Delhi

East Delhi

CC/159/2014

SAJJAN - Complainant(s)

Versus

DIRECTORATE OF HEALTH SERVICE - Opp.Party(s)

28 Feb 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  159/2014

 

	Sajjan Kaur W/o Late Shri Baljeet Singh Gulia R/o A-46, Naya Bazar Najafgarh, Delhi 110043	….Complainant
Versus
1	Directorate of Health Services Govt of NCT of Delhi DHS (HQ) F-17, Karkardooma, Delhi 11032	……OP1
2	Irrigation & Flood Control Department Acting through its Executive Engineer (CD-VII) Rohini Office Complex, Sector-15 Rohini, Delhi 110085	……OP2

 

         

Date of Institution: 07.02.2014

Judgment Reserved on: 28.02.2022

Judgment Passed on: 28.02.2022

                  

QUORUM:

Sh. S.S. Malhotra (President)

Ms. Ritu Garodia (Member)

Sh. Ravi Kumar (Member)

 

Order By: Ms. Ritu Garodia, Member

 

JUDGEMENT

1. The complaint pertains to deficiency in service on the part of OP in not reimbursing the medical expenditure incurred by the complainant on her husband’s treatment in a hospital which is stated to be not on the panel of the OP.
2. Brief facts as stated in the complaint are that the husband of the complainant, late Shri Baljeet Kumar Gulia, retired as driver from the Irrigation & Flood Control Department, Civil Division VIII, Rohini, Delhi/OP2. He was a beneficiary of Delhi Government Employees Health Scheme. A card no. 196322 was issued by OP1. It is submitted that the objective of OP1 is to provide comprehensive care facilities to government employees. The husband of complainant was suffering from cancer. He started his treatment in Rajiv Gandhi Cancer Institute and Research Centre. He was subsequently shifted to Apollo Hospital as an emergency case.  He expired on 15.06.2013 after prolonged illness. The expenditure incurred on his treatment was Rs. 4,84,323/-.
3. A Representation dated 12.10.2012 along with relevant documents for reimbursement of medical bills was submitted to OP2.The son of the complainant was informed that the medical bills were not sanctioned by the competent authority vide OP2 letter dated 24.6.2013. No reason for rejection was provided. It is alleged that the complainant faced much hardship due to non-reimbursement of medical bills due to gross negligence on the part of OP. The complainant prays for refund of Rs. 4,84,323/- along with interest and compensation.
4. The complainant has annexed copy of medical facility card, documents relating to claim under DGEHS, correspondence between the parties, permission for treatment from the concerned department, death certificate, medical bills of Indraprastha Apollo Hospital and Emergency Treatment Certificate from Indraprastha Apollo Hospital.
5. Court proceedeings shows that complaint was admitted on 24.02.2014. Notice to OPs was served but none appeared on behalf of OP1 on next date of hearing. An authority letter was filed by OP1 on 25.08.2015 but written statement was not accepted as be beyond the statutory period.
6. OP2 in its reply states that Late Shri Baljeet Singh had voluntarily retired from his service w.e.f. 28.02.2004. A medical facility card was issued to him on 12.01.2012. He was getting cancer treatment from Rajiv Gandhi Cancer Institute and Research Centre. The medical bills for the same were sanctioned and paid. Thereafter, the medical bill from Indraprastha Apollo Hospital were submitted by his son vide letter dated 12.10.2012. It was found that Apollo Hospital was not empanelled by Delhi Government for cancer disease. Furthermore, the beneficiary was not referred by Rajiv Gandhi Cancer Institute to Indraprastha Apollo Hospital. It is alleged that the family shifted him as per their own wish.
7. The bills from Apollo Hospital were forwarded to OP1 by OP2 for the requisite sanction but was rejected. OP2 also admitted informing the son of the complainant about the rejection vide letter dated 24.06.2013. OP2 has filed a partial list of hospitals empanelled by Delhi Government.
8. The complainant in his rejoinder has denied that Indraprastha Apollo Hospital is not in the list of empanelled hospitals of Delhi Govt for cancer diseases or that the beneficiary was shifted to Indraprastha Apollo Hospital as per family’s own wish. The beneficiary was shifted at Apollo Hospital for better treatment as it is a fundamental right of every citizen to avail the best possible remedies.
9. Complainant and OP2 filed evidence by way of affidavit supporting their averments. Complainant’s son has filed duly filled medical claim form and a letter providing reasons for shifting the patient to Apollo Hospital. In that letter complainant’s son submits that his father was operated on 02.04.2012 in Rajiv Gandhi Cancer Institute. As the treating doctor was transferred and his father developed infection, his father’s condition became serious. He had to admit his father in Apollo Hospital in emergency.
10. We have perused the documents and pleadings filed by both the parties. It is admitted by both the parties that late Sh. Baljeet Singh, retired from OP2 department on 28.02.2004 and a medical facility card was issued to him on 12.01.2012. OP2 admits that beneficiary was getting cancer treatment from Rajiv Gandhi Cancer Institute and Research Centre and medical bills for the treatment were sanctioned and paid.
11. It is also admitted that beneficiary was shifted to Indraprastha Apollo Hospital and a bill amounting to Rs. 4,84,323/-  was submitted to OP2 for reimbursement by the beneficiary son on 12.10.2012. The complainant‘s son has filed duly filled medical claim form and a letter providing reasons for shifting the patient to Apollo Hospital. In that letter, complainant’s son submits that his father was operated on 02.04.2012 in Rajiv Gandhi Cancer Institute. This letter has not been denied by OP2. The treating doctor was transferred and his father developed infection. As a result, his father’s condition became serious. He had to admit his father in Apollo Hospital in emergency.
12. A close examination of documents shows that late Shri Baljeet Singh was referred by Department of Health Services to a DGEHS approval hospital on 21.08.2012.
13. OP has filed a partial list of hospitals empanelled with Delhi Government. The relevant portion reproduced is as follows :

