DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the 20^th  day of February 2016

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P.  Member                              Date of filing: 02/07/2015        

(C.C.No.93/2015)

     V.Syed Ali

          S/o Late Sri. V. Mohamed

          No. D.26, Vellachalil House,

          Gandhi Nagar

          Poochira, Puthupariyaram,

          Palakkad- 678 731                                         :        Complainant

(Rep. by authorized agent Sri. M. parameswaran)

Vs

         Dr. V. Kalarani

         Chief Medical Superintendent

         Railway Hospital,

         Palakkad- 678 009.                                          :        Opposite party

        (By Adv.T.R Rajagopalan)

O R D E R

By Smt. Suma. K.P, Member,

          Complainant is retired railway employee and joined the “Railway Employees Liberalized Health Scheme” (RELHS)  by remitting the required fees which was recovered from his “Death Cum Retirement Gratuity (DCRG)”.  Accordingly, he was supplied with RELHS card.  The same was registered in the Railway Hospital Palakkad on 5/7/2005.  Based on the scheme the complainant and his wife was eligible for free treatment from any ailment in the  Railway Hospital, Palakkad.  As per standing orders, an employee or retired employee can take treatment from private hospitals when he/ she is staying beyond the jurisdiction of Railway Hospital (2.5 kms.)and facing an emergency due to sickness.  The amount spent for such treatment is to be reimbursed to the party on claiming in the prescribed format.  On 24.03.2013, the complainant went to his relative’s house at Chadanamkurissi to meet his sickly grandmother.  On 25.03.2013 he felt severe stomach pain.  His relatives took him to the nearest private hospital named Thankam Hospital (PMRC), West Yakkara, Palakkad.  This hospital is only half kilometre away from the house where the complainant stayed.  From the hospital the complainant’s sickness was diagnosed as “Antral Gastritis and Distal Esophagitis” and treated after various tests.  The treatment completed  on 26.03.2013 and a sum of Rs. 2,179/- was paid to the private hospital towards treatment charges.  The Railway Hospital Palakkad is 8 km away from the house where the complainant stayed.  The complainant submitted his claim for reimbursement of Rs. 2,179/- in the proper format to the Chief Medical Superintendent on 22.04.2013.  When the payment was delayed, he made several correspondences with authorities under the provisions of Right to Information Act 2005.

On 24.06.2014, the Chief Medical Superintendent, Railway Hospital Palakkad advised the complainant that “As emergency nature is not established, your claim does not qualify for reimbursement.  However, you may claim the charges for OGD scopy, if you desire so, as reimbursement as special investigation, in the prescribed form as the same facility is not available in RH/PGT.  Hence, your claim with necessary bills are returned herewith”. Complainant resubmitted the claim but no progress in the reimbursement claim was found.  Hence, he issued a lawyer notice on 26.12.2014 to the opposite party.  There was no response from opposite party.  Hence, he had approached before this Forum claiming reimbursement of private treatment charges, along with compensation for deficiency in service, mental agony, cost and interest. 

Notice was issued to opposite party for appearance. Opposite party entered appearance and filed version denying all the allegation in the complaint.  The opposite party resisted the claim stating that complainant is not entitled for the same since, he was treated outside the Railway Hospital and as per the rules also and he is not entitled for the same.  

          Under para:633 of Indian Railway Medical Manuel, it is stated that the railway beneficiaries are entitled free of charge to medical attendance and treatment:

1. In such railway hospital, health unit or consulting room maintained by the authorized Medical Officer, at or near the place where the patient falls ill, as can, in the opinion of the authorized Medical Officer, provide the necessary and suitable facilities; or
2. If there no such hospital, health unit or consulting room as referred to in case (a) above, in such Government Hospital, Health Centre or Dispensary at or near that place, as can, in the opinion of the authorized Medical Officer ,provide the necessary and suitable facilities; or
3. If there is no such hospital, Health Centre or Dispensary as referred to in clauses (a) and (b) above, any other hospital with which arrangements have been made for the treatment of the railway employees at as near that place as can, in the opinion of the authorized Medical Officer provide the necessary and suitable medical facilities.

