Complainant by filing this complaint has submitted that complainant is covered by the Central Government Health Scheme in short (C.G.H.S.) as an employee of the Central Government and as well as his family members and dependants as applicable to enjoy various medical and health related benefits.  Fact remains the father of the complainant, Late Jogesh Chandra Sen was a Central Government employee and during his lifetime he enjoyed services under the Central Government Health Scheme along with his wife Late Durga Sen and after his death, Late Durga Sen had been enjoying the services under the Central Government Health Scheme till her sad demise and both Late Jogesh Chandra Sen and Late Durga Sen were Central Government Health Scheme beneficiaries.

          Late Durga Sen, the mother of the complainant used to stay with the complainant and was under his care and maintenance and due to her old age, she was admitted in the Peerless Hospital & B.K. Roy Research Centre on 20.12.2010 and was discharged from the said Hospital on 28.12.2010 and during that period of treatment final bill was paid by the complainant.  Accordingly as per C.G.H.S., complainant submitted for reimbursement and complainant had done so after discharge and full payment of bill of the hospital and practically advance payment has been made for smooth and continuous treatment of his mother and money receipts were issued by the said Hospital against the said advance payments and said advance payments and receipts thereof had been recorded in the Final Bill being No. BN/10/011503 dated 28.12.2010 issued by the said Hospital at the time of discharge of the patient.

          But accidentally, amongst the doldrums of the treatment process in which the family members of the patient was in, the money receipts of the advances made on various dates were misplaced by the complainant but immediately after discovering the said misplacement, complainant asked the said Hospital for a duplicate copies thereof and the Hospital officials readily provided the complainant with the same from their records and practically complainant paid Rs.5,000/- on 20.12.2010, Rs.15,000/- on 22.12.2010 and Rs.10,000/- on 25.12.2010 and in the said voucher it is specifically mentioned that it is paid by the patient party and it was received by the Hospital.

          On 11.02.2011 the mother of the complainant being the beneficiary of C.G.H.S. raised her medical reimbursement claim (M.R. Claim) to the op no.3 in proper form by filing up the claim form along with necessary documents and are enclosing letter dated 11.02.2011 with the said claim form along with necessary documents were duly received by the op no.3 on 15.02.2011.  But anyhow ultimately on 22.02.2011 the mother of the complainant expired due to her old age at her home while living with and under care of the complainant. 

          For the first week of November-2011, the complainant received a letter dated 06.09.2011 enclosing therewith the claim form along with all the documents submitted for reimbursement as aforesaid.  The said documents were thereby returned by the op no.3 to the beneficiary of C.G.H.S., Late Durga Sen with an endorsement that money reimbursement claim could not be honoured since money receipt was not submitted for processing bill.

          Being unable to realize the meaning and purport of the said endorsement and why the claim was dishonoured, complainant again approached to the Head Quarter of C.G.H.S. and thereafter he came to know that the money receipts of the advance payments made during the treatment period of his mother which was also needed to be submitted along with the Final Bill while filing the claim.  But fact remains that the details of the bills is maintained in the money receipts and was submitted in original berofe op no.3 and it was very hard for the complainant to produce original bill advance payment Bill because it has attached with loss and that matter was reported to the op and after that complainant lodged a general diary with the Survey Park Police Station on 04.05.2012 reporting the loss of the said money receipts from the residence of the complainant and a G.D. Entry No.231 dated 04.05.2012 was endorsed thereof.

          Subsequently on 14.05.2012 complainant affirmed an affidavit before the Notary Public at Calcutta declaring that the complainant has not received any sum as regards reimbursement in connection with the lost receipts and after that complainant submitted the same to approach the hospital authorities who readily provided his with Duplicate Copies of the lost Money Receipts from their own records in their official pad and that was also filed.  But ultimately op repudiated the claim by a letter dated 12.02.2013 and while repudiating the claim and returning the claim of the complainant with endorsement, duplicate money receipts are not accepted and ops failed to consider that all the duplicate money receipts were mentioned in the Final Bill which was submitted in original and that the Final Bill was evidence enough that full and final payment was already made by the beneficiary or on behalf of her.

          So, it is amply clear that op with bad intention and without any reasons repudiated the claim and by such act, complainant has been harassed by the ops for which complainant has prayed for refund of Rs.37,105/- along with interest and compensation etc.

          On the other hand op by filing written statement submitted and alleged that as per rule of Money Receipts are required to be filed along with the Final Receipt but normally the persons received money from the other Government concern namely, Insurance and others by placing those Original Money Receipts and by placing Duplicate Receipts and Final Receipts were place before complainant for receiving the sum of amount again by suppressing the material facts in many cases.  So as per Government Rule Original Money Receipt must be submitted and that was not submitted for which the complainant’s claim was refused.  So there was no deficiency or negligence on the part of the op.

          Further it is submitted that after filing of the claim by the present complainant on the death of her mother a G.D. was made on 04.05.2012 and thereafter Affidavit was made on 14.05.2012 but no such G.D. was made long prior to death of her mother in respect of claim of loss of the Original Money Receipts and considering all those facts as per Government Rule M.R. claim of the complainant could not be allowed and it was repudiated.  So there was no fault on the part of the op and for which complaint should be dismissed.