 

	Rajiv Gandhi Cancer Institute & Research Centre, Sector 5, Rohini, Delhi 85	Specialized purpose : Cancer diagnosis, Cancer Chemotherapy and Radiotherapy (Not empanelled for Surgery) Credit facility not available)
	Indraprastha Apollo Hospital, Mathura Road, Sarita Vihar, New Delhi 110044	A Radiological Investigations & Nuclear Medicines, Laparoscopic Surgery, Dialysis, Urology, Organ Transplant (Renal, Liver), Lithotripsy, Joint Replacement, Radiation Therapy, Cardiology, Cardiac Surgery, Cardio Thoracic, Vascular Surgery

14. The list shows that Rajiv Gandhi Cancer Institute & Research Centre was empanelled for cancer diagnosis, chemotherapy and radiology. It is clearly set down that it was not empanelled for surgery.  Nevertheless, the medical bills for surgery in Rajiv Gandhi Cancer Institute were sanctioned and paid.
15. The Complainant has filed an emergency treatment certificate by Indraprastha Apollo Hospital. The same is reproduced as below:

This is to certify that Mr. Baljeet Singh (ID No. 10115820) is a case of Ca- Right Lung. He has been treated with Surgery, Chemotherapy and Radiotherapy in RGCI earlier. He now presented with severe pain Right side arm and thoracic inlet region. There was impending Right Brachial Plexus Palsy due to tumor Compression. In view of that he was admitted on 22.08.2012 and operated in Emergency and resection of Right Pan Coast Tumor was done on 23.08.2012. Postoperatively he was on ventilator support for one week in ICU. He was finally discharged on 05.09.2012.

16. The complainant was operated for emergency resection of Right Pan Coast Tumor in Indraprastha Apollo Hospital which is also empanelled with government though cancer surgery is not covered. The sanction of bills were rejected by letter dated 24.06.2013.
17. A common man is usually not aware of empanelment of different government hospitals for different treatment. OP1 was established for taking care of health care needs and welfare for government employees and pensioners.  The relevant authorities are required to be more responsive and cannot deprive an employee of his legitimate reimbursement in a mechanical manner. In the present case, DGEHS has paid the bills for cancer surgery in RGCRI even though such surgery was specifically not covered. How can it expect a layman to have knowledge of such empanelment.
18.  Hon’ble Supreme Court has taken the following views in Shivkant Jha Vs Union of India in (W.P. (C) No. 694 of 2015 :

It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.

19. DGEHS was established so that government employees are not left without medical care after retirement. In the facts of present case, the beneficiary was shifted to Apollo Hospital for emergency treatment when his condition became serious.  The prime consideration in serious disease like cancer is take treatment from a hospital that a person might consider best for saving his life. The department cannot deny the right of a critical patient to get best possible treatment.
20. We, therefore, find OP guilty of deficiency of service in not reimbursing the claim of complainant. We hold OP1 and OP2 jointly or severally liable for reimbursing the medical bills of complainant amounting to Rs.4,84,323/- along with 9% interest from date of filing of complaint to date of payment. We also award Rs.40,000/- as compensation for mental harassment, agony and inconvenience suffered by her and Rs.10,000/- towards litigation expenses.
21. Let this order be complied with within 30 days from the date of this order.
22. Copy of the order be supplied / sent to the parties free of cost as per rules.
23. File be consigned to Record Room.
24. Announced on 28.02.2022.

 

DELHI

 

 

(Ritu Garodia) Member

(Ravi Kumar) Member

(S.S. Malhotra) President