BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.115/08
Dated this the 26th day of August 2013.
( Present: Sri. G. Yadunadhan, B.A., LLB. : President
Sri. L. Jyothikumar, B.A., LLB. : Member
ORDER
By G. Yadunadhan, President
The case of the complainant is that he is a retired Railway Employee. On his retirement he has been joined in the RELHS Scheme introduced by the Railway after paying necessary contribution as required expecting the benefit of the scheme for himself and his family after superannuation. As per the above said scheme the complainant and his family members are entitled for the medical expenses and also entitled to get reimbursement of the medical expenses for the treatment incurred in private hospital as well. Complainant’s wife Sarojini is a known Coronary Artery patient under the treatment for the last so many years of Railway Hospital at Perambur and other hospitals she has been attending the hospital for regular check up as per the advise from the Railway hospital from 29.05.2004. She suddenly developed chest discomfort, pain on the left arm, sweating and tiredness showing symptoms of cardiac problems .So she was immediately taken to a local private hospital for the treatment from where she was given a course of injections and medicines and was later discharged on 02.06.2004 with the advise to have better treatment from a well equipped hospital. So when the complainant and his wife were planning to attend railway Hospital Perambur, she again developed the earlier symptoms and had no other alternative but to rush to some other hospital having modern facilities. Accordingly on 04.06.2004 she was taken to Malabar Institute of Medical Science ltd, Kozhikode. She was admitted in the above said hospital and after necessary examinations including Echo Cardiogram. Again on 08.06.04 her condition was critical and had an attack and was admitted in ICCU and her condition was very bad as advised by doctors Angiogram was taken and the same revealed multiple block in the heart and the only course left open before the doctors was an emergency bypass surgery on 10.06.04 to her so as to save her life. The treatment and surgery in the above said hospital has incurred an expenditure of Rs.1,29,794/-(Rupees one lakh twenty nine thousand seven hundred ninety four only) to the complainant.
Thereafter complainant had approached the opposite party for the reimbursement of the medical expenses incurred by him during the course of the above treatment with all relevant documents as required by the office of the opposite parties as the beneficiary of the above said scheme. Unfortunately the scheme was repudiated by the opposite parties stating that “ Regretted since the surgery not warranted”. The review application filed by the complainant also was denied by the opposite party stating that” emergency has not been proved” vide the letter dtd.10.05.2007. Due to the act of the opposite party complainant suffered great loss and hardships. The action on the part of the opposite parties amounts to deficiency of service. Hence opposite parties are liable to reimburse the amount spend by the complainant for the treatment of his wife in view of the terms made by them, and also pay a compensation of Rs.50,000/-
Opposite parties are entered in appearance and filed their version. According to the opposite parties he is totally false to state that the complainant is entitled to get reimbursement of the medical expenses incurred in any private hospitals as per the norms of Railway Employees liberalized Health Scheme. The Railway Board has fixed certain norms to be complied by the beneficiary while starting treatment in a private hospital and also for claiming reimbursement incurred for that private treatment on the basis of EMERGENCY ALONE to prove the emergency in his wife’s treatment. They are:-
a) If a patient falls ill at a place, where there are no Government or Railway Medical
facilities available for treatment.
b) If transporting the patient to the nearest Govt/Railway hospital would result in
Loss of life.
c) If authorized medical attendant certifies that Govt/Railway facilities available
near the place are inadequate to treat the patient.
d) If patient was admitted to the private hospital in an unconscious state by strangers
in emergencies.
The case of the complainant do not come within the purview of any of the categories mentioned above. The private treatment taken in a planned manner can not give the employee any right for medical reimbursement beyond the guidelines issued by the Railway Board. As per the complaint the complainant waited up to 04.06.04 to see the same symptoms to take her to Malabar Institute of Medical Science at Calicut for immediate treatment rather than availing the service of Railway doctor or Railway authorities at Calicut. The alleged emergent by pass surgery was conducted on 10.06.04 to save her life. Therefore a claim for reimbursement was made in this case can not come within the definition of a claim for compensation of deficiency of service. Hence complaint is liable to be dismissed with cost.
Points for consideration.
