Punjab

Sangrur

CC/421/2014

DEV RAJ - Complainant(s)

Versus

MEDICAL REFEREE (SHO) - Opp.Party(s)

ROHIT JAIN

06 Feb 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    421

                                                Instituted on:      01.08.2014

                                                Decided on:       06.02.2015

Dev Raj son of Sadhu Ram, resident of Chittan Nagar, Imamgarh Road, Near Eidgah, Malerkotla.

                                                                ..Complainant

                                Versus

1.     The Medical Referee (SMO), Employee’s State Insurance Corporation, Civil Hospital, Malerkotla.

2.     The Branch Manager, Employee’s State Insurance Corporation, Karbala Road, Near Dr. Zakhir Hussain Statdium, Malerkotla.

3.     Employees’ State Insurance Corporation through its Regional Director, Sector 19-A, Madhya Marg, Chandigarh.

                                                        …Opposite parties

 

For the complainant    :       Shri Rohit Jain, Advocate.

For OP No.1              :       Shri Daljit Singh, Advocate.

For OP No.2&3         :       Shri S.M.Goyal, Advocate.

 

 

Quorum:    Sukhpal Singh Gill, President

                K.C.Sharma, Member

                Sarita Garg, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Dev Raj, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is insured with the OPs under insurance number 6585776. It is further averred in the complaint that the complainant is suffering from the disease, namely COPDRA and the same is covered under the ESB i.e. Extended Sickness Benefit.  It is further averred that after thorough check up of the complainant, the doctors of ESI at Malerkotla and Ludhiana declared the disease of the complainant under ESB and was allowed allowances at Extended Sickness Benefit rates and Rs.6000/- were paid through cheque and Rs.1800/- were paid in cash against receipt to the complainant for 124 days from 1.7.2010 to 1.11.2010 @ Rs.102/- per day. It is further averred that the complainant is suffering from the same disease and was entitled for extended sickness benefit rates and for the same approached OP number 2, but on checking, OPs refused to recommend the name of the complainant for Extended Sickness Benefit rates. Nothing was done despite appearance of the complainant before the Medical Board.  Further case of the complainant is that though he was suffering from the disease namely COPDRA and was unable to join his duty and further was unable to work properly, as such, he was entitled to get the benefit under the ESB scheme.  Further case of the complainant is that he also filed complaint number 66 dated 2.2.2012, which was decided on 26.8.2013 and the Forum directed the Ops to pay the benefits of 189 days to the complainant within one month and to constitute medical board within one month to examine the complainant.  OPs constituted a medical board and the complainant was examined on 6.11.2013 and the medical board declared that the disease of the complainant falls under ESB scheme and also asked the Ops to pay benefits under ESB for more 330 days from 6.5.2011 to 31.3.2012 or the date of fitness, whichever is earlier, but the OPs failed to pay the benefits for 189 days and the complainant filed an application under section 25 and only then the complainant got complied with the orders.  But, the Ops have not paid the benefit for 330 days, which is said to be clear cut case of deficiency in service on the part of the OPs. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant an amount of Rs.33,660/- i.e. for 330 days @ Rs.102/- per day along with interest @ 12% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by OP number 1, legal objections are taken up on the grounds that the complainant has not arrayed necessary parties to the complaint, that the complainant is not a consumer and that the complainant has not come to the Forum with clean hands. On merits,  it is stated that since the complainant was referred to Medical Board by the  then medical referee (SMO) and he appeared before the board and thorough check up was conducted, accordingly findings were given by the Board.  As the complainant did not appeal against the findings of the Board, therefore, findings of the medical board are binding upon the complainant.  It is stated that the complainant was not suffering from any disease which falls under ESB.  However, any deficiency in service on the part of the OP number 1 has been denied.

 

3.             In reply filed by OPs number 2 and 3, preliminary objections are taken up on the grounds that the complainant has no locus standi to file the present complaint, that the complaint is not maintainable, that the complainant has not come to the Forum with clean hands and that the complainant is not a  consumer of the OPs. On merits, it is admitted that the complainant approached the Ops for extended sickness benefit rates and the complainant was asked to appear before the medical board and accordingly he appeared before the medical board and it was found that the disease of the complainant was not covered under the Extended Sickness Benefit.  The other allegations of the complainant are denied. It is denied that the Ops failed to give the ESB benefits to the complainant.   It is further stated in the reply that the Ops constituted a special medical board and the complainant was examined on 6.11.2013 and the medical board recommended that the disease of the complainant falls under ESB and also asked that he is entitled to the benefits under ESB for 330 days more from 6.5.2011 to 31.3.2012 or the date of fitness whichever is earlier, but other allegations of the complainant  are denied.  The case of OPs is that the complainant was asked to furnish the medical certificate of incapacity for remaining period vide letter dated 18.09.2013, but the complainant did not furnish the requisite medical certificates of incapacity for the remaining period to prove that he was unfit to work due to incapacity and sustained loss of wages. It is further stated that the complainant was paid an amount of Rs.13,491/- for 132 days on 10.10.2013 The complainant himself did not submit the medical certificates of incapacity from the period 15.3.2011 to 31.3.2012 and onwards till today.  However, any deficiency in service on the part of the OPs number 2 and 3 has been denied.

