BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI

                                  Consumer Complaint No. 493 of 2015

                                Date of institution:           01.10.2015

                                              Date of Decision:            26.05.2016

Raj Kumar, House No.31, Village  Palsora, Chandigarh.

    ……..Complainant

                                        Versus

1.    Director General, Employees’s State Insurance Corporation, Panchdeep Bhawan, Comrade Inderjeet 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.

7.    Medical Officer, ESIC Dispensary 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 Sidhu, 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 and 5.

Shri Balkar Singh, Sr. Assistant on behalf of OP No.4

Shri Yogesh Kumar, Jr. Assistant on behalf of OP No.6

Shri Chinder Singh, Jr. Assistant on behalf of OP No.7

(Mrs. Madhu P. Singh, President)

ORDER

                The complainant has filed the present complaint seeking following directions to the opposite parties (for short ‘the OPs’):

(a)    to reimburse him the amount of medical bills of Rs.1,11,417/-.   

(b)    to pay him compensation of Rs.1,00,000/- for harassment and mental agony.

(c)    to pay him cost of litigation to the tune of Rs.25,000/-.

                The complainant has pleaded in the complaint that he had worked with Majestic Hotel, Phase-9, Mohali and his insurance No. was 1213258687. He had deposited ESI contribution @ 6.5% which included contribution of employer.  Due to sudden acute chest pain on the night of 29.12.2013 the complainant was taken to General Hospital, Sector 16, Chandigarh from where he was referred to PGI, Chandigarh. The complainant could not get referral slip from ESI Dispensary as the chest problem started after off hours of ESI Dispensary i.e. on the night of 29.12.2013. Thus, the case of the complainant falls under Section 96-A of ESI Act which states that IPs and their family members had to resort to private treatment during the off hours of ESI Dispensary/Emergency Centre due to unavoidable circumstances.  The complainant remained under the treatment of PGI from 31.12.2013 to 23.01.2014 during which period he had to undergo By Pass Heart Surgery. After completing all the formalities, the complainant submitted bills to the tune of Rs.1,11,417/- for reimbursement to OP No.7 on 23.05.2014.  Since then the complainant had been visiting OP No.7 but he neither received any satisfactory reply nor reimbursement of his medical bills.  The complainant also went to OP No.5 but he also paid no heed to the requests of the complainant. Thus, alleging deficiency in service on the part of the OPs, the complainant has filed the present complaint. 

2.             OP No.1, 2, 3 and 5 in the preliminary objections of their written statement have pleaded the bills of the complainant are to be cleared by the Punjab Govt. as per notification dated 21.10.2002, being more than Rs.50,000/- .   The complainant has not impleaded the Punjab Govt. as a party in the complaint.  No allegations have been leveled against OP No.1, 2 and 3 thus, the complaint against them is liable to be dismissed.  OP No.5 has no role to play in the verification, passing, sanctioning of the bills as per Section 45 (2) of the ESI Act. Payment of Rs.70,921/- has been made to the complainant by the DHS vide letter dated 17.11.2015 as per CGHS rates.  There is no proof that the complainant had visited the office of OP No.5.  OP No.5 is always ready and willing to help the IP provided he is contacted telephonically or in writing but the complainant never tried to approach OP No.5. Denying any deficiency in service on their part, these OPs have sought dismissal of the complaint against them.

3.             OP No.4 in its separate written statement has pleaded that the complainant has already been reimbursed Rs.70,921/- as per CGHS rates  vide ECS dated 30.10.2015 of District Treasury Office, Mohali.  After processing, the reimbursement bills were sent to DHS(SI) Punjab   and after verification the bills of the complainant were received from SMO I/C ESI Hospital Mohali on 04.07.2014.  OP No.4 had sent back the bills with objections vide letter dated 24.07.2014.  Ultimately OP No.4 issued sanction of Rs.70,921/- vide letter dated 31.08.2015 and the amount has been paid to the complainant.  OP No.4 has also sought dismissal of the complaint against it.

4.             OP No.6 and 7 in their identical written statements have pleaded that after processing the bills were sent to DHS (SI) Punjab. There was a change in the system of reimbursement and probably that was the cause of delay which OP No.6 has regretted.

5.             Evidence of the complainant consists of his affidavit Ex.CW1/1 and copies of documents Ex C-1 to Ex C-5.

6.             Evidence of OP No.1, 2, 3 and 5 consists of affidavit of Sanjeev Kumar, Social Security Officer Ex.OP-1/1 and copies of documents Ex.OP-1 to OP-4.

7.             Evidence of OP No.4 and 6 consists of affidavit of Dr. Gurcharan Singh Ex.OP-1/4. Evidence of OP No.7 consists of affidavit of Dr. Baljit Kaur Ex.OP-1/7. 

