BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SAS NAGAR, MOHALI

                                  Consumer Complaint No. 309 of 2015

                                 Date of institution:          06.07.2015

                                                  Date of Decision:            30.12.2015

Sanjeev Kumar, House No.C299, LBS Colony, Village  Palsora, 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, ESIC Local Office, Phase-VII, Industrial Area, Mohali.

4.    Medical Officer, ESI Dispensary Phase-II, Mohali.

5.    SMO, ESIC Hospital, Phase-VII, Industrial Area, Mohali.

………. Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

CORAM

Mrs. Madhu. P. Singh, President.

Shri Amrinder Singh Sidhu, Member.

Present:    Shri Jasbir Singh, counsel for the complainant.

Shri Ravi Inder Singh, counsel for OP No.1 and 3.

Shri Balkar Singh, Sr. Assistant on behalf of OP No.2

Shri Darshan Singh, Sr. Assistant on behalf of OP No.4

Dr. Gurcharan Singh, SMO on behalf of OP No.5

(Mrs. Madhu P. Singh, President)

ORDER

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act for issuance of following direction to the OPs:

(a)    to reimburse the medical bills amount of Rs.2,26,113/-.      

(b)    to pay him compensation of Rs.2,00,000/- for harassment and mental agony.

(c)    to pay him cost of litigation to the tune of Rs.20,000/-.

                The complainant has pleaded in the complaint that he is working with M/s. Tynor Orthotics Pvt. Ltd., Mohali since 01.08.2013 with insurance No.1213070461. He is regularly depositing ESI contribution @ 1.75% from his salary alongwith employer contribution @ 4.75%.  The complainant took treatment from INSCOL, Hospital, Sector 34, Chandigarh from 22.07.2014 to 04.08.2014 due to the injuries which he suffered in a road accident.   The complainant submitted medical bills amounting to Rs.2,26,113/- for reimbursement  with OP No.4 on 18.09.2014. Till date, despite his repeated visits to the OPs, reimbursement of the medical bills has not been made to him. Thus, alleging deficiency in service on the part of the OPs, the complainant has filed the present complaint. 

2.             OP No.1 in the written statement has pleaded that the complainant has not approached this Forum with clean hands. As per Punjab Govt. notification dated 21.10.2002 the bills more than Rs.50,000/- are to be cleared by the Punjab Govt. No allegation has been leveled against the answering OP.  The DHS has clearly stated that only bills pertaining to PGI are to be cleared and nothing else.  Thus, OP No.1 has sought dismissal of the complaint against it.

3.             OP No.2 in its separate written statement has pleaded that the complainant was first admitted in PGI on 21.07.2014. As per the PGI the complainant was riding two wheelers, which hit the divider. At that time the complainant was under influence of alcohol.  The bills submitted by the complainant were considered under Rule 2.7 of ESIC Operational Manual 2015 and were rejected. Thereafter the bills were returned to OP No.5.

4.             OP No.3 has pleaded in the written statement that it has no role to play in the verification, passing, sanctioning of the bills as per Section 45 (2) of the ESI Act. ESI has already set up Branch Offices headed by Branch Managers who are equivalent to the Social Security Officers and are available in the office alongwith 4-5 officials at all working days to help the beneficiaries in getting their due benefits.   The complainant has not submitted any proof regarding his visit to OP No.3. There is no deficiency in service on the part of OP No.3.

5.             OP No.4 in its short reply has pleaded that the Director Health Services (SI) Punjab has already declined the claim of the complainant vide letter No.6956 dated 11.09.2015. The contents of the para have been stated to be matter of record.

6.             OP No.5 in its reply has admitted receipt of medical bills of the complainant from OP No.4 vide letter dated 02.09.2014 and thereafter the same were sent to DHS through courier vide dispatch dated 05.09.2014.  The bills were received back on 23.04.2015 and against the bills were sent to the DHS vide No.368 dated 23.04.2015.

7.             Evidence of the complainant consists of his affidavit Ex.CW1/1 and copies of documents Ex C-1 to Ex C-5.

8.             Evidence of OP No.1 and 3 consists of affidavits of Dr. Hardeep Sahni, Ex.OP-1/1 and of Sanjeev Kumar, Social Security Officer Ex.OP-3/1 and copies of documents Ex.OP-1/2  and OP-1/3.

9.             Evidence of OP No.2 consists of affidavit of Dr. Usha Bansal Ex.OP-2/1.

10.           Evidence of OP No.4 consists of affidavit Dr. Jagdish Singh Gill Ex.OP-4/1.  Evidence of OP No.5 consists of affidavit Dr. Gurcharan Singh Ex.OP-5/1.

11.           We have heard learned counsel for the complainant and OP Nos.1, and 3 and Shri Balkar Singh, Sr. Assistant, Shri Darshan Singh, Sr. Assistant and Dr. Gurcharan Singh for OP No.2,4 and 5  and gone through the written arguments filed by the complainant and OP Nos.1 and 3.

