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BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBHZADA AJIT SINGH NAGAR (MOHALI)

                                  Consumer Complaint No.  47 of 2015

                                 Date of institution:            05.02.2015

                                                Date of Decision:             27.07.2015

Kiran Bala, House No.2844, Sector 66, Mohali, District Mohali.

    ……..Complainant

                                        Versus

1.     The Director General, Employee’s State Insurance Corporation, Panchdeep Bhawan, Comrade Inderjeet Gupta (CIG) Marg, New Delhi 110002.

2.     Regional Director, Employee’s State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.

3.     Senior State Medical Commissioner, Employee’s State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.

4.     Director Health Services (ESI), Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.

5.     Social Security Officer, ESIC, Local Office, Phase-VII, Industrial Area, Mohali.

6.     SMO, ESIC Hospital, Phase-VII, Industrial Area, Mohali.

………. Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

CORAM

Mrs. Madhu. P. Singh, President.

Shri Amrinder Singh Sidhu, Member.

Mrs. R.K. Aulakh, Member.

Present:     Shri Jasbir Singh, counsel for the complainant.

                Shri Ravi Inder Singh, counsel for OP Nos.1,2,3 and 5.

Dr. Daljit Kaur and Shri Shinder Singh, Jr. Assistant for the OP Nos.4 and 6.

(Mrs. Madhu P. Singh, President)

ORDER

                The case of the complainant is that she is working with M/s Ivy Health and Life Science Pvt. Ltd., Mohali since 14.11.2011 with insurance No.1213278027.  Her husband Roshan Lal after being referred by OP No.6 took Super Specialty treatment from PGI Chandigarh for the period 25.03.2013 to 22.08.2013. Thereafter, the complainant submitted medical bills amounting to Rs.5724/- for reimbursement on 11.09.2013 to the ESI dispensary after completing all the formalities. Thereafter, he followed up with the OPs number of times but the amount of medical bills has not been reimbursed to him.

                Thus alleging negligence and deficiency in service on the part of the OPs, the complainant has sought directions to them to reimburse her the amount of medical bills of Rs.5,724/-  with interest @ 18% per annum and also pay him Rs.40,000/- for harassment and  Rs.10,000/- as costs of litigation.

2.             OP No.1, 2, 3 and 5 in their written statement have averred that they the bills are first submitted to the concerned dispensary and then to Medical Superintendent or SMO Incharge of the Hospital. After verification it is sent to the Director Health Services for passing and sanctioning the same and then to State Medical Commissioner, ESIC who issues the cheque of the sanctioned  amount. Then the cheque is sent to Director Health services and then to concerned dispensary by DHS who gives the same to the concerned person.  In the present case the bills were submitted on 11.09.2013 and the sanction was granted by the DHS on 20.01.2013 and cheque No.3428676  amounting to Rs.5672/- in favour of Roshan Lal was sent to DHS Office. The cheque was returned by the ESI  on the ground that the sanction was issued by the DHS on the name of Roshan Lal whereas it should have been on the name of the complainant. Then a revised sanction from the office of DHS on the name of Kirna Bala was received on 5.03.2015 and cheque No.927001 dated 05.03.2015 was issued and sent to the DHS Office. Thus, OP No.1, 2, 3 and 5  have  denied any deficiency in service on their part and have sought dismissal of the complaint.

3.             OP No.4 and 6 in the written statement have pleaded that the complainant submitted the bills on 11.09.2013 and after completing the formalities sent to the same to SMO ESI  Hospital, Mohali on 20.11.2013 from where it was sent to DHS on 04.12.2013 and cheque was received on 22.07.2014 in the name of husband who was not an IP. The cheque was sent back on 29.10.2014 for correction of the name and new cheque was received on 10.03.2015 which was received by the complainant on the same date.  

4.             Evidence of the complainant consists of her affidavit Ex.CW1/1 and document Ex C-1 to C-4.

5.             Evidence of OP Nos.1,2,3 and 5 consists of  affidavit of Ranjana Goswami, SSO Ex.OP-1/1 and copies of documents Ex.OP-1 to OP-2.

6.             Evidence of OP Nos. 4 and 6 consists of affidavit of Dr. Daljit Kaur Ex OP4/1.

7.             We have heard learned counsel for the complainant, OP Nos.1, 2, 3 and 5 and Dr. Daljit Kaur for OP No.4 and 6 and gone through the written arguments filed on behalf of the parties.

