Punjab

Ludhiana

CC/16/13

Shri Narinder Sexena - Complainant(s)

Versus

Northern Railway - Opp.Party(s)

C.K.Jha Adv

26 Oct 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

Consumer Complaint No. : 13 of 04.01.2016

Date of Decision            :  26.10.2017

Narinder Nath Saxena s/o Sh.Manohar Lal Saxena aged 88 years, 124/2J, Sarabha Nagar, Ludhiana.

….. Complainant

                                                            Versus       

1.The Railway Board, Government of India, New Delhi through its Chairman.

2.The Northern Railway, (Head Quarter), Baroda House, New Delhi through its General Manager.

3.Northern Railway, Ferozepur Cantt., through its Divisional Railway Manager.

4.The Northern Railway, Sub Divisional Hospital, Ludhiana through its Chief Medical Supdt.I/C.

…Opposite parties

 

          (Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

COUNSEL FOR THE PARTIES:

For complainant               :         Sh.Chander Kumar Jha, Advocate

For Ops                           :         Sh.Iqbal Singh, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                           Complainant, a pensioner from Northern Railway, claims to be covered under RELHS rules. Retirement of complainant took place on 30.6.1987 in the previous pay scale of Rs.1320-2040, corresponding to the present scale of 5200-20200. Complainant went to Navi Mumbai to meet his younger son and at his residence, he met with an accident resulting in sufferance of hip injury on 7.10.2012. Complainant was requiring immediate medical treatment and that is why, he remained hospitalized under emergency circumstances in MGM New Bombay Hospital, Plot No.35, Sector-3, Vashi, Navi Mumbai. Various tests on the complainant were conducted and even he was operated upon in emergency wing of the said hospital. Thereafter, complainant remained as outdoor patient. Complainant has to incur huge expenses of Rs.2,35,076/- for surgery and treatment of fracture. Complainant lodged claim with Ops by submitting all the bills, reports and prescription slips as well as other information and the certificate given by the attending doctor. Claim for medical reimbursement was lodged with Chief Medical Superintendent, Northern Railway, Ferozepur Cantt. That claim was repudiated vide letter dated 2.9.2013, but handed over to the complainant on 5.7.2014. Repudiation of claim alleged to be illegal, illogical and unjustified. Due to illegal repudiation of claim, complainant claims to have suffered great physical as well as mental pain, agony and harassment as well as financial loss. Legal notice dated 18.7.2015 even was served by complainant on Ops through counsel, but to no effect and as such, by claiming as if Ops rendered deficient services and adopted unfair trade practice, prayer made for directing Ops to make payment of claim amount of Rs.2,35,076/- along with compensation for mental harassment and agony of Rs.25,000/- with interest @12% per annum. Without specifying the amount of litigation expenses, same even claimed.

2.                 In written reply jointly submitted by OP1 to OP4, it is pleaded interalia as if complaint is not maintainable in the present form; complainant has not availed the services of Ops for consideration and as such, he is not a consumer as well as this Forum has no jurisdiction to entertain, try and decide the complaint. Allegations of rendering deficient services or of adoption of unfair trade practice denied by Ops, but by claiming that claim lodged by complainant is false and frivolous. Complainant got admitted in a private non-recognized hospital of Mumbai with complaints of pain at left of hip with restricted movement, past fall at home. It is claimed that at the time of admission, all clinical parameters like pulse and BP were normal and that is why mention was made as under:-

“Pulse  - 100/min, Bp-120/100 mmHg, conscious, no convulsive feature, adequate urine output, no feature of shock, a febrile, no external wound and no active bleeding.”

It is claimed that patient took treatment as a case of fracture neck of femur left side, but without mention of date of occurrence. Further, it is claimed that patient underwent left hemiarthroplasty two days after admission, which itself shows as if emergency was not involved. Rather, hemiarthroplasty is a replacement surgery which is done on elective basis. So, complainant alleged to be estopped by his act and conduct from filing this complaint. Moreover, complainant alleged to have suppressed the material facts and he has no cause of action. Other allegations of the complainant not admitted except that repudiation of claim is done. That repudiation alleged to be duly justified.

3.                 Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C44 and thereafter, counsel for complainant closed the evidence.

4.                 By way of additional evidence, document Ex.CW1/45 even was tendered and thereafter, additional evidence was closed by counsel for complainant.