Under para:647 of Indian Railway Medical Manuel, it is, stated that reimbursement allowed if medical attendance was availed at the instance of the Authorized Medical Officer:

1.  A railway employee obtaining medical attendance and / or treatment for himself or a member of his family or dependent relatives should under the provisions of para 633 consult his Authorized Medical Officer first and proceed in accordance with his advice.  In case of his failure to do so, his claim for reimbursement will not be entertained except as provided hereinafter.  All claims for reimbursement should be scrutinized with a view to see that the Authorized Medical Officer, or another Medical Officer who is either of equivalent rank or immediately junior in rank to his authorized Medical Officer and attached to the same hospital/ health unit as the Authorized Medical Officer, was consulted in the first instance.

Under para:648 of Indian Railway Medical Manuel, it is, stated that reimbursement allowed in treatment in an emergency:

1. Where in an emergency, a Railway Employee or his dependent has to go for treatment (including confinement) to a Government hospital or a recognized hospital or a dispensary run by a philanthropic organization, without prior consultation with the Authorized Medical Officer, reimbursement of the expenses incurred, to the extent otherwise admissible, will be permitted.  In such a case, before reimbursement is admitted, it will be necessary to obtain, in addition to other documents prescribed, a certificate in the prescribed form as given in Part C of certificate B of Annexure-III to this Chapter from the Medical Superintendent of the hospital to the effect that the facilities provided were the minimum which were essential for the patient’s treatment.  In such cases, the General Managers are delegated with powers to allow:

1. full reimbursement of medical expenses in case of  Govt. hospitals;   

and

2. up to a limit of Rs. 50,000/- in case of recognized hospitals and dispensaries run by philanthropic organizations.  All cases above      Rs. 50,000/- should be referred to the Railway Board along with proforma given in Annexure VI to this chapter, duly filling all the columns.

2. In case where the treatment had to be taken in a private / non-recognized hospital in emergent circumstances, without being referred by the Authorized Medical Officer, the General Managers are empowered to settle reimbursement claims up to Rs. 30,000/- per case.  It should be ensured that treatment taken in private hospitals by Railway men is reimbursed only in emergent cases and for the shortest and unavoidable spell of time.  All claims above Rs. 30,000/- should be referred to the Railway Board along with the duly filled in proforma given annexure VI to this chapter.

Thus, it is humbly submitted that in order to become entitled for reimbursement of medical expenses for treatment, the railway employee or the retired railway employee who are enrolled in the scheme, obtaining medical attendance and/ or treatment for himself or a member of his family or dependant relative, should under the provisions of para 633 consult his authorized Medical Officer first and proceed in accordance with his advise in case of non-emergency cases.  In emergency cases, the reimbursement will be governed as per para 648 of the Medical Manuel, for which the employee has to sufficiently prove that he or his family members or dependent relative had to take treatment in emergency by obtaining emergency certificate from the Hospital from which the patient has taken treatment.  In case of failure, the claim for reimbursement will not be entertained.

          In the case, this complainant the above conditions are not met and as such he is not entitled for reimbursement of medical expenses as claimed.  In the complaint he has stated that he had availed treatment for self in emergency on 25.03.2013 from Thankam Hospital and the said hospital is just half a k.m away from the place of his residence; whereas, Railway Hospital is situated 8k.m far from his residence.  Under para 633 of IREM Specifies that railway beneficiaries falling sick should report to the authorized Medical Officer where he falls sick. The Divisional Railway Hospital is just 8 k.m away from the place of his residence.  It is a well equipped hospital with all major specialties and it could not take much time for him to reach the hospital.  If it is assumed without admitting that the situation was so critical that the complainant cannot wait to reach the Divisional Hospital, he could have attended the nearby govt. hospital for treatment i.e, the district hospital which is nearer than the Divisional Railway Hospital.  It  is seen that complainant had taken treatment from Thankam Hospital in an emergency situation as the case papers produced by him along with his claim do not establish this fact.  It was further stated that except for OGD examination, all other investigations could have been arranged from the Divisional Railway Hospital itself.  Since, OGD examination facility is not available, the complainant was advised that the amount spent by him towards the same may be claimed for reimbursement of special investigation in the prescribed form, which was not done.  Thus, there is no merit in the complaint of the complainant and it has to be dismissed. 

