DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

Rup Chand Bhardwaj, R/o #715-A, MIG Super, Phase-XI, Mohali.

                                                        ---Complainant

V E R S U S

[1]     The Govt. of India, Ministry of Health & Family Welfare, New Delhi, through its Secretary, MH & FW (DH & FW), Nirman Bhawan, Maulana Azad Road, New Delhi – 110 108.

[2]        Dr.S.C.Anand, Addl.Director, CGHS, Chandigarh Homoeopathy Dispensary Campus, Sector 34, Chandigarh.

---Opposite Parties

BEFORE:            SH.LAKSHMAN SHARMA                    PRESIDENT

MRS.MADHU MUTNEJA                 MEMBER

                        SH.JASWINDER SINGH SIDHU            MEMBER

Argued By:       Complainant in person.

Sh. A.K. Vohra, Adv for OPs

PER MADHU MUTNEJA, MEMBER

1.              The instant complaint relates to alleged deficiency in service by the OPs for not reimbursing the complete amount spent by the Complainant on medicine as per the bills submitted.

                Factually speaking, the Complainant being a Central Govt. pensioner, is a beneficiary along with his family, of the Central govt. Health Scheme (for brevity ‘CGHS Scheme’), He had submitted several bills for reimbursement claim to OP No.2. According to the Complainant, OP No.2 has not reimbursed the complete amount as per the bills submitted. The Complainant has thus filed the present complaint requesting for payment of the shortfall along with interest and cots. The claim is with regard to the following:-

[a]        Rs.13,752/- for self eye-operation, against which OP No.2 paid Rs.7046/- and disallowed Rs.6706/-.

[b]        Rs.3342/- for treatment of wife, against which OP No.2 paid Rs.50/- and disallowed Rs.3292/-.

[c]        Rs.682/- for self treatment, against which OP No.2 paid ‘Nil’ and disallowed the whole amount of Rs.682/-.

[d]        Rs.715/- for self treatment, against which OP No.2 paid Rs.252/- and disallowed Rs.463/-.

[e]        Rs.735/- for treatment of wife, against which OP No.2 paid Rs.375/- and disallowed Rs.360/-.

                The Complainant has attached the rates admissible for the treatment for the said claims by the CGHS as annexures.

2.              After admission of the complaint, notices were sent to the OPs.

3.              OPs No.1 & 2 in their joint reply have taken the preliminary objection that the complaint has been filed u/s 12 of the Consumer Protection Act, 1986 (for brevity ‘the Act’), for alleged deficiency in service due to non-reimbursement of complete bill amounts. OPs have stated that under the rules/instructions the amounts spent by the beneficiary are payable only as per the rules and regulations.

                OPs have further stated that the relationship between the Complainant and the OPs is not that of consumer and service provider, as the Complainant does not fall within the definition of consumer as per Section 2(d) of the Act. The Complainant is only a beneficiary of the CGHS Scheme being a Central Govt. pensioner.

                OPs have further contended that the cause of action, if any, arose to the Complainant when the alleged short payments were made. The relevant payments were released to him on 8.6.2006, 18.8.2006 and 16.07.2008, against which complaint could be also filed within two years  only. Hence placing reliance on Section 24-A of the Act, the OPs have stated that the complaint has been filed beyond limitation and the claim is time-barred.

                On merits, the OPs have stated that Hon’ble National Consumer Disputes Redressal Commission has held in the case of Additional Director CGHS, Pune Vs. Dr. R.L. Bhutani, that a person who is a beneficiary under the CGHS Scheme is not a consumer and the service rendered to him does not come under the definition of service as per the Consumer Protection Act, 1986.

                OPs have further discussed each amount claimed by the Complainant as under:-

[a]        Against a claim bill of Rs.13,752/- only Rs.900/- was payable as per letter dated 21.12.2004 (AnnexA-1). In fact, Rs.7050/- has inadvertently been allowed wrontly to the Applicant and is still recoverable from him.

