ORDER Date:
Vikram Kumar Dabas, Member
The complainant has been working with M/s Lark Labs India Ltd., Okhla Industrial Area Phase – II, He has been regularly depositing ESI Contribution at the rate of 1.75% from his salary along with the Employee’s Contribution at the rate of 4.75%. He is thus a consumer of OP1 who is rendering medical services under the ESI Scheme. He was suffering from Acute with Chronic problem of fissure and piles and on 4th March 2014 had visited ESIC Hospital Tigri New Delhi. He was referred to OPD of ESIC Hospital Sreemaa Anand Mayee Marg Okhla, where he went on 23/04/14 and 21/05/14 but his problem persisted and could not be cured. On 30/05/14 suddenly his condition became very serious and was rushed to Batra Hospital, New Delhi. He was diagnosed as a case of Fistula in ANO with Abscess with Hemorrhoidectomy with Anal Spasm and Ulcerative Colitis with large bowl perforation with gangrene of Caecum. Fistulectomy with abscess drainage with Hemorridectomy with Anal Dilation was carried out after admission in surgery of said hospital. On the same day he was admitted in ESI Hospital, Okhla from where he was discharged on 21/06/2014. He was again admitted to Batra Hospital on 21/06/14 with complaints of wound dehiscence of anterior abdominal wall prolapse ileostomy with fistula between ileostomy and skin. He was operated by debridement repair of burst abdomen resection with repair of ileostomy and closure of abdominal flap on 26/06/2014. Again a repair of burst abdomen was carried out on 27/06/14 before he was discharged on 17/07/14.
The complainant had incurred an expense of Rs. 232434/- (Two Lacs Thirty Two Thousand Four Hundred Thirty Four) on account of his treatment in Batra Hospital from 30/05/2014 to 15/06/14. He had also paid a sum of Rs. 3843/- (Three Thousand Eight Hundred Forty Three) for Medicines/OPD Card, in respect of his treatment in Batra Hospital for the second time i.e. from 21/06/14 to 17/07/14 the expenses was directly borne by OP1.
The complainant lodged a claim for reimbursement of a sum of Rs. 236277/-(Two Lacs Thirty Six Thousand Two Hundred Seventy Seven) in respect of his treatment at Batra Hospital from 30/05/14 to 15/06/14. The claim however, was rejected by OP2 vide its letter no. 3184 dt 21/08/2015. The complainant has alleged deficiency in service on the part of OPs and has sought a direction for payment of claim along with compensation and cost of litigation.
The OPs have contested the complaint and have filed a written statement. The OPs have taken preliminary objection that the complaint is misconceived and is based on false and incorrect facts. The OPs have denied that there were any deficiency in service on their part and have claimed that this complaint is not maintainable and is liable to be rejected. The defence of the OP’s is contained in the following preliminary objections/submissions, the same are reproduced as below :-
‘’The Complainant is working in a private company and he is claiming ESIC benefits under the Rules and Procedure of ESIC. The complainant attended ESIC Hospital, Tigri on 04.03.2014. The complainant was advised by the Doctor to attend OPD in ESIC Okhla, New Delhi for follow up treatment. The complainant was diagnosed with chronic problem of fissure and piles. The attending Doctor prescribed medicines and gave certain instructions regarding diet etc. to the Complainant as fissure is a chronic disease and it requires prolonged period of time to develop said disease. Thereafter, the complainant attended OPD in ESIC Okhla time to time. He was regularly checked and evaluatedby the Doctors and medicines were prescribed for further periods.
The Complainant was admitted to Batra Hospital on 30.05.2014. As per the discharge summary issued by the said hospital, the patient was admitted for evaluation. He was taken to OT (Operation Theater) and planned for emergency surgery. He underwent Fistulectomy with abscess drainage with Hemorridectomy with Anal dilation. At the time of admission his general condition was fair and all his vitals (Heart rate/Blood Pressure) were normal. The complainant developed perforation on the 2nd Post operation day. He was again taken to OT.
The complainant was diagnosed with perforation, which occurred due to the operation. He was discharged from the Batra Hospital on 15.06.2014. As per the discharge summary issued by the said hospital, the patient was in a stable condition and only oral medications prescribed. No injectable’s were prescribed by the Doctors to the complainant. It shows and confirms that the complainant was completely stable after surgery. After getting discharged from the Batra Hospital, the complainant attended ESI Hospital at Okhla on 15.06.2014 itself for follow up treatment. After examination it was found that the complainant had would dehiscence and prolapsed ileostomy. He was admitted to ESI Hospital Okhla on 15.06.2014 itself and remained admitted till 21.06.2014.