          The opposite party had submitted that the disease as stated in the case paper produced by the complainant from the private hospital does not fall in the category of emergency.  If it is a real emergency as claimed by the complainant, the hospital would have documented it in the case papers and they would have admitted him for appropriate care as an in-patient.  A copy of the case paper was produced by him at the time of claiming medical reimbursement.  On a mere perusal of the said case paper, it would reveal the fact that the complainant had the duodenal ulcer (abdominal pain) for the past 15 years and the symptom for the present uneasiness has been stated to be loss of appetite and loss of weight.  However, other health parameters like BP, etc. have been stated to be normal.  These symptoms cannot be stated to be life threatening and the complainant could have attended the Divisional Railway Hospital, Palakkad which is situated within 8 k.m radius from his place of residence.  Moreover, he was treated as an out-patient and he had attended the said hospital again on the very next day for further investigations, which clearly establishes the fact that it was not an emergency case.   It is submitted that, except OGD scopy all other investigations could have been arranged from the Railway Hospital itself which is well equipped for such investigations.  Since, the OGD scopy facility is not available at the Divisional Railway Hospital, he was advised that the same may be claimed as reimbursement of special investigation in the prescribed form, which he failed to do so.

          It is also submitted that the reimbursement of medical expenses claim preferred by serving railway employees and retired railway employees who are enrolled in the above scheme are governed by set of rules as provided under Indian Railway Medical Manuel.  The documents produced by the complainant do not prove that he had undergone treatment at Thankam Hospital in emergency.  As such the question of claim amount being meager or high or that the same will not have any effect on the monitory position of Railway does not arise.  It is submitted that what is required under the rule is that the claim has to conform to the rules governing the same.  In the case of the complainant, he has availed the treatment from Thankam Hospital not on the basis of any reference by the Authorized Medical Officer as such the same would not fall under para 647 of Medical Manuel.  The complainant has also failed to establish that he had availed treatment in emergency, as the disease for which he had taken treatment from the private hospital does not fall under the category of emergency and the case papers produced by him also does not bear any such endorsement.  The complainant has been treated as an out-patient alone proves that his was not an emergency case. Hence the complaint has to be dismissed.

          Both parties filed respective chief affidavits Exts. A1-A8 was marked from the part of complainant and Exts. B1-B2 marked from the part of the opposite parties . Evidence was closed and matter was heard.

          The following issues are to be considered;

1. Whether there is any deficiency of service from the part of opposite

Party?

2. If so, what are the reliefs and costs?

 ISSUES 1 & 2

          The opposite parties resisted the claim stating that the complainant was treated at Thankam Hospital, Palakkad just 6 to 8 k.m away from railway hospital from where clinical examination were also conducted in two days without admitting therein.  The emergency was not stated in the medical records submitted before Forum.  Opposite party contented that all the test conducted at Thankam Hospital were also available at Railway Hospital.  The relevant rules for reimbursement of the Retired Employees Liberalized Health Scheme states that “No reimbursement is allowed in cases where the beneficiaries had to take medical treatment in places other than the Railway Hospital.  If referred to other Railway Hospital for indoor treatment charges may be recovered by the treating Hospital”.  There are several other conditions incorporated under para 612-A of IRMM. Opposite party can act only according to the rules prescribed by railway board from time to time.  They had also advised the complainant that since, the OGD facility is not available in the Railway Hospital, Palakkad he can claim the charges for OGD scopy in the prescribed format.  In these circumstances, we direct the opposite parties to pay an amount of Rs. 1000/- towards charges

spend for OGD examination by the complainant.  Considering the nature of the case the parties shall bear their respective costs.  Hence, complaint is disposed of accordingly.

Pronounced in the open court on this the 20^th  day of February  2016.

       Sd/-

                     Shiny.P.R.

                      President   

                        Sd/-

                     Suma.K.P.

                      Member

A P P E N D I X

Exhibits marked on the side of complainant

Ext.A1 Series - Photocopies of Medical Identity Card (RELHS).

Ext.A2 Series- Photocopies of treatment records pertaining to test, medicines, cash bill etc.a

Ext.A3-  Photocopies of claim for reimbursement of private treatment expenses.

Ext.A4- photocopy of  letter sent by complainant to Public Information Officer(Medical).

Ext. A5- photocopy of letter dated 24.06.2014 from Southern Railway Palakkad.

Ext. A6- Photocopy of letter dated 08.07.2014 sent by the complainant to CMS/RH/PGT

Ext.  A7- Photocopy of lawyer notice dated 26.12.2014 sent to CMS/RH/PGT.

Ext. A8 -Photocopy of acknowledgement card dated 6.01.15

Exhibits marked on the side of opposite party

Ext. B1- An extract of para 612 –A of IRMM.

Ext. B2- photocopy of case paper dated 25.03.2013

Witness marked on the side of complainant

Nil

Witness examined on the side of opposite parties

Nil

Cost Allowed

No cost allowed.