BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI
Consumer Complaint No.678 of 2014
Date of institution: 02.12.2014
Date of Decision: 28.05.2015
Mukesh Mandal # 3777, Sector 56, Palsora, UT Chandigarh.
……..Complainant
Versus
1. Director General, Employees’ State Insurance Corporation, Panchdeep Bhawan, Comrade Indjerjeet Gupta (CIG) Marg, New Delhi 110002.
2. Regional Director, Employees’ State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.
3. Senior State Medical Commissioner, Employees’ State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.
4. Director Health Services (ESI), Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.
5. Social Security Officer, ESIC Local Office, Phase-VII, Industrial Area, Mohali.
6. SMO, ESIC Hospital, Phase-VII, Industrial Area, Mohali.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
CORAM
Mrs. Madhu. P. Singh, President.
Shri Amrinder Singh, Member.
Mrs. R.K. Aulakh, Member.
Present: Shri Jasbir Singh, counsel for the complainant.
Shri Ravi Inder Singh, counsel for OP No.1,2,3 & 5.
Dr. Daljit Kaur and Shri Shinder Singh on behalf of OP Nos.4 and 6
(Mrs. Madhu P. Singh, President)
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act for issuance of following direction to the OPs:
(a) to pay him Rs.62,000/- for purchase of Phonak Naida Q30 Sin hearing Aid for both ears of his son;
(b) to pay him compensation of Rs.2,00,000/- for harassment and mental agony.
(c) to pay him cost of litigation to the tune of Rs.20,000/-.
The complainant has pleaded in the complaint that he is working with M/s. Modern Business Equipments & Services P. Ltd., Mohali since 12.11.2010 with insurance No.1408720254. He is regularly depositing ESI contribution @ 1.75% from his salary alongwith employer contribution @ 4.75%. The son of the complainant aged five and half years is deaf from both ears since his birth. The complainant got his son checked up with OP No.6 for treatment on 02.07.2014 who referred the son of the complainant to PGI Chandigarh for further treatment vide prescription slip Ex.C-1. As per certificate dated 02.07.2014 the Manager Local Office, Mohali recommended the son of the complainant for super specialty treatment. The Medical Board of PGI vide certificate dated 14.08.2014 Ex.C-5 recommended Phonak Naida Q30 Sin Hearing Aid for both the ears of son of the complainant. The complainant approached OP No.6 to supply him the hearing aid for his son. OP No.6 called quotations for the hearing aid and the lowest quotation was of Rs.62,000/-. Then OP No.6 forwarded the case for approval to OP No.4 for purchase of hearing aid from M/s. Aawaaz Speech and Hearing Clinic, Chandigarh. OP No.4 rejected the proposal vide letter dated 29.09.2014 on the ground that under Section 5.3 in respect of children of IP, congenital diseases requiring referral to SST and genetic disorders would be eligible for coverage upto the ceiling mentioned earlier only in case the child is born after the IP had become eligible. However, the complainant has pleaded that as per ESIC (General) Regulations 1950 Para 95 the family of insured person shall become entitled to medical benefit and shall continue to be so entitled so long as the insured person is entitled to receive medical benefit for himself. Thus, rejection of claim of the complainant amounts to deficiency in service and unfair trade practice on the part of the OPs.
2. OP No.1, 2, 3 and 5 in their written statement have averred that they have no role to play in this case as the matter has not reached to them. The case of the complainant was rejected by OP No.4 at the initial level only. These OPs have come to know from the reply of OP No.4 and 6 submitted in this Forum that OP No.4 had written a letter to OP No.6 that an amount of Rs.20,000/- can be reimbursed for each ear after the case was reconsidered. Thus, OP No.1, 2, 3 and 5 have sought dismissal of the complaint.
3. OP No.4 and 6 in the written statement have pleaded that the son of the complainant was born on 15.12.2008. The eligibility certificate was obtained and registration was done on 27.11.2010. As per letter dated 29.09.2014 the claim was not covered under Para No.5.3 because the illness of son of the complainant was before date of registration. However, after reconsideration the case, an amount of Rs.20,000/- could be reimbursed for each ear of son of the complainant. Thus, OP No.4 and 6 have also sought dismissal of the complaint.
4. Evidence of the complainant consists of his affidavit Ex.CW1/1 and copies of documents Ex C-1 to Ex C-11.
5. Evidence of OP No.1, 2, 3 and 5 consists of affidavit of Dr. Arun Kumar Gupta, Ex.OP-1/1 and copies of documents Ex.OP-1 and OP-2.
