Delhi

North

CC/321/2015

RAJ KUMAR GUPTA - Complainant(s)

Versus

DVB EMPLOYEES TERMINAL - Opp.Party(s)

04 May 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No.: 321/2015

 

Sh. Raj Kumar Gupta

S/o Late Sh. C.L. Gupta

R/o H.No. 67, Maya Sadan

Ishwar Colony, Bawana,

Delhi-110039                                                                     …                     Complainant

 

                                                          Vs

DVB Employees Terminal Benefits Fund

(Medical Reimbursement Cell)

Pension Trust, Rajghat Power House,

New Delhi

Through its Chairman                                                       …            Opposite Party No.1

 

The Director (Admn.)/ CMO

Fortis Escorts Heart Institute

& Research Centre Ltd.

Okhla Road

New Delhi-110025                                                          …            Opposite Party No.2

ORDER

04/05/2023

Ashwani Kumar Mehta, Member:-

 

1.       The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the Complainant is a retired employee of Delhi Vidyut Board (later on taken over by NDPL) who retired in July, 2005 and is entitled for medical Treatment as per the DGHES/ CGHS norms. The OP-2/Hospital is on the panel of OP-1 for medical Treatment of its pensioners as per the DGHES/ CGHS norms. On 04.04.2012, the Complainant was hospitalized at Fortis Escorts Heart Institute/OP-2 where he was advised for operation and dual chamber pacemaker implantation. The fact regarding said implantation and procedures to be performed was intimated to the OP No.1, through OP No.2. Accordingly, the said implantation was done by OP-2.

 

2.           At the time of discharge, the Complainant paid a sum of Rs.3,08,875/- to OP-2 as the cashless facility was reportedly not available at that time and the due procedure of reimbursement of claim was carried out on 08.06.2012 with OP-1 who released a sum of Rs.1,15,000/- on account of the cost of the  pacemaker implanted by OP-2 for which  the OP No.2 had charged a sum of Rs.2,60,000/- as the cost of the said device. The Complainant has completed all the formalities required for reimbursement of the expenses incurred by him for treatment and for reimbursement of Rs.1,45,000/- i.e. the difference of the cost of the said device which was paid by him to OP-2 but the OP-1 vide letter dated 11.04.2014 had intimated the Complainant that admissible payment has already been paid/reimbursed as per the rules. It has been alleged that neither the OP No.2 nor the OP No.1 informed the Complainant at any point of time that the Complainant had to pay a the difference of the cost of the said device i.e. 1,45,000/-. Since the Complainant was entitled for Medical Treatment as per DGHES/CGHS norms, the Opposite parties were under obligation to provide the cashless facility or the reimbursement of the medical treatment/ the cost of the device. It was kept concealed from the knowledge of the Complainant as to whether the cost of the device shall be charged as Rs.2,60,000/- and the admissible payment for the cost of the device was Rs.1,15,000/-. Since the opposite parties have illegally withheld the aforesaid amount of Rs.1,45,000/- i.e. the part payment of the cost of the pace maker, the Complainant had filed the present complaint with the prayer for directions to OPs to:-

1. release a sum of Rs.1,45,000/- (Rupees One Lakh Forty Five Thousand Only) together with interest @18% p.a. calculated upto date;
2. pay a sum of Rs.1,00,000/- (Rupees One Lakh Only) on account of compensation in favour of the Complainant and against the Opposite Parties, for the inconvenience, harassment and mental agony suffered by the Complainant caused by the Opposite Parties;
3. A sum of Rs.25,000/- (Rupees Twenty Five Thousand Only) may be awarded as costs of the litigation in favour of the Complainant and against the Opposite Parties;

3.       Accordingly, notices were issued to the OPs and in response to the Notice issued, the OPs have filed their reply as under:-

Reply of OP-1 (DVB Employees Terminal Benefits Fund)

 

4.       The OP-1 has submitted that the OP No.2 i.e. hospital is under the obligation to disclose the cost of the device to be implanted to the Complainant. However, the OP No.2 had issued a letter to the Complainant that the treatment given by the hospital to the Complainant is as per the entitlement and the rates charged are as per DGHES/CGHS approved rates. The subjected dispute is between Complainant and the OP No.2. The OP No.1 has no role in this case as the OP No.1 has already reimbursed/ released the admissible amount of expenditure incurred as per the CGHS circular of M.H. & F.W., O.M. No. S-11011/7/95-CGHS(P) Dated 12/6/1996 relating to Ceiling for Reimbursement of the Cost of Coronary Stents, Rotablotar, Single Chamber Pacemaker and Dual Chamber Pacemaker to CGHS Beneficiaries. A sum of Rs.1,15,000/-, being the cost of pacemaker, as per the ceiling limit defined under CGHS have been reimbursed to the Complainant. His claim for balance amount is Rs.1,45,000/- from OP-1 is not supported by any rules and thus cannot be granted. It has further been contended that the Complainant has not been able to show as to how he is entitled in excess of the CGHS guidelines and applicable rule/rates.

Reply of OP-2  (Fortis Escorts Heart Institute,& Research Centre Ltd.)

