This is an application u/s.12 of the C.P. Act, 1986. Complainant by filing this complaint has submitted that he is working now in Srei Sahaj E-Village Ltd., as Service Centre Agency under National e-Governance Plan (NeGP) which is initiated by Panchayat and Rural Development (P&RD), Govt. of West Bengal & Department of Information Technology (DIT), Govt. of India and complainant has been working in the Company since January, 2010 but unfortunately he suffered from Kidney damages and for that kidney transplantation was done on Woodland Hospital on 02-11-2011 and for which he spend about 8 lakhs for renal transplantation. He has stated that after operation he came to learn that he is entitled to get such relief and reimbursement from ESI but very painful to note that he was not ever informed about ESI benefits. So, he had no other option except to borrow money from others and selling land property and also took loan and ultimately his operation was done and he paid the entire cost of the operation. On joining in his office after recovery from the ailment he came to know that ESI Regional Office through mail about insurance benefit then as per instruction of Sr. State Medical Commissioner he contacted with Administrative Medical Officer, E.S.I.S(MB) Schemes, Govt. of West Bengal, P-233, CIT Scheme-VIIM, Bagmari Road, Kolkata-54 and submitted his reimbursement claim for Rs.3,97,164-32 on 13-08-2012 and after taking necessary approval of AMO office of Govt. of West Bengal (Ministry of Labour & ESI) Ref. Memo No.DESI/AMO/RI/55 Dated 09-04-2013, waiting for few days did not get any clarification from the Commissioner of AMO Office when he came to know that visiting of AMO office the claim has been rejected on 02-05-2013 then he visited to Dr. S.K. Chowdhury, Sr. State Medical Commissioner (EZ), ESIC, 5/1, Grant Lane, Kolkata – 12 to find out the reason of the claim rejection. Mr. Chowdhury told him that there is a process before the transplantation of kidney and patient should be approved from ESI Deptt. and as per this rule of ESI, he could not have any situation to get this approval from respective department because he did not know for the ESI benefit. In the mean time the situation was very severe that nobody was kinown about the ESI facilities. Thereafter, AMO office forwarded a letter on 16-05-2013 to the Medical Commissioner, ESIC, Head Quarters office, Panchdeep Bhawan, C.I.G. Marg, New Delhi – 110 002 for consideration of this claim but Mr. Chowdhury is standing by on his position about this matter, further he did not get any reply from their end. At first AMO officials agreed to deliver above mentioned order copy but after that they did not provide him any other copy of order. Thereafter, he appealed to the Assistant Director, Consumer Disputes Redressal, Kolkata Central Regional Office 14-08-2013 and they send a letter to Mr. Chowdhury on 26-08-2013 for clarification but he did not reply till now. It is submitted by the complainant there is no ESI approval of kidney transplantation hospital for which to save his life he took such risk and practically he claimed 4 lakhs only and AMO office approved around Rs.1.92 lakhs only and moreover complainant was alleged that practically OPs even after receipt of letter AMO Office did not dispose the same and according to regulation 96A of the ESI Act, Government of West Bengal approved this to the victim but OPs as Government Authority has no done this and in the above circumstances, complainant has prayed for disposing the said amount and also for harassment and other costs. On the other hand, OP by filing written statement submitted that no doubt complainant is an insured person under the Employees’ State Insurance Act, 1948 as amended and he cannot go beyond the provision of the Act and as per provision of Section 59 of the Act there are ESI Hospital Dispensaries and Medical and Surgical services for the benefit of insured persons and in case of requirement of medical treatment either due to employment injury or otherwise, the insured person will have to be treated by his Panel Doctor appointed by ESI Corporation. If the Panel Doctor is of the view then the patient is required to be hospitalized, he will be referred to his nearest ESI Hospital and under the treatment of the insured person seems to be not possible in the ESI Hospital, he would be referred to only tie up Hospital for better treatment but complainant did not did not adopt all these procedures as an insured before admitting him in Woodland Hospital for Renal Transplantation. Further it is submitted that as per provision of Section 75(1)(8) of the ESI Act, any dispute relating to benefit or other dues payable or recoverable under this Act, shall be decided by the Employees’ Insurance Court. So, the present complaint is not maintainable. Decision with Reasons After proper study of the entire complaint and written version and also considering the materials on record including the provision of ESI Act (General Regulations 1950 also) that reimbursement of expenses incurred in respect of medical treatment can be made as per provision of Section 96A. But fact remains in this case it is undisputed fact that complainant finding no other alternative getting no such help from any corner only to save his life he was admitted to Woodland Hospital for renal transplantation. Truth is that he already paid Rs.8 lakhs for his operation and somehow he has recovered. The matter was reported to the ESI Authority by the complainant and that was referred to Administrative