By Smt. C.S. Sulekha Beevi, President,

1. The case of the complainant is that he was an employee of M/s Eurospin Industries Ltd., Chelembra, Malappuram District which was covered under ESI Scheme. That on 10-4-2000 while on duty he met with an accident. After preferring an appeal against the decision of the ESI Medical Board denying his disability, as per order dated, 31-1-2003 in MTA 13/2001 his disablement was fixed as 10%. That he is presently receiving this benefit from ESI Corporation. That there was no relief for his pain and therefore he approached the Orthopaedic Department of Medical College, Kozhikkode on 13-4-2005. Doctor advised for MRI Scan and it was seen from the report that there was disc prolapse of L3, L4 and L5 vertebrae. That the MRI scan was taken as continuation of the treatment of accident and therefore complainant is entitled to reimbursement of Rs.4,000/- paid towards charges for MRI. That the Insurance Medical Officer (IMO), Chungam refused to entertain the claim stating that the establishment is closed down and that contributions are not paid at present. That opposite party committed much delay in even replying and considering the claim of complainant. That he is entitled to reimbursement of Rs.4,000/- incurred for medical treatment. Hence this complaint alleging deficiency in service.

2. Opposite party filed version admitting the averments about the employment, accident and also the payment of consequential accidental benefit. The averments that complainant is still unable to do normal work and has severe back pain are denied as false. That complainant has not preferred claim before the Insurance Medical Officer, Chungam an d has not furnished the 'Entitlement Certificate with Sickness benefit'. That medical reimbursement claims of Insured persons on specialty/super specialty treatment is paid from the Revolving Fund kept by the ESI Corporation, for which certain qualifying conditions for eligibility are prescribed. That Insurance Medical Officer is the authority to process and pass such claims. On receiving such claims Insurance Medical Officer has to send request to the Manager of the Branch Officer of ESI Corporation concerned. The later in turn will issue an “Entitlement Certificate with Sickness Benefit' based on the monthly contributions remitted by the Insured person to ESI Corporation. Only on getting such an Entitlement Certificate the insured person will become eligible for getting medical reimbursement on specialty/super specialty treatment. Medical investigation charges above Rs.1,000/- come under the category of super specialty investigation and so the said claim comes under category of super specialty treatment. That the present claim is submitted after closing down of the establishment and there are no contributions paid. That for this reason also the claim cannot be honoured. The delay caused while returning the claim form was due to inadvertent clerical error and also due to heavy pendency of claims. That there is no deficiency in service and that complainant is not entitled to any reliefs.

3. Evidence consists of the affidavit filed by complainant and Exts.A1 to A15 marked on his side. Counter affidavit filed by opposite party. No documents for opposite party. Either side has not adduced any oral evidence.

4. Points for consideration:-

(i) Whether opposite party is deficient in service.

(ii) If so, reliefs and costs.

5. The only question that arises for consideration is whether complainant is entitled for medical reimbursement of Rs.4,000/- which is the expense incurred by him for taking MRI Scan on 17-5-2005.

6. The complaint is resisted by opposite party mainly on the following contentions:-

(i) That complainant has neither submitted the claim before Insurance Medical Officer of Chungam nor has he furnished the 'Entitlement Certificate with Sickness Benefit'. That due to failure to comply with these procedural norms the claim is unsustainable.

(ii) That the accident occurred on 10-4-2000 and the claim for treatment charges in the year 17-5-2005 has no direct nexus with the accident.

(iii) That the complainant is not eligible for medical reimbursement because the claim request is made after closure of the establishment and that there is no monthly contributions remitted to the ESI Corporation presently on behalf of the complainant.

7. On perusing the evidence and materials placed before us except the sworn affirmation of the complainant in the affidavit there is no other evidence to show that complainant had submitted his claim to the Insurance Medical Officer, Chungam. It is the case of complainant, that the Insurance Medical Officer, Chungam refused to entertain his claim since the establishment is closed and therefore he has directly submitted the application before Director of Insurance Medical Services. When the officers under opposite party refuse even to consider the claim then the consumer/insured person is left with no remedy but the approach the next higher authority. It can be understood that this was the reason why the claim was submitted to Director of Insurance Medical Services directly and was unsupported by “Entitlement certificate with Sickness Benefit.” But we cannot fully ignore the inability of a Governmental authority to overcome the hurdles of such necessary formalities. For these reasons we move to proceed to consider whether complainant is entitled to the reimbursement of Rs.4,000/- apart from the technical grounds which make his claim unfit to be considered.

