DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.528 of 2016
Date of institution: 31.08.2016 Date of decision : 19.04.2017
Dinesh Bhatt, House No.2727, Sector 56, Chandigarh.
……..Complainant
Versus
1. Senior State Medical Commissioner, Employees’ State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.
2. Director Health Services (ESI), Parivar Kalyan Bhawan, Sector 34-A, Chandigarh.
3. Social Security Officer, O/o Senior State Medical Commissioner, Employees’ State Insurance Corporation, Sector 19-A, Madhya Marg, Chandigarh.
4. Senior Medical Officer, ESI Dispensary Phase-VII, Mohali.
………. Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Shri Ajit Pal Singh Rajput, President
Mrs. Natasha Chopra, Member
Present: Shri Jasbir Singh, counsel for the complainant.
Dr. Daisy, Medical Officer on behalf of OP No.2 & 4.
Shri Abhi Singh Gill, proxy counsel for OP Nos. 1 & 3.
ORDER
By Ajit Pal Singh Rajput, President
Complainant Dinesh Bhatt has filed this complaint against the Opposite Parties (hereinafter referred to as the OPs) under Section 12 of the Consumer Protection Act. The brief facts of the complaint are as under:
2. The complainant is working with M/s. Sunrise Contract Solutions Pvt. Ltd., Mohali since 01.09.2011 with insurance No.1213242409. He is regularly depositing ESI contribution @ 1.75% from his salary alongwith employer contribution @ 4.75%. The complainant took treatment from PGI Chandigarh in emergency from 18.08.2014 to 21.08.2014 due to the injuries which he suffered in a road accident. The complainant submitted medical bills amounting to Rs.21,773/- for reimbursement with OP No.4 on 28.05.2015. Till date, despite his repeated visits to the OPs, reimbursement of the medical bills has not been made to him. Hence, the complainant has sought directions to the OPs to reimburse the medical bill of Rs.21,773/- alongwith interest @ 18% and also to pay him Rs.50,000/- for harassment and Rs.25,000/- as litigation cost.
3. OP No.1 and 3 in the written statement have pleaded that the complainant has not approached this Forum with clean hands. The answering OPs have no role to pay in verification and passing of the bills. The medical benefit is to be provided by OP No.2 through concerned dispensary and hospital. Thus, OP No.1 and 3 have denied any deficiency in service on their part and have sought dismissal of the complaint against them
4. OP No.2 and 4 in have pleaded that an amount of Rs.19,548/- at CGHS rates has been reimbursed to the complainant on 14.10.2016 through District Treasury Office, Mohali. After processing they are sent to SMO I/c ESI Hospital, Mohali and after verification, the bills are sent to DHS (SI) Punjab Chandigarh for sanction. The delay in sanctioning the bills was due to change in the system for reimbursement.
5. In order to prove the case, the complainant tendered in evidence his affidavit Ex. CW-1/1; copies of PGI Treatment card Ex.C-2; application for refund Ex.C-3; instructions regarding payment of Super Speciality Treatment Ex.C-4; duties of Social Security Officer Ex.C-5 and order of Hon’ble National Commission dated 01.04.2015 Mark-A. In rebuttal, OP No.1 and 3 tendered in evidence of Chander Bhushan, Social Security Officer of OP No.1 as Ex.OP-1/1 and copy of letter Ex. OP-1. OP No.2 and 4 tendered in evidence affidavit of Dr. Daisy Sahota, Medical Officer Ex.OP-4/1.
6. Learned counsel for the complainant has argued that despite submission of medical bills for reimbursement with OP No.4 on 28.05.2015 for Rs.21,773/-, only payment of Rs. 19548/- has been made on 14.10.2016 during proceedings of the present complaint. The complainant has been forced to file the complaint. He has argued that compensation for harassment and mental agony may be awarded to the complainant.
7. On the other hand learned proxy counsel for OP No.1 and 3 has argued that these OPs have no role to play in verification and passing of the bills and the responsibility lies on OP No.2 for the same. The authorised representative of OP No.2 and 4 has argued that since the payment has been made to the complainant on 14.10.2016 hence there survives no cause of action for the complainant and the complaint deserves to be dismissed.
8. We have gone through the pleadings, evidence, written as well as oral submissions of the parties. ESIC is the guardian of the welfare of the IPs under the Act and is charged with the duty of seeing that they do not suffer undue hardship and inconvenience in matters governed by the Act including medical treatment and reimbursement of super specialty treatment expenses. Reimbursement of medical bills as prescribed under the ESIC Act also ensures hassle free and cashless services to the IPs. In the face of such a situation, OP Nos.1 and 3 simply cannot shift their statutory duty of prompt treatment to the IPs and prompt payment of their medical bills. The shelter taken by OP No.1 and 3 under Section 45 (2) is of no use to them as they have failed to discharge their supervisory duty when it is found that though the complainant has submitted his bills on 28.05.2015 and there is a considerable delay in realization of the medical bills as the payment has been made to the complainant on 14.10.2016 during pendency of the complaint.
9. Admittedly the complainant has submitted bills for medical reimbursement on 28.08.2015 and after verification the said bills were forwarded to OP No.2 for verification and sanction. No doubt OP No.2 has the role to sanction the reimbursement of medical expenses but ultimately it is OP No.1 and 3 who are responsible to make the payment. The complainant has proved on record instructions dated 23.07.2008 Ex.C-4 of the ESI vide it has been stated that SSMC/SMC and M.S. of ESIC Hospitals should ensure hassle free, cash less services to the Insured persons and their families. It was the duty of the officers of the ESIC that the bills are passed within the shortest possible time so that petty workers, who are covered under the scheme and had spent sufficient amount from their own pocket are reimbursed at the earliest possible. Be the delay has occurred at the level of the OP No.1, 2 and 3 but OP No. 1 and 3 being the principal executor of the scheme cannot remain as a silent spectator and OP No.3 being the Social Security Officer having been assigned the duty of assisting the insured persons in getting medical care/cash benefits under ESI scheme cannot be absolved of its duty on the ground that the matter of reimbursement of bills is pending with the various authorities and it has no role whatsoever to play in the matter. We do not find any amiss at the level of OP No. 4 as it has forwarded the medical bills of the complainant to OP No.2 for verification and sanction.
10. Accordingly, in view of our aforesaid discussions, we allow the present complaint against OP No.1 to 3. The complaint against OP No.4 is dismissed. OP No.1 to 3 are directed to pay to the complainant a lump sum compensation of Rs.15,000/- (Rs. Fifteen thousand only) for mental agony and harassment and for litigation expenses.
The OP No.1 to 3 are further directed to comply with the order of this Forum within 30 days from the date of receipt of this order failing which the aforesaid awarded amount shall carry interest @ 9% per annum from the date of decision till actual payment.
The arguments on the complaint were heard and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room.
Pronounced
Dated: 19.04.2017
(A.P.S.Rajput)
President
(Mrs. Natasha Chopra)
Member
