Date of filing : 17-12-2011
Date of order : 22-12-2012
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.348/2011
Dated this, the 22nd day of December 2012
PRESENT
SRI.K.T.SIDHIQ : PRESIDENT
SMT.P.RAMADEVI : MEMBER
SMT. K.G.BEENA : MEMBER
K.Kunhiraman, S/o.Chindan Nair, } Complainant
R/at Karicheri, Mudalakund,
Po.Kolathur, Kasaragod Taluk & Dist.
(Adv.Benny Jose, Kasaragod)
1. Insurance Medical Officer, E.S.I. Dispensary, } Opposite parties
Chala Road, Vidyanagar, Kasaragod.
2. The Superintendent, E.S.I hospital,
Thottada, Kannur.
(Ops 1 & 2 Addl.Govt.Pleader)
3. The Managing Director,
Employees State Insurance Corporation,
Trivandrum.
4. The Director of Insurance Medical Service,
Thycaud, Thiruvananthapuram. 695014.
O R D E R
SMT.K.G.BEENA,MEMBER
Complainant is working as attender in Kasaragod Institute of Medical Sciences since 1-3-2010 onwards and a member of ESI scheme, there is a deduction of `106/- from his salary in each month towards the contribution to ESI. The complainant’s wife Sreeja had delivered from KIMS, Kasaragod,. The said medical procedure is having ESI coverage, but so far the bill for `17,800/- is not honored by ESI Corporation. The treatment expenses of his mother comes to `7000/- is also not honored by ESI Corporation. The opposite parties are liable to clear those 2 bills. The opposite parties are bound to pay the amount due to the hospital on account of the treatment of the family members of the complainant.
2. According to opposite party No.1, as per Sec.58 of ESI Act 1948, the authority to administer medical benefits including re-imbursement of medical expenses is vested with the state government through a machinery under the control of Director of Insurance, Medical Services, Thaycaud, Trivandrum and this party or ESI Corporation does not have any direct control and supervision over the services rendered by opposite parties 1 & 2. According to opposite parties 1 & 2 complainant has not approached the ESI authorities so far for reference letter or approval for admission or treatment of his mother or wife in any empanelled hospital for treatment. He admitted the mother and his wife without any prior reference or approval and has not obtained any prior reference or approval. The complainant has not approached the opposite parties so far the reimbursement of bills and hence there is no deficiency of service on the part of opposite parties and hence opposite parties may be exonerated from proceedings.
3. Complainant produced medical bills of his mother NandiniAmma i.e. `7,000/-, medical bill of his wife Sreeja `17,800/-, ESI card, and entitlement certificate of employees Sate Insurance Corporation which is marked as Exts. A1 to A4 respectively. As per Ext.A4, Sri.K.Kunhiraman Nair is entitled to medical benefit from 1-7-2011 to 31-12-2011. Treatment of his mother and wife are done within the policy period. Opposite parties also produced documents such as policy, Ext.B1 proceedings of the Insurance medical Services, (Ext.B2) Trivandrum list of empanelled centres for speciality treatment and investigations which are marked as Exts B1 and B2 requesting policy is admitted by opposite parties. Opposite parties 1 & 2 in their version stated that complainant has not so far approached the opposite parties for reimbursement of bills. As a policy holder complainant is entitled for medical benefit under ESI coverage for the treatment of his mother and wife.
4. After perusing the documents produced by both parties and facts of the case we are of the view that complainant is entitled for reimburse of medical bills of his mother and wife as an ESI policy holder. For which the complainant has to submit an application in proper form to opposite party No.4. Opposite parties 1 & 2 raised a contention that complainant has not approached opposite party No.4 so far. The authority of administer medical benefits including re-imbursement of medical expenses is vested with the State Government through a machinery under the control of Director of Insurance, Medical Services, Thaycaud, Trivandrum.
Therefore the complainant is hereby directed to submit an application before opposite party No.4 within 30 days from the date of receipt of this order and if such an application is received, opposite party No.4 is hereby directed to process the application as soon as possible and consider the pending bills of `7000/- and `17,800/- of the complainant within 30 days from the date of receipt of application. Failing which necessary steps will be taken.
MEMBER MEMBER PRESIDENT
Exts.
A1.22-8-2011 Bill issued by Kasaragod Institute of Medical Sciences
A2. 23-11-2011 Bill issued by Kasaraod Institute of Medical Sciences
A3. Photocopy of ESI Card.
A4. 5-8-2011 Entitlement Certificate.
B1.Declaration form
B2. Photocopy of Proceedings of the Director of Insurance Medical Services, Trivandrum.
MEMBER MEMBER PRESIDENT
Pj/
