PER SHRI. S.S. PATIL - HON’BLE MEMBER :
1) This is the complaint regarding deficiency in service on the part of Opposite Parties as Opposite Parties did not sanction the medical expenses incurred by the Complainant.
2) The facts of the complaint as stated by the Complainant are that he is the retired Central Government employee (retired from Income Tax Dept.). He had gone through the eligibility criteria successfully as prescribed by the Ministry of Health, Central Government Health Services and he is having identity card valid for entire life. (I. Card No.303507 issued by the Opposite Party).
3) The Complainant states that he was hospitalized in Dr. Shroff’s Eye Clinic, recognized under [C.H.S. (Central Government Health Services)] for diagnosis of Age-related Macular degeneration with Macula Exudates a disease causing of central vision of both eyes. The Complainant was admitted in Dr. Shroff’s eye hospital on the advise of Nair Hospital as diagnosis of the above said disease was not available in Nair Hospital.
4) The Complainant further stated that, the Complainant incurred expenses for the above said treatment to the tune of Rs.1 Lac. He was treated on 23/02/2005. Then the Complainant preferred a claim of the above incurred expenses before Opposite Party No.2 who intern submitted the same to Opposite Party No.3 for further approval on 01/04/05. Thereafter the Complainant reminded Opposite Party No.2 & 3 vide his letter dtd.19/09/05. On 17/10/05, Opposite Party No.2 reminded Opposite Party No.3 about the Complainant’s claim. Then reminders dtd.28/12/05, 17/07/06 were also sent vide letters dtd.09/10/06, 15/12/06, 25/05/07, 20/02/07, 06/06/07. A letter under RTI Act was sent to the Opposite Parties. The Opposite Party No.3 replied to the RTI application vide its letter dtd.28/07/08 and 05/08/08 stating that Opposite Party No.1 & 2 had been directed to settle the claim.
5) The Complainant further stated that on 25/08/08, he received a letter from Opposite Party No.1 with one cheque of Rs.50,000/- dtd.21/08/08. The Complainant has specifically stated that his claim was of Rs.1 Lac but Opposite Parties have sanctioned only Rs.50,000/- without giving any reason for not sanctioning the full claim and they have delayed the payment by 3½ years. During the above said period, the Complainant being a Sr. Citizen of 76 years of age has incurred expenses for attending the offices of the Opposite Parties and in making correspondence with them.
6) The Complainant has finally prayed that –
a) The Opposite Parties be held guilty of deficiency in service and for, adopting unfair trade practice.
b) The Opposite Parties to reimburse the remaining claim of Rs.50,000/- against the claim of Rs.1 Lac alongwith interest
@ 18 % from the date of filing the complaint till the realization of the same.
c) The Opposite Parties to pay the sum of Rs.25,000/- towards the expenses incurred by the Complainant for
correspondence with the Opposite Parties.
d) To direct the Opposite Parties to pay to the Complainant Rs.1 Lac compensation for mental agony and harassment c
caused to the Complainant.
7) The Complainant has attached the relevant correspondence letters addressed to the parties and written by the Opposite Parties to the Complainant and to each other.
8) The complaint was admitted and Opposite Parties were served with the notices. Opposite Parties appeared before this Forum and submitted their written statement wherein it is admitted that the Complainant is a Central Government Pensioner and he has been availing medical facilities under Central Government Health Scheme, Mumbai and he has been issued a CGHS Pensioner Card. However, it is stated that the CGHS is not governed by the Consumer Protection Act. The Forum has no jurisdiction to entertain the complaint. The Complainant is not a consumer and facilities provided by CGHS are not the services within the meaning of Consumer Protection Act,1986.
9) It is further submitted by the Opposite Party that the amount for which the applicant was entitled, has already been reimbursed to the Complainant vide cheque of Rs.50,000/-. The applicant is not entitled for the rest of the amount i.e. R.50,000/-. It is stated that, after considering the relevant papers, with respect to the treatment and its charges, in various hospitals, it is found that the amount claimed by the Complainant is exorbitant. Only claim of Rs.50,000/- is admissible and this amount has been paid to the Complainant.
10) It is also admitted by the Opposite Party that Dr. Shroff’s Eye Clinic is one of the Private Hospitals recognized under CGHS. Scheme. It is further admitted that the Complainant was referred by the Municipal Hospital to Dr. Shroff’s Eye Clinic as per the normal procedure. Further it is submitted that the Government has approved the rates for availing the treatment under package deal in Dr. Shroff’s clinic.
11) It is further clarified by the Opposite Party that Opposite Parties at Sr. No.1 and 2 mentioned in the title of the complaint are one and the same.
