DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.493/2012
Sh. Satish Kumar Sharda
S/o Late Sh. D. S. Sharda
R/o H.No.1553, Sector-21,
Gurgaon-122016 ….Complainant
Versus
Director General (CGHS)
Ministry of Health and Family Welfare
Nirman Bhawan, New Delhi-110001 ….Opposite Party
Date of Institution : 20.09.2012 Date of Order : 23.09.2017
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
RDER
Complainant, who is a retired Govt. servant, has filed the present complaint by stating that he is a holder of CGHS Card No. 848715 valid till March, 2014 issued through CMO, CGHS dispensary, Gurgaon. He being 73 years old Sr. Citizen started getting medical complications which were mild in nature earlier and were attended to locally. However, two and half years earlier in 2010 it became so painfully unbearable for him on account of acute swelling of his lower limb, hypertension and anaemic that he was constrained for hospitalization in the CHGS empanelled Sri Balaji Action Medical Institute, Paschim Vihar on 07.03.10 but inspite of transfusion of a couple of bottles of blood and allied treatments, instead of improving, his condition started deteriorating from bad to worse which is clear from the following medical reports:-
Position on March 08 March 13 March 16
Haemoglobin 7.1 6.1 3.5
TLC 7.7 10.3 15.3
Neutrphils 79 92 95
Lymphocytes 18 07 05
Platelet Count 280 147 46
It is stated that the complainant’s Doppler study showed right lower limb DVT for which IVC filter was done and he continued to experience weight loss and progressive weakness and there was no improvement. With such Alarming deterioration in the medical chart he virtually reached delirious stage, closed to collapse when he could not even stand firmly on his feet ; that under these circumstances his family sought discharge from Sri Balaji Action Medical Institute and immediately rushed him to Sir Ganga Ram Hospital (SGRH) where he was diagnosed for admission “in Emergency” ; that SGRH prepared the Initial Assessment History Sheet on 16.03.10 at the time before admission for treatment; that transfusion of 6 bottles of blood and advanced medical treatment as indoor patient from 16.03.10 the complainant was discharged after 15 days on 31.03.10; that this indoor treatment costed him Rs.2,64,402/-; that in his self explanatory representation dated 02.06.10 he preferred reimbursement of his mediclaim claim to the OP who forwarded it to the addressee on 17.06.10; that after a delay of 11 months the OP just forwarded a copy of their routine proforma letter dated 06.05.11 whereby the complainant’s reimbursement claim was rejected; that the relevant clauses mentioned therein are hardly applicable in the case of the complainants; that for example there had been no instance where the complainant ever got any CGHS reimbursement claim or this CGHS card of the complainant is valid upto March, 2014 (Annexure-1) to only action pertaining to this letter was attributed to clause “Others” wherein the reference for rejecting the complainant’s mediclaim was referred to OP’s Expert Committee’s decision and in this noting OP specifically referred this individual case to an expert committee comprising of HOD Medicines, HOD Haematology, HOD Cardiology and CTVS Surgeon and this expert committee rejected the mediclaim in a routine rule book manner without proper application of mind and examining the case on merits objectively. The opinion of the Expert Committee was “ (i) there is no a ‘de-novo’, medical emergency admission and basically patient was shifted from one hospital to another, (ii) There is no Emergency Certificate from SGRH, New Delhi & (iii) The reason for admission is the haemoglobin of 3.5 grm% (This report is not available in the investigation chart) the low haemoglobin requires blood transfusion which was already given at the previous hospital (Action Medical Institute).” According to the complainant, he was never shifted from one hospital to another and because of the unusual circumstances he had to obtain a discharge certificate on request from the previous hospital and his appearance before the SGRH was as a “de-novo patient” diagnosed for treatment “in emergency “ he was admitted in this category. The emergency condition for his urgent admission in CGHS could have been verified from the hospital’s Initial Assessment History Sheet dated 16.0.3.10. It is further submitted that the said opinion of the said committee was re-examined after the complainant requested for ex-post facto approval for reimbursement of his mediclaim. In the office noting the Addl. Secretary-DG (CGHS) opined “why cannot he be given on CGHS rates” but without specially attending to this query office attention was drawn to the opinion of the Technical Committee that the case does not qualify for reimbursement and hence the case was rejected. It is stated to satisfy the OP’s objection for the complainant’s admission in SGRH in emergency the complainant obtained a certificate from the SGRH on 29.09.11 which was submitted in the original to the OP with his representation dated 29.09.11; followed by reminders but of no use. Hence, this complaint for issuing the following directions to the OP:-
“(i) Reimburse mediclaim of Rs.2,64,402/- (Rupees Two Lacs Sixty Four Thousand Four Hundred and Two only) which the Complainant incurred during his in-door hospitalization for 15 days from 16-03-2010 to 31-03-2010 in the Sir Ganga Ram Hospital, New Delhi, where he was admitted on 16.03.2010 as a ‘de-novo’ patient in Emergency.
