Delhi

North

CC/10/2019

J.P. SHARMA - Complainant(s)

Versus

THE EMPLOYEES STATE INSURANCE CORPORTAION & ORS - Opp.Party(s)

SANJAY GOEL, PRAVEEN KUMAR, BHAWNA

01 Nov 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

Consumer Complaint No.: 10/2019

Sh. J.P. Sharma

S/o Late Sh. J.H. Lal Sharma

188/B, Guru Nanak Pura,

Laxmi Nagar, Delhi-110092                                                            …………             Complainant

 

                                                          Vs

 

The Employees State Insurance Corporation

through its Director General

C.I.G. Road

New Delhi-110002                                                                          …            Opposite Party No.1

 

The Medical Commissioner,

E.S.I Corporation

C.I.G. Road

New Delhi-110002                                                                        …            Opposite Party No.2

 

The Nodal Officer/D(M)D,

E.S.I. Corporation,

Tilak Vihar Dispensary Complex,

New Delhi-110018                                                                      …            Opposite Party No.3

 

The I.M.O. Incharge

E.S.I. Dispensary,

Mori Gate, Delhi-110006                                                          …            Opposite Party No.4

 

    ORDER

 01/11/2023

Ashwani Kumar Mehta, Member:

 

1.    The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the Complainant is a Member/Beneficiary of Pensioner’s Medical Scheme of ESIC and he had obtained Medical Treatment under the advice of Dr. Himanshu M.D., DM Nephrology, at R.M.L. Hospital on 03.05.2017 as the E.S.I. Hospital do not have the OPD/Indoor Facilities for Nephrology. Hence, the Complainant had to incur Medical Expenses for sum of Rs.22,557/- for the medicines/ injections/ pathological tests which were urgently required as per advice of Nephrologist of R.M.L. Hospital. The Complainant submitted all the Original bills for Rs.22,557/- on the prescribed perform i.e. Essentiality Certificates duly signed by the treating Doctor of Dr. Ram Manohar Lohia Hospital on 16.06.2017 to the I.M.O Incharge, E.S.I. Dispensary, Mori Gate, Delhi-110006 i.e. OP-4. The true copies of relevant documents have been annexed with the complaint. Again on 09.06.2017, the Complainant was referred to Urology Department of empanelled hospital, i.e. Jay Pee Hospital, Noida by E.S.I. Hospital, Jhilmil and the said hospital had charged Rs.13,351/- from the Complainant. Hence, consequently, the Complainant had also submitted the bill of sum of Rs.13,351/- for reimbursement on 16.08.2017 out of which a sum of Rs.5709 has been paid by the ESIC but rest of the amount of Rs.4,548/- and Rs.3,094/- i.e. a total of Rs. 7642/- has still not been paid by the Nodal Officer, ESI Corporation i.e. Opposite Party(s).

 

2.       It is further alleged that another two bills of Rs.7,789/- and Rs.4,164/- were also submitted to the E.S.I. Dispensary, Mori Gate, Delhi on 16.07.2018 by the Complainant on account of medical treatment of his wife namely Smt. Raj Sharma, who is legally dependent upon him, for reimbursement the said Bills but surprisingly, the Opposite Parties have not reimbursed the amount of said bills till date. However, it is further pertinent to state that all the documents are in possession of the OP-3. As such, total amount of Rs.42,152/- is not paid by the Opposite Party i.e. Nodal Officer, E.S.I. Corporation, New Delhi for which a notice/ intimation was also sent to the Opposite Party(s) on 30.10.2018 inter-alia requesting for clearing all the dues within 15 days from the date of receipt of the notice alongwith bank-interest apart from claiming damages to the extent of Rs.50,000/- on account of harassment, torture and mental agony as faced by the Complainant. Apparently there is deficiency of services on the part of the Opposite Party(s) as they have been deliberately and willfully failed to pay the above said amount and therefore, are liable to pay the following amounts to the Complainant:-