8. Admittedly complainant met with an accident whilst on duty and had undergone treatment. As per Ext.A1 order of Appellate Tribunal the loss of earning capacity of complainant was fixed as 10% and complainant is receiving this disablement benefit. His case is that due to continuous sufferings he consulted orthopaedician at Kozhikkode and MRI Scan was taken. It was revealed from this scan that he is having disc prolapse of L3, L4 and L5 vertebrae. According to complainant the treatment is direct and continuous with the accident, because in Ext.A14 which is the out patient ticket dated, 17-4-2000 the doctor had noted “Tenderness over L4 and L5 Vetrebrae”. That the actual cause of backache was revealed only when MRI Scan was taken in 2005. Complainant also relied upon Ext.A15 which is a Certificate issue by Dr.Jyodish K.S. Stating that complainant was under his treatment for low back ache for the last four years. Apart from Ext.A15 there is no document to show that complainant had undertaken any treatment after 2000. As per Ext.A14 complainant was having tenderness on L4 and L5 in 2000 after the accident. He was discharged as recovered. There are no documents showing continuous medical treatment after 2000 till 2005. Complainant has not examined the doctor who has issued Ext.A15 and neither has filed any affidavit of the said doctor. Though it is stated in Ext.A15 that complainant was under going continuous treatment under the said doctor for four years this does not find a place in the complaint or affidavit. What is stated by complainant is that since he did not have any relief of pain he approached the doctor on 13-4-2005. For these reasons we are not inclined to rely upon Ext.A15 to hold that complainant had been under treatment continuously for four years prior to MRI Scan. After the accident happened in 2000 the MRI Scan was taken in 2005. Against Ext.A1 order complainant has preferred appeal before Industrial Tribunal for enhancement of the disability of 10% which is pending. The appeal was founded mainly on the MRI Scan report which is the subject matter of this complaint. A Review Petition against Ext.A1 order was also filed basing upon the same MRI Scan report praying to enhance the disability. This Review petition was dismissed on 15-1-2008. On perusal of the evidence and records we do not find any clinching or substantive evidence to hold that complainant was undergoing continuous treatment after the accident till 2005 and that the MRI Scan was taken as part of this continuous treatment.

9. Further opposite party has stated that there are special formalities to be complied for considering the claim for investigation of super specialty category. It is also the case of opposite party, that since the establishment is closed and no contributions are paid at the time of submitting the claim it is not possible to honour the claim. No reliable evidence is placed before us to completely overrule the possibility that the MRI Scan was taken for any new ailment/suffering. For these reasons we hold that complainant is not entitled to reimbursement of Rs.4,000/-. The denial of claim was by opposite party is on sustainable grounds. We do not find any deficiency in service on the part of opposite party.

10. In the result, we dismiss the complaint. Parties are directed to suffer their respective costs.

Dated this 7th day of May, 2009.

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER

APPENDIX

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1 to A15

Ext.A1 : Photo copy of the order dated. 31-1-2003 of Hon'ble Medical Appellate

Tribunal, Kozhikkode.

Ext.A2 : Copy of claim letter dated, 24-6-2005 submitted by complainant

to opposite party together with acknowledgement.

Ext.A3 : Photo copy of the O.P. Ticket No.036747 dated, 13-4-2005 of Medical

College Hospital, Ortho Dept., Calicut.

Ext.A4 : Original Bill-cum-receipt No.B.345 dated, 17-5-2005 of Dr. Shaji's MRI Centre,

for Rs.4,000/-.

Ext.A5 : Photo copy of the MRI Scan report dated, 17-5-2005.

Ext.A6 : Carbon copy of the letter dated, 09-1-2006 by complainant to opposite party.

Ext.A7 : Photo copy of the letter dated, 23-1-2006 by opposite party to complainant.

Ext.A8 : Photo copy of the letter dated, 26-4-2006 by complainant to opposite party.

Ext.A9 : Photo copy of the letter dated, 28-4-2006 by Mr. Janardhanan to complainant.

Ext.A10 : Letter dated, 04-12-2007 sent by opposite party to complainant.

Ext.A11 : Carbon copy of the registered post acknowledgement due dated. 31-1-2008 sent by

complainant to the Information Officer of opposite party.

Ext.A12 : Reply letter dated, 04-3-08 by State Public Information Officer to complainant.

Ext.A13 : Photo copy of the O.P. Ticket No.5204 dated, 10-4-2000 of ESI

Dispensary, Chungam.

Ext.A14 : Photo copy of the O.P. Ticket No.33588 dated, 17-4-2000 of Medical

College Hospital, Calicut.

Ext.A15 : Photo copy of the certificate dated, 01-6-2005 issued by Associate Professor,

Orthopaedic Department, Medical College Hospital, Calicut.

Witness examined on the side of the opposite parties : Nil

Documents marked on the side of the opposite parties : Nil

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER