THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.212/2016
Dated this the 30th day of August, 2019
(Smt. Rose Jose, B.Sc, LLB. : President)
Sri. Joseph Mathew, M.A., L.L.B. : Member
ORDER
Present: Hon’ble Smt. Rose Jose, President:
This petition is filed under Section 12 of Consumer Protection Act 1986.
The petitioner is a member of ESI Chakkorathukulam and his mother Smt. Reena is also under the coverage of ESI benefits. His case is that, due to heavy bleeding Smt. Reena was admitted at PVS hospital for treatment. Since she was admitted in a private hospital the opposite party denied his claim for reimbursement of her treatment expenses under the ESI scheme. Smt. Reena underwent hysterectomy surgery there and had spent huge amount of Rs.50,000/- towards the hospitalization and surgical expenses. Since he is a member of ESI his mother is also entitled to get the treatment expenses reimbursed by the opposite party and the denial of his legitimate claim amounts to deficiency in service on the part of the opposite party and this caused much mental pain and other hardships to him and to his mother apart from the huge financial loss suffered. Hence this petition is filed to direct the opposite party to allow his claim and reimburse the hospitalization and treatment expenses of his mother Rs.50,000/- and compensation for their sufferings and also cost of the proceedings.
The opposite party in their version denied all the allegations of the petitioner as false and baseless. It is contented that this petition is not maintainable before this Forum either in law or on facts and this petition is filed as an experimental basis without any bonafides.
It is admitted that the petitioner is a beneficiary of ESI. It is also admitted that the petitioner had submitted a medical reimbursement claim before them on 03/03/2016 for the expenses incurred for the treatment of his mother Smt. Reena at their empanelment hospital of PVS for the continuous bleeding for 6 months along with emergency certificate. It is stated that his claim was denied for the reason that the said treatment of Smt. Reena is not come under the definition of emergency category. This fact was informed to the petitioner also. It is also stated that when Smt. Reena came to ESI dispensary for examination on 08/12/2015, she was referred to ESI Hospital Ferok since there was no treatment facility for her bleeding at that dispensary. Two times she was treated at Ferok ESI Hospital by the Gynaecologist there. But thereafter instead of continuing treatment there and without any reference from the Genealogist the patient directly started treatment at PVS Hospital as per her own will. Petitioner’s house is situated only 3 kms away from the ESI dispensary Chakkorathukulam but even then she went to the PVS hospital without collecting the reference letter from the ESI dispensary.
The opposite party also stated that there is direction of the Insurance Medical Service Director as well as from the State Medical Commissioner of ESI Corporation that in cases where there is no ESI dispensary or hospital nearer to the house of a patient comes under the emergency category disease, then the patient can take treatment from an Empanelment Hospital and can submit claim for reimbursement of medical expenses along with the emergency certificate issued by the doctor who had treated the patient at the Empanelment Hospital. This fact was informed to the petitioner also. The petitioner’s mother was continuing treatment for the ailment for a long period and the bleeding was not happened all on a sudden. She has got enough time to obtain a reference letter from the Ferok ESI Hospital through ESI dispensary Chakkorathukulam for availing treatment from an empanelment hospital. Since the petitioner has not followed the procedures prescribed for taking treatment from an empanelment hospital, legally they are not liable to reimburse the alleged treatment expenses of the petitioner’s mother Smt. Reena and so there is no deficiency in service on their side in denying the claim of the petitioner and hence prayed to dismiss the petition with their cost.
The petitioner filed affidavit in lieu of his petition and produced Ext.s A1 to A8 documents in support of his averments.
The opposite party in their version admitted that as per the direction of Insurance Medical Service Director and State Medical Commissioner ESI Corporation, a patient under ESI coverage can apply for re-imbursement of treatment expenses incurred for the treatment in an empanelment hospital along with the emergency certificate of the doctor issued from that hospital if the patient comes under the emergency category. The reasons according to the opposite party for the rejection of the petitioner’s claim is that the ailment of the patient ie. bleeding was not happened suddenly but the patient was under treatment for a long period. The other reason is that, the patient has not obtained a reference letter from the ESI Hospital for availing treatment from an empanelment hospital. Here the petitioner has not utilized this facility or obtained a reference letter as prescribed.
The petitioner also had admitted that Smt. Reena was under treatment for the ailment for about 6 months but according to him the bleeding increased heavily all on a sudden with acute abdominal pain and so he didn’t get time to obtain a reference letter from the ESI dispensary and that is why she was admitted at the PVS hospital without obtaining the reference letter. In his affidavit it is stated that it will take “at least 3 days for obtaining a reference letter from the ESI hospital and during nights and holidays there was no doctor in this hospital. In this case there was no time to wait for 3 days”. This statement of the petitioner was not denied by the opposite party also. Ext. A1 is the copy of emergency admission of the patient issued from PVS hospital dated 03/03/2016 wherein it is reported that “Smt. Reena was admitted in this hospital as an emergency on 03/03/2016 at 11.32am case of Heavy Menstrual Bleeding six months increased since 10 days and symptomatic Fibroid Uterus Abdominal pain Obstetrics and Gynaecology”. Ext. A5 is the copy of Form of Essentiality Certificate dated nil issued form PVS Hospital wherein it is stated that “Smt. Reena, 47 yaers. female M/o. Nipun, employed in the KTC Hudai has been under treatment at this hospital for the period 03/03/2016 to 0503/2016.”
Ext. A6 is the copy of ESI card IP No. 5403459646 of Sri. Nipun K. Thus Ext. A1 emergency admission letter issued from PVS Hospital addressed to the Medical Superintendent, ESI Hospital, Ferok proved that Smt. Reena was admitted at PVS Hospital for heavy menstrual bleeding and Ext. A5 shows that she was treated there from 03/03/2016 to 050/03/2016. Admittedly the petitioner and his mother is under the coverage of ESI benefits. The petitioner also had produced the emergency certificate before the opposite party as prescribed. From the evidence it is found that the claim was repudiated merely on technical reason. The opposite party has not cross examined the petitioner even after giving many chances. The denial of the legitimate claim of the petitioner due to mere technical reason in our view is unfair and deficiency in service on the part of the opposite party. Ext. A5 is the Form of Essentiality Certificate. It shows that the petitioner had spent a total amount of Rs.49,666/- as the treatment expenses of his mother Smt. Reena.
So, considering all the facts stated and evidence on record, the following order is passed.
The opposite party is ordered to reimburse the treatment expenses of the petitioner’s mother Rs.49,666/- (Rupees forty nine thousand six hundred sixty six only) along with Rs.4,000/- (Rupees four thousand only) as cost of the proceedings to the petitioner within 45 days from the date of receipt of this order. Failing which the whole amount will carry 7% interest per annum from the date of default till payment.
Dated this the 30th day of August, 2019
Date of filing: 17/05/2016
SD/-PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. Copy of Emergency Admission dated 03/03/2016
A2. Copy of IP receipt voucher issued by PVS Hospital
A3. Copy of IP Bill Breakup details
A4. Copy of discharge summary
A5. Copy of form of essentiality certificate
A6. Copy of bank pass book
A7. Copy of O.P. ticket issued by the opposite party
A8. Copy of ESI card
Documents exhibited for the opposite party:
Nil
Witness examined for the complainant:
None
Witness examined for the opposite party:
None
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
