Punjab

Ludhiana

CC/16/54

Sher Singh - Complainant(s)

Versus

Nr.Rly.Ludhiana - Opp.Party(s)

M.S.Sethi Adv.

14 Sep 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

Consumer Complaint No. 54 of 19.01.2016

Date of Decision            :   14.09.2016

 

Sher Singh aged 80 years s/o Late S.Sarwan Singh r/o 3558, St. No.7, New Janta Nagar, Gill Road, Ludhiana.

….. Complainant

                                                         Versus

 

1.The Chief Medical Supdt. Northern Railway, Ferozepur, Punjab.

2.The Divisional Railway Manager(P).Northern Railway, Divisional Office, Ferozepur Cantt, Punjab.

3.The Senior Divisional Medical Officer, Northern Railway, Ludhiana.

4.Northern Railway, (Ferozepur Division), Ferozepur, through Sr.Divl.Comml.Manager.

5.The Chief Medical Director (CMD), Baroda House, New Delhi.

 

…Opposite parties

 

 

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

 

 

QUORUM:

 

SH.G.K.DHIR, PRESIDENT

MRS.VINOD BALA, MEMBER

 

COUNSEL FOR THE PARTIES:

 

For complainant                      :        None.

For OPs                          :        Sh.Iqbal Singh, Advocate 

 

PER G.K.DHIR, PRESIDENT

 

1.                Complainant, a retiree in rank of CRS LUD claims to have hired the services of OPs under liberalized health scheme known as RELHS for availing relief of medical treatment for self and wife. Ferozepur office of OPs issued card dated 19.4.2005 after receiving Rs.7816/- vide M.R.No.964135 dated 19.4.2005 with CBS/FZR. Endorsement dated 5.2.2013 bearing serial No.1072-2073 also was recorded on that card. Complainant was having ailment of hernia since 1990 on left side of organic genital, that is below the stomach. During night air used to slip away, but the same was not giving any extra pain. Before the operation, on the right side hernia also surfaced, due to which, the complainant started having pain on account of involvement of both side of organic genital. On 28.2.2014, there was intolerable pain felt by the complainant. There was no arrangement in H/unit at Ludhiana for emergency operation and as such, complainant approached the nearest best hospital namely Khosla Hospital, 451, Model Town, Ludhiana. Senior DMO Dr.Chetna Kapoor was informed about the operation. Claim was submitted with OPs qua amount of Rs.29,000/- concerning surgery treatment undertaken at the said hospital during the period from 28.2.2014 to 2.3.2014. That claim was repudiated on 3.11.2014 by OP1 on the ground that patient was symptomatic for two months prior to admission, due to which, he was enough time to report to his authorized medical officer at HU/LUD for arrangement of treatment. Besides, the claim for reimbursement was repudiated on the ground that emergency could not be justified as per the terms of Railway Board Letter No.205/H/6-4/Policy-11 dated 31.01.2007. Thereafter, OP5 vide letter dated 23.3.2015 also dismissed the appeal on the same ground. That repudiation of the claim alleged to be illegal and without justification. Complainant claims that being senior citizen of age of 80 years, he has suffered mental tension, agony and financial loss on account of deficiency in service on the part of OPs. Besides, repudiation of claim alleged to be an act of unfair trade practice. No treatment for surgery of bilateral inguinal hernia was available at Railway Hospital, Ludhiana is a fact admitted by OP1 in repudiation letter dated 3.11.2014. Due to intolerable pain, complainant had to rush to the nearest hospital     for getting rid of the pain and that is why, he was admitted in emergency in Khosla Hospital, Ludhiana for treatment. Even certificate of the concerned doctor of Khosla Hospital mentions that operation was performed on emergency basis. Complainant claims that terms and conditions of the policy have not been supplied to him and as such, repudiation of claim is erroneous. Prayer made for directions to Ops to reimburse the claim of the complainant to the tune of Rs.29,000/- along with interest @18% p.a. till realization from the date of lodging of claim. Compensation for mental harassment of Rs.30,000/- and litigation expenses of Rs.5500/- and miscellaneous expenses of Rs.2500/- more claimed.