8.                The complainant is a member of the ESI Scheme having insurance No.1213278027. The husband of the complainant namely Roshan Lal being the beneficiary of the scheme had undergone treatment at PGI from 25.03.2013 to 22.08.2013 after being referred by OP No.6. After the treatment, the complainant submitted bills for Rs.5724.00 to OP No.6 which are duly acknowledge. Since the submission of bills, the complainant has not received the amount of Rs.5724.00 from the OPs and, therefore, the complainant being a consumer of the ESI Scheme has filed the present complaint against the OPs being service provider on the ground of delay in reimbursement of the medical bills by alleging deficiency in service and unfair trade practice causing mental agony to her.   

9.             The OP No.1,2,3 and 5 filed joint reply wherein they have explained the procedure and steps for receipt of the bills, sanction of bills and issuance of cheque of sanctioned amount to the end beneficiary. These OPs have admitted having received the bills on 11.09.2013 by the office of OP No.6 who has forwarded the same to OP No.3 on 20.01.2014 and thereafter OP No.4 issued the sanction for reimbursement of the amount of Rs.5672.00 to the complainant. Once the sanction is received by OP No.3, the cheque was prepared on 30.06.2014. Thus, there is a delay of five months in processing and sanctioning of the claim on the part of OP No.4 whereas once the sanction has been received by OP No.3 it has prepared the cheque on the same day and sent to the concerned quarter for handing over the same to the complainant. However, it is learnt that the cheque was issued in the wrong name i.e. in the name of patient, whereas it should have been issued in the name of IP i.e. the complainant. Therefore, it was resubmitted to the OP No.4 for re-sanction and finally the cheque has been issued in the correct name to the complainant on 05.03.2015 during the course of proceedings. The delay, as per the OPs is not willful and intentional but is procedural and has been explained by them from step by step and thus there is no deficiency in service.

10.            It is admitted that the complainant has received the amount of Rs.5672.00 by way of cheque during the course of proceedings. The limited question now left to be seen whether delay caused by the OPs in honouring claim of the complainant and issuing cheque of reimbursement of the claimed amount after a delay of 14 months is bonafide or negligent act on the part of the OPs.

11.            OP No.6 has accepted the bills on 11.09.2013 and forwarded the same to the concerned quitter i.e. OP No.3 on 20.01.2014. Thus, OP No.6 has acted as per rules and not caused any delay in discharge of its duties.  It is OP No.4 who has consumed more than five months in processing and sanctioning the claim of the complainant and that too has defaulted by issuing wrong sanction i.e. instead of the complainant the sanction has been issued in favour of Roshan Lal husband of the complainant. It is OP No.4 again took more than 9 months to rectify the said mistake and issued fresh sanction in favour of the complainant. Thus, in the whole chain, we hold the act of OP No.4 as negligent as no due care has been observed by OP No.4 while issuing the sanction and that too late by five months and further as no laid down time frame has been adhered by OP No.4 while discharging its duty as per ESI guidelines. The OP No.4 has not explained the reasons of 5 months delay in sanctioning the claim and 9 months delay in rectification of the error. Thus, the acts of OP No.4 have primarily caused financial loss and mental agony to the complainant in not honouring the claim of the complainant as per the time frame provided in the ESI Act and rules framed thereunder, which has caused financial loss and mental agony to the complainant. Thus, the complaint deserves to be allowed against OP No.4 and the complainant deserves to be compensated.

12.            Since there is no bonafide delay on the part of the OP Nos.1, 2, 3, 5 and 6 has been found in processing the medical bills of the complainant, hence complaint against them deserves to be dismissed. Hence complaint against these OPs is dismissed.

13.            The complaint is allowed against OP No.4 with the following directions:

(a)    to pay to the complainant  interest @ 9% per annum on Rs.5,672.00 for the period  from 11.09.2013 to 05.03.2015

        On account of delay in processing the claim  and rectification of the mistake

(b)    to pay to the complainant a lump sum compensation of Rs.25,000/-  (Rs. Twenty five thousand only) for mental agony, harassment and costs of litigation. 

                Compliance of this order be made within a period of thirty days from the date of receipt of a certified copy of this order. Certified copies of the order be furnished to the parties forthwith free of cost and thereafter the file be consigned to the record room.

Pronounced.                           

July 27, 2015.     

                             (Mrs. Madhu P. Singh)

                                                                        President

(Amrinder Singh Sidhu)

Member

(Mrs. R.K. Aulakh)

Member