(ii) Award compensation of Rs.1,00,000/- (Rupees One Lac Only) for the mental, physical, psychological, financial constraints and harassment and also the litigation expenses which the septuagenarian senior citizen could ill afford especially in is sickly condition with no other source of income besides his pension.”
In the written statement the OP has inter-alia stated that the complainant was admitted in Action Medical Institute on 07.03.10 for treatment of swelling of lower limb and anemia; that on request he was discharged on 16.03.10 and he got himself admitted in SGRH on the same day for the treatment of weight loss and progressive weakness; that the complainant was discharged from SGRH on 31.03.10; that an Expert Committee of the eminent doctors of Safdarjung Hospital has opined that “ this was not a de-novo medical emergency and basically the patient was shifted from one hospital to another; that relying on a judgment delivered by the Division Bench of Delhi High Court in WP (C) No. 13740/05 – Balram Sharma was Union of India decided on 04.07.08 it is stated that the medical reimburse can be made in full when the following conditions are met:
“14 We are, therefore, of the view that in balancing the interest of the Government, on the one hand, which is limited to financial resources and its paying capacity and on the other hand, it has duty towards its employees to reimburse the medical expenses, a balance can be struck by directing the respondent/Government to reimburse medical expenditure in full when the following conditions are met:-
a) The private hospital where the treatment is taken by a Government employee is on the approved list of the Government.
b) The illness for which the treatment is required is of emergent nature which needs immediate attention and either the Government hospitals have no facilities for such treatment or it is not possible to get treatment at Government hospital and it may take unduly long for the patient to get treatment at Government hospital.
c) The concerned employee/patient takes permission to get treatment from the Government hospital, which is granted and/or referred by the Government hospital to such a private hospital for treatment.”
but since all the conditions are not met in the present case the complaint is liable to be dismissed. Hence, it is prayed that the complaint be dismissed.
Complainant has filed a rejoinder.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Dr. Kanwal Kumar, Additional Director, CGHS (HQ), South Zone, New Delhi has been filed in evidence on behalf of the OP.
Written arguments have been filed on behalf of the parties.
We have heard the oral arguments on behalf of the parties and have also gone through the file very carefully.
It is not dispute that earlier the complainant had been admitted in Sri Balaji Action Medical Institute (in short, SBAMI) which is on the panel of the OP on 07.03.10 and he got himself discharged on his own request from the said hospital on 16.03.10 and thereafter he was got admitted in SGRH which was not on the panel of the OP. The submission of the Complainant in this behalf is that since his condition had been deteriorating day by day in SBAMI and his Haemoglobin (Hb) had fallen from 7.1 (08.03.10) to 3.5 (16.03.10 and Platelet Count from 280 (08.03.10) to 46 (16.03.10) and he had been continuously experience weight loss and progressive weakness and he got himself discharged from the SBAMI and got himself admitted in SGRH in the emergency ward. On the other hand, the submission made on behalf of the OP is that the Complainant had been getting proper treatment at the SBAMI and his admission in SGRH was not a de-nova admission and it was in continuation of his treatment which was getting from SBAMI and that he got himself admitted for further treatment in SGRH which was not on the panel of the OP and, hence, the Complainant is not entitled to any relief.
The medical documents filed on the record prove that the Complainant had been getting the same treatment at SBAMI for which he had got himself admitted to SGRH. Thus, the treatment provide to the Complainant in respect of the disease remained the same in both the hospitals. First hospital was on the panel of the OP while the second hospital i.e. SGRH was not on the panel of OP. It is not the Complainant’s case that SBAMI was not equipped with the facilities of providing proper treatment to the Complainant. However, his case is that since his Hb and the Platelet Counts were fallen gradually, he had to get himself discharged from the SBAMI and admitted in SGRH. We are also of the considered opinion that since immediately after getting himself discharged from the SBAMI the Complainant got himself admitted in SGRH with the same diagnose and it was not a de-novo admission in SGRH and was in continuation of the treatment which was given to the Complainant at SBAMI. However, it is also undisputed fact and is also in no doubt from the medical record that the Hb of the Complainant at SBAMI had fallen speedily. It was 7.1 on 08.03.10 and fallen to 3.5 on 16.03.10 on which date the Complainant got himself discharged from SBAMI. Similarly, his Platelet Counts on 08.03.10 were 280 which came to 46 on 16.3.10 (document Mark A.) It is further borne out from the medical record that the Complainant had been given 10 units of blood in SBAMI (document Mark B) and despite that his Hb fallen to 3.5 gram on 16.3.10. Thus, the treatment being given to the Complainant at SBAMI was not giving proper relief to the Complainant and this necessitated him to get himself discharged from the said hospital and to get himself admitted in SGRH. There is evidence on the record to show that he had been admitted in the emergency ward in SGRH. Had the Complainant continued to take the treatment from SBAMI the said hospital would have also raised the medical bills? It is not that hospital has been providing treatment to the Complainant free of cost. Yes, it is certain that the SBAMI must be providing medical treatment to the Complainant as per the guidelines and the rate fixed by the OP. On the other hand, as SGRH being not on the panel of the OP must have charged its own rate. The claim of the Complainant in question had been rejected on the ground that the admission of the Complainant was not a de-novo and the complainant was shifted from one hospital to another. The Complainant did not feel satisfied and had pursued the matter with the OP and ultimately in the meeting of Technical Standing Committee held on 25.05.16 (document Mark C) the committee observed as follows:-
“ The committee went through the documents in the file and of the opinion that, the patient was a case of SLE, Autoimmune, Hemolytic Anaemia, Auoimmune Thrombocytopenia, DVT with IVF filter placement, underwent treatment initially at Action Balaji Hospital and later at Sir Ganga Ram Hospital.