Whether any deficiency on the part of Opposite parties? Whether complainant is entitled to get any amount? If so what is the relief and cost.
Complainant examined as PW1 and Ext.A1 to A7 were marked. No oral evidence adduced by Opposite parties . Documents produced and marked as Ext.B1 on Opposite party’s side. Ext.A1 produced by the complainant shows the patient was admitted with unstable angina, heart attack 8 years prior to the admission in the hospital at Malabar Institute of Medical Science on 04.06.04. While perusing of the Ext.A1, it was issued on 28.01.05. It means A1 document issued after a lapse of 7 months. Ext. A2 document not disclosed inability to move or transferred to Railway Hospital nothing was mentioned. Being a retired Railway officer at least he should have possessed minimum knowledge of Ext.B1 document. What prevented them to intimate and take permission from Railway Hospital regarding the admission on 04.06.04 in MIMS. For that no explanation is given. Opposite parties filed B1 document which shows the claiming of reimbursement for the private treatment can be considered only on the basis of emergency alone. As per Ext.B1 document there are certain procedure to reimburse the medical claim, issued by Executive Director(Health) Railway Board stating that the emergency covers, the patient falls ill where no Govt. or Railway medical facilities available, transporting the patient to the nearest Govt/Railway hospital would result in loss of life; authorized medical officer has certified that the facilities available near the place are inadequate to treat, the patient was admitted to private hospital in an unconscious conditions by the strangers, in addition to this “emergency means” road accident, acute attack etc. Here complainant is admitted in the hospital on 04.06.04 and operation was conducted on 10.06.04. Meanwhile complainant could have obtained the approval by railway hospital, but it was evident that no attempt was made for obtaining the approval in this case. Another thing is if the patient was brought on 04.06.04 with any of the condition to satisfy the existence of emergency situation no doctor would have to wait for the next 6 days to perform an emergency by pass surgery in order to save the life of the patient, there is no explanation from the complainant for not taking his wife to railway hospital at Perambur on any day between 04-06-04 to 10-06-04. Since the case was remanded back from the Hon’ble State Commission directing the Lower Forum to re-consider the evidence of PW2. On thoroughly perused the evidence of PW2, Forum found that there is an evidence to show that the condition of the patient is instable. The surgery was conducted upon her is on 10-06-2004 and witness deposed that Doctor who conducted surgery they waited 6 days for medical stabilization. Sometimes it may happened these are all medical ethics. The condition of the patient could have speak only the doctor who treated the patient or posted for surgery. So Fora cannot go beyond the opinion of the Doctor. The critical nature Doctor stated in her version that “ If it was not done the surgery immediately there was a risk of death. She was not in a position to be transferred elsewhere”. Opposite party failed to adduce any evidence to rebut the complainant’s evidence on this point. Considering this emergency supported by PW2, Fora not in a position to go beyond the evidence of PW2. Under these circumstances complainant is entitled to get the amount which already spent for her treatment and also compensation. Therefore opposite party is directed to pay an amount of Rs.1,29,794/- towards the treatment and also pay Rs.10,000/- as compensation. Comply the order within one month failing which opposite parties shall pay 12% from the date of order.
Pronounced in the open court this the 26th day of August 2013.
Date of filing:30.04.2008.
SD/-PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. Photocopy of certificate issued from MIMS Hospital dt. 28-1-2005.
A2. Photocopy of Discharge Summary issued from MIMS Hospital.
A3 series ( 12 in Nos. Photocopy of bills.
A4. Photocopy of letter dt. 7-4-07 sent by the complainant to the 2nd O.P.
A5. Photocopy of letter dt. 10-5-2007.
A6. Photocopy of Lawyer notice dt. 12-7-2007.
A7. Photocopy of Reply notice dt. 3-8-2007.
Documents exhibited for the opposite party.
B1. Photocopy of letter dt. 31-01-2007 of Railway Board.
Witness examined for the complainant:
PW1. Kunhiraman (Complainant)
PW2. Dr.Ashish Kumar.M, Senior Consultant cardiologist in MIMS Hospital.
Witness examined for the opposite party.
None
SD/- PRESIDENT
// True copy //
(Forwarded/By order)
SENIOR SUPERINTENDENT.
