Punjab

Ludhiana

CC/15/344

vinod Kumar - Complainant(s)

Versus

ESIC Corpn. - Opp.Party(s)

Sukhdev Chand Adv.

09 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No. 344 of 21.05.2015

Date of Decision          :   09.12.2016

 

Vinod Kumar son of Shri Ram Gopal resident of House No.157/1, Ward No.14, Near Girls Khalsa High School Ahmedgarh, District Sangrur.

….. Complainant

Versus 

1.ESI, Corporation, ESI Headquarters, Near Indraprastha Post Office Kotla Road New Delhi, through its Director General.

2.The Regional Director, ESI Corporation, Sector 19A, Madhya Marg, Chandigarh.

3.The Director, Health Services Social Insurance, Punjab, Sector-34-D, Chandigarh.

4.The Manager, Employees State Insurance Corporation Focal Point, Ludhiana.

5.The Incharge, ESI Hospital Bharat Nagar Chowk, Ludhiana.

6.Satguru Partap Singh Apollo Hospitals, Ludhiana, Dhandari Kalan, Ludhiana, through its authorized representative.

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

MRS. VINOD BALA, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant                     :       Sh.Sukhdev Chand, Advocate

For Op1 to OP5             :       Sh.Sudhir K.Gupta, Advocate

For OP6                         :       Sh.R.K.Bhandari, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          To recapitulate, the case of the complainant is that he owing to working with OP6 got the insurance cover for self and family under the provisions of The Employee’s State Insurance Corporation Scheme(hereinafter in short referred to as ‘ESIS’). Due deductions made from the salary of the complainant as contribution towards the above said scheme. The mother of the complainant  namely Mrs.Sudesh Rani, aged 58 years, due to critical condition was rushed to hospital of OP6 and got admitted there on 6.2.2015 with acute abdomen pain. Said hospital conducted an emergency exploratory laparotomy on the same day. In that process, the perforation peritonitis with cecal perforation with descending colon tumor   was manifested. Even a subtotal colectomy was performed. Mother of the complainant remained admitted in well equipped hospital of OP6 during the period from 6.2.2015 to 27.2.2015. Expenditure of Rs.6,37,147/- was incurred on this treatment, but due to working of the complainant in the hospital of OP6, rebate of Rs.68,000/- was given and as such, complainant paid Rs.5,69,147/-. In the discharge summary, it is specifically mentioned that the treatment continued due to medical condition of the patient. Due to financial constraints, complainant took his mother to his residence at Ahmedgarh, District Sangrur (Address given in the title of the complaint). Mother of the complainant passed away on 27.2.2015 itself, when she was taken to home. Thereafter, the complainant approached OP1 to OP5 by claiming that he along with his family members are covered under the parameters of ESIS. Complainant tried to submit all the requisite documents of deceased like hospital bills etc., for getting the claim amount paid, but Ops flatly refused to consider the claim of the complainant. Documents were even not accepted from the complainant. After serving the legal notice and by pleading deficiency in service on the part of Ops, prayer for directing Ops to pay the amount of Rs.5,69,147/- (amount of medical incurred expenses) along with compensation for mental harassment and agony of Rs.1 lac made.

2.                In written statement filed by Op3 dated 09.11.2015, it is admitted that the complainant is working in the hospital of OP6 and contributing to ESI scheme. The complainant has not disclosed in the first line of para no.2 of complaint, the name of the hospital, where he got his mother admitted for treatment and same itself shows as if the complainant did not approach OP3 for treatment of his mother. Admittedly, the complainant got her mother treated from OP6 hospital because he is working there. As factum of treatment and admission of the      mother of complainant in hospital is matter of record and as such, complainant has to prove   the same by producing documentary evidence. Admittedly, the complainant served notice dated 1.6.2015 on OP3. It is claimed that the said notice was duly replied by directing the complainant to provide the original bills of the medical treatment of his mother. Complainant instead of submitting the bills, has filed the present complaint. Directions sought to complainant to produce the original bills, temporary insurance certificate, eligibility certificate and salary statement showing the deductions of ESI contribution. On supply of these documents, OP3 undertook to forward the bills to the higher authorities for consideration and payment under C.G.H.S.Rules/Rates. Complainant never approached OP3 for payment for treatment of his mother and nor any doctor refused for her treatment. Reimbursement of the incurred expenditure by the insured persons qua the treatment outside the hospital of OP3 is to be reimbursed as per ESIC Regulations-96a. All ESIC Model Hospital of the Corporation provide cashless treatment to the insured persons as per the policy. As per record available in the office of OP3, complainant never approached OP3 and as such, complainant is not entitled to any claim or any compensation for mental harassment.

