By Sri. MOHANDASAN.K,PRESIDENT
1. Complaint in short is as follows.
Complainant was a school teacher in M.M.A.L.P School Vadakangara and he retired from the service on 31/05/2015. His sole income is his pension. He is suffering from hearing and visual deficiency and he is undergoing treatment for a long period. His wife and children are his dependents and they do not have any source of income. His son Mr.Arjunan.V.M is a student and he was also suffering from ophthalmic issues. In March 2012 complainant approached Government Taluk Head Quarters Hospital, Malappuram for the ophthalmic treatment of his son. The Eye specialist of the hospital directed him to approach Aravind Eye Hospital at Coimbatore. Mr. Arjun was suffering from Glaucoma after neurological surgery. He underwent treatment at Aravind Eye hospital Coimbatore because of the advice given by the Eye specialist attached to Government hospital Malappuram. The complainant submits that at the relevant period of treatment there was no treatment available in Kerala for the ophthalmic complaint of Mr. Arjun. The concerned eye specialist from government hospital referred him and the District Medical Officer counter signed the same and, on that basis, he approached Aravind Eye hospital Coimbatore. The complainant spent Rs.9585/- (Rupees Nine thousand five hundred and eighty-five only) for his treatment. There after he continued treatment from 14/06/2013 to 20/06/2013 as inpatient. During this period surgery was conducted as part of treatment for Glaucoma and at that time he incurred 4,071/-(Four thousand and seventy one only) rupees. The complainant applied for medical reimbursement from the opposite party, but the opposite party denied the claim as per letter B1/240/2018 of GEdn. The reason shown in the letter was that the treatment underwent at Coimbatore Aravind Eye hospital was not a recognized establishment for considering medical reimbursement. The letter stated that the treatment underwent by the complainant’s son was available in all government hospitals in Kerala. The complainant alleges that this particular treatment was not available in hospitals of Kerala during the period and that reason he was referred by Eye specialist of Government hospital, Malapppuram and the same has approved by District Medical Officer. Complainant submitted that the treatment expenses of the son held at Coimbatore Aravind eye Hospital was allowed by the Health Department as per GO(MS) No. 378/2012 dated 7/04/2012 and order of D3/10280/2017dated 26/09/2017 of DDE, Malappuram. The complainant submits that in the said order it can be seen Coimbatore Aravind Eye Hospital as approved one for medical reimbursement purpose. Hence the denial of the claim of the complainant is not justifiable. Complainant constrained to avail the treatment from the Aravind Eye Hospital Coimbatore since his son was under threat of loss of total visual power and only because of that situation as per proper instructions from the government Doctor and department he took his son to Coimbatore Aravind eye hospital The denial of the reimbursement application caused much hardships and loss to the complainant despite of submitting the entire relevant documents to the opposite parties. The act of the opposite parties amounts deficiency in service. The complainant prays for the refund of treatment expenses worth Rs. 13,656/- (Rupees Thirteen thousand six hundred and fifty six only) along with compensation of Rs. 25,000/- (Rupees Twenty-five thousand only) and cost of Rs. Rs. 25,000/- (Rupees Twenty five thousand only).
2. On admission of the complaint issued notice to opposite parties and they entered appearance and also filed version. The opposite parties admitted that he was a teacher and he retired from the service on 31/5/2015. They also admitted that the complainant had submitted claim for medical reimbursement and the same was rejected. The first opposite party had forwarded the claim of the complainant to the General Education Department for special sanction. The General Education Department considered the request and on that basis an amount of Rs. 1034/- (Rupees One thousand and thirty four only) was allowed on 26/09/2018. But there was clerical mistake in the said order that the treatment availed from Aravind Eye hospital Coimbatore as recognized one, the opposite party submit that it was a mistake on their part and so that order cannot be treated as precedent. The opposite party contented in their version, that the treatment availed from the outside of state cannot be accepted after relaxing the relevant rules. The opposite party had issued a reply after considering the request of the complainant. Considering these aspects and finding that the Commission does not have jurisdiction to entertain the complaint, complaint be dismissed at the cost of the complaint.
3. Complainant and opposite parties filed affidavits and documents. Documents on the side of Complainant marked as Ext. A1 to A3 series. Ext. A1 is a letter of AEO, Mankada, No. E/5528/18 along with rejection order dated 3/07/2018 of General Education (B) Department. Ext. A2 is Referral letter dated 16/04/2012 from Government Taluk Head Quarters, Malappuram along with Performa filled by the authorized medical attendant. Exit A3 is an order dated 10/05/2018 of General Education (B) department. Opposite party produced a file pertaining to the claim of the complainant and it is marked as Ext.B1 series.
4. Heard complainant and the opposite parties, perused the affidavits and documents and stood for the consideration of following points:
- Whether the complaint is maintainable?
- Whether the complainant is entitled for the medical reimbursement?