 

4.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-9 copies of prescription slips, Ex.C-10 to Ex.C-18 copies of medical certificates, Ex.C-19 copy of notice, Ex.C-21 to Ex.C-21 copies of postal receipts, Ex.C-22 to Ex.C-24 copies of letter, Ex.C-25 copy of order dated 26.8.2013, Ex.C-26 to Ex.C-32 copies of letters, Ex.C-33 copy of form number 10, Ex.C-34 copy of order dated 10.2.2014, Ex.C-35 copy of order dated 7.11.2013, Ex.C-36 copy of order dated 18.2.2014, Ex.C-37 affidavit, Ex.C-38 to Ex.C-39 copies of letters, Ex.C-40 to Ex.C-41 copies of medical records, Ex.C-32 copy of medical report and closed evidence.  The learned counsel for OP number 1 has produced Ex.OP1/1 affidavit, Ex.OP2&3/1 to Ex.OP2&3/14 copies of letters, Ex.OP2&3/15 copy of reply of legal notice, Ex.OP2&3/16 affidavit and closed evidence.

 

5.             We have carefully perused the complaint, version of the opposite parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits dismissal, for these reasons.

 

6.             Keeping in view the arguments of the learned counsel for the parties and after perusal of the documents tendered by the parties, the Forum is of the opinion that the complainant comes under the definition of ‘consumer’ and this Forum has the jurisdiction to entertain and decide the present complaint.

 

7.             It is an admitted fact that the complainant is a member of the OPs under insurance number 6585776.  It is also an admitted fact that the complainant was given benefit i.e. Rs.6000/- and Rs.1800/- for 124 days for the period from 1.7.2010 to 1.11.2010. 

 

8.             In the present case, the learned counsel for the complainant has contended vehemently that since the complainant was suffering from COPDRA disease and as such was entitled to get benefits i.e. Rs.102/- per day for 330 days under the Extended Sickness Benefit , but the same has not been paid to the complainant despite his repeated visits to the Ops.   On the other hand, the learned counsel for OP number 1 has contended vehemently that since the complainant was referred to the medical board and as per the findings of the medical board, the complainant was not suffering from any disease which falls under Extended Sickness Benefit.   Whereas, the learned counsel for OPs number 2 and 3 has contended that there is no deficiency in service on the part of the OPs.  It is contended further that the Ops constituted a medical board and the complainant was examined on 6.11.2013 and thereafter he was asked to furnish the medical certificates of incapacity for remaining period vide letter dated 18.9.2013 of OP number 2, but the complainant did not furnish the requisite medical certificates of incapacity for the remaining  period to prove that he was unfit to work due to incapacity and sustained loss of wages.   It is further contended that the complainant did not provide the incapacity certificate to the Ops, as such, he is not entitled to get the benefit for 330 days as prayed for.  We have also perused the copy of letter dated 28.10.2013, a copy of which on record is Ex.C-30 wherein in the last para of the letter, it is clearly mentioned to furnish the medical certificates as per section 46(1)(a) of the ESI Act for payment of the remaining period, but the complainant did not take any action. We have also perused a copy of the letter Ex.C-33 which has been addressed to M/s. Vishal Sales Corporation, but nothing is readable who had submitted this letter to Vishal Sales Corporation, whereas the same should be duly stamped and signed by the Branch Manager, Employees State Insurance Corporation, Malerkotla as is evident from the copy of other letters produced by the complainant along with the copy of letter Ex.C-40 wherein the name of insured person is ‘Samra’ relating to Islamia Girls College. As such, we feel that the letter Ex.C-33 is not at all helpful to the case of the complainant.   In the circumstances, we feel that since the complainant himself has failed to submit to the Ops the medical certificate of incapacity for the period from 15.3.2011 to 31.3.2012, we are unable to pass any order against the Ops for the payment of ESB for such a period of 330 days.  We further find that as such no deficiency in service on the part of the Ops can be ruled out for non payment of ESB for the above said period.  

 

9.             In view of our above discussion, we dismiss the complaint of the complainant. However, the parties are left to bear their own costs.  A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                February 6, 2015.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                              (K.C.Sharma)

                                                                Member

 

 

                                                              (Sarita Garg)

                                                                   Member