3.                In separate written statement filed by OP6, it is pleaded that averments of the complaint exaggerated beyond proportion and as such, those are alleged to be false and frivolous. No relief virtually claimed against OP6 and complaint against OP6 alleged to be filed just for dragging it in litigation. Besides, it is claimed that the complaint is bad for mis-joinder of parties because impleadment of OP6 not required. No negligence or carelessness to OP6 attributed and as such, complainant has no cause of action against OP6. Admittedly, the complainant is an employee of OP6 hospital and he got treatment of his mother from OP6 hospital. Admittedly, the mother of the complainant discharged from the hospital of OP6 after treatment on 27.2.2015 and thereafter, she expired on that day itself. Reimbursement of expenditure incurred by the insured person to be made as per ESIC regulations and allegations of harassment or of deficient services denied specifically.

4.                In separate written joint statement filed by OP1, OP2, OP4 and OP5, it is not denied that the complainant contributing towards ESI schemes, being an employee in a hospital of OP6. Complainant never approached OP5 for treatment of his mother, but he got the same from hospital of OP6 due to working there. Treatment of the mother of the complainant is a matter of record and the complainant has to prove the same by documentary evidence. Factum regarding incurring of expenditure qua the treatment of mother of the complainant is not denied, but the complainant has to prove the quantum by producing the original and true copies of the bills. Reimbursement of the incurred expenditure by the insured persons outside the hospital of OP5 is to take place as per ESIC regulations-96A. It is also claimed that all ESIC Model Hospital of the Corporation provide cashless treatment to the insured persons as per the policy, but the complainant never approached the said authority and that is why, record not available in the office of OP5. Complainant not entitled to any relief because he did not suffer any harassment.

5.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.P1 to Ex.P96 and thereafter, closed the evidence.

6.                On the other hand, counsel for OP1 to OP5 tendered in evidence affidavit Ex.R5/1 of Ms.Ritu Miglani, Medical Officer of ESI Dispensary, Mandi Ahmedgarh, District Sangrur and Ex.R5/2 of Dr.Rakesh Kumar, Medical Superintendent, ESIC Model Hospital, Bharat Nagar, Ludhiana and then closed the evidence.

7.                Counsel for OP6 tendered in evidence affidavit Ex.RA of Sh.Rajesh Gambhir, Assistant General Manager(Finance) of OP6 hospital along with document Ex.D1/6 and thereafter, closed the evidence.

8.                Written arguments not submitted by any of the parties. Oral arguments alone addressed and those were heard. Records gone through minutely. 

9.                Submission advanced by Sh.R.K.Bhandari, Advocate representing OP6 has force that no claim put forth against OP6 and as such, cause of action against OP6 not available. It is so because complainant claimed himself to be an employee of OP6 and got treatment of his mother from that hospital. OP6 provided rebate of Rs.68,000/- as per contents of para no.3 of the complaint and as such, virtually concession to complainant provided by OP6 being its employee. If such concession provided by OP6 to the complainant, then certainly OP6 not rendered deficient services at all. Rather, claim of the complainant is that he being subscriber to ESI Scheme entitled for reimbursement of the incurred medical expenses of Rs.5,69,147/-.That claim to be adjudged and paid by OP1 to OP5 and not by OP6. So, relief certainly claimed against OP1 to OP5 and not against OP6. Impleadment of OP6 as party as such is unwarranted altogether. As complainant has no cause of action against OP6 and as such, complaint against OP6 merits dismissal and the same is hereby dismissed.