12) It is further submitted that the Complainant was advised PDT which was not in the approved list. Accordingly the claim preferred for treatment of PDT was transmitted to DGHS New Delhi on 01/04/05 for sanction. The Opposite Party has also admitted that the Complainant has reminded the Opposite Parties on 19/09/05 and on latter dates also.
13) In para 21 of the written statement the Opposite Party has submitted that the office of the Additional Director CGHS, Mumbai was directed by Opposite Party No.3 to settle the claim of the Complainant. But the amount was not indicated since the admissible amount was to be worked out as per the approved schedule of charges. The Complainant had claimed a sum of Rs.1 Lac. However, as per the AIIMS rates, the admissible amount worked out to be of Rs.50,000/- and this amount has been reimbursed to the Complainant. It is further submitted by the Opposite Party that sanction of the claim of Complainant was not within the powers of this office. The amount of Rs.50,000/- was passed by the Opposite Party office at Mumbai only after the approval from the Opposite Party No.3. The amount sanctioned in accordance with the rates of private hospitals recognized under CGHS. The delay in obtaining the sanction was purely of administrative in nature. The claim papers were not traceable in the Directorate for quiet some times.
14) In para 29 of the written statement, the Opposite Party has also admitted that the medical services provided by CGHS is entirely to the satisfaction of its beneficiary. It is further explained by the Opposite Party that there are fixed rates of charges approved by the Government. The reimbursements of charges are strictly as per schedule of charges. The Government has not approved all services being provided by the private hospitals to the general public. The Complainant has availed the treatment for his eyes under package deal while paying a sum, of Rs.1 Lacs. The said package has not been approved by the Government in its schedule of charges. The reimbursement has been worked out as per AIIMS rate. The Complainant has incurred Rs.1 Lac in Dr. Shroff’s Eye Clinic but the same procedure is available for Rs.50,000/- in AIIMS Hospital in Delhi. Therefore, the reimbursement was restricted to the lowest rate i.e. Rs.50,000/- against the Complainant’s claim of Rs.1 Lac. Finally the Opposite Party has prayed for the dismissal of the complaint with cost.
15) The Opposite Party has attached the xerox copies of the correspondence letters between the parties dtd.18/07/08, dtd.06/05/03 and Central Government Office Memorandum, dtd.07/04/1999 and citations.
16) The Complainant has thereafter submitted affidavit of evidence and written argument wherein he reiterated the facts and points mentioned in the complaint. Opposite Party also filed written argument wherein the facts mentioned in the written statement are reiterated.
17) We heard the Ld.Advocates for both the parties and perused the papers submitted by both the parties and our findings are as follows.
18) The Complainant is a consumer within the meaning of Sec.2(1)(d) of the Consumer Protection Act as held by the Hon’ble National Consumer Dispute Redressal Commission in IV (2005) CP 197(NC) in Jagdishkumar Bajpayee V/s. Union of India in Revision Petition No.570/2002 decided on 20/10/05, it is held that “CGHS a welfare measure is part and parcel of service benefits available to employees in service and retired employees – Complainant – Consumer –“.
19) The Complainant has availed the services of the Opposite Parties as the Opposite Parties have specifically admitted in written statement that the Complainant has been availing medical facilities under Central Government Health Scheme and he has been issue a CGHS Pensioner’s Card. Even the Opposite Party has belatedly sanctioned the Complainant’s claim of Rs.50,000/- in the year 2008 i.e. after 3 ½ years. The main dispute between the Complainant and the Opposite Party is that the Complainant had submitted a claim of Rs.1 Lac and Opposite Party had sanctioned the claim of Rs.50,000/- only on the ground that the amount sanctioned was in accordance with the rates of private hospitals recognized under C.G.H. Scheme. If this admission of the Opposite Parties is taken in to consideration then the Opposite Party should have sanctioned as per the rates of private hospital and in instant case the charges of the Dr. Shroff’s Eye Hospital were Rs.1 Lac.
20) In addition to the above admission, the Opposite Party has also admitted in para 29 of the written statement that the medical services provided by the Opposite Party are entirely to the satisfaction of its beneficiary. If it is so, then it was the obligation of the Opposite Party to sanction the whole claim of the Complainant.
21) It was further stated by the Opposite Party that there are fixed rates of charges approved by the Government. But the Opposite Party has miserably failed to give such rates of fixed charges.
