| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No.04 of 04.01.2019 Decided on : 31-07-2024 Shivinder Kumar aged about 65 years S/o Kanwar Sain Retd. Manager (qc), Food Corporation Of India, District Bathinda, Now R/o H No.13409, Street No.2, Thakur Colony, Bathinda 151201. ........Complainant Versus Food Corporation Of India, District Office, Grain Market, Bathinda-151001, through Its Area Manager. .......Opposite party Complaint under Section 35 of the Consumer Protection Act, 2019 QUORUM Smt.Priti Malhotra, President Smt.Sharda Attri, Member Present : For the complainant : Sh.S.K Gupta, Advocate. For opposite party : Sh.Vinod Garg, Advocate. ORDER Priti Malhotra, President The complainant Shivinder Kumar (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Food Corporation Of India (here-in-after referred to as opposite party). Briefly stated, the case of the complainant is that he retired from the service of opposite party in year 2013 as Manager (QC). In the year 1999, opposite party launched a Self-Contributory Medical Health Scheme for its retd. employees vide circular No.48/1999 dated 15.12.1999 from file No.EP.43(1)/90-Vol.III. This scheme was modified vide circular No.EP-12-2012-13 dated 28.6.2012 vide which limit of IPD was enhanced to Rs.1,00,000/- and for OPD was Rs.12,000/- per financial year. He was having CPF No.8919 and he became the member of the said scheme from the date of his retirement i.e. 30.4.2013 and he was issued a Medical Health card No.329. Opposite party in supersession of the said scheme for retd. employees issued circular No.48 of 1999 dated 15.12.1999 from file No.EP.43(1)/90-Vol.III introduced FCI Post-Retirement Scheme (known as PRMS) as a part of superannuation benefits for the retired employees of FCI vide circular No.EP-12-2016-23 dated 30.12.2016 effective from 1.4.2016. The complainant has already paid token annual membership fee of 50/- for years 2016-17 and 2017-18. It is alleged that the complainant is diabetic and he suffered Coronary Artery Disease on 2.5.2016 and was got admitted in the Pragma Hospital Bathinda. He was diagnosed with 90% blockage of Left Artery (LAD) and he got his treatment from Fortis Hospital Mohali on 7.5.2016 that is empanelled hospital of opposite party. As per the medical treatment, the Angioplasty and stent placement are common procedures to open arteries in the heart that are clogged and complainant was treated with angioplasty and stent placement. The medical procedure of placement of stent in the LAD was adopted by the Fortis Hospital Mohali which was not successful for the unknown reasons, but the complainant pulled on the life with problem as his stent replacement was not successful and he was having psycho fear about the bypass surgery. It is further alleged that the complainant again felt uneasiness in the breathing etc. and he was diagnosed with 75% blockage of LAD whereas stent was placed in the month of May 2017. As such, the complainant wanted to opt second alternative i.e. Natural Bypass (EECP) at SAAOL HEART CENTRE CHATTARPUR NEW DELHI under the Supervision of Dr.Bimal Chhajer MBBS, MD from 29.8.2017 to 7.10.2017. The Insurance Ombudsman Delhi has held that Natural Bypass (EECP) treatment at SAALOL HEART CENTRE is regularly given by trained doctors from All India Institute of Medical Sciences Delhi. The treatment is cheaper and safe from the conventional angioplasty. It is in no way a day care process and required hospitalization for number of days as 40 to 45 days sittings are required with medicines and special equipment. Only 3-4 hours daily sitting was provided per shift per day. The Doctor at SAALOL HEART CENTRE given 35 sittings EECP (Natural Bypass) and 20 sittings of Biochemical Angioplasty (BCA) to the complainant and a bill of Rs.1,29,500/- was paid by the complainant to the hospital towards treatment, bed/nursing charges and Rs.504/- was spent towards purchase of medicines. The total amount of Rs.1,30,004/- was paid towards treatment by the complainant. The procedure adopted by the doctors at SAALOL HEART CENTRE, Chattarpur, New Delhi is not new to allopathic system. The medical bill of Rs.1,30,004/- for treatment duly verified by the doctor i.e 11 paper, one cash receipts of Rs.32000/-, two prescription, 5 cash memos, lab reports was submitted to opposite party for payment on 17.11.2017. It is further alleged that the Manager (A/Cs), District Office, Bathinda vide his letter No.C(1)/pay bill/medical bill/2017-2018/5114 dated 28.12.2017/05.01.2018 to the Assistant General Manager (Admin) FCI, Regional Office, Punjab sought clarification for payment of medical bill of the complainant. The clarification required by Manager (A/c) was whether the ex-official is eligible for reimbursement, if yes then how much amount to be passed. The Manager (A/Cs), District office, Bathinda again vide his letter No.C(1)/pay bill/medical bill/2017-2018/6119 dated 27.2.2018 to the Assistant General Manager (Admin) FCI, Regional Office, Punjab sought clarification for payment of medical bill of the complainant. The Assistant General Manager (Admin) FCI, Regional Office, Punjab vide letter No.A/(8407)/76/E1/7144 dated 16/19.04.2018 sought clarification from the Chief Medical officer, Food Corporation of India, Zonal Office (N) Noida at his own sweet will adding the clause of 6.8 of FCI Hqrs Circular No.EP-12-2016 dated 30.12.2016 requesting for the clarification illegally, arbitrarily