Punjab

Ludhiana

CC/13/598

Manmohan Singh - Complainant(s)

Versus

Employee State Ins. Corp - Opp.Party(s)

Inder Mohan

13 Aug 2014

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                          C.C. No.598 of 19.08.2013

                                                          Date of decision: 13.08.2014 

Manmohan Singh son of S.Joginder Singh r/o H.NO.6-E, ELS Colony No.8, near Shyam Nagar, Ludhiana.

                                                          ….Complainant.

                                       Versus

 

1.Employees State Insurance Corporation, Bharat Nagar Chowk, Ludhiana, through Manager.

2.E.S.I.C.Model Hospital, Bharat Nagar Chowk, Ludhiana through Principal Officer/authorized signatory.

                                                …Opposite parties.

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:    Sh.R.L.Ahuja, President.

                   Sh.Sat Paul Garg, Member.

                   Smt.Priti Malhotra, Member.

                  

Present:       Sh.Indermohan Pal Singh, Adv, for complainant.

                   Sh.S.K.Pathak, Adv. for OP1.

                   Sh.Sudhir Kumar Gupta,Adv, for Op2.

 

ORDER

R.L.AHUJA, PRESIDENT.

  

 

1.                Present complaint under Section 12 of the Consumer Protection Act, 1986, has been filed by Sh.Manmohan Singh(hereinafter in short to be described as ‘Complainant’) against Employees State Insurance Corporation, Bharat Nagar Chowk, Ludhiana, through Manager and others (hereinafter in short to be described as ‘OPs’) directing them to make payment of Rs.77,439/- being the medical reimbursement for the expenses incurred by the complainant on the treatment of his billeted foot and right hand from G.T.B. Hospital, Ludhiana alongwith Rs.1 lakh towards damages for harassment and mental agony suffered by the complainant and Rs.10,000/- as litigation expenses to the complainant besides interest @18% per annum to the complainant.

2.                In brief, the case of the complainant is that the complainant is employed with Dada Motors, Savitri-I, G.T.Road, Dholewal, Ludhiana as Works Manager and has been serving with Dada Motors since 7.7.2011. The complainant is a holder of ESIC Card and a fixed amount is being deducted from his salary on account of health insurance of complainant alongwith his family including his wife, daughter and mother. The Ops being an insurance corporation and hospital are bound to provide health insurance to its members/insurance holders by reimbursing the medical expenses of members/insurance holders and also to provide medical treatment in their hospital under the policies/cards issued by them. The abovesaid insurance card was issued to the complainant by the Ops on 14.8.2011 and the regular amounts are being deducted from the salaries of the complainant and are being paid to the Ops on account of health insurance. As per terms of insurance, the complainant and his family members were covered and the complainant was entitled to reimbursement for the medical expenses spent by him on his treatment or on the treatment of his family in case of any mishap occurs with them. Unfortunately, on 28.12.2011, the complainant met with an accident and suffered burn injury on his billeted foot and right hand. The complainant was rushed to the hospital of Ops for treatment, but the injuries being of serious in nature and the concerned doctors of Ops refused to admit the complainant in their hospital. On this, the complainant and his brother Anil Kumar requested the concerned doctors/authorities of Ops to refer the case of the complainant to some other hospital, but they refused to do so. So, the complainant was taken to Guru Teg Bahadur Sahib (C) Hospital, Ludhiana, where, Dr.Rahul Tandan, Plastic and Cosmetic Surgeon admitted the complainant and started treatment of the complainant. The elder brother of the complainant namely Anil Kumar again approached the Ops for issuing reference, referring the complainant to G.T.B.Hospital, but the Ops did not accede his requests. The complainant remained hospitalized from 28.12.2011 to 6.2.2013 and thereafter, remained under treatment as outdoor patient for a long time and a huge amount was spent on his treatment i.e. Rs.77,439/-. The complainant has been regularly approaching the Ops with a request to reimburse the medical expenses spent by him on his treatment and also furnished requisite documents and affidavit dated 11.12.2012 on the asking of the Ops but the Ops have not reimbursed the medical expenses spent by him on his treatment till date and finally on 4.3.2013, they refused to pay even a single penny to the complainant. Such act and conduct of Ops is claimed to be deficiency in service on their part by the complainant. Hence, this complaint.

