Punjab

Sangrur

CC/473/2016

Mohanjeet Kaur - Complainant(s)

Versus

Employee State Insurance Corporation - Opp.Party(s)

Shri Rohit Jain

02 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

                                                               

                                                Complaint No.  473

                                                Instituted on:    01.08.2016

                                                Decided on:       02.01.2017

 

Mohanjeet Kaur wife of Shri Ashok Dhiman c/o Vasant Valley Public School, Somsons Colony, Dhuri Road, Malerkotla, Distt. Sangrur.

                                                        ..Complainant

                                        Versus

1.     Employees State Insurance Corporation through its Manager, Karbala Road, Near Dr. Zakhir Hussain Stadium, Malerkotla, District Sangrur.

2.     Employees State Insurance Corporation, Madhya Marg, Sector 19-A, Chandigarh through its Deputy/Regional Director.

3.     Medical Officer, Incharge SBI Dispensary, Lal Bazar, Malerkotla, Distt. Sangrur.

4.     Medical Superintendent, Deputy Director Zonal, ESI, Model Hospital, Bharat Nagar, Ludhiana.

5.     Director Health Services (SI), Punjab, Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.

                                                        ..Opposite parties

 

For the complainant  :       Shri Rohit Jain, Adv.

For OPS no.1&2       :       Shri S.M.Goyal, Adv.

For OP No.3 to 5      :       Dr. Nadeem Akhtar. 

 

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

                Vinod Kumar Gulati, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Smt. Mohanjeet Kaur,  complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is an employee as teacher in Vasant Valley Public School, Somsons Colony, Malerkotla and is covered under/insured with the OPs and her ESI IP number is 1213511881 and is paying the necessary contribution to the OPs, as such is a consumer of the OPs. 

 

2.             The case of the complainant is that she was having the fibroids in her uterus and on 18.11.2013 she felt severe pain in her stomach and was got admitted in Singla Surgical and Maternity Hospital, Sangrur and was operated on the same day and remained admitted upto 23.11.2013, where she spent more than Rs.36,701/- on her treatment including medicine, attendant, her food etc.  Thereafter, the complainant submitted claim form along with all the documents and bills amounting to Rs.36,701/- with the OPs in December 2013/January, 2014 and also submitted self declaration form that the complainant is ready to get the amount on the government rates and medical officer, ESI Dispensary, Malerkotla passed the claim of the complainant for Rs.15,077/-, but later on nothing was done in her favour. Further case of the complainant is that now she received letter dated 28.4.2016 along with original bills and claim form submitted with the OPs, from OP number 3 vide which the complainant was asked to clear objections and after that to submit the bills, but no objection was mentioned in that letter.   Further grievance of the complainant is that the complainant visited the Ops a number of times, but nothing was done by the OPs. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.36,701/- along with interest from  January 2014 till realisation and further claimed compensation and litigation expenses.

 

3.             In reply filed by OPs number 1 and 2, legal objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complainant has not come to the Forum with clean hands and that the complainant is not entitled to claim any relief. On merits,  it is admitted that the complainant is an employee as teacher in Vasant Valley Public School, Somsons Colony, Malerkotla and is covered under the ESI scheme as stated above.  It is further admitted that the complainant spent an amount of Rs.36,701/- on the treatment.  However, it has been denied that the complainant submitted the claim form along with all the documents and bills amounting to Rs.36,701/- with the OPs as stated in the complaint. It has been denied that the complainant told that it was an emergency case and at that time it was not possible for the complainant to get the patient referred from their doctor and after got her admitted in the hospital and at last the OPs returned the documents to the complainant on the lame excuse that certain formalities have not been complied with by the complainant.   It is stated further that the complainant never submitted the documents to the OPs.  It is stated that in the circumstances of the case, no claim is payable to the complainants.

 

4.             In reply filed by Ops number 3 to 5, legal objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complaint is not maintainable, that the complainant has not come to the Forum with clean hands.  On merits, it is admitted that the complainant spent an amount of Rs.36,701/- on the treatment of his wife including medicine etc. It is admitted that the complainant submitted the bills and documents to the OPs for Rs.36,701/-  along with the self declaration form of the complainant regarding ready to get the amount on the government rates with the Medical Officer, ESI Dispensary, Malerkotla and deducted the claim as per the rules of the government and total amount of Rs.15077/- was calculated for approval of OP number 4 on 7.2.2014, but later on OP number 4 refused to pass the claim of the complainant and objection was raised that it is not an emergency case and as per the opinion of the Gynae Specialist of the ESIC Corporation Model Hospital, Ludhiana letter dated 29.9.2014 the case of the complainant was not an emergency case and ‘surgery and fibroid uterus’ can be done in the ESI Hospital.  As such, it is stated that the claim has rightly been rejected by the OPs. However, any deficiency in service on the part of the OPs has been denied.

 

5.             The learned counsel for the complainant has produced Ex.C-1 and Ex.C-2 copies of letters, Ex.C-3 copy of bank passbook, Ex.C-4 copy of ESI I card, Ex.C-5 copy of contribution slip, Ex.C-6 copy of employee detail, Ex.C-8 copy of self declaration form, Ex.C-8 copy of discharge slip, Ex.C-9 to Ex.C-12 copies of bills , Ex.C-13 copy of medical reimbursement form and Ex.C-14 affidavit of the complainant and closed evidence. On the other hand, the learned counsel for the OPs number 1 and 2  has produced Ex.OP1&2/1 affidavit and closed evidence.  The learned counsel for OPs number 3 to 5 has produced Ex.OP3to5/1 affidavit, Ex.OP3to5/2 copy of letter dated 29.9.2014, Ex.OP3to5/3 copy of delivery of medical benefit and closed evidence.

 

6.             We have very carefully perused the pleadings of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

7.             In the present case, the grievance of the complainant is that she is the consumer of the Ops as she is covered under ESI IP number 1213511881 and has further contended that she was having fibroids in her uterus and on 18.11.2013 she got severe pain in her stomach and was admitted in Singla Surgical and Maternity Hospital, Sangrur, where she spent an amount of Rs.36,701/- but despite submitting the bills and other documents, the Ops failed to pay the claim amount.  On the other hand, the stand of the OPs is that the claim of the complainant has rightly been rejected on the ground that it was not an emergency case and as per the opinion of the Gynae Specialist of the ESIC Corporation Model Hospital, Ludhiana letter dated 29.9.2014 the case of the complainant was not an emergency case and ‘surgery and fibroid uterus’ can be done in the ESI Hospital.   Further it is contended that the complainant never approached the ESI Dispensary for getting the treatment prior to her admission in the Singla Surgical and Maternity Hospital, Sangrur on 18.11.2013.  The complainant has not produced even a single document on record to show that she ever approached the OPs number 1 and 2 for getting any treatment, more so when it is clearly stated in the written reply of the OPs number 3 to 5 that the case of the complainant was not an emergent case and the treatment can be very much provided in the ESI Hospital itself.  Further there is no explanation from the side of the complainant that why she did not approach the ESI Hospital.  In the circumstances, we feel that since the complainant has herself failed to prove her case, we are unable to go with the contention of the OPs that there is any deficiency in service on the part of the OPs.

 

9.             In view of our above discussion, we dismiss the complaint of the complainant, leaving the parties to bear their own costs. A copy of this order be supplied to the parties free of cost.  File be consigned to records.

                Pronounced.

                January 2, 2017.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                                                         

                                                            (Sarita Garg)

                                                                Member

 

 

 

 

                                                        (Vinod Kumar Gulati)

                                                                  Member