12.           The factum of complainant being IP of the ESI Scheme, the factum of accident dated 21.07.2014 when the two wheeler driven by the complainant hit the divider causing injury to the complainant and further admission of the complainant in PGI on 21.07.2014 in PGI is not disputed by the OPs. As per the complainant on 21.07.2014 when he met with an accident he was admitted in PGI and got himself discharged on 22.07.2014 and has taken further treatment from INSCOL as indoor patient from 22.07.2014 to 04.08.2014 and incurred total expenditure of Rs.2,26,113/- on his treatment vide bills Ex.C-2. After release from the INSCOL Hospital he got the fitness certificate from ESI Dispensary SAS Nagar Mohali i.e. OP No.4 vide Ex.C-3.  The complainant thereafter submitted the claim document for reimbursement of the amount with OP No.4 vide Ex.C-1 with the self declaration duly signed and verified dated 19.08.2014 Ex.C-4. The claim of the complainant was considered by OP No.2 under Rule 2.7 of the ESI Operational Manual 2015 and rejected on the support and strength of LAMA Summary dated 22.7.2014 of PGI, Chandigarh and returned to OP No.5. OP No.5 was directed by OP No.2 to re-submit the claim of only expenses incurred in PGI which is reimbursable to the claimant. As per Ex.OP-1/3 the amount of Rs.1,13,562/- is admissible for reimbursement to the complainant after removal of objections raised by OP No.2. As per OP No.5 he has submitted the revised claim of the complainant to the office of OP No.2 on 23.04.2015 and OP No.2 has further submitted the said bills of revised claim  on 30.07.2015 for further action by OP No.1 and the bills are still pending for clearance at the level of OP No.1.  As per the complainant the inter departmental communication which has been exchanged between the OPs, since the submission of his claim documents, he has not been informed by any quarter regarding the status of his claim till the filing of the present complaint. He has learnt all these facts during the course of proceedings.

13.           After perusal of the exhibits and documents i.e. the inter departmental communication exchanged between the parties, it is ample clear that the complainant has availed the medical services of PGI on the day of accident, being in emergency, without the referral from ESI Dispensary and has no where violated the Regulation 96 of the ESI Scheme. The perusal of LAMA summary relied upon by OP No.2 clearly shows that on the day of accident, the complainant was driving the two wheelers under influence of alcohol. He was given emergency treatment by PGI, Chandigarh. The complainant of his own volition against the medical advice got himself discharged from the hospital and undertaken the treatment from a private hospital INSCOL Sector 34, Chandigarh. The complainant has failed to show whether INSCOL Hospital was also an empanelled hospital under the scheme for providing emergency services to the insured. Therefore, the OP No.2 has rightly restricted the claim of the complainant to the treatment undertaken by him from PGI. Had the complainant continued his treatment from PGI, as per OP No.2 he was entitled to reimbursement of Rs.1,13,562/- as per Ex.OP-1/3. The said amount claim has been sent by the OP No.2 to OP No.1 vide his letter dated 30.07.2015. OP No.1 vide Ex.OP-1/3 has not disputed the receipt of revised bills. The sanction and approval of said amount mentioned in the revised bills falls within the purview of OP No.1 as per rules of the ESI Scheme. OP No.1 has failed to show any reasons for withholding the said amount which otherwise is a legal and legitimate right of the complainant to get the reimbursement of the said amount of Rs.1,13,562/-.

14.           All the OPs have failed in their duty to inform the complainant about the status of his claim of Rs.2,26,113/- and further failed to keep him updated about the objections raised by OP No.2 and removed by OP No.5. OP No.1 has failed in its duty particularly in sanction and release of the revised bills received by it from OP No.2. Thus, all the OPs have erred in discharging their statutory obligations as envisaged under the ESI Act which is social beneficial act for the welfare and protection of industrial workers.

15.           Non reimbursement of Rs.1,13,562/-, which as per OP No.2 are admissible to the complainant, is an act of deficiency in service which is writ large on the part of both OP No.1 and 2. Therefore, due to the acts of omission and commission of the OP No.1 and 2 the complainant has suffered both financial loss as well as mental agony and harassment. The complainant has successfully proved the same against OP No.1 and 2. Therefore, against OP No.1 and 2 deserves to be allowed and the complainant deserves to be compensated.

16.           However, the complaint against OP No.3,4, and 5 being devoid of merit, deserves to be dismissed.

17.           In view of above discussion, the complaint against OP No.1 and 2 is allowed. OP No.1 and 2 are jointly and severally liable to:

(a)    reimburse the amount of Rs.1,13,562/- (Rs. One lac thirteen thousand five hundred sixty two only) of medical bills as per Ex.OP-1/3, alongwith interest @ 9% per annum from the date of submission i.e. 02.09.2014 till actual payment.

(b)    pay a lump sum compensation of Rs.25,000/- (Rs. Twenty five thousand only) for mental agony, harassment and costs of litigation.

                Compliance of above directions be made within a period of one month from the date of receipt of a certified copy of this order. Certified copies of the orders be sent to the parties free of costs and thereafter the file be consigned to the record room.

Pronounced.                           

December 30, 2015.     

                             (Mrs. Madhu P. Singh)

                                                                        President

(Amrinder Singh Sidhu)

Member