DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAHIBZADA AJIT SINGH NAGAR (MOHALI)
Consumer Complaint No.277 of 2017
Date of institution: 12.04.2017 Date of decision : 04.07.2018
Ravi Chander, H.No.1036, Amb Sahib Colony, District Mohali (Punjab).
…….Complainant
Versus
1. Senior State Medical Commissioner, ESIC, Sector 19-A, Chandigarh through Senior State Medical Commissioner.
2. Director Health Services (ESI), Parivar Kalyan Bhawan, Sector 34-A, Chandigarh through Director Health Services (ESI).
3. SMO, ESIC Hospital, Phase-VII, Industrial Area, Mohali through SMO.
4. Social Security Officer, ESIC, Local Office, Phase-VII, Industrial Area, Mohali through Social Security Officer.
……..Opposite Parties
Complaint under Section 12 of
the Consumer Protection Act.
Quorum: Shri G.K. Dhir, President,
Shri Amrinder Singh Sidhu, Member.
Mrs. Natasha Chopra, Member.
Present: Shri Jasbir Singh, counsel for the complainant.
OP No.1 to 3 ex-parte.
Shri Adarsh Malik, Advocate, counsel for OP No.4.
Order by :- Shri G.K. Dhir, President.
Order
Complainant, due to his working with M/s. Aqua Systems Pvt. Ltd., Phase-8, Mohali since from 01.09.2014, has been depositing his ESI contribution @ 1.75% from salary alongwith employer’s contribution @ 4.75% regularly since start with respect to insurance policy No.1207317514. Complainant got treatment from Civil Hospital, Phase-VI, Mohali after being referred by OP No.3 for treatment of right eye operation. This treatment got during period from 15.10.2014 to 16.10.2014 and thereafter medical reimbursement bill of amount of Rs.9,140/- was submitted with OP No.3 on 30.01.2015 vide diary No.67. Complainant approached OP No.3 and even OP No.4 for reimbursement of medical claim bill amount, but of no use and that is why this complaint for seeking reimbursement of Rs.9,140/- alongwith interest @ 18% per annum and compensation for mental harassment and agony of Rs.50,000/-, but litigation expenses of Rs.25,000/-.
2. OP No.1 to 3 are ex-parte in this case. OP No.4 filed reply by not denying about contribution by complainant to ESI scheme due to his employment referred above. It is claimed that as per Section 58 of ESI Act (hereinafter referred as ‘the Act’), the State Govt. to provide for insured persons and their families (where benefit is extended to the family) reasonable medical, surgical and obstetric treatment. Medical bills are required to be submitted by the insured person to the ESI dispensary allotted to him under jurisdiction of State Govt./OP No.2. Thereafter these bills to be verified by concerned Medical Superintendent or SMO and those to be sent to OP No.2, if necessary, for further action regarding reimbursement of bills. No action on part of OP No.4 required. Admittedly OP No.4 has its office in premises of branch office, Mohali, but he works under the direct control of Regional Director, ESIC. OP No.4 conducts inspection/survey of factories/establishments, but on the directions of regional office. OP No.4 has nothing to do with the hospital working. Contents of other paras of the complaint pertain to remaining OPs.
3. Complainant to prove his case tendered in evidence his affidavit Ex.CW-1/1 alongwith documents Ex.C-1 to Ex.C-3 and thereafter his counsel closed evidence. On the other hand, counsel for the OP No.4 tendered in evidence affidavit Ex.OP-4/1 of Shri L.N. Meena, Assistant Director ESIC and thereafter closed evidence.
4. Written arguments submitted by complainant. Oral arguments heard and records gone through.
5. Undisputedly complainant due to contribution towards ESI insurance plan scheme entitled to benefit of that scheme. Contents of affidavit Ex.CW-1/1 of complainant alongwith copy of medical reimbursement bill Ex.C-2 establishes that bill for amount of Rs.9,140/- was submitted by complainant with OP No.3 on 30.01.2015, but despite that payment alleged to be not made till date and as such certainly there is deficiency in service on part of OP No.3 and other concerned OPs.
