Punjab

Fatehgarh Sahib

CC/232/2013

Pawan kumar - Complainant(s)

Versus

Employee Insu.Corp. LTD - Opp.Party(s)

Sh Vinay Sood

07 Aug 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB.

                    Consumer Complaint No.232 of 2013

                                                           Date of institution: 05.11.2013

                                                                  Date of decision  :   07.08.2015

Pawan Kumar aged 45 years son of Joginder Pal R/o Near Defence Bandh, Sirhind and also C/o Navdeep Industries Sirhind, Tehsil and District Fatehgarh Sahib.

……..Complainant

Versus

 

1.  Employee State Insurance Corporation, G.T.Road, Mandi Gobindgarh, Tehsil Amloh, District Fatehgarh Sahib through its Branch Manager.
2. Employee State Insurance Corporation, Madhya Marg, Sector 19-A, Chandigarh through its Regional Officer.
3. The Director Health Services(SI) Punjab, Pariwar Kalyan Bhawan, Sector 34, Chandigarh.

…..Opposite parties      

Complaint Under Sections 12 to 14 of the Consumer Protection Act

Quorum

  Sh. Ajit Pal Singh Rajput, President                                                          Smt. Veena Chahal, Member                                                                      Sh. Amar Bhushan Aggarwal, Member                                                                                

Present :       Sh.Vinay Sood, Adv. Cl. for the complainant                                  Appearance of OPs No.1&2 exempted.                                                     Dr. Gurmohinder Singh, Rep. for OP No.3.

ORDER

By Sh. Amar Bhushan Aggarwal, Member.

                    Complainant, Pawan Kumar aged 45 years son of Joginder Pal R/o Near Defence Bandh, Sirhind and also C/o Navdeep Industries Sirhind, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite parties (hereinafter referred to as “the OPs”) under Sections 12 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under:

2.                 The complainant is an employee of Navdeep Industries at Sirhind and insured with the opposite parties vide policy No.1213079899 and is paying the monthly insurance premium to the opposite parties. The opposite parties are having its own hospital at Mandi Gobindgarh and as per the insurance policy they are bound to give free treatment at its own hospital or to reimburse the claim of insured/complainant. During last year the wife of the complainant namely; Asha Rani, suffered from some illness and she was got treated by the opposite parties. As the opposite parties did not have medicines, they asked the complainant to get the same from the market and they assured the complainant to reimburse the amount spent very soon. The complainant purchased medicines from Durga Medicose, Sirhind, vide bill No. 2013 dated 27.02.2012 for Rs.1030/- and vide bill No. 2153 dated 15.03.2012 for Rs.1030/-( Total Rs.2060/-). Thereafter the complainant lodged the claim of Rs.2060/- with opposite parties but till date the said amount has not been reimbursed despite several request letters written to them.  Thereafter, in the month of January 2013, the mother of the complainant suffered bone weakness problem and on medical examination, the doctors of OPs advised to conduct X-ray of Spine from outside, as they have neither any facility to conduct X-ray nor have its lab.  After X-ray of spine and on taking second opinion, it was found that the mother of the complainant had bone weakness and there is no spine problem.  Hence, the complainant got treated his mother from Sood Clinic, Sirhind and for her treatment the complainant got done several tests of his mother from Gurtirath Diagnostic Centre Sirhind and he spent Rs.5500/- on the treatment and tests.  The complainant approached the opposite parties for the reimbursement of said amount but they clearly told that the Government has no money to reimburse the medical bills so they did not give the reimbursement forms to the complainant due to which the complainant could not lodge the claim for reimbursement of medical bills. The OPs have not provided any medical facility, laboratory and X-ray in its clinic for the labour class, from whom they received monthly premium for providing them all the medical assistance free of cost. Therefore, it is a matter of unfair trade practice and deficiency in service on their part. Hence, this complaint for  giving directions to the opposite parties to pay the claim amount i.e. Rs.7560/- and further to pay Rs.50,000/-, as compensation on account of harassment and mental pain  and Rs. 7700/-, as cost of unwanted litigation.

3.                 Notice of the complaint was sent to opposite parties No.1 and 2, who appeared through Sh. Chander Bhushan, Representative and in view of the statement of said representative that the medical bills are to be cleared by Director Health Services,  OPs No.1 and 2 were exempted and the Director Health Services(SI) Punjab was impleaded as OP No.3.

4.                 The complaint was contested by OP No.3, who filed the written reply. In reply to the complaint OP No.3 stated that the medicines, which were not available in the dispensary/hospital, could not be provided to the patient and the same has to be purchased from outside by the patient. OP No.3 further stated that they wrote a letter to SMO ESI, Mandi Gobindgarh to provide the concerned record with regard to the present case and then the SMO ESI replied, vide its office letter No.629 dated 09.06.2014, clearly mentioning that as per their office record, no medical bill has been received. OP No.3 further stated that neither the complainant has approached the concerned hospital for the treatment of his mother nor there is any record for the treatment of the mother of the complainant as alleged.  The facilities of laboratory, X-ray etc are not available in the dispensary level and the complainant had approached the dispensary lever only as per the record produced by the complainant, hence, there is no deficiency in service or unfair trade practice on their part. After denying the other averments made in the complaint, they prayed for dismissal of the complaint.