with malafide intention to harass the complainant. It is further alleged that the complainant and Manager (A/Cs), District office, Bathinda has not mentioned any clause in the request letters. The bill was to be reimbursed after taking into consideration clause 6.6. The complainant has also menitoned Para 7.10 of the PRMS scheme. It is further alleged that opposite party has violated the Para 7.10 of PRMS by sending the claim to Assistant General Manager(A/cs) FCI, Regional Office, Punjab vide letter C(1)/pay bill/medical bill/2017-2018/5114 dated 28.12.2017/05.01.2018 after a gap of 49 days from the receipt of the claim whereas the claim has to be forwarded to the Medical Officer within 15 working days of the receipt of the claim. Opposite party again sought clarification regarding the claim from Assistant General Manager FCI, Regional Office, Punjab vide letter C(1)/pay bill/medical bill/2017-2018/6119 dated 27.2.2018 after gap of 93 days from the receipt of the claim, but there was no action taken by the Assistant General Manager(A/cs) FCI, Regional Office, Punjab. Para 7.10 was again violated by Assistant General Manager FCI, Regional Office, Punjab as request for claim was not processed within 15 working days after receipt of claim. The claim was processed by Assistant General Manager(Admin) FCI, Regional Office, Punjab on 16/19.4.2018 vide letter No.A/(8407)/76/E1/7144 dated 16/19.04.2018 after 5 months of receipt of claim. The complete processing of the claim should be completed within 60 working days failing which the concerned official/officer shall be liable for administrative action. The Chief Medical officer of Zonal Office Noida of opposite party returned the claim of the complainant vide letter No.CMO/Genl. Correspondence/2017-18/NZ dated 24.4.2018 to Assistant General Manager (Admn) FCI, Regional Office, Punjab. with the remarks that "The case is not covered under the Para 6.8 of of FCI Hqrs Circular No. EP-12-2016 dated 30.12.2016. It is further alleged that the Assistant General Manager (Admin) FCI, Regional Office, Punjab of opposite party forwarded the clarification letter of The Chief Medical officer, Food Corporation of India, Zonal Office(N) Noida, to opposite party vide letter No.A/(8407)/76/E1/7774 dated 23/28.05.2018 with further delay of 30 days. There was already delay of 5 months from the date of receipt of claim. Opposite party again violated the clauses/schedule of PRMS scheme. Opposite party informed the complainant about the rejection of the bill with a further delay of 28 days vide letter dated C(1)/pay bill/medical bill/2017-2018/1830 dated 19.06.2018/21.06.2018. Despite of clear instruction in PRMS, opposite party has illegally, negligently and with malafide intention harass and put the complainant to loss. On this backdrop of facts, the complainant has prayed for directions to opposite party to make payment of his claim to the tune of Rs.1,30,004/- and to pay Rs.1 lakh as compensation and Rs.5500/- as litigation expenses. Upon notice, opposite party appeared through counsel and contested the complaint by filing written version and raising legal objections that in view of the law laid down by Hon'ble National Consumer Disputes Redressal Commission in case title The DGM CPF Vs. Kashmir Singh & others, the employee of FCI is not 'consumer' in terms of Section 2(1) (d) of 'Act'. As such, the complaint is liable to be dismissed. The intricate questions of law and facts are involved in the complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant concealed the material facts and documents from this Forum and opposite party. As such, he is not entitled to any relief. He lodged the claim with opposite party under FCI post retirement medical scheme (PRMS), under clause 6.8 that is related to indoor treatment. He submitted duly filled certificate B in claim form that is meant only for claims against indoor treatment. According to clause 6.8 of the scheme, the claim of the complainant is not covered. As such, his claim was repudiated vide letter dated 19/21.6.2018. The clause 6.8 is reproduced as under:- “6.8) An additional special lifetime ceiling of Rs.4,00,000/- will be applicable to a member for indoor treatment of self/spouse/dependent children (as specified in this scheme) for the following specified major diseases, provided the treatment is done at a Govt. Hospital or at a FCI empanelled hospital or such other hospital of national repute as may be notified by CMD, FCI for this purpose:- (a) Bypass surgery of heart/angioplasty/Valve replacement (b) Pacemaker Implant (c) Neuro Surgery (d) Kidney/Renal/liver/bone-marrow/other organ transplant (e) Joint Replacement and Surgery (f) Pulmonary valvotomy/surgical treatment of lung (h) Cancer. A member would be able to avail this option either at one go or on multiple occasions subject to overall lifetime limit.” It is further pleaded that the claim was decided after seeking full clarifications. The Bathinda office of opposite party sought clarification from Regional Office, Chandigarh vide letter dated 28.12.17/05.01.18 and also vide letter dated 27.2.18. The Regional Office Chandigarh sought further clarification from its Zonal Office vide letter dated 16/19.4.2018 regarding the claim of the complainant and Chief Medical Officer vide letter dated 24.4.2018 clarified that the claim of complainant is not covered under Para No.6.8 of FCI HQ PRMS Circular No.EP-12-2016-23 dated 