Tamil Nadu

StateCommission

A/81/2021

1.The Chief Medical Superintendent, - Complainant(s)

Versus

R. Gopalsamy Sashtri, - Opp.Party(s)

M/S. K. MUTHAMIL RAJA

17 Mar 2023

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI – 600 003.

BEFORE        Thiru. S. KARUPPIAH                           PRESIDING JUDICIAL MEMBER

                      Thiru. R. VENKATESAPERUMAL        MEMBER

 

F.A. No.81/2021

  (Against the Order dt.02.12.2019 in C.C. No.17/2016 on the file of the

D.C.D.R.C., Coimbatore)

DATED THE 17^th  DAY OF MARCH 2023

 

1. The Chief Medical Superintendent,                               

Railway Divisional Hospital,

Salem – 636 005.

 

2. The Divisional Railway Manager,

Southern Railway Divisional Office,

Salem – 636 005.

 

3. The General Manager,

Southern Railway Head Quarters Office,

Chennai – 600 003.                                              .. Appellants/Opposite parties 1 to 3.

 

- Versus -

R. Gopalasamy Sashtri,

S/o. Late V. Rathinasabapathy,

No.L 229, TNHB Colony,

Nehtajipuram,

Neelikonampalayam Post,

Coimbatore – 641 033.                                                         .. Respondent/Complainant.

 

Counsel for Appellants  / Opposite parties : M/s. K. Muthamil Raja

Counsel for Respondent  / Complainant            : M/s. A. Deivasigamani

 

This appeal came up before us for final hearing on 16.03.2023 and on hearing the arguments of both sides and on perusing the material records, this Commission made the following order in open court :-

ORDER

Thiru. S. KARUPPIAH, JUDICIAL MEMBER

          This appeal has been preferred by the appellants / opposite parties against the order of the District Commission, Coimbatore dt.02.12.2019 in C.C. No.17/2016.

1.         The factual background culminating  in to  appeal is as follows:-

The complainant worked as a TTE in the Railways and retired from service on 31.05.2014.  On 25.12.2012 while he was in service when travelled between Salem and Trichy, he experienced chest pain.  Immediately, he was admitted in the Railway Hospital, Trichy.  Since, the complainant was willing to go to his native at Coimbatore, he was discharged from the Railway Hospital.  When he reached Coimbatore again he experienced the same chest pain and got admitted in Sri Ramakrishna Hospital on 25.12.2012.   Angio was taken on 26.12.2012 and it was found that 100% stenosis and diagnosed as interior and Posterior myocardial infraction requiring PTCA with stunting.  Surgery was conducted on 29.12.2012 and got discharged from the hospital on 03.01.2013.    Meanwhile, the Railway Medical Officer, Podanur visited the complainant and confirmed the emergency nature of his treatment.  Subsequently, he submitted a claim form for Rs.2,03,380/- towards medical expenses to the 1^st opposite party.  His claim application was found satisfied after verification of all the records.   But he was sanctioned only to the tune of Rs.85,000/-.  After sometime, the Divisional Finance Manager, Salem in his letter dated 09.07.2013 returned the claim file to the 1^st opposite party with a direction to clarify with the Chief Medical Officer, Perambur whethere the treatment was an emergency one.  Thereafter, one Dr. P.V. Thanuja gave the opinion that the treatment was not an emergency one considering the fact that the admission was on 25.12.2012, but the surgery was done on 29.12.2012.  Based on this findings, the claim was not paid to the complainant.  Hence, legal notice dt. 06.10.2015 was sent to the opposite parties.  For which, the claim was rejected on 16.12.2015.  The act of the opposite parties amounted to deficiency in service.   For which the complainant claimed the medical reimbursement of Rs.2,00,000/-, Rs.25,000/- towards compensation for mental agony and cost of Rs.3,000/-.

2.         The opposite parties admitted the complaint of chest pain and treatment undertaken by the complainant in Sri Ramakrishna Hospital, Coimbatore.  But they contented that the operation was not an emergent one and the Railway Hospital has got all the facilities to treat such ailment and as per the opinion of the Medical Officer he is not entitled for any reimbursement.  Moreover, the 1^st opposite party mistakenly mentioned Rs.85,000/- instead of Rs.45,000/- which alone is permissible under CGHS.  Hence, they prayed to dismiss the appeal.

3.         The District Commission after perusal of the entire materials, directed the opposite parties to refund a sum of Rs.85,000/- along with a compensation of Rs.12,000/- and cost of Rs.3,000/- totally Rs.1,00,000/- to the complainant.