2.                In written statement filed by OPs, it is pleaded interalia as if complaint in the present form is not maintainable; there is no deficiency in service on the part of OPs and nor any unfair trade practice adopted by OPs. Besides, it is claimed that the complainant has not approached this Forum with clean hands because he has suppressed the material facts. Complainant has not availed the services of OPs for consideration and as such, he is not a consumer, due to which, this Forum has no jurisdiction. It is also claimed that the complainant has no cause of action and the complaint has been filed just for abusing the process of law. Complainant has himself admitted that he was suffering from Hernia since 1990 i.e. for the last 25 years and as such, there is no question of any emergency whatsoever. As per the existing guidelines, reimbursement is awarded only in case of emergency. Patient has ample time to report to his Authorized Medical Officer, Health Unit, Ludhiana and he could have referred the complainant for treatment to Divisional Hospital, Ferozepur, where such type of surgery performed in routine. As per discharge slip of the complainant, he was having pain for 1-2 months and as such, he(complainant) was having enough time to report to his Authorized Medical Officer, Health Unit, Ludhiana, who could have arranged for the treatment. The repudiation of claim alleged to be perfectly legal and valid because no emergency was involved. Each and every other averment of the complaint denied by terming the same as wrong. Complainant got treatment in private non recognized hospital at Ludhiana with main complaint of pain bilateral inguinal area for one to two months prior to admission. At the time of admission, pulse rate was 84/min, BP was 152/94 mmhg and complainant was conscious-oriented. Besides, there was adequate urine output and there were no feature of shock and febrile. The complainant was diagnosed as a case of bilateral inguinal hernia, due to which, he underwent treatment for bilateral hernioplasy with mesh under spinal anesthesia. Vitals of the complainant were stable at the time of admission. Inguinal hernia is not an emergency procedure.

3.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex. C1 to Ex. C7 and thereafter, closed the evidence.

4.                On the other hand, counsel for OP1 to OP5 tendered in evidence affidavit Ex.RA of Dr.Chetna Kapoor, Senior Divisional Medical Officer along with documents Ex.R1 to Ex.R3 and then closed evidence.

5.                Written response to OPs written statement dated 10.6.2016 even submitted by the complainant. Oral arguments of complainant as well as counsel for OPs heard and records gone through carefully.

6.                Complainant in para no.1 of the complaint as well as in para no.2 of his affidavit Ex.CA specifically pleaded that he hired the services of OPs under the liberalized health scheme known as RELHS. So, in view of that complainant contends that he is entitled for claiming medical reimbursement as per the terms and    conditions of that scheme. Complainant claims to have got the treatment in emergent circumstances from Khosla Hospital, Ludhiana by way of his admission for the period from 28.2.2014 to 2.3.2014 by spending Rs.29,000/- on such treatment. Copy of bill Ex.C5 dated 2.3.2014 in this respect has been produced on record. Said bill Ex.C5 also points out that the complainant was admitted in surgical unit of Khosla Hospital, Ludhiana on 28.02.2014 at 9:00 AM, but discharged therefrom on 2.3.2014 at 11:00 AM. That treatment was got by the complainant on account of severe pain in bilateral inguinal area. Certificate Ex.C6 of Dr.Rajesh Khosla has been produced by the complainant to establish that he was diagnosed as a case of bilateral inguinal hernia and was operated on emergency basis. Date and time of performance of operation neither mentioned in Ex.C5 and nor in Ex.C6 and nor in any other documents produced by the complainant. However, that operation took place between 9:00 AM of 28.2.2014 to 11:00 AM of 02.3.2014 is a fact borne from perusal of bill Ex.C5. Complainant vehemently contends that as he spent Rs.29,000/- for having emergency treatment and as such, he is entitled for refund of the same. From the material placed on record by the complainant or OPs, it is not made out as to on which date, the  bilateral inguinal hernia operation was performed. Disclosure of that date or production of the record of treatment alone could have helped in finding as to whether the said treatment got in emergent condition or not.