- Relief and cost.
5. Point No.1 &2
The case of the complaint is that his son underwent treatment for secondary Glaucoma at Aravind Eye hospital, Coimbatore and he is entitled for the reimbursement of treatment expenses. The complainant initially approached Taluk Government hospital at Malappuram for the treatment and from there the concerned Eye specialist referred him to the Aravind Eye hospital, Coimbatore. The complainant produced the referral letter before the District Medical Officer, Malappuram and from there he got it counter signed and thereafter, he underwent treatment at Aravind eye Hospital, Coimbatore. Complainant states that the opposite parties allowed once his reimbursement claim stating that treatment at Aravind Eye Hospital,Coimbatore as approved one. Unfortunately, when the complainant submitted fresh claim, it has been rejected by this opposite parties, stating that the treatment held at Coimbatore Aravind Eye hospital is not recognized by the concerned Rule. The contention of the complainant is that during the relevant period no effective treatment was available in our State for the ailment, and the situation was an emergent one and that reason he was compelled to take his son to the nearest specialty eye treatment center at Coimbatore after following all the procedures. Hence the denial of the claim by the opposite party is not justifiable and amounts deficiency in service.
6. The definite contention of the opposite party is that treatment availed by the complainant is from out of the State and it is not covered by the Rule relevant in this regard. Once the claim of the complainant was considered as a special case and an order to reimburse the treatment expense was passed. But that practice cannot be followed in this claim application. According to them it is not possible to relax the rules relevant in medical reimbursement matter. They also stated that averment in the order regarding the approval of the treatment at Aravind Eye Hospital, Coimbatore is a mistake which cannot be taken as precedent and so complaint is to be dismissed.
7. It is an admitted fact that the complainant is an employee under the opposite party and he is entitled for medical reimbursement benefit. But in this complaint the contention of the opposite party is that the treatment availed from the out of State cannot be considered for reimbursement. At the same time the document shows that the complainant initially approached before an eye specialist attached to Taluk Government hospital, Malappuram and he referred the patient to Aravind Eye Hospital, Coimbatore. The same referral letter has seen by the District Medical Officer also. There is no proper explanation from the opposite parties for referring this complainant to the Aravind Eye hospital, Coimbatore. If the contention that the treatment was available for this particular ailment in all Taluk, District and Medical colleges in Kerala where the complainant could have availed the same from the Taluk Head Quarters Hospital, Malappuram itself. If that is being the position, the contention of the complainant that the particular treatment was not available for the ailment of the complainant’s son cannot be ignored. Opposite party also not established that the said treatment was available in Taluk, District and Medical college hospitals as claimed in the affidavit. So we are of the view that the complainant rightly availed treatment for secondary Glaucoma at Aravind Eye Hospital Coimbatore, following all the procedures. Hence complainant is entitled to the medical reimbursement benefits. The government had considered the request of the complainant once and it was decided in his favor. Now there is no sufficient reason to reject the claim of the applicant, since the claim is genuine.
8. The complainant appeared in person before the Commission and submitted his personal infirmities to hear and see properly. His son also facing acute visual deficiency. Hence it will be just to consider the prayer of the complainant in a compassionate way.
9. The opposite party stated in the affidavit that the claim for reimbursement stands forwarded for examination by the District Medical Officer for the period of 17/04/2012 to 26/06/20125 worth Rs.28,029/-(Rupees Twenty eight thousand and twenty nine only). But there are no details about the report of District Medical Officer Malappuram before this Commission.
10. Point No.3
The complainant is a school teacher and his sole income is his pension. He contended that his wife and children are dependents of him and they do not have any other source of the income. The complainant approached this Commission for the medical reimbursement benefit which is denied solely due to technical reasons. The treatment expenses claimed by the complainant is also not a huge amount. The right of complainant cannot be denied on technical reasons if he otherwise entitled. He has stated that due to the denial benefit by the opposite parties he suffered a lot of hard ships and mental agony. The opposite parties have got a contention that the Commission has no jurisdiction to entertain the claim. But there is no roper explanation under what ground the complaint is not maintainable before the Commission.
11. Hence Commission allows the complaint and direct the opposite parties as follows: -
- The opposite parties are directed to allow the medical reimbursement claim of the complainant Rs.13,656/-(Rupees Thirteen thousand six hundred and fifty six only) as prayed in the complaint.
- Opposite parties are directed to pay Rs.10,000/-(Rupees Ten thousand only) as compensation for the deficiency in service on the part of the opposite parties.
- Opposite parties are also directed to pay Rs.5000/-(Rupees Five thousand only) as cost of the proceedings.
The opposite parties shall comply this order within one month from the date of receipt of copy of this order, failing which the complainant will be entitled for interest for the above said amount at the rate of 9% per annum from the date of receipt of copy of this order.
Dated this 25th day of October, 2021.
