ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

1.     This is the Complaint filed by the Complainant under Section 12 of Consumer Protection Act 1986, against the Opposite Party (herein referred in short as O.P) alleging the deficiency in service in not allowing his hospital claim of Rs.6,29,840/- and for its reimbursement, Rs.1,00,000/- towards compensation for deficiency in service, causing mental agony and for harassment and  other reliefs as this forum deems fit.

2.     The brief facts of the complaint are that: the complainant is an employee in “First Flight Courier Limited” since 2005 to 2018 and has been insured with insurance corporation for himself and his family and his insurance IP is 5021052073.  His father Krishnappa aged about 67 years was not keeping well. He was admitted to St. Philomena hospital, Vivek Nagar, Bangalore  on 21.03.2018 as he was suffering from severe cough. He was diagonised as having severe cough and was also bleeding in the small intestine and blood started bleeding from the stools and he was advised to be shifted to ICU for further treatment, as there was danger to his life. Hence the complainant gave his consent to the hospital authorities to provide him treatment and ventilator support was also given to the patient as the patient was not able to  breath freely.  On 05.05.2018 after the treatment, his father was discharged from the hospital.

3.     The complainant further approached Op for reimbursement of the claim of Rs.6,29,840/- by producing all the hospital medical bills and other relevant documents.   His father was treated in St.Philomina Hospital Bangalore and not in a private multi speciality hospital.  His claim was rejected by OP for which he had to issue legal notice. It was replied stating that his claim was rejected.   The rejection of his claim is opposed to public policy and that he has to suffer huge loss and also undergo mental agony and hence this complaint.

4.     Upon the service notice, OP appeared before the Forum and filed its version contending that the ESI corporation has been constituted and a grievance committee comprising of State Medical Officer, Regional office ESIC Bangalore, Deputy Medical Superintendent, ESIC Model Hospital, Bengaluru, Deputy Director ESI (S) Medical services Government of Karnataka, Bengaluru the Public Grievance Officer, Regional Office ESIC Bengaluru, and the branch Officer, Super Speciality treatment Section are the members of the said committee and the medical bills of the complainant was placed before the said committee which held the meeting on 11.07.2018, and examined the bills of the private hospitals and observed that at the time of admission of the father of the complainant, on 21.03.2018, it was not a case of medical emergency as the father of the complainant was suffering from cough since 10 days and exertional dyspnea for the last five days.

5.     The Complainant  did not approach the ESI Dispensary at Vivek Nagar which is near to his residence and also ESI Hospital Indiranagar which is just 5 kms away from his residence for consultation and treatment. He could have informed the concerned ESI hospital dispensary within 24 hours of admission to the private hospital, so as to enable ESIC to depute a medical officer to see the condition of the patient and to recommend as to whether the patient can be shifted to ESI hospital or ESI tie-up hospitals for better management and to provide further treatment.

6.     A circular has been issued by Govt. of Karnataka in this regard and only the cases falling under alone to be considered as medical emergencies (i) heart attack (ii) road traffic accident/employment injury (iii) snakebite (primary treatment) (iv) burns due to any cause more than 30% involving head and neck external genetalia or hands (iv) poison (v) Dengue (vi) Ectopic pregnancy with tubal rupture.  The said circular has been circulated to all the hospitals and the director of ESIS has transferred power of sanctioning reimbursement to the OP. 

7.     It is further contended that as per the provisions of the ESI persons injured or their families would get direct admission in the ESI/ tie-up hospitals in case of emergency. 

8.     The complainant’s father was suffering from LRTI Acute Bronchitis, diabetes mellitus, hypertension, old CVA at the time of admission to St. Philomena Hospital which is not at all listed as medical emergency. Hence the committee rejected the claim of the complainant. This complaint is filed to make wrongful gain. The ESI scheme is governed by the provisions of the special Act i.e. Employment State Insurance Act. Primary and Secondary treatment/ medical arrangement are done by state Government concerned and Super Speciality care to be done by ESI corporation.  To adjudicate the dispute and claims, Section 74, 75 and 76 have been incorporated. Under the provision of Section 75(3), no civil court shall have jurisdiction to decide or deal with any question or dispute and under the Act, the same to be disposed by the Medical board or medial appeal tribunal. Denying all the other allegations and contending that the forum has no jurisdiction to entertain the complaint prayed the forum to dismiss the same.