7.                No affidavit of Dr.Rajesh Khosla, who gave certificate Ex.C6 has been tendered and as such, there remains  sole statement of the complainant qua the alleged emergency. However, affidavit Ex.RA of Dr.Chetna Kapoor, Senior Divisional Medical Officer has been produced by the OPs to establish that the required treatment was not emergent because the admissions of the complainant himself establishes that he    was suffering from Hernia since 1990 i.e. for the last 25 years. Besides, as per that affidavit Ex.RA, the discharge slip of the patient(complainant) was showing as if he was having pain for 1-2 months. In view of this gap of 1-2 months, certainly the complainant was having enough time to report to his authorized medical officer, Health Unit, Ludhiana for getting him referred to the approved hospital. Even the complainant has not placed on record the record of admission detail consisting of particulars as to whether he got himself admitted through OPD service or emergency service or to an ICU Bed or general bed or cabin bed. These admission details required to be submitted for finding out as to whether the treatment of the complainant in emergent condition was required. It is so because copy of Abstracts of Indian Railway Medical Manual 2000 consisting of guidelines for pensioners/family pensioners in connection with claim of medical reimbursement produced by the parties on record, itself lay that such admission record needs to be placed on record for establishing the emergency condition. Besides, letter Ex.R1 containing those guidelines provides that following clinical findings should be made available for evaluation as to whether the treatment in emergent condition required or not? Those findings with respect to pulse rate; B.P.; level of consciousness, any convulsive feature, urine output, any other feature of shock, body temperature, extent of external wound, extent of active bleeding and extent of chest pain or pain in other parts of the body should be produced. Besides, particulars with respect to the type of medical treatment given immediately after admission should also be produced. Further particulars required to be produced should be concerning the list of emergency medicines used immediately after admission and type of surgical procedure done immediately after admission. Record of those medicines or of surgical procedure even has not been produced and nor the other details    qua urine output and other feature of body temperature etc has been produced and as such, complainant wants to prove the emergency without producing the requisite record contemplated by para 648 of Abstracts of Indian Railway Medical Manual 2000. Para 648 of Indian Railway Medical Manual 2000 provides that where in an emergency, a Railway employee or his dependent has to go for treatment (including confinement) to a Government hospital or a recognized hospital or a dispensary run by a philanthropic organization, without prior consultation with the Authorized Medical Officer, reimbursement of the expenses incurred to the extent otherwise admissible will be permitted. In such a case, before reimbursement is admitted, it will be necessary to obtain in addition to other documents prescribed, a certificate in the prescribed form as given in part C of certificate B of Annexure III to this Chapter from the Medical Superintendent of the hospital to the effect that the facilities provided were the minimum which were essential for the patient’s treatment. In such cases, the General Managers are delegated with powers to allow full reimbursement of medical expenses in case of treatment from Government hospitals etc, but upto to the limit of 50,000/-. However, para 648(2) of Indian Railway Medical Manual provides that in case, where the treatment had to be taken in private/non-recognized hospitals in emergent circumstances, without being referred by the authorized medical officer, the General Managers are empowered to settle reimbursement claim up to Rs.30,000/- per case. Further as per this para 648(2) of Indian Railway Medical Manual, in case the treatment taken in private hospitals by Railway men, then reimbursement permissible only in case such treatment got in emergent cases and for the shortest and unavoidable spell of time. In case before us, treatment has been got by the complainant from a private/non-recognized hospital and as such, it is for the complainant to establish that he got the treatment in emergency.

8.                Emergency means any condition of 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. Definition of this emergency situation is given on the back of the Abstract of Indian Railway Medical Manual 2000, copy of which is produced by the complainant himself. Complainant has not brought any evidence except the certificate Ex.C6 on record to establish that Hernia operation was essential, otherwise the same would have been detrimental to his health or would have jeopardized his life.  The condition of emergency has to be confirmed by the authorized medical officer ex-post facto as pre definition of emergency. That confirmation from the authorized medical officer ex-post facto not shown to be got by the complainant and as such, complainant wants to avail the relief without proving the required admission details. Certainly a retired employee admitted in Indian Railway hospital in emergency will be provided necessary help as per Railway Pensioner’s Medical Guide, but that help has to be provided as per rules, which provides that confirmation of an emergency by the authorized medical officer ex-post facto is essential. That ex-post facto confirmation from the authorized medical officer not obtained, but only the certificate Ex.C6 of an unauthorized hospital produced without bothering to produce the required record of admission detail etc., and as such, certainly the complainant has failed to prove that treatment got by him in emergent condition. Had the complainant produced on record, the date and time of operation and the record of used medicine or the detail of surgical procedure carried out, only then he would have succeeded in proving the emergency condition. With holding of the record in this respect leans in favour of holding that complainant unable to prove that he got the Hernia treatment in emergent condition and that is why he has not bothered to get the confirmation from the authorized medical officer of such an emergency.

9.                An inguinal hernia occurres when tissue pushes through a week spot in  the groin muscle. This causes a bulge in the groin or scrotum. Hernias are more common in men. The main symptom of an inguinal hernia is a bulge in the groin or scrotum. This bulge may form over a part of weeks or months or it may appear all of a sudden after lifting of heavy weight coughing, bending, straitening or laughing.          In case of sudden pain, nausea and vomiting, patient will have to call a doctor for finding  the extent of Hernia. Complainant in this case himself claims to be suffering from Hernia since from 1990 and as such, it was for him to explain as to what kind of pain necessitated his admission in a private/non-recognized hospital. Record of treatment or of use medicines or of carried out tests or of carried out surgical procedure or disclosure of date of surgical operation alone could have enabled the complainant in proving that treatment was got in emergency condition. Withholding of all these records lead to the inference that the complainant though was having sufficient chance to contact the authorized medical officer, but he choose not to do so. So, repudiation of claim through letter Ex.R3 and dismissal of appeal through letters Ex.R2 and Ex.C4 is quite appropriate. Rather, in Ex.C4, it has been held by the Appellate Departmental Forum that the surgery undertaken was a planned elective procedure, due to which, there was ample time and opportunity available with the complainant to approach the AMO. Those findings recorded in Ex.C4 are absolutely correct in view of the       above discussion and as such, repudiation of medical claim is in accordance with the rules and regulations.

10.              Complainant estopped from claiming that terms and conditions of the RELHS scheme were not made available to him because after getting of card in 2005, he could have made efforts for getting the copy of those terms and conditions from the department or from any other source. As the complainant himself got enrolled under the Liberalized Health scheme known as RELHS on payment of premium and obtained the card and as such, complainant being educated,definitely was aware of the terms and conditions on which medical claim for treatment from the private unauthorized hospital in emergent conditions was reimbursable to him.

11.              Complainant availed the medical claim services under the scheme on payment of premium and as such, complainant is a consumer.

12.              The unreported copies of judgments marked as Annexure-A, Annexure-B, Annexure-C and Annexure-D, today( as produced by the complainant) shows that emergent treatment was got in those cases under circumstances that there was no occasion for approaching the authorized medical officer. Those are not the conditions existing in this case before us as discussed in detail above and nor the complainant able to prove to have got the treatment in an emergency condition and as such, benefit from those unreported cited cases cannot be gained by the complainant. As repudiation of the claim is justified and as such, there is no deficiency in service on the part of OPs and nor any unfair trade practice shown to be adopted by the Ops.

13.              Therefore, as a sequel to the above discussion, complaint dismissed but without any order as to costs. Copies of order be supplied to parties free of costs as per rules.

14.                        File be indexed and consigned to record room.

 

                     (Vinod Bala)                              (G.K. Dhir)

            Member                                      President

Announced in Open Forum

Dated:14.09.2016

Gobind Sharma.