6. Evidence of OP No.4 and 6 consists of affidavit of Dr. Daljit Kaur Ex.OP-4/1.
7. We have heard learned counsel for the complainant and OP Nos.1, 2, 3 and 5 and Dr. Daljit Kaur and Shri Shinder Singh for OP No.4 and 6 and gone through the written arguments filed by the complainant.
8. Admittedly the complainant is IP with the OPs and as per agreed terms between the parties is entitled to medical reimbursement for the expenditure incurred by him on his dependants including his son. Admittedly the complainant’s minor son namely Kartik aged five years and half months was referred to PGI Chandigarh by OP No.6 vide Ex.C-1 as his son was suffering from hearing impairment. After reference the complainant took his son to PGI and was diagnosed in the PGI as an outdoor patient vide Ex.C-3. After diagnosis the PGI Medical Board recommended Phonak Naida Q30 Sin Hearing Aid for both the ears of son of the complainant vide certificate Ex.C-5. The complainant thereafter approached OP No.6 with the request to provide the hearing aid for his son vide his request dated 08.09.2014 Ex.C-6. After following the due process OP No.6 referred the matter to OP No.4 on 15.09.2014. After processing the case of the complainant, OP No.4 vide Ex.C-10 rejected the claim of the complainant on the following grounds:
“In respect of children of IP, congenital diseases requiring referral to SST and genetic disorders would be eligible for coverage upto the ceiling mentioned earlier only in case the child is born after the IP had become eligible for SST.”
9. The complainant has alleged that the action of OP No.4 is illegal as the rule cited by the OP No.4 while rejecting his claim is not applicable to his case and the claim has been wrongly rejected. Thus, on this allegation, the present complaint has been filed.
10. Admittedly, the complainant has been referred to the PGI authorities by OP No.6 and as per Medical Board of PGI the complainant’s son required to have hearing aid. However, during the pendency of present complaint it is learnt that OP No.4 after reconsidering the case has sanctioned Rs.20,000/- each for both ears for digital hearing aid and the complainant has received the hearing aid on 23.02.2015.
11. Perusal of Ex.C-10 revealing the grounds of rejection are important to be seen whether those grounds were applicable to the case of the complainant or not. In this regard, the complainant has drawn our attention to Ex.C-11 i.e. rules governing high cost treatment. These rule pertain to high cost treatment and in no manner cost of hearing aid being Rs.40,000/- can be termed as high cost treatment and secondly rule 5.3 deals with congenital diseases and genetic disorders. In the case of the complainant hearing impairment has not been defined by any of the doctor as genetic disorder or congenital diseases. Therefore, the reasons of rejecting the claim of the complainant vide Ex.C-10 are ill founded and not available to OP No.4.
12. Further upon review, during the pendency of the present complaint the OP No.4 has allowed the claim of the complainant without citing any rule or reasons governing the case of the complainant. The action of OP No.4 thus initially rejecting the claim of the complainant by citing wrong rule of 5.3 and thereafter reconsidering the case without citing any rule per se shows an act of deficiency in service and unfair trade practice indulged by OP No.4.
13. Though the complainant has now received the amount for treatment of his son and got the hearing aid on 23.02.2015, there is no doubt that there is delay in processing and honouring the claim of the complainant from 29.09.2014 to 23.02.2015 and finally the complainant has got his legal due after the intervention of this Forum. Thus, the delay in processing and realizing the claim at the hands of OP No.4 has caused physical agony to the son of the complainant and mental agony and financial loss to the complainant. The complaint, therefore, deserves to be allowed against OP No.4 only and the complainant deserves to be compensated. OP Nos.1, 2, 3, 5 and 6 have no role to play in rejection of the claim of the complainant and thus the complaint against these OPs deserves to be dismissed.
14. The complaint is allowed with the following direction to OP No.4:
(a) to pay a lump sum compensation of Rs.20,000/- (Rs. Twenty thousand only) to the complainant for mental agony, harassment and costs of litigation.
Compliance of the above directions be made by OP No.4 within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the orders be sent to the parties free of costs and thereafter the file be consigned to the record room.
Pronounced.
May 28, 2015.
(Mrs. Madhu P. Singh)
President
(Amrinder Singh)
Member
(Mrs. R.K. Aulakh)
Member