10.              Complainant in para no.4 of the complaint himself claims that he approached OP1 to OP5 by trying to submit the requisite documents of hospital bills etc for getting the claim amount of Rs.5,69,147/-, but OP1 to OP5 refused to consider the claim. However, case of the OP1 to OP5 is that complainant never approached OP3 and OP5 and nor submitted the documents. Complainant has not mentioned the date as to when he approached OP1 to OP5 for submission of requisite documents and as such, allegations in this respect certainly are vague. Had really the complainant approached OP1 to OP5 or any of them for submission of requisite documents, then he would have disclosed the date of approach to OP1 to OP5, but the same has not mentioned and as such, case of the complainant is not believable that he actually approached OP1 to OP5 or any of them at any time.

11.              It is submitted through written statement filed by OP1 to OP5 that in case, complainant submits the documents, then his case will be forwarded to the higher authorities for consideration because payment to be made as per ESIC regulations-96A. In the written statement filed by OP3, it has been specifically claimed that the complainant required to submit the original bills, temporary insurance certificate, eligibility certificate and salary statement showing the deduction of ESI contribution, so, that claim may be processed as per rules. That formality has to be complied with by the complainant and as such, complainant must do that, so that his claim may be processed. Rather, complainant has produced the original bills and other documents on the file of this forum and as such, complainant has tried to meet the requirement of submission of documents. However, reply to legal notice Ex.C89 was submitted by Ops is disclosed by contents of Ex.C96 and as such, it is not a case, where response to the notice sent by the complainant was not given by Ops. After going through the contents of Ex.C96, it is made out that the complainant was informed that he should contact the concerned dispensary for reimbursement of his claim because as per rules of ESIC and policy, the medical bills of treatment to be reimbursed by the concerned dispensary only. So, due response to the complainant was given by disclosing the procedure needed to be followed for reimbursement of the claim.So,simple issue of legal notice Ex.C89 through postal receipt Ex.C90 to Ex.C95 not enough to hold that Ops are deficient in service. This complaint filed on 21.5.2015 i.e. four days prior to       the date of reply Ex.C96 to the legal notice. So, submission advanced by counsel for Ops has force that this complaint is filed in haste without doing the needful    by the complainant himself. As Ops in their written statement has claimed that complainant never approached ESIC concerned and as such, fault also lay with the complainant in not performing his part of submission of original bills etc. However, those bills and records has been produced on the record of the file of  this case in the shape of documents Ex.C1 to Ex.C87 and copy of death certificate of Smt.Sudesh Rani Ex.C88 and as such, Ops if really interested in processing the claim, should have called upon this Forum to handover those documents to them, so that processing of the claim may be done as per rules. That has not been done by   OP1 to OP5 and as such, deficiency in service on the part of OP1 to OP5 is to this extent only. On account of this deficiency, complainant suffered some of the mental harassment and as such, keeping in view the deficiency in service on the part of OP1 to OP5 and mental suffering of the complainant in mind as pointed out above, it is fit and appropriate to allow meager compensation amount for mental harassment along with litigation expenses.

12.              Therefore, as a sequel of the above discussion, complaint allowed in terms that complainant will submit the original bills of medical treatment of his mother along with temporary insurance certificate, eligibility certificate and salary certificate showing deduction under Employee’s State Insurance Scheme contribution with OP3 within 30 days from the date of receipt of copy of order and after receipt of those documents, OP3 will forward the same to higher authorities for reconsideration. That reconsideration must take place within 60 days from the date of submission of above referred documents by complainant with OP3. Compensation for mental harassment of Rs.3,000/- (Rupees Three Thousand only) and litigation expenses of Rs.2,000/- (Rupees Two Thousand only) more allowed in favour of complainant and against OP1 to OP5 only. Complaint against OP6 is dismissed. Payment of these costs be made by OP1 to OP5 within 30 days from the date of receipt of copy of order, whose liability held as joint and several. Copies of order be supplied to parties free of costs as per rules.

13.                        File be indexed and consigned to record room.

 

                      (Vinod Bala)                                (G.K.Dhir)

                       Member                                          President

Announced in Open Forum

Dated:09.12.2016

Gurpreet Sharma.