5.                 In order to prove the case, the complainant tendered his affidavit Ex. C-1, copy of treatment record of Asha Rani Ex. C-2, attested copy of cash memo No.2153 dated 15.03.2012 Ex. C-3, attested  copy of letter dated 8/9-5-13 Ex. C-4, attested copy of letter dated 09.05.2013 Ex. C-5, attested copy of letter dated 19.06.2013 Ex. C-6, attested copy of letter Ex. OP-7, attested copy of certificate Ex. C-8, attested copy of medical reimbursement certificate Ex. C-9, attested copy of Identity Card Ex.C-10, attested copies of courier receipts Ex. C-11 to Ex. C-15, copy of reports  dated 28.01.2013 Ex. C-16 & Ex. C-17, copy of medical reimbursement Ex. C-18, copy of treatment record Ex. C-19, copy of receipt No.8894 dt. 29.01.2013 Ex. C-20, copy of report dated 21.01.2013 Ex. C-21, copy of treatment record/test report dt. 29.01.2013 Ex. C-22,  copy of bill No.2013 dated 27.02.2012 Ex. C-23 and copy of medical prescription Ex. C-24 and closed the evidence. In rebuttal the OP No.3 tendered in evidence affidavit of Dr. B.S.Multani, MO, as Ex. OP3/1 and closed the evidence.

6.                 The Ld. counsel for the complainant argued that the complainant submitted the medical bills Ex. C-9 to Ex. C-18 along with necessary documents to the competent authority and various reminders requesting them to make the payment, but even then the payment was not made. So there is deficiency in service and unfair trade practice for which the OPs be penalized and be also ordered to make the payment of medical bills.

7.                 On the other hand the representative of OP No.3 has argued that there was no deficiency in service or any unfair trade practice on their part and pleaded for dismissal of the complaint.

8.                 After hearing the Ld. counsel for the parties and going through the pleadings, evidence produced by the parties, written and oral arguments, we find that there is force in the plea of the Ld. counsel for the complainant that there is deficiency in service on the part of the OPs by not reimbursing the payment of medical bills for so long period.

9.                 Employee State Insurance Corporation(ESIC) is the guardian of the welfare of the IPs under the Act and charged with the duty of seeing that they do not suffer undue hardship and inconvenience in matters governed by the Act including medical treatment and reimbursement of treatment expenses.  Reimbursement of medical bills as prescribed under the ESIC Act also ensures hassle free and cashless service to the IPs. In the face of such a situation, OPs No. 1 and 2 simply cannot shift their statutory duty of prompt treatment to IPs & Prompt payment of their medical bills.

10.               OPs No. 1 and 2 have failed to discharge their supervisory duty when it is found that though complainant has submitted bills in 02/2012 and there is considerable delay in realization of the medical bills as the payment has been made to the complainant in June 2015 during the pendency of the present complaint. Through the complaint had been filed in 11/2013 even then the OPs took more than 1 ½ years to make the payment. OPs No. 2 and 3 took extraordinary unexplained long period of clearing the petty amount of the beneficiary which is deficiency in service and has also caused mental tension and harassment to the complainant.

11.               OP No.2 is directed to ensure that in future, it will take all appropriate steps to help the beneficiaries of ESI Scheme in getting their claims settled at the earliest and also get them medical care/cashless facilities under the scheme. It will be appropriate if OP No.2 being the principal executor of the scheme of ESI take up the matter with the office of DHS i.e. OP No.3 and resolve the bottlenecks being impediments in timely clearance of the bills at the level of OP No.3, because in the instant case inordinate and unexplained delay of more than 1 ½ years has been caused at the level of OP No.3. We deem it fit to direct OP No.2 to take up this issue with the office of OP No.3 for streamlining the process for the beneficiaries of ESI scheme.

12.               Therefore, the complaint is allowed against OP No.2 and 3 and is dismissed against OP No.1 and OPs No. 2 and 3 are jointly and severally liable for causing mental agony and harassment to the complainant. Therefore, they are directed to pay to the complainant:

 a)  Interest on the amount of bills @ 9% p.a. from the date of filing of complaint i.e. 05.11.2013 till realization.

b)        To pay lump sum compensation of Rs.5,000/- for harassment & costs of litigation within a period of 45 days from the date of receipt of copy of this order.  If payments is not made within the stipulated period, it will also carry interest @ 9% p.a. till realization.

13.               The complaint could not be decided within the statutory period as the OPs requested many times for adjournment since there was scope for compromise, as per their version. The case was also fixed for compromised in Lok Adalat, but compromise could not be effected. Thus, there was delay in the disposal of the present complaint.

14.               The arguments on the complaint were heard on 27.07.2015 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.

Pronounced

Dated:07.08.2015

(A.P.S.Rajput)               President

 

(Veena Chahal)              Member

                                                                             (A.B.Aggarwal)              Member