Delhi

New Delhi

CC/658/2013

Gopi Nath Nigam - Complainant(s)

Versus

M/S. Central Government Health Scheme - Opp.Party(s)

28 Oct 2016

ORDER

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

Case No.C.C./658/2013                                             Dated:

In the matter of:

          GOPI NATH NIGAM

          S/o LATE SHRI RAM NARAYAN LAL NIGAM

          R/o C-247, MINTO ROAD COMPLEX

          NEW DELHI-110001

 

          ……..COMPLAINANTS

VERSUS

1. CENTRAL GOVERNMENT HEALTH SCHEME,

THROUGH ITS CMO

MINTO ROAD, CONNAUGHT PALACE,

NEW DELHI-110001.

 

2. CENTRAL GOVERNMENT HEALTH SCHEME,

              THROUGH ITS DIRECTOR

              9, BIKANER HOUSE HUTMENTS,

              SHAHJAHAN ROAD,

              NEW DELHI-110001

       .... OPPOSITE PARTIES

 

PRESIDENT: S.K. SARVARIA

ORDER

  Complainant is the senior citizen and retired from Ministry of Defence. The OP is providing the health services to the govt. employees. It     is     alleged by the complainant that on 28/01/13 his wife fell down at home and due to emergency she was admitted to the Indraprastha Apollo Hospital, Sarita Vihar, Delhi where Dr.Rajagopalan Krishanan diagnosed her as “Revision Salvage Surgery of Failed” and operated. She was discharged on 8/2/13.

       It is alleged by the complainant that before surgery he informed OP No.1 about the emergency admission of his wife, upon which OP refused to directly pay to the hospital and asked for submitting the medical claim for reimbursement.

       It is further alleged by the complainant that on 11/2/13 he filed the claim for reimbursement with OP No. 1, when he did not get any response from OP, he again wrote reminder letter to OP No. 1 dt.18/02/13 regarding reimbursement of his claim but nothing has been done by the OP.

       It is alleged by the complainant that on 17/5/13 OP released a sum of Rs. 1,10,621/- out of the total claim of Rs. 3,70,546/- as full and final settlement of his claim. It is also alleged by the complainant that the deduction made by the OP is totally wrong and arbitrary. Hence this complaint.

       Notice of the complaint was sent to the OP through post on 21/9/13. Since none was present, matter was adjourned to 25/11/13. On 25/11/13, Sh. Rajat Gaur Advocate appeared and collected the copy of complaint.

       Counsel for OP filed its W.S. wherein he denied any deficiency in service on its parts and stated that the MRC claim of the complainant has been cleared as per CGHS Rates.

       Complainant filed his Rejoinder as well as his evidence by way of affidavit wherein he has corroborated the contents of his complaint.

       OP despite several opportunities failed to place on record its evidence by way of affidavit and as such its right to file evidence was closed vide order dt. 30/9/16.

       Ld. AR for the complainant stated on 30/9/2016 that he did not want to address the oral arguments, and was relying upon the pleadings evidence as well as the citation placed on record by him.

       Complainant has placed on record the copy of CGHS Identity Cards, copy of emergency certificate dt.28/01/13, copy of discharge summary, copy of medical bills, copy of reimbursement form, and copy of letter dt.18/2/13 in support of his case.

       We have carefully gone through the complaint and the documents annexed with it, as the complainant had paid an amount for hiring the services of OP as alleged in para no. 2 of the complaint, the complainant is the consumer within the meaning of sec 2(d) of the Consumer Protection Act.

       In its written statement OP has stated that MRC claim of the complainant has been cleared as per CGHS rates, and remained silent about the emergency certificate. Moreover, despite several opportunities OP failed to place on record its evidence by way of affidavit which lead to the closure of its Defence.  In its written statement OP has stated that MRC claim of the complainant had been cleared as per CGHS Rates, he also placed on record the statement of CGHS regarding the claim reimbursement. There was a specific direction dt.9/4/2014  to the OP to file the Rules of CGHS alongwith its affidavit, but despite several opportunities OP failed to comply with the order and as such its defence was closed. Therefore, OP could not prove facts pleaded in the reply.

       From the unrebutted testimony of the complaint as well as the documents placed on record, we are of the consideredp opinion that OP has processed the claim of the complainant ignoring the most important document i.e. Emergency Certificate and the emergency situation due to which the complainant has to approach Indraprastha Hospital, Sarita Vihar and had arbitrarily  released the sum of Rs. 1,10,621/- out of the total claim of Rs. 3,70,546/- to the complainant. This act of OP amounts to deficiency in services.

       We therefore hold OP guilty of deficiency in service and direct it as under:-

1. Pay to the complainant a sum of Rs. 2,59,925/- alongwith 9% simple interest for the date of filing of complaint till payment.
2. Pay to the complainant a sum of Rs.10,000/- towards mental pain and agony suffered by him.
3. Pay to the complainant a sum of Rs. 5,000/- from litigation claiming.  

 

This final order be sent to server (www.confonet.nic.in ). A copy each  of this order each be sent to both parties free of cost by post.

File be consigned to record room.

 

Pronounced in open Forum on _______________.

 

                                      (S K SARVARIA)

                                          PRESIDENT

 

 

 

                                      (H M VYAS)                                     (NIPUR CHANDNA)

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