30.12.2016. Accordingly, the regional office conveyed the same to the FCI District Office, Bathinda vide letter dated 23/28.05.18. The complainant is not 'consumer' of opposite party and complaint is liable to be dismissed on this ground alone. The complainant has no locus-standi or cause-of-action to file the complaint against opposite party. The complaint is not maintainable in its present form and is liable to be dismissed. On merits, after controverting all other averments of the complainant, opposite party has reiterated its stand as taken in the legal objections and prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 3.1.2019, (Ex.C16) and documents, (Ex.C1 to Ex.C15). In order to rebut the evidence of complainant, opposite party has tendered into evidence affidavit of Ashish Tripathi dated 26.2.2019, (Ex.OP1/1) and documents, (Ex.OP1/2 to Ex.OP1/19) We have heard learned counsel for the parties and gone through the file carefully. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above. We have given careful consideration to these submissions. Admittedly, the complainant is diabetic and he suffered Coronary Artery Disease with 90% blockage and availed treatement from Fortis Hospital Mohali on 7.5.2016 where he was treated with Angioplasty and stent placement, but unfortunately, the complainant suffered the same problem and was diagnosed with 75% blockage of Left Artery (LAD). Provenly, this time the complainant preferred treatment from SAALOL HEART CENTRE and an amount of Rs.1,30,004/- was spent by him on his treatment for the period from 29.8.2017 to 7.10.2017. Provenly, the claim lodged for reimbursement has been rejected by opposite party. Opposite party has raised the legal objection that the complainant/employee in question of FCI is not 'consumer' in terms of Section 2(1) (d) of 'Act'. We do not agree with the objection raised by opposite party as the scheme under which the complainant is covered is self-contributory scheme i.e. the complainant has paid due consideration for availing the benefits of the scheme in question. Thus, he do fall under the definition of 'consumer' and has rightly filed the present complaint. The Medical Health Scheme in which the complainant is covered is self-contributory for the retirees of the Corporation. The relevant portion of circular No.EP-1212-2013 of Food Corporation of India, Headqurters 16.20, Barakhamba Lane dated 28.6.2012,(Ex.C1) in this regard is reproduced as under for ready reference:- “Attention is invited to Headquarter Circular No.48 of 1999 dated 16.2.1999 issued from File No.E.P. 43(1)/90-Vol.III) introducting self-contribtory Medical Health Scheme for the retirees of the Corporation wherein the contribution is made by the serving employees subject to deposit of one month Basic Pay plus DA as on the date of their retirement. The Corporation has no liability to make any contribution to the existing scheme even if it goes in deficit. The benefits under the scheme have been enhanced from time to time but it continues to be a self funded scheme.” The complainant lodged the claim with opposite party under FCI post retirement medical scheme (PRMS). Opposite party has placed on record claim form, (Ex.OP1/2) where the complainant has duly filled certificate B of the claim form in which it is specifically mentioned “To be completed in the case of patients who are admitted to Hospital for treatment.”. Evidently, the complainant got Natural Bypass (EECP) treatment at SAALOL HEART CENTRE. We are of the considered opinion that Natural Bypass (EECP) procedure is unique technique in medical field. No indoor admission is required in this procedure. There is no dispute qua the treatment availed by the complainant for the ailment suffered. The repudiation of the claim is on the ground that the claim of the complainant is not covered under Clause 6.8 of the scheme in question. As per record, the requirement of the referred clause of the scheme is that the person must have taken the treatment as indoor patient. We are not convinced with the technical objection raised by opposite party when it is clear enough on record that the complainant suffered major ailment during the coverage period of the scheme and opted to get the treatment which though do not require the admission in the hospital, but definitely the complainant was provided the treatment as per the protocol (though without admission) and provenly, he has paid Rs.1,30,004/- for the treatment undergone. Also, it has been observed that opposite party has voilated the terms and conditions of the scheme in question as it has not processed the claim of the complainant within the stipulated period as prescribed in the scheme which certainly caused harassment to the complainant. In view of what has been discussed above, present complaint is partly allowed with Rs.5000/- as cost and compensation against opposite party. Opposite party is also directed to pay the claim to the complainant after verifying the medical treatment bills. The compliance of this order be made within 45 days from the date of receipt of copy of this order. In case of non-compliance of the order within the stipulated period, thereafter opposite party will be liable to pay additional cost of Rs.3000/- to the complainant. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced 31-07-2024 - (Priti Malhotra)
President (Sharda Attri) Member
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