CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.265/2010
AND
Case No.266/2010
SH. OM PRAKASH CHAUDHARY
S/O CH. MOHAN LAL MAAN
R/O 135/9, KISHAN GARH,
VASANT KUNJ, NEW DELHI-110070
…………. COMPLAINANT
Vs.
- MAX SUPER SPECIALITY HOSPITAL
1, PRESS ENCLAVE ROAD, SAKET,
NEW DELHI-110017
- CENTRAL GOVT. HEALTH SCHEME
THROUGH ADDITIONAL DIRECTOR
CGHS SOUTH ZONE, SEC-8,
R.K. PURAM, NEW DELHI
…………..RESPONDENTS
Date of Order:29.08.2018
O R D E R
A.S. Yadav - President
By this order we shall dispose of the aforesaid complaints as both the complaints have been filed by Mr. Om Prakash Chaudhary for reimbursement of the amount spent by him on the treatment of his wife at Max Super Speciality Hospital, Saket, New Delhi.
The complainant is a retired employee of Central Govt. from the Income Tax department. He was issued CGHS card No.87601 of which he and his wife were beneficiaries. The complainant was entitled for semi-private ward in the Central Govt.’s recognized private hospitals. The case of the complainant is that on 28.03.2009 his wife was admitted in Max hospital in emergency as at that time dispensary no.71 to which the card pertains was closed. His wife was discharged on 20.04.2009. The complainant spent an amount of Rs.8,33,685/- on the treatment of his wife and submitted the bill for reimbursement with OP-2. The complainant enquired from OP-2 several times but did not get any response and after a lapse of more than five months the complainant received a letter from OP-2 wherein his claim was rejected on false and frivolous grounds that emergency is not justified on the day of admission. It is submitted that officials of OP-2 waited for five months in the hope of getting something for reimbursing the claim but since they did not get anything from the complainant hence the claim was rejected.
The complaint No.266/10 was filed on 06.05.2010 before this Forum. On the same day another complaint No.265/10 was also filed as the wife of the complainant was again admitted in the same hospital on 25.04.2009. The complainant spent an amount of Rs.10,57,488.83 on the treatment of his wife. The claim was rejected on the ground that there was no emergency on the day of treatment. It is stated in the complaint that the claim was rejected as the illegal gratification was not paid by the complainant to the officials of OP-2. Terming the action of OP as deficiency in service, the present complaint has been filed whereby the complainant has prayed for reimbursement of Rs.10,57,488.83 with interest and also sought compensation and litigation expenses.
Initially the complainant was filed against Max Devki Devi Heart & Vascular Institute as OP-1 and Central Govt. Health Scheme as OP-2. OP-1 was deleted on 27.01.2011 as an application was moved for deletion of its name on the ground that it is a separate entity from Max Super Speciality Hospital. Thereafter an application was moved for impleading Max Super Speciality Hospital and thereafter Max Super Speciality Hospital was impleaded on 30.09.2011 as OP-1.
OP-2 in its reply stated that wife of the complainant was admitted in OP-1 hospital on 28.03.2009 at about 3.30 PM for treatment of sudden jerky movements of the whole body. Since the Max Devki Devi Heart and Vascular Institute is not the empanelled hospital of the CGHS i.e. OP-2, so the matter of the complainant was referred to the Medical Superintendent, Safdarjung Hospital, New Delhi for expert comments with the request to justify the emergency. The expert of Safdarjung Hospital opined that the emergency in this matter is not justified. On the basis of expert opinion of the Safdarjung Hospital, the claim of the complainant was rejected by OP-2. It is stated that the claim of the complainant has been denied as per rules and procedure of the CGHS. The opinion of the expert is essential in emergency treatment.
It is stated that the complainant has not adopted the prior permission from the OP for treatment in a non-empanelled hospital. The complainant may go to any government hospital and take the treatment and if such facilities are not available with that hospital then the patient may go to any empanelled hospital of CGHS in case of emergency. But the complainant went to non empanelled hospital and without any emergency hence, his claim is rejected by OP-2.
Both these claims were rejected on the ground that “treatment taken in private unrecognized hospital. No emergency on the day of treatment as per opinion of S.J. Hospital”.
We have gone through the case file carefully.
It is submitted by Ld. Counsel for the complainant that the complainant took his wife to CGHS dispensary No.71 which was closed. Since it was a case of emergency, therefore, the complainant took his wife to OP-1 i.e. Max Hospital.
The fact of the matter is that both these matters were referred to the expert committee of the Safdarjung Hospital to find out whether there was any case of emergency and as per the opinion of the hospital, it was not a case of emergency. This Forum cannot sit over the opinion of the Safdarjung Hospital.
Even otherwise we have gone through the discharge summary and as per that on first occasion, the wife of the complainant was admitted on 28.03.2009 and was discharged on 20.04.2009 and discharge summary shows that wife of the complainant was admitted with the complaints of six months history of abdominal bloating and 1 month history of decreased appetite, vomiting, frothy urine, decreased urine output. She was admitted in emergency. The question is that she was suffering form abdominal pain for the last six months with one month history of decreased appetite, vomiting, frothy urine and decreased urine output. The complainant has not placed anything on record to show that his wife has taken treatment anywhere. It is significant to note that Max hospital was not on the panel of the CGHS. It was a private unrecognized hospital and treatment can be taken in private hospital only in case of emergency. No emergency is made out as per opinion of Safdarjung Hospital. It was submitted by Ld. counsel for the complainant that the wife of the complainant was taken to Max Hospital because they were residing at Kishan Garh, Vasant Kunj, New Delhi and Max Hospital was close to their residence. It is not correct. The nearest hospital was Fortis Hospital which is at distance of 1 km from the house of the complainant. As per Google map, the distance of Max Hospital is around 8 kms from Vasant Kunj and likewise the distance of Safdarjung Hospital is about 8 kms from Vasant Kunj. The complainant should have taken his wife to Safdarjung Hospital but he has not taken her there rather he took his wife to a private unrecognized hospital and as per the opinion of Safdarjung Hospital it was not a case of medical emergency.
On second occasion the wife of the complainant was taken to Max Hospital on 25.04.2009 and discharged on 19.04.2009 on the request of the attendant of the patient. Due to personal reason the patient was transferred in AIIMS. It was a case of renal failure. Second time she was taken to the hospital with complaints of sudden jerky movements of the whole body with drowsiness and severe headache. She was discharged on 19.05.2009. Again the matter was referred to the Safdarjung Hospital and as per opinion of the Safdarjung Hospital, it was not a case of emergency.
As per the report of the Safdarjung Hospital, it was not a case of emergency and, therefore, there was no reason for taking the patient to the unrecognized private hospital for treatment. We have already stated that the Safdarjung/AIIMS were at same distance. The complainant could have easily taken his wife to government hospital. Since as per the report of the Safdarjung Hospital, it was not a case of emergency hence OP was justified in rejecting the claim. No case of deficiency in service is made out against OPs. Hence the complaints are dismissed.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(RITU GARODIA) (H.C. SURI) (A.S. YADAV)
MEMBER MEMBER PRESIDENT