22) It is also submitted by the Opposite Party that the Complainant has availed the services of the private clinic viz Dr. Shroff’s Eye Clinic for his eyes treatment under a package deal while paying a sum of Rs.1 Lac. The same package has not been approved by the Government in its schedule charges. In this respect also the Opposite Party has certainly failed to produce any such schedule of charges which do not approve the charges of Dr. Shroff’s eye clinic. On the other hand the same Opposite Party already has admitted in the earlier paragraph of written statement that “Dr. Shroff’s Eye Clinic is one of the private hospitals recognized under CGH Scheme. The Complainant has referred by the Municipal Hospital to Dr. Shroff’s Eye Clinic as per the normal procedure. The Government has approved the rates for availing the treatment in private recognized hospitals. The Opposite Party has further admitted in para 5 of the written statement that the beneficiaries are referred by the Municipal Hospitals for treatment which is not available in Municipal Hospital. The Complainant was accordingly referred to Dr. Shroff’s Eye Clinic for his treatment. Under the above circumstances, certainly it was the obligation on the part of this Opposite Party to sanction the complete claim of the Complainant.
23) In para 8 of the written statement the Opposite Party has submitted that “various types of treatment are available in private hospitals recognized under CGHS. Though private hospitals are recognized under CGHS, the treatment of all types is not approved for one reason or the other. The Complainant was advised PDT which was not in the approved list. Accordingly the claim for PDT was transmitted to DGHS New Delhi. In this respect the Opposite Party has clearly failed to produce the approved list which does not include PDT and if the PDT was not included in the approved list, why the claim was not rejected ? and why only 50 % of the claim was sanctioned ? The reasons given by the Opposite Party appears to be really absurd and without any logic.
24) It was also claimed by the Opposite Party that “after considering the papers with respect to the treatment and its charges in various hospitals, it is found that the amount claimed by the Complainant was exorbitant. This is really an ambiguous statement made by the Opposite Party. He has neither mentioned the papers nor charges of other hospitals which were considered by him. This is certainly a lame excuse to avoid the liability towards the pensioner who is unfortunately Opposite Party’s consumer.
25) The Opposite Party has attached a letter from Opposite Party No.3 addressed to Opposite Party No.1 stating that his letter dtd.01/04/05 was received by Opposite Party No.3 on 17/07/08 i.e. after more than 3 years and 3 months. In this letter it is conveyed to Opposite Party No.1 that the claim may be settled at his end (Opposite Party’s end) by exercising delegated powers of AIIMS rate for PDT at Rs.50,000/- per sitting as conveyed earlier vide this Directorate’s letter No.D.12011/34/2002 dtd.07/05/03 in case of Shri R.K. Agnihotri. In this respect the reference of Agnihotri’s case - was given. It was a matter of 2003. The present case is of 2005. The rates for treatment of PDT in the year were not given. There is no mention in respect of sittings in which the treatment was completed. For this purpose we perused the memorandum dtd.07/04/99 produced by the Opposite Party only stating that “Reimbursement may be limited to AIIM’s rates. In case of Delhi & outside Delhi. In case rates have not been fixed by AIIMS for any particular procedure investigation/test, reimbursement may be made as per actual. The Opposite Party has failed to give rates of AIIM & for PDT as on 23/02/05. Even the Opposite Party’s have failed to produced any document of AIIMS showing the rate as Rs.50,000/- per sitting for treatment of PDT or whether there was no any fixed rates for the said treatment at relevant time. In absence of this relevant information in writing or with a documentary proof, the letter of Opposite Party No.3 stating that the claim may be settled at 50,000/- per sitting does not appear to be as per the rules and regulations mentioned in above said memorandum. Therefore, the Opposite Parties are certainly guilty of deficiency in this respect by delaying the claim by more than 3 ½ year and by not sanctioning the complainant’s legitimate claim of Rs.1,00,000/- in light of the observations made by this Forum in para no.18 to 25. Therefore, the Complainant is entitled for the remaining medical expenses of Rs.50,000/- for his medical treatment and also compensation for mental and physical harassment caused to him at the old age.
26) In view of the above observations we pass the following order -
O R D E R
i.Complaint No.70/2009 is partly allowed.
ii.Opposite Parties are directed to reimburse jointly and/or severally Rs.50,000/- (Rs. Fifty Thousand Only) to the
Complainant against his medical claim with interest @ 9 % p.a. from 13/02/2005 till its entire payment.
iii.Opposite Parties are also directed to pay jointly and/or severally a compensation of Rs.25,000/- (Rs. Twenty
Five Thousand Only) to the Complaint towards mental agony and physical harassment.
iv.Opposite Parties are directed to pay jointly and/or severally Rs.5,000/- (Rs. Five Thousand Only) to the
Complainant towards the cost of this complaint.
v.Opposite Parties are also directed to comply with the above said order within 30 days from the receipt of this
order.
vi.Certified copies of this order be furnished to the parties.
