2 in time?  Learned counsel for the complainant has contended that the complainant received a severe heart attack on 29.12.2011 when he was at home and his family members immediately took him to Max Hospital , Gurgoan , Haryana which is admittedly a Panel Hospital at which  intimation was duly given to OP1/OP2 telephonically which was recorded in the D.O.  register on the same date.  It is further contended that on refusal by the Max Hospital on the ground that the said hospital only deals with the Orthopedic & Joint replacement the complainant was taken to Paras Hospital which was close to the Max Hospital . As complainant was in critical condition falling severe heart attack and the family members of the complainant were not aware with rules of OP1/OP2 the information could not be sent to OP1/OP2 . Counsel for complainant has further contended that in case of emergency the complainant has to be taken to the nearby hospital to give him the treatment and one can not bother to rush for the panel hospital. Counsel for complainant has relied upon a circular No. Admn.-7(27)/2011/584 dated 05.07.2011 issued by the Office of OP1 in which at S. No. 28 it is mentioned that Max Hospital deals with Orthopedic & Joint replacement  for which the patient can be treated. Counsel for OP has denied this contention of the complainant and states that the Max Hospital has the facility of heart treatment also but in the case of the complainant  when complainant was having severe heart attack he was taken to the panel hospital but  as the panel hospital has refused to give treatment  to the complainant he has taken to the Paras Hospital (OP3) in case of emergency and in case of  emergency the claim cannot be rejected on the technical ground as  in the instant case the claim is rejected merely on the ground that the intimation regarding his hospitalization in OP3’s hospital  was not given  to complainant as per office order no. 16 where it has stated that “the claim of reimbursement of specialized medical treatment will be entertained only if the patient was referred by DTC Medical Board for such treatment one of the empanelled hospital  besides  other Govt. Hospitals, except in case of emergency”.  Counsel for complainant has relied upon official noting of the department which he has obtained under RTI in which it has been mentioned at Page -N5 that Shri Omsingh  A.T.I. T. No. 17956 suddenly fell ill and his family took him in the Max Hospital and  intimation of which was given to the Control Room immediately but as there was no treatment for heart problem and on refusal of the hospital to admit the complainant,  the family members of the complainant took him into Paras Hospital on the same day and got him admitted there and family members of the complainant forget to send the message to office or they were not aware of this fact. Since employee was unconscious  he cannot inform the office again and there is no mistake of employee and the claim of the employee can be reconsidered. Counsel for complainant also relied upon circular  No. IRD-HQ 2014/326 dated 26.02.2014  in which DYGM IR  has stated that “most of the cases of Medical reimbursement are rejected by the DTC Medical Board merely on the ground that information of hospitalization of employees members of their  families are not reported in stipulated time despite of the fact that information has been registered in the D.O. register well in time within 24 hrs of hospitalization but not forwarded to Medical Board on the same day by Depot Officials  on one or other pretext causing thereby rejection of medical bills by Medical Board and resulting into mental agony , harassment and monetary loss to the concerned employees. Such callous attitude and negligent acts have been viewed seriously by the Higher Authorities. In order to overcome from situation it is decided that information received by concerned officials in then D.O. register shall be considered sufficient enough by the DTC Medical Board to deal  the medical bills for reimbursement.”    In view of the circular dated 26.02.2014 where information to the Medical Board does not  reach though the information has been registered in the D.O. register can be resolved by issuing such circular  and in this case when the complainant has intimated the office and the information has been registered in the D.O. register with in time but before reaching to the panel hospital and on refusal by the panel hospital to give treatment to the complainant as  it  was not dealing for the problem of heart attack and in emergent  condition he was taken to Paras Hospital which is nearby , the office shall  have considered this fact also.  Counsel for OP has simply relied upon circular no. 27.08.1991 vide which it has mentioned that claim for reimbursement of the Specialized Medical Treatment will be entertained only if the patient was referred by DTC Medical Board for such treatment to one of the empanelled Hospital besides other Government Hospitals , except in case of emergency where the employee/ dependant family members, if any, will have to intimate the Medical Board within the next subsequent working day.  In the instant case intimation of  being  taking to the complainant to the panel hospital due to heart problem reaches with OP1 and Op2 on 29.12.2013.  On perusal of the discharge summary of  complainant it is crystal clear that the patient was admitted in  Paras Hospital on 29.12.2011 at 10:54AM  on the same day when he was taken to the Max Hospital and intimation was given to OP1/ OP2.  Discharge Summary also mentioned that the complainant was admitted with the complaints of  Retrosternal Chest Pain, Sweating & Ghabrahat.  In view of the above discussion we are of the opinion that complainant was taken to OP3 Hospital in emergency condition when  he was denied to be admitted and treated  by Max Hospital on  the ground that they were not  dealing with heart problem and  hence is entitled to the reimbursement of the  amount spent by him on his treatment by OP1 and OP2. We do not see any cause against OP3 and the complaint may be dismissed against it. Accordingly, we direct OP1 and  OP2  to pay  jointly and severally Rs. 1,33,748/- along with interest @ 9% p.a. from the date of institution of this complaint till realization and Rs. 20,000/-  as compensation for mental agony and pain suffered by him along with Rs. 10,000/- as litigation cost.
6. The OP1 and OP 2 shall comply this order within 30 days from the date of receipt of this order failing which an interest @ 9  % shall be payable on the entire awarded amount.

Copy of this order be made available to the parties as per law.  File be consigned to record room. 

                Announced on this           day of  _______  2017.