 

5.       The OP-2 has submitted that the rates charged for the pacemaker was not more than the rate at which the pacemaker was procured by OP No.2 and the Complainant was informed in advance about the cost and benefits of the said medical device and the Complainant with his own free will and volition chose the same with full knowledge of the cost factor and accordingly cleared all the dues. After consent of the Complainant that dual chamber pacemaker was implanted successfully. It is further submitted that the Complainant was charged as per DGHES/CGHS approved rates. Copy of informed consent is also submitted. The OP-2 has further stated that it raised the invoices wherein complainant was charged as per the DGHES/CGHS approved rates and the Complainant cleared all the dues and the role of OP No.2 was, thus, over. The processing and disbursement of medical claim is a matter between complainant and OP No.1. Therefore, OP No.2 neither had any knowledge nor any involvement in either sanction or rejection of the claim by OP No.1

6.       The OP-2 has further contended that it can be seen from the undertaking signed by  Sh. Vikas Gupta, son, attendant of the patient who was advised to undergo PTCA, that “he  has undertaken to pay all the hospital bills & expenses in respect of the treatment of the above patient.” Besides, in the Informed Consent for Procedures and Authorization for Conscious Sedation, the signature of patient/ Complainant has also been taken. The OP-1 has also filed a copy of CGHS circular of M.H. & F.W., O.M. No. S-11011/7/95-CGHS(P) Dated 12/6/1996 relating to Ceiling for Reimbursement of the Cost of Coronary Stents, Rotablotar, Single Chamber Pacemaker and Dual Chamber Pacemaker to CGHS Beneficiaries which indicated  that the maximum ceiling for Pacemaker (Dual Chamber) is Rs.1,15,500 or the actual cost, whichever is less.

Findings

7.       The complaint has been examined in view of the facts of the case and averments/documents/Evidences/arguments put forth by the complainant & OPs and it has been observed that the OP-2 did not inform the complainant at any point of time during treatment that the cost of the device (dual chamber pacemaker) shall be charged as Rs. 2,60,000/- instead of the CGHS rate i.e. Rs.1,15,000/- and the difference shall be borne by the Complainant. On this allegation, the OP-2 has contended that the Complainant was informed in advance about the cost of the device amounting to Rs.2,60,000/- and the Complainant at his own free will and violation consented for implantation of Dual Chamber Pacemaker and he was charged at as per approved CGHS rate. In support of its contention, the OP-2 has also filed copies of the informed consent taken from the Complainant but on perusal of these records, filed by the OP-2 alongwith his reply dated 04.03.2016 as “informed consent for procedures” and “second undertaking for payment”, it has been observed that the “informed consent” was taken only for:-

 

1. Procedure and Alternatives
2. Risks
3. Anesthesia
4. Photography
5. HIV test
6. Blood Transfusion

 

And “undertaking for payment”, signed by Sh. Vikas Gupta son of the Complainant also stands for payment of all hospitals bills and expenses in respect of the treatment of the patient/Complainant as the cashless facility was not available in the OP-2 Hospital for pensioner/complainant and both these documents do not indicate that the patient was explained and informed that the charges of device were Rs.2,60,000/- instead of CGHS rates i.e. Rs.1,15,000/- and the difference of Rs.145000/- shall be borne by the complainant being non-reimbursable as per the CGHS/DGHS circular. It has also been stated by the OP-2 at Para 9 and 10 of the reply that the patient was charged as per DHEGS/CGHS approved rates which has also been found factually incorrect because as per CGHS circular of M.H. & F.W., O.M. No. S-11011/7/95-CGHS (P) Dated 12/6/1996, the cost of Pacemaker (Dual Chamber), is prescribed as Rs.1,15,000/-.

 

 8.       Since the OP-2 has failed to produce any documents/evidence to counter the allegations of the Complainant that he was never explained/informed by the OP-2 at any point of time that the cost of the device shall be charged as Rs.2,60,000/- and the admissible payment for the cost of the device is Rs.1,15,000/-, we are of the considered view that the complainant has suffered directly due to deficient service of the OP-2 (Fortis Escorts Heart Institute,& Research Centre Ltd.) in terms of the deficiency defined in the Act which includes  any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. However, no deficiency of service has been observed on the part of OP-1.

                

 9.        Therefore, we feel appropriate to direct the OP-2 (Fortis Escorts Heart Institute & Research Centre Ltd.) to pay Rs.1,45,000/- (Rupees One Lakh Forty Five  Thousand only) within thirty (30) days from the date of this order, with interest at the rate of 9% p.a. from 10-12-2015 (date of filing of complaint) till the date of the payment. Besides, the OP-2 is also directed to pay Rs.50,000/-(Rupees Fifty Thousand only) as compensation to the Complainant for the mental pain, agony and harassment. It is clarified that if the abovesaid amount is not paid by the OP to the Complainant within the period as directed above, the OP shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

 

10.        Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

                                                                  Sd/-                                                                                             Sd/-

ASHWANI KUMAR MEHTA                                                             DIVYA JYOTI JAIPURIAR

                              Member                                                                              President       

              DCDRC-1 (North)                                                                DCDRC-1 (North)