5.                 On the other hand, counsel for Ops tendered in evidence affidavit Ex.RA of Dr.Amarendra Chatterjee, Chief Medical Superintendent along with documents Ex.R1 & Ex.R2 and then closed the evidence.

6.                 Rebuttal to additional evidence was not lead.

7.                 Written arguments not submitted by any of the parties. Oral arguments by counsel for parties addressed and those were heard. Records gone through minutely. 

8.                 Complainant has produced on record copy of legal notice Ex.C1 sent by him to Ops through postal receipts Ex.C2 and reply to that legal notice was sent by Chief Medical Officer of Railway and the same is produced on record as Ex.C3.

9.                 Ex.C4 is the admission details of complainant submitted for getting medical reimbursement claim. After going through Ex.C4, it is made out that complainant availed emergency services in the hospital after getting him admitted on 7.10.2012 at 3:30 PM. Mention of deep fracture of femur is specifically made in Ex.C4. Even though pulse rate mentioned as 100, but B.P as 120/100 and the other parameters of body temperature, urine output etc are normal in Ex.C4, but despite that admission of complainant was in emergency wing on account of acute pain in hip due to deep fracture and as such, certainly contents of Ex.C4 enough to establish that complainant on account of acute pain, had to be got admitted in the hospital on 7.10.2012 at 3:30 PM in emergency. This certificate Ex.C4 not shown to be false at all and as such, reliance on this must have been placed by Ops for finding that complainant on account of feeling of acute pain due to fracture injury,had to avail the emergency services of hospital.

10.               Representation through Ex.C5 was submitted by the complainant with Chief Medical Superintendent, Sub Divisional Hospital, Northern Railway, Ludhiana for disclosing that he suffered hip joint fracture on 7.10.2012, due to sudden fall in his younger son’s house in Navi Mumbai and that is why, he had to be hospitalized and subsequently operated upon in emergency circumstances in MGM’s New Bombay Hospital. Complainant through this representation Ex.C5 claimed as if he is covered under RELHS because he retired from Railway on 30.6.1987 in the above mentioned pay scale. Along with this representation Ex.C5 dated 18.3.2013, complainant submitted necessary documents, list of which alleged to be attached as Ex.C6. Medical reimbursement claim form Ex.C7 for this treatment of complainant during period from 7.10.2012 to 15.10.2012 even was submitted by the complainant along with details of bill numbers and amounts contained in Ex.C8 and bill details of medicines Ex.C9, final bill summary Ex.C10 as well as receipt of advance deposit amount of Rs.20,000/- issued by MGM New Bombay Hospital Ex.C11 and similar receipt of advance deposit of Rs.1 lac Ex.C12 and of Rs.40,000/- as Ex.C13. As per receipt Ex.C14, the paid amount is Rs.1,83,483/-, but the balance of Rs.23,483/- payable. Besides this, cash/credit memo records of purchased medicines from MGM Medical Store are produced on record as Ex.C15 to Ex.C40. Even the other receipts regarding expenses on conducted tests etc produced on record as Ex.C41 to Ex.C44. So, all this material produced on record enough to establish that complainant had to spent expenses referred in the above referrers bills, memos etc for his emergent treatment got on account of sustenance of hip fracture injury. Despite submission of these documents and claim form, the claim of the complainant was repudiated vide letter dated 2.9.2013 Ex.CW1/45.

11.               After going through Ex.CW1/45, it is made out that the said claim was repudiated on ground that retired railway employee can get the treatment from recognized private hospital or civil hospital under emergency only. Those emergencies alleged to be on account of roadside traffic accident. However, through this Ex.CW1/45, it is mentioned that no emergency was involved because the   medical parameters of the complainant were normal and as such, repudiation of medical claim defended. Though Ex.CW1/45 is of date 2.9.2013, but the said letter was received by the complainant on 5.7.2014 is a fact borne from the contents of endorsement on footnote of Ex.CW1/45. In view of receipt of this letter on 5.7.2014 by the complainant, the complaint could have been filed within two years there from and the same has been done by filing this complaint on 4.1.2016 and as such, this complaint is within limitation.