On 21.06.2014, the complainant was again re-admitted to Batra Hospital on cashless basis from ESI Hospital Okhla for large bowl perforation which had occurred on the 2nd Post Operation day, when the patient was initially admitted to Batra Hospital. The Perforation occurred due to the surgery which was done earlier in Batra Hospital. The complainant was admitted in Batra Hospital from 21.06.2014 to 17.07.2014. All the medical expenses of the patient during the said period was directly paid by the ESIC to Batra Hospital. The complainant did not incur any expense.
The complainant who is covered under the ESIC and Insurance Scheme can get benefit of medical reimbursement from impanelled/non-impanelled private hospitals only in a case of emergency treatment. It is further submitted that all employee’s covered under the ESIC and their family members have to get medical advice or treatment only in ESIC hospitals and dispensaries. If for any reason treatment for any particular ailment/disease and/ or for any procedure, facilities are not available in ESIC hospitals and dispensaries, then the patients covered under ESIC scheme are referred for specific procedures, ailments and treatment to such hospitals which are empanelled and registered with ESIC. The patient getting treatment on their own in private hospitals, which is impanelled with ESI Corporation cannot get medical reimbursement of bills for treatment in such private hospitals without taking prior permission from ESIC except in cases of emergency.
After discharge from the private hospital, the complainant applied for reimbursement of the total medical expenses incurred in his treatment amounting to Rs. 2,36,277/-. It is pertinent to mention that as per the case history of the complainant, he was diagnosed with a chronic disease and it requires prolonged period for medication. The complainant without taking prior permission from the ESIC attended to the private hospital for evaluation and treatment. The private hospital advised for surgery and it was planned surgery conducted in a private hospital. He was conscious and oriented at the time of admission to the private hospital and his surgery was planned procedure not undertaken in emergency cases.
That the complainant herein is wrongfully claiming reimbursement of medical expenses incurred by him from the Opposite Parties herein. The complainant is not entitled of any relief from the Ld. Forum against the O.P. ‘’
The OPs have contested the complaint on merit and have reiterated their stand as reproduced above by way of preliminary objections/submissions.
Evidence was led on both the sides by way of affidavits. We have heard arguments advanced at the bar and have perused the record.
The Learned Counsel for the complainant has forcefully contended that the Complainant was admitted in Batra Hospital in an emergency and he was entitled to reimbursement of the expenses incurred on the treatment as per the guidelines issued for reimbursement of expenses by the OPs. He has referred to discharge summary dated 15/06/14 in this regard. On the other hand the Learned Counsel of the OPs has contended that the Complainant had visited the hospital on his own and had failed to get his case referred from an ESI Hospital/Dispensary. He had contended that the claim of the complainant has been rightly rejected by the OPs. We have given our thoughtful consideration to the contentions raised.
A careful consideration of medical record placed on the file specially the discharge summary dated 15/06/14 makes it amply clear that the complainant was admitted in Batra Hospital in an emergent condition. He was diagnosed as a case of fistule in Ano with Abscess with Hemorrhoids with Anal Spasm with ulcerative Colitis with large bowl perforation with gangrene of Caecum. An emergent operation was performed on him to relieve him of the agony.
The fact that gangrene had already set in lends credence to our opinion. The onset of gangrene is life threatening and has to be treated immediately without any loss of time. In our considered opinion therefore it was an emergent condition where the complainant had got himself admitted in Batra Hospital which was on the panel of ESI. We therefore, hold that the rejection of the claim by the OP1 was unjustified. We hold OPs deficient in rendering services to the complainant and direct them as under:
1. Pay to the complainant a sum of Rs. 2,36,277 (Two Lacs Thirty Six Thousand Two Hundred Seventy Seven) along with interest @ 10% per annum with effect from 16/12/15 (from the date of filing of the complainant ) till payment.
2. We direct OPs to pay a sum of Rs. 25000/- (Twenty Five Thousand) to the complainant as compensation for pain and agony suffered by him.
3. Pay to the complainant a sum of Rs. 5,000/- as cost of litigation.
This order shall be complied with by the OP within a period of 30 days from the date of receipt of this order failing which interest @ 12% shall be payable on the entire above mentioned amount till realisation. Copy of this order is sent to all the parties free of cost. File be consigned to Record Room.
Announced on this …………….......