Sl. No.	Details of claims	Amount of Claim
1.	Principal Amount as claimed towards unpaid Medical Bills details of which are as under:- (i) Bills relating the treatment of Sh. J.P. Sharma amounting to Rs.22,557/- submitted on 16.06.2017; (ii) Bills relating the treatment of Sh. J.P. Sharma amounting to Rs. 4,548/-  submitted on 16.08.2017; (iii) Bills relating the treatment of Sh. J.P. Sharma amounting to Rs.3,094/- submitted on 16.08.2017; (iv) Bills relating the treatment of Smt. Raj W/o J.P. Sharma amounting to Rs.7,789/- submitted on 16.07.2018; (v) Bills relating the treatment of Smt. Raj W/o J.P. Sharma amounting to Rs.4,164/- submitted on 16.07.2018;
2.	Damages on account of suffering harassment, torture & causing mental agony;	Rs.50,000/-
3.	Litigation Expenses inclusive of lawyer’s fees;	Rs.25,000/-
	Grand Total	Rs.1,17,152/-

 

The Complainant has, therefore, filed this complaint praying to:-

1. Pass an award in the total sum of Rs.1,17,152/- (Rs. One Lakh Seventeen Thousand One Hundred  Fifty Two Only) inclusive of damages and legal expenses;
2. Award pendent-lite as well as future interest @ 18% p.a. till realization of money;
3. Any other relief or order which this Hon’ble  District Forum deems fit and proper be also passed in favour of the Complainant and against the Opposite Party under the above said facts and circumstances of the case. 

 

3.       Accordingly, notices were issued to the OPs and in response to the Notices issued, the OPs have filed joint reply stating that the as per the provision of ESIC, pensioner is required to visit ESIC Dispensary/ Hospital in the first instance and if the treatment is no available in the ESIC institution then he is referred to tie-up hospital to take treatment on cashless basis in hospital. If a ESIC pensioner visit to an empanelled hospital in emergency without reference from the ESIC Hospital, he is required to meet the expenditure on his own and to seek reimbursement from the concerned respondent office. In that case, he has to submit requisite document i.e. emergency certificate, prescription and bills duly attested by the treating doctor of the empanelled hospital from where he has taken treatment in emergency etc. It is further added by the OPs that the pensioner/ Complainant is bound to comply the rules/notification/regulation issued by the OPs office, while submitting claim for re-imbursement of expenditure incurred by him. It is further contended by the OPs that the Complainant has not visited any of the ESI Hospital/ Dispensary for treatment and preferred visit to RML hospital, Delhi for treatment on its own. It is further submitted that the ESIC Indira Gandhi Hospital Jhilmil is nearer to his residence and instead of visiting the said hospital, he visited RML hospital on its own which is at greater distance from his residence. If he had visited ESIC Hospital Jhilmil, he would have been referred to ESIC Basaidarapur for Nephrology and further treatment. Even ambulance services could have been provided to him for smooth transfer to ESIC Hospital, Basaidarapur from ESIC Hospital, Jhilmil. The bill of the amount Rs. 22,557/- was submitted by the complainant with the respondent office on 21.09.2017. The said bill was examined by the Respondent office and found that the same was incomplete and following objections were sent to the Complainant for clarification as mention below.

1. That the OPD slip of RML Hospital does not show name of drug for which re-imbursement has been claimed.
2. That there was no justification as to why 7 (Seven) injection of Invanz were purchased in bulk without the any permission or asserting its availability from the central store of the respondent/ ESI Dispensary.
3. That the Complainant was advised to provide original prescription slip where Invanz was prescribed by the doctor and till date he has failed to provide the same.
4. That all the bills to be attached with prescription of the specialist of Government Hospital/ ESIC Hospital.
5. That the Complainant has not visited the respondent’s dispensary of ESIC for procurement of any medicine.
6. That the complainant could not clarify as to why the cutting of medicine was done in prescription slip and if the same was done by the doctor and may be get certified by the treating doctor.