3.                Upon notice of the complaint, Ops were duly served and appeared through their respective counsels. However, when the case was fixed for filing written statement on behalf of OP1, Op1 failed to file the written reply despite granting last opportunity and as such, defence of OP1 was struck off vide order dated 6.11.2013 by this Forum.

4.                OP2 filed the written reply, in which, OP2 has submitted that the complainant does not fall under the definition of consumer under the Act. The complainant has to be provided with Medical Facilities available in the hospital of answering OP, if he satisfies all the conditions. However, it may be submitted that answering OP is neither liable nor responsible for the re-imbursement of any medical expenses incurred by the patient as all the reimbursement are made by the State Government as per ESIC Regulation-96-A. Further, it is submitted that the insured person is under obligation to approach the ESI Dispensary or ESIC Model Hospital Emergency Room, which is opened 24 hours and thereafter to get the benefits available in the scheme or in the case directly taken treatment from outside, the re-imbursement will be reimbursed as per ESIC Regulations-96A. All the ESIC Model Hospital of the Corporation provide cashless treatment to the IPs as per the policy. The complainant never approached the ESIC Model Hospital Emergency room as per the record available in the office of answering OP. It is denied that the complainant met with an accident on 28.12.2011. The complainant has to prove this fact and the injuries suffered by him with some documentary evidence. Further, it is submitted that the answering OP never denied the admission of the complainant to the hospital and for his treatment. It is wrong that the complainant remained hospitalized from 28.12.2011 to 6.2.2013. As per the discharge slip filed by the complainant, he remained admit in Guru Teg Bahadur Sahib (C) Hospital from 27.1.2012 to 6.2.2012. It is denied that the complainant had spent an amount of Rs.77,439/- on his treatment. The bills are falsely prepared to the false claim. Further, it is submitted that as per the terms of the policy/insurance, the answering OP is not responsible for any re-imbursement of the medical expenses spent by the complainant. The answering OP deals with all the medical facilities on cashless basis. The complainant never approached answering Op for any reimbursement of the medical expenses, except this complaint. The affidavit filed by the complainant is based on the false information. As the complainant has never approached or visited the hospital of answering OP, so the question of providing requisite service or treatment to the complainant does not arise. The complainant is entitled for the re-imbursement of medical expenses from his concerned dispensary as per his entitlement. There is no deficiency in service on the part of the answering Op. At the end, all other allegations made in the complaint against the answering OP are denied being wrong and incorrect and made prayer for dismissal of the complaint with costs.

5.                When the case was fixed for evidence of complainant, an application for amendment of complaint was filed by the complainant which was allowed vide order dated 7.3.2014 by this Forum and the amended complaint was filed by the complainant by amending the word mother with that of “Foot” and the name of the hospital from CMC to “GTB”. Thereafter, learned counsel for the OP1 and OP2 has suffered statement that the written reply of complaint already filed be read as the reply of the amended complaint.

6.                Learned counsel for the complainant in order to support the case of the complainant, adduced evidence by placing on record affidavit of complainant as Ex.CA, in which, complainant has reiterated all the averments made by him in his complaint. Further, learned counsel for the complainant has proved on record the documents Ex.C1 to Ex.C86.

7.                On the other hand, to refute the case of the complainant, learned counsel for the Op1 and OP2 adduced evidence by placing on record affidavit Ex.RA of Dr.Rakesh Kumar, its Officiating Medical Superintendent, in which, he has reiterated all the contents of the reply filed by the Op1 and OP2 and refuted the case of the complainant. Further, learned counsel for the Op1 and OP2 has proved on record document Ex.OP1.

8.                We have heard the learned counsel for both the parties and have also gone through the record on the file as well as evidence of the parties very carefully.