6. Copy of prescription form for insured person’s family members under ESI scheme produced as Ex.C-1 and as such complainant virtually is registered with ESI for getting benefit of ESI medi claim insurance scheme. Though it is sought to be projected during course of arguments on behalf of OP No.4 as if amount of Rs.9,140/- has already been paid, but no record of this payment is produced and as such virtually dispute still persists as to whether claim amount of medical bill in question stands reimbursed to complainant or not. If amount of bill in question had already been disbursed to complainant or any part thereof disbursed to complainant, then complainant will be entitled to the left out amount of Rs.9,140/- but as it is not surely projected as to whether amount of Rs.9,140/- actually has been paid or not and as such direction needs to be issued to OP No.1 to 3 to reimburse amount of Rs.9,140/- of medical bill in question within 40 days from today, but by making adjustment of amount, if any, already paid by them to complainant before today. However, on the left out amount of Rs.9,140/- minus the amount already paid (if any), OP No.1 to 3 will be liable to pay interest @ 9% per annum from today till payment, in case payment of Rs.9,140/- or the balance amount referred above, not paid within 40 days from today. Issue of such direction is essential for ensuring that due payable amount to complainant is not left out.
7. Copy of bill Ex.C-2 in question is produced to show as if the same was received through diary No.67 dated 30.01.2015 by OP No.3. It is not disputed that complainant got treatment as ESI beneficiary from Civil Hospital, Phase-VI, Mohali and as such certainly the guidelines issued through circular Ex.C-3 to govern the case regarding reimbursement of medical expenses amount.
8. Counsel for OP No.4 vehemently contends that function of ESI and Punjab Govt. is to undertake joint venture in implementing the ESI benefit scheme and as such role of OP No.4 does not remain. After citing provisions of Section 58 of ESI Act, it is vehemently contended by counsel for OP No.4 that as OP No.4 has no role to perform either in sending the bill to Director for verification or to Treasury concerned or to any other authority and as such complaint against OP No.4 is not maintainable. It is also contended that complainant has never approached OP No.4 for helping him in matter of seeking reimbursement of submitted medical bill and as such deficiency in service on part of OP No.4 is not there at all. Rather the amount to be paid by SSMC, who is bound to have tie up with hospitals and as such it is contended that OP No.4 should not be held liable for delay, if any, in making payment of the bill amount. Certainly after going through Section 58 (3) of ESI Act, it is made out that ESI Corporation to enter into an agreement with State Govt. regarding the nature and scope of medical treatment that is to be provided to the insured persons or the family members. Even if this provision is there, despite that after referring to circular dated 14.03.2012, it has been held by 2nd Addl. Bench of Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh in First Appeal No.1630 of 2014 decided on 07.01.2015 titled as Senior State Medical Commissioner, ESIC & another Vs. Savita & another, that duty of Social Security Officer is to discuss with employees working in the premises about the availability of benefits and thereafter to report about their grievances, if any. The guidelines issued vide above circular of the Corporation aims at providing prompt action in matter of grant of benefits under the Scheme expeditiously. After holding all this, duties of SSOs were discussed by holding that liability of SSOs in respect of not getting the benefit provided at earliest remains there. Even Hon’ble National Consumer Disputes Redressal Commission, New Delhi while deciding Revision Petitions No.640 and 641 of 2015 on 01.04.2015 in case titled as Senior State Medical Commissioner and another Vs. Rajinder Singh & others held that Director Health Services is a necessary party in matters pertaining to grant of benefits to beneficiaries under ESI Scheme. Hon’ble National Commission in this case held further that in future Director (Health Services) should be impleaded as a party in all such cases because powers regarding reimbursement lies with the Director. It was also held in this un-reported case by Hon’ble National Commission that it is the duty of Director Health Services to see that no such like bills remain pending for months and years together. Rather such like bills should be passed or rejected within one week from their receipt and as such it is obvious that Hon’ble National Commission as well as Hon’ble State Commission has specifically made responsible the Director Health Services for ensuring passage or rejection of bills in question at earliest. So Director Health Services i.e. OP No.2 cannot shirk from responsibility referred above of ensuring early passage or rejection of medical bills like one presented by complainant with OP No.3.