                                                       Decision with reasons

          On careful study of the entire complaint and the written version and also after hearing the Ld. Lawyers for the both parties including the documents, it is clear that the matter of the complainant was covered by the Central Government Health Scheme (C.G.H.S.) under the Central Government and admitted fact is that complainant’s mother Durga Sen was admitted to Peerless Hospital and B.K. Roy Research Centre on 20.12.2010 and was discharged on 28.12.2010 and filed a Final Payment Bill of all the outstanding dues were made by the complainant to the Hospital.  It is undisputed fact that complainant submitted the Final Bill dated 28.12.2010 along with the Final Bill Advance Payment Bill (dated 20.12.2010 Rs.5,000/-, Rs.15,000/- dated 22.12.2010 and Rs.10,000/- on 25.12.2010) were submitted when the first claim was submitted by her mother Durga Sen for which the op returned the entire claim application with document directing the beneficiaries to submit advance payment original bill.

          It is also undisputed fact that Durga Sen, the mother of the complainant ultimately died due to her old age on 22.02.2011.  Thereafter complainant again submitted a fresh claim along with documents and duplicate copy of the advance payment bill.  But complainant was asked by the op to submit the original payment advance voucher, but complainant failed to produce it and subsequently complainant lodged the G.D. to Survey Park Police Station on 04.05.2012 i.e. long after one and half year from the issuance of the original advance payment bill by the Hospital Authority in the month of December-2010 and reasons for such delay was not explained and practically that lodging of diary was made by the complainant after first refusal of the claim on the ground of non-submission of the original advance payment bills.  So, apparently there was sufficient ground on the part of the op not to allow the claim.

          Fact remains that complainant subsequently submitted an Affidavit declaring that he never submitted any bill in respect of his mother’s treatment during the present period for the bill as paid by him for his mother treatment to any other authority whether Insurance or Central Government before the authority (op).  But op’s authority did not accept such affidavit on the ground and op did not submit all those papers along with claim application not at the first time when it was submitted by her mother and not even it was submitted on his mother’s death and after repudiation of the claim on two occasions all those matters were subsequently returned.  So, some doubt was created in the mind of the op and as per Government Rule, their claim was repudiated.

          It is undisputed fact that original final bill was submitted by the complainant after receiving it from the Peerless Hospital and B.K. Roy Research Centre and from the said bill, it is found that the total amount of the bill was Rs.37,105/- and from the said bill, it is found that on 25.12.2010 advance payment was made of Rs.10,000/- and on 22.12.2010 advance payment of Rs.15,000/- and on 20.12.2010 advance payment of Rs.5,000/- were paid by the complainant and balance amount of the total bill i.e. Rs.7,105/- was received on the date of issuing of final bill.  So, it is apparently proved that Peerless Hospital Authority received Rs.37,105/- and no doubt it was paid some in advance and some in cash.  So, regarding payment of final bill to the extent of Rs.37,105/- there was no denial that treatment was not done or payment was not made and Peerless Hospital had not denied all fact.

          Only problem is that the advance payment of original bill has not been submitted.  No doubt op has rightly pointed out that many persons in such a manner has been enjoying the benefits of mediclaim policy or C.G.H.S. or W.B.H.S.-2008 and to protect the public money the rule is that if original bill is not filed then the bill cannot be considered.  But in the particular case, we have gathered that the op authority ought to have directed the complainant to file a bond swearing such an affidavit that such a bill has never been submitted to any other Insurance Companies for getting mediclaim benefit of the treatment of her mother and also to declare that he does not posses any other claim, he or his mother never posses any insurance policy or any mediclaim policy for any medical treatment reimbursement and if same are filed by the complainant in that case invariably we find that op may release that amount only but no other interest in view of the fact that there is fault on the part of the complainant from very beginning.

          In fact regarding loss of original advance payment bill and other matters were reported after submission of second claim petition by the complainant on the death of his mother.  So such an irresponsible consumer ought to have more cautious before filing the complaint when terms and conditions for granting C.G.H.S. benefit is there and that is the Government Policy and one authority cannot go beyond the Rules and Regulation of Central Government and in case of exception circumstances if any matter is required to be disposed by the op and it shall be a precedent.  So, as obtained precaution, op rightly refused the said claim.  Anyhow we have not found any fault on the part of the ops.  But after considering the entire fact, we find that if complainant files further bond and affidavit swearing such declaration that he and his mother has no other medical Insurance Policy of any insurance company and he never applied in any such claim before any such Insurance Company and if it is filed before the op in that case op shall have to release claim of the complainant after accepting the said claim to be filed fresh by the complainant to the op and op shall have to decide of the same.

          Accordingly the complaint succeeds.

          Hence, it is

                                                              ORDERED

          That the complaint be and the same is allowed on contest without any cost against the op.

          Op is directed to receive further fresh claim along with all papers along with one bond and affidavit to that effect that complainant shall declare on oath that he or his mother has no other insurance policy (Mediclaim Policy) and he and his mother never submit any such claim in respect of the present claim for reimbursement and in such reimbursement has been issued by any other Insurance Companies and if same are complied by the complainant in that case op shall have to release the claim of the complainant in respect of the treatment of her mother and the final bill submitted by the complainant as per law.  But op shall have to dispose of the matter just after re-submission of the claim by the complainant along with the document and no doubt op shall have to dispose of the matter after receiving of the fresh claim of the complainant within one month positively and handover such claim and delay on the part of the op shall be treated as harassment and after expiry of one month from the date of receipt of the fresh claim of the complainant if finally it is not disposed of by the op, penalty should be charged and same may be more than Rs.20,000/-.

          Complainant is directed to submit his fresh claim as per spirit of this order to the op along with the copy of this judgement immediately on receipt of the same by the op, op shall have to act and dispose of the matter within one month from the date of this order failing which for each op penal action shall be started u/s 27 of C.P. Act 1986 against them.