4.       It is further stated by the OPs that the Complainant failed to provide the satisfactory reply to the objections raised. Therefore, the reimbursement was made after deducting the amount of medicine/ injection Invanz costs Rs.19,320/- from the total bill amounting Rs.22,557/- and the balance amount of Rs.3,058/- was reimbursement at the CGHS rate. It is further stated by the OPs that the bill of amount Rs.13,351/- could not be reimbursed due to following objections:-

1. That the complainant has not provided all original papers i.e. referral slip of ESI Hospital, discharge summary, OPD slip, etc. of Jaypee Hospital.
2. That when complainant was referred for cashless treatment in Jaypee Hospital, why he did spend on tests and investigations.
3. That the complainant was asked to submit the OPD prescription from ESIC hospital, Hospital Jhilmil wherein he was advised for surgery (TURP).
4. The respondent that the Complainant in reply to letter dated 11.03.2019 had said the matter is Subjudice and need not be replied at this stage.

5.       With regard to the allegations of the Complainant in para no.7 of the complaint, the OPs have contended that the Complainant took his wife directly to Batra Hospital, about 35 km away from whereas ESI hospital Jhilmil is only 5 km from his house. It is basically OPD treatment case and most of the test is done/available in ESI hospital and rest can be done cashless after reference from ESI Hospital to empanelled hospital/ Diagnostic Centre. The Complainant again went to Jaypee hospital for the tests and has not submitted the emergency certificate in r/o treatment taken at private hospital. The OPs have also stated that there is no deficiency of the service on their part and they are not liable to pay any compensation, cost, litigation and others.

7.       Accordingly, the complaint has been examined in view of the facts of the case and averments/documents/Evidence put forth by the complainant and it has been observed that:

1. The OPs have not raised any objection to the genuineness of the treatment taken by the Complainant and his wife. Besides, the genuineness the documents submitted for claiming re-imbursement of the expenses incurred on the treatments.  The objections have been raised merely on technical reasons.
2. It is not in dispute that no facility for Urology/ Nephrology was available in ESI Hospital, Jhilmil and the Complainant was referred by the OPs vide referral letter dated 10.06.2017 and 02.08.2017.
3. The Revised guidelines relating to implementation of ESIC Pensioner Medical Scheme-2006, placed on record, also contain following Provisions:-

 

“5. Medical Treatment:

1. Cashless Medical Treatment.

(a) Treatment in emergency.

In case of emergency, the pensioner can go directly to any of the nearby empanelled hospital. For this purpose, instructions may be issued by the Nodal Officer to the tie-up hospital to accept admissions in emergency for cashless treatment for ESIC pensioners on production of medical cards.

(b) Treatment at ESIC Hospital.

• The medical treatment to pensioner shall be provided as under.
• The pensioner can take the treatment as per the facility available in the ESIC hospital.
• In case the facility in ESIC hospital is not available as per his entitlement then he can opt to have treatment from empanelled hospital and the referral to private hospital shall not be denied.

(c) Treatment from private hospital empaneled with ESIC:

• The pensioners shall be entitled for cashless medical treatment in Private Empanelled hospital on the basis of advice of ESIC Doctor/ Govt Specialist for specific listed procedure/ investigation. No other permission letter shall be required to be submitted to Tie-up hospital.

 

2. Treatment on re-imbursement basis.

iii. Treatment in Tie-up/ Non tie-up hospital without permission/ referral:

If the pensioner takes any elective treatment/ investigations from the tie-up/ non tie-up hospital in normal circumstances without any advice of ESIC Doctor/ Govt Specialist or without permission/  referral, the request for ex-post facto approval of such treatment shall be considered by the sanctioning authority and re-imbursement shall be limited to CGHS rates.

                                               

(d) The Letterhead of Referring ESI Hospital/Dispensary/ REFERRAL FORM (Permission Letter) dated 10.06.2017 and 02.08.2017 filed by the Complainant also states that:-

4.In case any addition procedure/treatment/investigation is essentially required in order to treat the patient for which he/she has been referred to, the permission for the same is mandatory required from the approving authority of the referring hospital either through e-mail, fax or telephonically (to be confirmed in writing at the earliest)

5. The referred hospital is requested to raise the bill as per the agreementon the standard proforma along with supporting documents within 6 days of discharge of the patient giving Bank account number, IFSC Code and RTGS number etc.