9.     In order to prove the case, Complainant and OP have filed their affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1. Whether there is deficiency in service

on the part of OP?

2) Whether the Complainant is entitled to

   the relief prayed for in the complaint?

10.   WE ANSWER:-

POINT NO.1 & 2 :            In the Negative.

                                For the following.

REASONS

POINT No.1 & 2:-

11.   It is not in dispute that the complainant’s father Krishnappa was admitted to St Philomena Hospital for acute Bronchitis, diabetes mellitus, hypertension and old CVA and he was given treatment from 21.03.2018, the day on which he was admitted to St Philomena hospital and discharged on 05.05.2018. It is also not in dispute that the complainant made a claim of Rs.6,29,840/- to the Op which rejected the claim.  Ex.P3 is the copy of the order wherein, the claim of the complainant has been rejected by the SST reimbursement committee.  Copy of the legal notice is also produced, wherein, complainant has demanded OP to pay the amount. The reason for rejection was also informed by giving a reply to the legal notice, wherein, it is clearly mentioned by the committee for SST, IP reimbursement as no emergency existed at the time of admission on 21.03.2018.

12.   OP has produced. Ex.R1 the particulars of the insured person and also circulars issued on 09.07.2017 , 28.03.2018 and 29.05.2018 wherein it is clearly mentioned what are all the medical emergencies which required emergency treatment in the linked hospital and further the procedure for submitting the bills and also to take treatment in the linked/tie–up  hospitals with ESI and within 24 hours to provide information to the ESI authorities failing which not to honour the claim in respect of the treatment taken by the patient in a private hospital. 

13.   In view of the circulars and directions issued by Government/and the authorities to the OP and also in particular, the sufferance the complainant’s father was suffering on 21.03.2018 are not included in the medical emergency or life threatening condition, we are of the view that rejection of the medical claim on the said ground is not illegal and arbitrary. Further the committee setup for settling the claim in respect of the private hospital is governed by the above said officials who have responsibility towards discharge their duty. They cannot go beyond the rules, procedure and the guidelines prescribed by the ESI corporation and also the related controlling authorities.

14,   Even assuming for the moment that there was a medical emergency existing on 21.03.2018 in respect of the father of the complainant and as done was taken to St. Philomena’s hospital for treatment the same could have been informed by the complainant to the ESI authorities within 24 hours or thereafter as he stayed in the hospital nearly more than one and half months.. The complainant did not inform the ESI authorities at all.  What prevented him to do so has not been explained. In view of all these, we are of the opinion the complainant has failed to prove deficiency of service on the part of Op and hold that OP has acted in accordance with rules and regulations of ESI. Further the complainant could have after getting his father treated initially with St. Philomena’s Hospital, could have shifted to any of the recognized empannaled hospital for super speciality treatment as mentioned in Ex.R5.  In view of this we answer POINT NO.1 and 2 IN THE NEGATIVE and pass the following :-

ORDER

1. The Complaint is hereby dismissed. Parties directed to bear their own cost.
2. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be destroyed as per the C.P. Act and Rules thereon.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 13^th AUGUST  2019)

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Copy of Insurance Identity Card.

Ex P2: Discharge summary from St.Philomina Hopsital.

Ex P3: Copy of Claim rejection from the Op.

Ex.P4: Copy of Legal Notice dt:06.10.2018.

Ex P5: Reply Notice dated 25.10.2018.

Ex P6: Letter issued by First flight couriers.

Ex P7: Aadhar card of the complainant.

Ex P8: Medical bills and prescriptions.

Ex P9: Lab Reports issued by the St.Philomina Hospital.

Ex P10: X-ray 20 in numbers.

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Dr.D.N.Ravi Kumar, State Medical Officer of

           ESI Corporation of OP

Copies of Documents produced on behalf of Opposite Party/s

Ex R1: Copy of the Report of Grievance committee dated 11.07.2018.

Ex R2: Copy of Circular issued by Directorate of Medical Services dt:09.10.2017.

Ex R3: Copy of Circular dt:28.03.2018.

Ex R4: Copy of Circular dt: 29.05.2018.

Ex R5: Copy of list of Empanelled hospitals.

MEMBER                        PRESIDENT

A*