8.             We have heard learned counsel for the complainant and OP Nos.1, ,2, 3 and 5, Shri Balkar Singh, Sr. Assistant, Shri Yogesh Kumar, Jr. Assistant and Shri Chinder Singh, Jr. Assistant for OP No. 4, 6 and 7  and gone through the written arguments filed by them.

9.             The complainant is a member of the ESI Scheme and this fact is not disputed by the OPs. Being a member and as entitled, he has availed the medical services from the PGI during  the period from 31.12.2013 to 23.01.2014 and prior to that he was under treatment with General Hospital, Sector 16, Chandigarh from 29.12.2013 to 31.12.2013.  While undergoing bye pass surgery at PGI as indoor patient he has spent a total sum of Rs.1,11,417/- and submitted the medical bills for reimbursement of the said amount with OP No.7 on  23.05.2014. The payment has not been made to him as per rules within the prescribed period and, therefore, the complainant has filed the present complaint alleging deficiency in service.

10.           During the pendency of the present complaint, the OPs have made a payment of Rs.70,921/- on 30.10.2015. The said amount has been paid to the complainant, as per the OPs, as CGHS rates as the complainant was not entitled to full reimbursement of the amount claimed.  The receipt of payment of Rs.70,921/- on 30.10.2015 is not disputed by the complainant. However, the complainant has raised a grievance that the said payment is short and deficient and further there is delay in release of the payment by the OPs. Therefore, the ambit of the complainant has been now narrowed down to the following issues:

(i)     Whether there is deficient and short payment as against the claimed amount?

(ii)    Whether there is delay in making payment?

(iii)   If so, whether it amounts to deficiency in service and unfair trade practice, entitling the complainant for compensation thereto?

11.           For first issue i.e. deficient and short payment against the claimed amount, the OPs have relied upon a copy of the office Memorandum dated 21.02.2013 issued by the Govt. of India, Ministry of Health and Family Welfare on the subject revision of ceiling rates and guidelines for various coronary stents for CGHS/CS (MA) beneficiaries as the same is applicable to the OPs.  A copy of the said memorandum has been submitted during the course of arguments by OP No.4 justifying their decision to make the payment as per CGHS rates against the claimed amount. We are of the opinion that the OPs have rightly followed the spirit of the office memorandum above while honouring the claim of the complainant and there is no short or deficient amount paid to the complainant against the claimed amount.

12.           So far delay in processing and realizing the claim of the complainant is concerned, it is admitted fact that the complainant has submitted the bills with OP No.7 on 23.05.2014 and further it is admitted fact that the payment has been made to the complainant on 30.10.2015. Thus, there is a delay of one year and five months. OP No.4 i.e. the sanctioning authority as per State Govt. notification dated 21.10.2002, as revealed in the written statement of OP No.1,2,3 and 5, has  admitted the delay in processing the claim but has denied any intentional and willful delay. The delay as per OP No.4 is procedural as they have explained in Para No.6 of the written arguments. There were certain objections in the medical bills of the complainant which were finally got removed on 30.06.2015 and once the defects were removed, OP No.4 did not consume much time to process and clear the bill and without any delay on its part has released the amount. The counsel for the complainant has countered the contention of OP No.4 stating that the complainant is not privity to the inter se departmental communications regarding removal of objections, if any. Therefore, the delay is squarely attributable to the OPs.  Thus, the complainant has proved the delay in processing and realization of his claim against OP No.4, 6 and 7 who have dealt with the case file of the complainant.  So far OP No.5 is concerned; there is nothing on record to show that as to when the complainant has approached OP No.5 seeking his assistance in clearance of his bills. Further there is no record to show that OP No.5 has ever dealt with the case file of the complainant.  So far as OP No.1 to 3 is concerned, the complainant has not proved anything against them on this issue.

13.           Since the complainant has proved the delay of one year and five months in processing and realization of his claim, and such delay has been admittedly caused by OP No.4, 6 and 7.  The act of OP No.4, 6 and 7, therefore, causing delay in processing and realization of claim of the complainant is an act of deficiency in service on the part of OP No.4, 6 and 7 and on this account the complaint deserves to be allowed and the complainant deserves to be adequately compensated for suffering mental agony, harassment and financial loss.

14.           In view of above discussion, the complaint against OP No.4, 6 and 7 is allowed. The complaint against OP No.1, 2, 3 and 5 is dismissed. OP No.4, 6 and 7 are jointly and severally liable to:

(a)    pay a lump sum compensation of Rs.25,000/- (Rs. Twenty five thousand only) for mental agony, harassment and costs of litigation.

                Compliance of above directions be made within a period of one month 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 26, 2016

                          (Mrs. Madhu P. Singh)

                                                                        President

(Amrinder Singh Sidhu)

Member

(Mrs. R.K. Aulakh)

Member