9.                Perusal of the record reveals that it is a proved fact on record that the complainant is an employee with Dada Motors, Savitri-I, G.T.Road, Dholewal, Ludhiana and is a holder of ESIC Card and a fixed amount was deducted from his salary on account of health insurance of the complainant alongwith his family members including his wife, daughter and mother. It is a proved fact on record that the Ops had issued a ESIC Card in this regard and as per the terms of insurance card, the complainant and his family members were covered and the complainant was entitled to medical reimbursement for the medical expenses spent by him on his treatment or on the treatment of his family members in case of any mishap occurs with them. As per the allegations of the complainant that on 28.12.2011, he met with an accident and suffered burn injury on his billeted foot and right hand and he was rushed to the hospital of Ops for treatment, but the injuries being of serious in nature and the concerned doctors of Ops had refused to admit the complainant in their hospital. The complainant and his brother Sh.Anil Kumar had requested the concerned doctors/authorities of Ops to refer the case of the complainant to some other hospital, but they had refused to do so. Thus, the complainant was taken to Guru Teg Bahadur Sahib (C) Hospital, Ludhiana, where, Dr.Rahul Tandan, Plastic and Cosmetic Surgeon had admitted the complainant and started treatment of the complainant. The elder brother of the complainant namely Sh. Anil Kumar had again approached the Ops for issuing reference, referring the complainant to G.T.B.Hospital, but the Ops did not accede his requests. The complainant had remained hospitalized from 28.12.2011 to 6.2.2013 and thereafter, remained under treatment as outdoor patient for a long time and a huge amount was spent on his treatment i.e. Rs.77,439/-, for which, he made prayer to the Ops for reimbursement of the same.

10.              On the other hand, there is specific plea of the learned counsel for the Ops that neither the complainant came to the hospital of Ops nor the complainant intimated the Ops qua his accident or taking of his treatment from Guru Teg Bahadur Sahib (C) Hospital, Ludhiana nor he was ever referred by the Ops to the said hospital.

11.              Perusal of the evidence of the complainant reveals that the complainant has not placed on record any evidence or documents, from which, it could be presumed that the complainant ever approached the Ops for his treatment and he was refused by the doctors of the Ops to give treatment and further, there is no evidence on the file adduced by the complainant that they approached the doctors of Ops who refused to refer the complainant to some other hospital being the injuries of serious in nature on his person.

12.              So, it appears from the evidence of the complainant that the complainant ahs failed to prove his case by leading any cogent and convincing evidence qua shifting to the hospital of OP2 after the occurrence and getting any treatment there or he was refused by the doctors to give him treatment or referring him to other hospital. Rather, on the other hand, Ops have placed on record document Ex.OP-1, vide which, the procedure was described qua reimbursement of expenses incurred in respect of medical treatment under Regulation 96-A of ESI. So, it is apparently clear from the record that the complainant is not entitled to get reimburse the treatment expenses as per the Section 75(2-B)3) of ESI Act, 1948. So, there does not appear to be any deficiency in service on the part of the Ops.

13.              In view of the above discussion, we hereby dismiss the complaint of the complainant being devoid of any merit. Complainant is at liberty to approach the competent authority for seeking reimbursement of his claim under regulations 96-A of ESI. Copy of this order be sent to the parties free of cost and thereafter, file be consigned to the record room.

 

    (Priti Malhotra)                             (Sat Paul Garg)              (R.L.Ahuja)

     Member                                Member                       President.   

Announced in Open Forum

Dated:13.08.2014

Gurpreet Sharma.

 

Manmohan Singh vs. Employees State Insurance Corporation

 

13.08.2014

 

Present:       Sh.Indermohan Pal Singh, Adv, for complainant.

                   Sh.S.K.Pathak, Adv. for OP1.

                   Sh.Sudhir Kumar Gupta,Adv, for Op2.

 

Written arguments not filed. Arguments have been heard. Vide our separate detailed order of even date, complaint is dismissed. File be consigned to record room after due completion.

 

    (Priti Malhotra)                             (Sat Paul Garg)              (R.L.Ahuja)

     Member                                Member                       President.   

Announced in Open Forum

Dated:13.08.2014