[b]        Claim of Rs.3342/- relates to “Protinex” which is a “Dietary Supplement”. Hence not allowed.

[c]        Claim of Rs.682/- is for “Cobamet”  which is Tonic and Dietaric item. Hence again not allowed.

[d]        Against a claim of Rs.715/- a sum of Rs.463/- was disallowed as it related to cost of medicines purchased for out door treatment. As per Annexure A-4 treatment taken at private nursing home, requires prior permission of Additional Director, CGHS.

[e]        Against claim of Rs.735/- claim of Rs.360/- has been disallowed for the same purpose as it is also for out door treatment. Hence not permissible under instructions at Annexure A-4.

Denying all other allegations of the Complainant, OPs have prayed for dismissal of the complaint, with cost.

4.              Parties led evidence in support of their contentions.

5.              We have heard the Complainant in person and learned counsel for the OPs and have perused the record.

6.              The Complainant has made a claim for reimbursement of his medical bills. At the outset, the Complainant needs to understand that though medical services are covered under the ambit of the Consumer Protection Act but medical claims under the CGHS Scheme for beneficiaries, in our opinion, would not be covered under the provisions of the Consumer Protection Act. The Complainant has not hired or availed of any service of the OPs for consideration, which is a prerequisite for being a consumer as per Section 2(1)(d) of the Consumer Protection Act, 1986.

                In case The Additional Director C.G.H.S., Pune Vs. Dr. R.L. Butani, (1996) CPJ 255 (NC), Hon’ble National Consumer Disputes Redressal Commission has held that a govt. servant under the CGHS Scheme is not a consumer within the meaning of Consumer  Protection Act, 1986 as defined in Section 2(1)(d) of the Act and the services rendered to him under the CGHS, does not constitute service as defined under Section 2(1)(d) of the Act. The relevant part of which is reproduced hereinbelow: -

“………Whether the Complainant is a consumer? – (No) – Whether the services rendered to him by CGHS constitutes service? – (No).”

7.              Hence, though medical services are covered under the Act but reimbursement of claims made for medical services are not covered by the Act. Referring to the amounts spent by the Complainant, it is seen from the documents placed on record by the OPs that all the amount disallowed by them relate either to tonic, food & dietary supplement, bills for out door treatment without prior permission of the CGHS.  In this regard, the relevant portion of the Government Health Scheme for Settlement of Medical Claims of CGHS Beneficiaries placed on record at Annexure OP-3, is reproduced hereinbelow:-

3. Processing of the claims is to be done as per CS (MA) Rules and the following guidelines for examination of medical claims are to be followed while processing the claim:

(i) Prior permission of Additional Director, CGHS of the respective city is required for taking treatment in Government referral hospitals and private recognized hospitals under CGHS. No permission is required for treatment from Central/ State Government Hospitals and Hospitals under other Government Bodes.

xxx xxxxx xxxxx xxxxx

(v) Cost of all medicines are reimbursable in full except preparations classified as food, tonics, vitamins, disinfectants, toilet preparations etc. The list of inadmissible items is given in CS (MA) Rules.

xxx xxxxx xxxxx xxxxx

(xi) Medicines prescribed for outdoor treatment is not reimbursable under CGHS. However, expenditure on investigations and tests done in Government/ referral/ recognized hospitals may be reimbursed, if such tests/ investigations have been done on the advice of the special list of Government hospitals.

8.              The claim is also time barred as the cause of action is well beyond two years of 08.06.2006, 18.08.2006 and 16.07.2008.

9.              This Forum can definitely not go beyond the Govt. Guidelines laid down for the beneficiaries of the CGHS Scheme. Hence relying on the above Govt. Guidelines of the CGHS Scheme, as well as the ruling of the Hon’ble National Consumer Disputes Redressal Commission, this case is dismissed. No costs.

10.               Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

19^th December, 2011.                                                                    

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER