Tamil Nadu

South Chennai

CC/392/2015

M/s.Raja Gopalan - Complainant(s)

Versus

M/s.General Manager, Ripping Centre, BHEL - Opp.Party(s)

M/s. Raja Gopalan

10 May 2019

ORDER

                                                                        Date of Filing  : 28.09.2015

                                                                          Date of Order : 10.05.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.392/2015

DATED THIS FRIDAY THE 10^TH DAY OF MAY 2019

                                 

R. Rajagopalan,

B-2, Krishna Thulasi Apartments,

No.6, Arcot Street,

T. Nagar,

Chennai – 600 017.                                                        .. Complainant.                                                    

                                                                                               ..Versus..

 

The General Manager,

Piping Center, BHEL,

No.80, G.N. Road,

T. Nagar,

Chennai – 600 017.                                                  ..  Opposite party.

 

For the complainant                  : Party in person

Counsel for the opposite party : M/s. T.S. Gopalan & Co.

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986 prays to pay the medical expenses of Rs.2,89,900/- and to pay a sum of Rs.50,000/- towards compensation for mental agony and torture with cost of Rs.20,000/- to the complainant.

 

 

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he is a retired employee of BHEL a Public Sector undertaking at Trichy and a member of BHEL Retired Employees Contribution Health Scheme (RECHS).  The opposite party is the head of a BHEL Unit at Chennai.  He is responsible for providing medical facilities to the Retired employee and his spouse at Chennai under the RECH Scheme, including reimbursement of medical expenses.  He is required to authorize payment of contribution to the Scheme by the member register and renew the membership every year, from April to March.   The complaint has been caused due to non-reimbursement of the medical expenses incurred by the complainant from (1) April 2000 to March 2009 (9 years) and (2) February – March 2014 by the opposite party disregarding the observation of the Consumer Forum and High Court as stated below:

On 10.04.2000, the opposite party gave an authorization to the complainant to pay a sum of Rs.740/- for renewal of his membership of the RECH Scheme for the year 2000-2001.  The complainant paid the amount on the same day.  Yet he was  not allowed medical treatment at the company Dispensary – not even for a single day during the year.  He was also not authorized to renew his membership for subsequent years.  Hence, the complainant filed the consumer case No.97/2008 which was allowed and the opposite party was directed to restore the medical facilities to the complainant on the payment of pro-rata revalidation fees from 2011 to till date with compensation of Rs.10,000/- and cost of Rs.2,000/-.  Accordingly, the complainant paid the pro-rata of revalidation fees of Rs.6,660/- at the rate of Rs.740/- per year.  The complainant submits that even after payment of the prescribed fee for revalidation, the opposite party has miserably failed to reimburse the medical bills towards of Rs.34,000/- expended towards eye operation. 

2.     The complainant submits that the said consumer case No.97/2008 was filed for claiming medical expenses incurred towards eye operation.   Since, the opposite party raised a defence that there is no proper renewal, the Hon’ble Forum passed orders for renewal of Retired Employees Contribution Health Scheme on pro-rata of basis.  After receiving the revalidation fees and renewal of membership the opposite party denied the payment of reimbursement of medical expenses. The complainant submits that on 08.02.2014, one Saturday the complainant suddenly fell down in his house and developed paralysis and also sustained severe injury namely; fracture of hipbone and become semiconscious. Immediately, the complainant was taken to nearby St. Isabel Hospital wherein, the complainant underwent surgery on 10.02.2014 implants were affixed after due investigation and diagnosis. The complainant was discharged from the hospital on 21.02.2014.  The complainant was compelled to pay a sum of Rs.1,47,800/- towards medical expenses.   At the time of discharge, the complainant approached the opposite party for reimbursement of the said medical expenses of Rs.1,47,800/- under RECH Scheme enclosing Hospital Certificate, bills etc.  The said claim was returned after two months by the opposite party with the remarks that St. Isabel Hospital was not an approved / empanelled hospital by BHEL.  The complainant submits that the rejection of claim by the opposite party on the ground of non-empanellment is against the facts and law.  The booklet issued by BHEL, RECH Scheme shows that the St. Isabel Hospital is empanelled in the list that it is one of the well known hospital.  But it is not an authorized list of hospitals for inpatient treatment and reimbursement towards room rent and treatment charges.  The act of the opposite party amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

3.      The brief averments in the written version filed by opposite party is as follows:

The opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.    The opposite party states that the complainant was employed with the opposite party and a beneficiary under BHEL Retired Employees Contributory Health Scheme (RECHS) under the contract of personal service.  The scheme is only administered by the opposite party, employer.   Hence, the complainant is not a consumer and the complaint is not maintainable.  The opposite party states that the complainant made a claim for reimbursement of Rs.300/- per month from the year 2000 to 2006 and fixed outpatient treatment charges at the rate of Rs.500/- per month between 2006 to 20069and a sum of Rs.34,100/- towards expenses for cataract surgery without renewing the membership.  Hence, this opposite party has rightly repudiated the claim.  Thereafter, the complainant filed consumer case No.97/2008 which was partly allowed directing the opposite party to give renewal on pro-rata basis.  Thereby, the complainant is an effective member of RECH Scheme.  But the claim was barred by limitation.   Hence, this opposite party is not liable to pay the said amount of Rs.34,100/- and other claims.  The opposite party states that the claim of reimbursement of Rs.1,47,000/- towards hospital and other expenses incurred by the complainant for his hip fracture on 08.02.2014 could not be entertained the hospital which the complainant claimed to have got admitted and taken treatment was not a registered hospital for the purpose of the treatment.  Therefore, there is no deficiency in service on the part of the opposite party and hence, the complaint is liable to be dismissed.

4.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A6 are marked.  Proof affidavit of the opposite party is filed and no document is marked on the side of the opposite party.

5.      The points for consideration is:-

1. Whether the complainant is entitled to get reimbursement of medical expenses Rs.2,89,900/- as prayed for?
2. Whether the complainant is entitled to a sum of Rs.50,000/- towards compensation for mental agony with cost of Rs.20,000/- as prayed for?

 

6.      On point:-

Both parties filed their respective written arguments.  Heard the complainant and the opposite party’s Counsel also.  Perused the records namely; the complaint, written version, proof affidavits and documents.  The complainant pleaded and contended that he is a retired employee of BHEL a Public Sector undertaking at Trichy and a member of BHEL Retired Employees Contribution Health Scheme (RECHS) is admitted.   Further the complainant contended that the opposite party after constitution of the medical reimbursement scheme in the year 1995 denied the medical facilities and reimbursement of medical expenses of the complainant on the ground of failure to pay the contribution for the year 2000-2001.   Hence, the complainant filed the consumer case No.97/2008 which was allowed and the opposite party was directed to restore the medical facilities to the complainant on the payment of pro-rata revalidation fees from 2011 to till date with compensation of Rs.10,000/- and cost of Rs.2,000/-.  Accordingly, the complainant paid the pro-rata of revalidation fees of Rs.6,660/- at the rate of Rs.740/- per year as per Ex.A1 (S).  Further the contention of the complainant is that even after payment of the prescribed fee for revalidation, the opposite party has miserably failed to reimburse the medical bills to the tune of Rs.34,000/- expended towards eye operation.  In reality, the said consumer case No.97/2008 was filed for claiming medical expenses incurred towards eye operation.   Since, the opposite party raised a defence that there is no proper renewal, the Hon’ble Forum passed orders for renewal of Retired Employees Contribution Health Scheme on pro-rata of basis.  After receiving the revalidation fees and renewal of membership, denied the payment of reimbursement of medical expenses amounts to deficiency in service and unfair trade practice.  The complainant has filed the medical bills as per Ex.A2 & Ex.A3 towards eye operation.  Further the contention of the complainant is that he is entitled for a sum of Rs.1,100/- towards outpatient medical expenses but claiming a sum of Rs.1,08,000/- towards such expenses; is not acceptable without any proper medical bills and prescriptions.

7.     Further the contention of the complainant is that on 08.02.2014, one Saturday the complainant suddenly fell down in his house and developed paralysis and also sustained severe injury namely; fracture of hipbone and became semiconscious. Immediately, the complainant was taken to nearby St. Isabel Hospital wherein, the complainant underwent surgery on 10.02.2014 implants were affixed after due investigation and diagnosis. The complainant was discharged from the hospital on 21.02.2014 as per Ex.A3.  The complainant was compelled to pay a sum of Rs.1,47,800/- towards medical expenses.   But on a careful perusal of Ex.A2 (S), it is very clear that the complainant has paid a sum of Rs.1,08,208/-.  At the time of discharge, the complainant approached the opposite party for reimbursement of the said medical expenses of Rs.1,47,800/- under RECH Scheme enclosing Hospital Certificate, bills etc.  The said claim was returned after two months by the opposite party with the remarks that St. Isabel Hospital was not an approved / empanelled hospital by BHEL.  Ex.A6 is the rejection letter.  Further the complainant contented that the rejection of claim by the opposite party on the ground of non-empanelment is against the facts and law.  The booklet issued by BHEL, RECH Scheme shows that in Ex.A4 empanelled St. Isabel Hospital in the list that it is one of the well known hospital.  But it is not an authorized list of hospitals for inpatient treatment and reimbursement towards room rent and treatment charges.  But it is not denied that due to the sudden fall in the house, the complainant sustained severe hip fracture and became semiconscious.   Immediately, the family members taken the complainant to the known, familiar, nearby St. Isabel hospital. 

8.     As per the following decision cited in:

IN THE SUPREME COURT OF INDIA

CIVIL ORIGINAL JURISDICTION

WRIT PETITION (CIVIL) NO.694/2015

Between

Shiva Kant Jha

-Versus-

Union of India

Held that

“The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order.   The real test must be the factum of treatment.  Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned.  Once, it is established, the claim cannot be denied on technical grounds.  Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court”.

 The complainant is claiming a sum of Rs.2,89,900/- towards medical expenses.   But it is apparently very clear that the complainant has paid only a sum of Rs.1,08,208/- and another sum of Rs.34,100/- alone.  The complainant miserably failed to prove for the balance amount.

9.     The learned Counsel for the opposite party would contend that admittedly, the complainant was employed with the opposite party and a beneficiary under BHEL Retired Employees Contributory Health Scheme (RECHS) under the contract of personal service.  The scheme is only administered by the opposite party, employer.   Hence, the complainant is not a consumer and the complaint is not maintainable.  But admittedly, the complainant is a retired employee under BHEL and on payment of fees/renewal of fees/ revalidation of fees, the complainant is entitled to the benefit of medical reimbursement. 

As per Section 2 (d) (i) of the Consumer Protection Act, 1986 ‘Consumer’ means “any person who buys and goods for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferred payment and includes any user of such goods other than the person who buys such goods for consideration paid or promised or partly paid or partly promised, or under any system of deferred payment when such use is made with the approval of such person, but does  not include a person who obtains such goods for resale or for any commercial purpose”.

10.    Further the contention of the opposite party is that the complainant made a claim for reimbursement of Rs.300/- per month from the year 2000 to 2006 and fixed outpatient treatment charges at the rate of Rs.500/- per month between 2006 to 2009 and a sum of Rs.34,100/- towards expenses for cataract surgery without renewing the membership.  Hence, this opposite party has rightly repudiated the claim.  Thereafter, the complainant filed consumer case No.97/2008 which was partly allowed directing the opposite party to give renewal on pro-rata basis.  Thereby, the complainant is an effective member of RECH Scheme.  But the claim was barred by limitation.   Hence, this opposite party is not liable to pay the said amount of Rs.34,100/- and other claims.  On the other hand, on a careful perusal of the order dated:16.11.2009 in C.C. No.97/2008, the Hon’ble Consumer Court has not rejected the claim of medical expenses.  Equally, the claim of the complainant is reimbursement of medical expenses and not recovery of money.  The limitation question of deficiency in service as per Section 24 (A) is Consumer Protection Act, 1986.  In this case, the complainant has filed C.C. No.97/2008 within the prescribed time.  On the basis of the order passed in C.C.No.97/2008 after payment of pro-rata fees, this case has been filed; establishes the continuing cause of action.  The contention of the limitation raised by the opposite party is unsustainable. 

11.    Further the contention of the opposite party is that the claim of reimbursement of Rs.1,47,000/- towards hospital and other expenses incurred by the complainant for his hip fracture on 08.02.2014 could not be entertained the hospital which the complainant claimed to have got admitted and taken treatment was not a registered hospital for the purpose of the treatment.  But the law is well settled that ‘in an emergency case anybody can avail suitable treatment in any hospital which need not be empanelled’.  Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite party shall pay a sum of Rs.1,42,308/- (Rs.34,100/- + Rs.1,08,208/-) being medical expenses incurred by the complainant with a compensation of Rs.25,000/- for mental agony and cost of Rs.10,000/- to the complainant.

In the result, this complaint is allowed in part.   The opposite party is directed to pay a sum of Rs.1,42,308/- (Rupees One lakh forty two thousand three hundred and eight only) being medical expenses incurred by the complainant and to pay a sum of Rs.25,000/- (Rupees Twenty five thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 10^th day of May 2019. 

 

MEMBER                                                                                 PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	10.04.2000 & 04.03.2010	Copy of cash receipt for Rs.740/- dated:10.04.2000 and letter dated:04.03.2010 of BHEL acknowledging receipt of Rs.6,660/- for 9 years towards RECH Scheme
Ex.A2	18.10.2004	Copy of eye surgery bills dated:18.10.2004, 13.11.2004, 06.04.2007, 23.08.2007 and letter of the opposite party dated:18.09.2012
Ex.A3		Copy of medical reimbursement claim dated:12.04.2014 for surgery and treatment
Ex.A4		Copy of BHEL RECH Scheme containing list of well-known hospitals
Ex.A5		Copy of Madras High Court verdict
Ex.A6	20.06.2014	Copy of letter dated:20.06.2014 of the opposite party rejecting the claim

 

OPPOSITE PARTY SIDE DOCUMENTS:-  NIL

 

 

MEMBER                                                                                 PRESIDENT