9. Even Hon’ble National Commission in above cited case of Sr. Medical Commissioner & Anr. Vs. Rajinder Singh & another specifically held that duty of SSO is to find out ways to expedite the matter in respect of passage or rejection of medi claim bills by ESI beneficiaries. Even if complaint not made with SSO, despite that it is the bounden duty of SSO to find out that there was no such like bill pending. For that purpose SSO should made a request to Director Health Services to expedite the matter. So from these observations recorded in Para No.9 by the Hon’ble National Commission, it is made out that responsibility also is of SSO to ensure early passage or rejection of medi claim bills like this. As both Director Health Services and SSO as well as SMO of the concerned dispensary failed to discharge their duty of expeditious passage or rejection of medical bill in question and as such all the OPs are liable to pay compensation for harassment to complainant. They also are liable to pay litigation expenses amount to complainant. So even if role of OP No.4 or of OP No.2 in matter of verification of bills or of passing or sanctioning thereof may not be there, despite that they are liable for shirking their responsibility of not ensuring early passage or rejection of the medical bill in question.
10. Even in case titled as State of Rajasthan Vs. Mahesh Kumar Sharma, bearing Civil Appeal No.2278 of 2011 arising from SLP ( C) No.2888 of 2008, it has been held by Hon’ble Supreme Court of India on 02.03.2011 that the Govt. would be justified in limiting medical expenses to the extent it is permitted by its financial recourses. It is further held in this unreported case that it will not be proper for a Govt. employee or for his relations to claim reimbursement of medical expenses, otherwise than what was provided in the rules. Complainant unable to show by any evidence that his entitlement was for the total incurred expenditure. Rather the referred letter of 05.01.2017 shows that limit of medical expenditure fixed by ESI in 170th meeting of ESI Corporation. Even OPs have not led any evidence to show that the claimed amount of Rs.9,140/- is excessive in any manner or any part of this expenditure is incurred on any item, which has not been approved. So in view of this, complainant entitled for total reimbursement of bill amount of Rs.9,140/- of Ex.C-2.
11. Counsel for complainant points out to Clause-1 of circular Ex.C-3 for arguing that expenditure of super specialty treatment (including diagnosis) will be totally borne by ESI Corporation outside the existing ceiling w.e.f. 01.08.2008 and as such it is vehemently contended that the complainant got super specialty treatment and as such entitlement is for the entire incurred amount. However, when contents of circular Ex.C-3 in entirety read, then the same leaves no manner of doubt that the scope of services covered under super specialty treatment mentioned in Clause-6 alongwith inclusions. The inclusionary makes mention of expenses of more than Rs.3,000/- per test on any other investigation than the one mentioned in Clause-6. So it is obvious that certain restrictions on reimbursement are placed through Clause-6 of Ex.C-3 itself. Being so, entitlement for reimbursement of full amount of Rs.9,140/- virtually is there.
10. No other point argued.
11. As a sequel of above discussion, the complaint allowed in terms that OP No.1 to 3 will reimburse the amount of Rs.9,140/- of medical bill in question within 40 days from today, but by making adjustment of amount, if any, already paid by them to complainant before today. On the balance left amount of Rs.9,140/- minus amount already paid (if any), OP No.1 to 3 will be liable to pay interest @ 9% per annum from today till payment, in case payment of Rs.9,140/- or the balance amount referred above not made within 40 days from today. Compensation for mental harassment and agony of Rs.15,000/- and litigation expenses of Rs.5,000/- more allowed against all the OPs, whose liability held as joint and several. Payment of amount of compensation and litigation expenses be made within 30 days from the date of receipt of certified copy of the order. Certified copies of the order be supplied to the parties free of cost as per rules. File be indexed and consigned to record room.
Announced
July 04, 2018.
(G.K. Dhir)
President
(Amrinder Singh Sidhu)
Member
(Mrs. Natasha Chopra)
Member