12.               It is vehemently contended by Sh.Iqbal Singh, Advocate representing Ops that as per circular Ex.R2 issued by Ops, there is no scope available for any beneficiary to go to any private hospital himself or herself or their dependents on their   own volition, except in case of any emergency situation, but that emergency as per contention of counsel for Ops was not there in this case and as such, it is vehemently contended that repudiation of claim of medical reimbursement is justified. That submission of counsel for Ops certainly has no force because emergency is defined in Ex.R2 itself has meaning any condition or symptom resulting from any cause arising suddenly and if not treated at the early convenience, be detrimental to the health of the patient or will jeopardize the life of the patient. It is claimed that date of fall resulting in sustenance of hip fracture injury not mentioned and as such, treatment got was not necessitated in emergency condition at all. Even if the date of fall is not mentioned specifically, but the same made out from the contents of para no.3 of  affidavit Ex.CA; admission details Ex.C4; letter Ex.C5 as well as from para no.3 of complaint itself that the complainant        met with an accident at house of his younger son for sufferance of hip injury on 7.10.2012. So, date of sustenance of injury specified in the pleadings and proof.  Contents of Ex.C4 itself establishes that complainant got admitted on same day at 3:30 PM for availing emergency services of hospital and as such, certainly complainant able to prove that he has to get emergent treatment on account of sustained nature of injury. If complainant would not have availed the emergency treatment from the hospital at Mumbai itself immediately after fall resulting in sustenance of injury of fracture of hip, then certainly the said limb would have become un-functional. As complainant was in acute pain as per contents of Ex.C4 and as such, it was but natural for him to avail treatment from nearby available hospital at earliest, otherwise the same would have been detrimental to his health resulting in paralysis of hip limp, the tissue involved and other veins or arteries involved. Complainant could not have afforded to wait for recommendation of medical officer of Railway because the same would have aggravated his pain and sufferance. So, certainly due to sudden fall of complainant at house of his younger son in Mumbai on 7.10.2012, complainant had to get emergency treatment and as such complainant certainly is entitled to the reimbursement of medical claim, but as per calculation of the amount required to be made as per norms mentioned in section 2 available at page no.2 and 3 of Ex.R2.

13.               Complainant made available the record of hospital necessitating his admission in the emergency wing along with bills and if at all Ops were requiring  more details, then they should have called upon the complainant to submit more documents, but the same has not been done. Rather, repudiation letter EX.CW1/45 issued straightway by keeping the same by Ops with them and as such, it is obvious that Ops rendered deficient services. Keeping of letter Ex.CW1/45 by Ops with them for long itself is an act of deficiency in service.

14.               After going through contents of conditions of emergency mentioned in Ex.R1, it is made out that any other condition, in which, delay could result in loss of life or limb is to be taken as an emergency condition. In this case also, if complainant would have not got the treatment at earliest after sustenance of fracture of hip injury immediately, then certainly the delay could have caused the loss of limb. It is on account of this that doctors attending the complainant in their wisdom decided to admit the complainant in emergency wing as disclosed by contents of Ex.C4. Those circumstances of emergency services necessity were there and as such, repudiation of claim absolutely unjustified. Submission of counsel for Ops has no force that claim was rightly repudiated. As due to wrong interpretation of instructions contained in Ex.R1 and Ex.R2, the repudiation of claim has taken place and as such, certainly complainant has suffered a lot of mental tension, agony and harassment, due to which, he is entitled for compensation under this head along with litigation expenses. In order to ensure that due payable amount received by the complainant at earliest, interest of justice warrants that due calculated amount be paid by Ops to the complainant within 60 days from the date of receipt of copy of order, failing which, complainant will be held entitled to interest @6% per annum on the adjudged due amount w.e.f. today till payment.

15.               Therefore, as a sequel of the above discussion, complaint allowed in terms that OPs will reimburse the due amount to complainant for the treatment got by him at Mumbai during period from 07.10.2012 to 15.10.2012 by treating as if this treatment got in emergency condition. Payment of due amount be made as per calculation worked out in accordance with conditions mentioned in Ex. R2, within 60 days from the date of receipt of copy of order, failing which complainant will be entitled to interest @6% per annum on the adjudged due amount w.e.f. today till payment. Compensation for mental harassment and agony of Rs.7,000/- (Rupees Seven Thousand only) and litigation expenses of Rs.3,000/- (Rupees Three Thousand only) more allowed in favour of complainant and against OPs, whose liability to pay these amounts adjudged as joint and several. Payment of these amounts be made within 30 days from date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules.

16.                         File be indexed and consigned to record room.

 

 (Param Jit Singh Bewli)                                     (G.K.Dhir)

 Member                                                              President

Announced in Open Forum

Dated:26.10.2017

Gurpreet Sharma.