Medical Officer, Employees’ State Insurance (Employees Benefit Scheme) for reimbursement and AMO, ESI Medical Benefit Scheme sent a letter to Senior State Medical Commissioner (Eastern Zone) ESI Corporation for releasing a sum of Rs.1,92,905/- only which was found admissible and it was forwarded to Sr. State Medical Commission, E.Z. ESI Corporation for permission and that letter was sent on 09-04-2013 and copy was forwarded to complainant but even then Senior State Medical Commissioner did not release it and now, they are taking plea that before operation he has never been treated any ESI Hospital and ESI hospital did not refer to Woodland Hospital for operation. So, complainant did not apply the provision of ESI Act and Regulations. We have minutely considered the entire facts and materials. Fact remains Office of the Administrative Medical Officer, ESI Medical Benefit Scheme, Govt. of West Bengal already sanctioned Rs.1,92,905/- and directed to Sr. State Medical Commissioner E.Z. ESI Corporation to release it and in that letter Director of ESI (Medical Benefit Scheme), West Bengal specifically mentioned the expenditure of the total operation of the ESI Corporation decided ceiling limit so it is clear that Director, ESI Medical Benefit Scheme, West Bengal already sanctioned it asked ESI Corporation to release it but ESI Corporation is creating hindrance showing that complainant did not comply certain conditions but moot question is whether State Government has sanctioned it or not but about that the OPs are very silent but their only plea is that the complainant did not comply certain provision to get reimbursement but in this regard we have gathered from the letter of the Director, ESI (Medical Benefit Scheme, West Bengal) that State Government considered the present treatment of the complainant by the Woodland Nursing Home and it was completely not within the control of the ESI Hospital and after applying their judicious mind and on scrutiny of the claim they have released Rs.1,92,905/- and that has been received by the Senior State Medical Commissioner, Eastern Zone of ESI Corporation but they are not releasing it. Now, question is what prompted the ESI Corporation not to release it when Government has decided and sanctioned it then it is clear that OP has adopted unfair path and they have no moral and social approach in this regard when Government has considered pros and cons and, thereafter, such an amount was sanctioned then invariably OPs are bound to release it and there is no question of disallowing and to show any provision and this Forum is not in a mood to show any respect in defence of the OP because it is found they are neither human nor their administration had any morality because they went to defy the Director of ESI, Medical Benefit Scheme, West Bengal, also but we have failed to understand how Senior State Medical Commissioner, Eastern Zone of ESI Corporation can deny the reimbursement even after getting such order from Director, ESI Medical Benefit Scheme, West Bengal, then it is clear that Senior State Medical Commissioner probably has some plan not to release it without getting some alms. Practically, in this case we have gathered OP1 is the creator of the entire trouble and he has been harassing the complainant and he should be penalized heavily for his immoral activities and for denying the order of the State Government, we have failed to understand why State Government did not take any action against Senior State Medical Commissioner, Eastern Zone of ESI Corporation when the OP has been defying the order of the Director of Medical Benefit Scheme, West Bengal and as per provision of law invariably the complainant is a consumer under the OP1 and OP1 must be properly dealt with otherwise in such a manner he shall have to harass such a patient whose future is unknown even after such treatment. Whatever it may be after considering the entire facts and circumstances, we have gathered that the OP1 is the creator of the entire trouble and he is not willing to follow up the order of the Government i.e. of the OP2 and, may be, it is a clash between OPs1 and 2 but we are directing the OPs to release that amount immediately with compensation of Rs.30,000/- within one month failing which OP1 shall be imposed huge penalty of Rs.50,000/- for violating the order of the Director, ESI, Medical Benefit Scheme and this Forum also. In the result, the case succeeds. Hence, Ordered That the case be and the same is allowed on contest against the OP1 with a cost of Rs.5,000/- (Rupees Five thousand only) and against OP2 without any cost. OPs1 and 2 are jointly directed to pay a sum of Rs.1,92,905/-(Rupees One lakh Ninety Two thousand Nine hundred Five only) as reimbursement amount as per order of Director, Medical Benefit Scheme, West Bengal, vide Memo No. DESI/AMO/RI/55 Dated 09-04-2013 and OP1 is directed to comply it failing which the entire matter shall be dealt with very seriously and OP1 shall have to pay compensation of Rs.30,000/- to the complainant. OPs are directed to comply this order within one month from the date of this order failing which the punitive damages shall be imposed upon the OPs1 and 2 @Rs.500 daily till full satisfaction of the decree. OPs are directed to comply this order within one month very strictly otherwise penal measure shall be taken against them for which they shall be penalized further.
| | [HON'ABLE MR. Ashok Kumar Chanda] MEMBER[HON'ABLE MR. Bipin Muhopadhyay] PRESIDENT[HON'ABLE MRS. Sangita Paul] MEMBER | |