Opinion of Hematology expert may be taken for final decision, as the case pertains to hematology.”
Accordingly, the matter was referred to Dr. M. Mahapatra, Professor, Department of Hematology, AIIMS, New Delhi and copy of the hand written report is placed on the file copy of which is Annexure R-5. His report/opinion is reproduced as hereunder:-
“1. The case of the patient is referred to me to justify the emergency nature of admission to one hospital from other.
2. The whole case sheet is reviewed. The opinion is based upon the clinical and investigation findings in the case sheet.
3. The patient was being admitted to first hospital from 07.03.10 to 16.03.2010. He was a known case of Hypertension /CAD / hypothyroidism, present with anemia and DVT (RLL- Right Lower Limb). He received Vacmn Injection, IVC filter and blood transfusion.
4. His hemoglobin was dropped from 7.1 gm. to 3.5 gm as per record. The Platelet count also dropped from 28000/mm3 to 46000/mm3 during his stay in hospital.
5. Patient had severe anemia, Thrombocytopenia and active DVT. At that moment, he should have receive emergency medical attention for his prompt diagnosis of his illness. Sudden fall of Hb Hemoglobin) / Platelet with a active DVT is an emergency. Apart from blood transfusion, prompt diagnosis and immediate treatment was necessary.”
Thus from the said report/opinion it stands proved on the record that the Complainant required emergency treatment. The expert committee constituted by the OP considered the said report/opinion (Annexure R-5) and inter-alia observed as follows:-
“As per medical history and opinion of the medical experts the complainant required blood transfusion in such a medical condition, a simple medical process, which was being performed in Sri Balaji Action Medical Institute. The complainant was receiving proper treatment at Sri Balaji Action Medical Institute. As such, there was no need for complainant to change the hospital in the midst of treatment. Therefore, the petitioner wanted treatment at the Sir Ganga Ram Hospital was at his on volition.”
The document is Mark D. In our considered opinion, the expert committee should have consider the matter for the point of view that the course of the medical treatment was not changed in SGRH and the doctors of SGRH followed the same procedure and gave the same treatment to the Complainant but, however, his Hb gradually increased and rose upto 10.9 on 25.03.10. This was the drastic improvement in the medical condition of the Complainant. Therefore, in our considered opinion considering this fact the OP ought to have considered the case of the Complainant and passed an order accordingly. However, the OP stuck to its decision and since the admission in SGRH was not in de-novo admission the Complainant was not held entitled to the claim. In our considered opinion, the OP was not justified in reaching to this conclusion at least after receiving the report from Dr. M. Mahapatra referred to above. While observing this we are not oblivious of the fact that no patient under the CGHS scheme or any other such scheme run by the State Govt. is entitled to change the hospital as per his own choice and cannot be allowed to run from one hospital to another hospital but, however, in the present case the case of the Complainant stood on a peculiar footing. The overall medical condition of the Complainant improved in SGRH which was not improving in SBAMI for any reasons whatsoever. Therefore, we hold that outright rejection of the claim of the Complainant by the OP was not at all justified and the OP was deficient.
Medical record of SGRH shows that the Complainant had taken a deluxe room and room charges were Rs.5400/- per day The Complainant even admitted in SGRH from 16.3.10 to 24.04.10 (document Mark E).
As per the CGHS card of the Complainant Annexure-1 his entitlement is for the private ward. At the relevant time SGRH was not on the panel of the OP. Therefore, the OP shall consider the claim in question of the Complainant as per own rules and rates and shall thereafter pass the claim of the Complainant for the amount so calculated within a period of 60 days from the date of receipt of copy of this order. In the above facts and circumstances of the case, we do not think it expedient to award any compensation for mental agony or litigation cost to the Complainant. Complaint stands disposed off accordingly.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 23.09.17.