 

(e) Agreement between Director (Medical) Delhi, ESIC and Jaypee Hospital (A unit of Jaypee Healthcare Limited) also provide that:-

 

1.14: The tie-up hospital will provide medical care as specified in the referral letter; no payment will be made to tie-up hospitals for treatment/ procedure/investigation which are not mentioned in the referral letter. In case of unforeseen emergencies of these patients during course of diagnostic investigation for approved purpose, necessary life saving measures should be taken and concerned authorities may be informed accordingly later with justification.

 

1.15: If the tie-up hospitals feel necessity of carrying out any additional treatment/ procedure/ investigation in order to carry out the procedure for which patient was referred, the permission for the same is essentially required from the referring hospital either through e-mail or fax at the earlies on the same or next working day.

 

(f) It has also been found that:-

i. The OPs have now paid Rs.21,058/- out of Rs.22,557/- from the bill submitted by the Complainant on 16.06.2017 after deducting Rs.1,499/- without giving any reasons. If the claim has been paid by the OPs, it should have been paid completely. Otherwise the valid reason of deduction of Rs.1,499/- should have been  explained to the Complainant. Moreover, the payment of the bill during pendency of the case also prove admission of the lapse committed by the OPs. Therefore, the deduction of amount from the admitted bill is unjustified.

Ii. The OPs have also paid Rs.9,422/- out of Rs.11,953/- (Rs.7,789/- + Rs.4,164/-) from the bill submitted by the Complainant (for treatment of his wife) on 16.07.2018 after deducting Rs.2,531/- without giving any reasons. If the claim has been paid by the OPs, it should have been paid completely. Otherwise the valid reason of deduction of Rs.2,531/- should have been  explained to the Complainant. Moreover, the payment of the bill during pendency of the case also prove admission of the lapse committed by the OPs. Therefore, the deduction of amount from the admitted bill is unjustified.

iii. The OPs have not paid Rs.4,548/- and Rs.3,094/- (total Rs.7,642/-), submitted by the Complainant) on 16.08.2017. The refusal of the reimbursement of amount of genuine treatment, in light of the Provisions of the scheme explained in Para No.7 (c and d) above appears unjustified on the part of the OPs.

 

7. The cost of Rs.10,000/- was imposed upon OPs vide order dated 31.10.2019, out of which Rs.5,000/- was to be paid to the Complainant and another Rs.5,000/- was to be deposited Consumer Legal Aid Fund but these orders have not been complied by the OPs. Therefore, the additional cost of Rs.10,000/- is imposed upon the OPs. Hence, Rs.10,000/- (Rs.5,000/- + Rs.5,000/-) shall be paid to the Complainant and another Rs.10,000/- (Rs.5,000/- + Rs.5,000/-) shall be deposited in the “ State Consumer Welfare Fund (L/Aid), SBI Account No.10310544717, IFSC No.SBIN0018175” within 30 days from the receipt of this order.

 

8. In in view of the above observations we are of the considered opinion that there is deficiency of service on the part of the OPs in terms of the deficiency defined in the Act which includes any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. Therefore, we feel appropriate to direct the OPs to pay Rs.11,672/- (Rs.1,499/- + Rs.2,531/- + Rs.7,642/) (Rupees Eleven Thousand Six Hundred Seventy Two Only) jointly and severally within thirty (30) days with interest @ 9% from 14.01.2019 from the date of receipt of this order till the date of payment. Besides, the OPs are also directed to pay Rs.25,000/- as compensation  for mental pain, agony and harassment. The OPs shall also pay the cost as ordered in Para 7 (g) above. It is clarified that if the abovesaid amount is not paid by the OPs to the Complainant within the period as directed above, the OPs shall be liable to pay interest @12% per annum from the date of expiry of 30 days period.

   9.       Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

    

 

 

 

              ASHWANI KUMAR MEHTA                                     DIVYA JYOTI JAIPURIAR          

Member                                                                       President

DCDRC-1 (North)                                                         DCDRC-1 (North)