4.         Aggrieved over the above award amount, the opposite parties /  Railway Department prefer this appeal on the following grounds:

5.         That the order of the District Commission is erroneous and the District Commission failed to give due weightage to the opinion of the Medical Officer and the District Commission failed to note that as per the CGHS norms, the complainant is entitled only for Rs.45,000/- but wrongly awarded as Rs.85,000/-.   Hence, they prayed to allow the appeal. 

6.         Now the point for consideration before the Commission is:-

Whether the appeal is to be allowed?

7.         point:

Both sides filed their written arguments and we heard their oral arguments also.  Both sides relied upon their own facts as stated in the pleadings and written arguments.  Admittedly, the complainant suffered from chest pain and took treatment initially at the Railway Hospital and subsequently went to Coimbatore and got admitted in the Ramakrishna Hospitalfor treatment.   The opposite parties, Railway Department mainly contended that the treatment given to the complainant is not an emergent one and he can very well get treatment in the Railway Hospitals and so, he is not entitled for any refund.  If at all, he is entitled for refund it is limited to Rs.45,000/- as mentioned in the CGHS norms.First of all, we want to ascertain whether the condition of the complainant was serious and the surgery done to him was an emergency one or not?  It was the opinion of the one Medical Director as per Ex.A5 that since the surgery was performed after 2 days it was not an emergent one.  Whether the condition of the patient was critical or notcan be decided only by the Doctor who treated the patient.   After 1½ years,no one re-examine the factual situation and offer opinion.  When the Doctor after admiitting the patient ,took Angio on the next day itself and performed surgery within 2 days, no prudent man would think that it is not an emergent one.  Moreover, we now straight away refer the judgement of National Commission Disputes Redressal Commission in the caseof Chief Medical Superintendent ?///??????????

 

as per the above judgement even inaction for 2 days accepted as emergent.  So we conclude and confirm the finding of the District Commission that the condition of the complainant needed  an emergency treatment. 

8.         It is the case of the complainant that originally his claim was found to be genuine and he was allowed to reimburse the amount of Rs.85,000/- by the 1^st opposite party.  This fact was also admitted by the opposite parties.  Once, the Chief Medical Superintendent found that the claim was a genuine and he is entitled to Rs.85,000/- then we are unable to understand the necessity for the 2^nd opposite party to get the clarification withregard to the emergent nature.  Moreover, the above clarification was sought only on 09.07.2013 and the clarification was obtained only on 26.02.2014 and the claim was returned only on 16.12.2014.  So, nearly 1015 days was caused in honouring the claim of the complainant.    The delay is unacceptable with regard to the medical reimbursement claim.   The Honourable Supreme Court in the Judgment of Shiva Kant Jha Vs. Union of India in Writ Petition (Civil) No.694 of 2015.clearly held  as follows:

13) “It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights.  It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained.  Very little scope is left to the patient or his relative to decide as to the matter in which the ailments should be treated. Specialty Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients only to ensure proper, required and safe treatment.  Can it be said that taking treatment in Specialty Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order.  The right to medical claim cannot be denied merely because the name of the hospital is no 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 of the 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”.

9.         So we have no hesitation to conclude that the opposite parties wilfully and deliberately delayed the claim as such it is deficiency in service.  After all free medical treatment as well as reimbursement of medical expenses are part of the service condition.  For which, each employee subscribed some amount and there is a consumer and service provider relationship between the employer and the employee as far as this nature of complaints are concerned.   Moreover, as per Ex.B1, CGHS Norms the complainant as per item No.517  is entitled to Rs 45,000/-.  Even this amount was also not refunded to the complainant and no effort has been made by the opposite parties to pay the same.  Under such circumstances, if we order only Rs.45,000/- it will amount to grave injustice to the complainant who is entitled to get more compensation than awarded by the District Commission.  On considering the delay in granting reimbursement. we confirm   the  total amount of Rs.1,00,000/- awarded by the District Commission  as adequate, just and reasonable  award for which, there is no need for interference.  So, we confirm the finding and award of the District Commission and we dismiss the appeal with cost of Rs.5,000/-.

In the result,

1. This appeal is dismissed.
2. The Order dt.02.12.2019 of the District Consumer Disputes Redressal Commission, Coimbatore made in C.C. No.17/2016 is hereby confirmed.
3. The appellants are further directed to pay Rs.5,000/- (Rupees Five thousand only) to the respondent as cost in the appeal.

 

 

 

 

MEMBER                                                                      PRESIDING JUDL.MEMBER

   (RVP)                                                                                                       (S.K.)

 

 

KIR/TNSCDRC/Chennai/Orders/March/2023.