Andhra Pradesh

Chittoor-II at triputi

CC/60/2015

M.Rajasekhar, S/o. M.Nadamuni Reddy - Complainant(s)

Versus

The In-charge Medical Officer, ESI Dispensary - Opp.Party(s)

N.Ravi Kumar

06 Feb 2020

ORDER

Date of first filing : 11.12.2015

Date of first disposal :22.07.2016

Matter remanded and case restored on:21.08.2019

Date of dispotal:06.02.2020

 

 

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

CHITTOOR AT TIRUPATI

 

 

      PRESENT: Sri. T.Anand, President (FAC).

             Smt. T.Anitha, Member

 

 

 

THURSDAY THE SIXTH DAY OF FEBRUARY, TWO THOUSAND AND TWENTY

 

 

 

C.C.No.60/2015

 

 

Between

 

M.Rajasekhar,

S/o. M.Nadamuni Reddy,

Hindu, aged about 32 years,

Annaswamypalli Village,

Karakambadi Post,

Renigunta Mandal,

Chittoor District.                                                                              … Complainant

 

 

 

And

 

 

1.         The Incharge Medical Officer,

            ESI Dispensary,

            RC. Road,

            Tirupati.

 

2.         The Joint Diector,

            ESI Insurance Medical Services,

            D.No.6/1471, Sankarapuram,

            Kadapa.

 

3.         The Director,

            ESI Insurance Medical Services,

            ESI Staff Quarters,

            No.A11, S.R.Nagar,

            Hyderabad – 500 038.

 

4.         The Regional Director,

            ESI Corporation,

            Hill Fort Road,

            Near Secretariate,

            Hyderabad.                                                                            …  Opposite parties.

 

 

 

 

            This complaint coming on before us for final hearing on 24.01.20 and upon perusing the complaint, written version and other relevant material papers on record and on hearing Sri.N.Ravikumar, Sri.B.Sreeramulu counsel for the complainant, and M.Vani, A.G.P., counsel for opposite parties 1 to 3,  and Sri.D.Srikanth, counsel for opposite party No.4, and having stood over till this day for consideration, this Forum makes the following:-

 

 

 

ORDER

DELIVERYED BY SRI. T.ANAND, PRESIDENT (FAC)  

ON BEHALF OF THE BENCH

           

            This complaint is filed under Sections-12 and 14 of C.P.Act 1986, by the complainant for the following reliefs 1) to direct the opposite parties 1 to 4 to reimburse the medical expenses of Rs.2,82,969/- with accrued interest at 24% p.a. from 01.09.2014 till realization, 2) to direct the opposite parties 1 to 4 to pay a sum of Rs.1,00,000/- towards compensation for the mental agony suffered by the complainant and for costs of the litigation.

            2.  The averments of the complaint in brief are:- that the complainant is working in Telugu Ganga Water Works in Municipal Corporation, Tirupati. He is the subscriber of ESI Corporation. His I.P.No.5203666915, subscribing Rs.400/- per month and the same is deducting from the salary of the complainant and remitting to ESI Corporation regularly.

            3.  That every year ESI member will get the benefits and privileges to his / her entire family consisting of spouse, children and parents.

            4.  That the father of the complainant by name M.Nadhamuni Reddy, met with an accident on 02.08.2014 at about 2 p.m. near Bommala Quarters at Annaswamypalli cross, Karakambadi road, Tirupati. Immediately, the injured was shifted to Suraksha hospital, Tirupati, for first aid and on the advise of the doctors, the injured was shifted to Apollo hospital, Chennai, by their relatives for emergency treatment, as the injured is in serious condition. After admitting the injured at Apollo hospital, Chennai, they informed the same to complainant, as such the complainant could not admit his father in ESI hospital.

            5.  M.Kumaraswamy Reddy, brother of the complainant gave complaint in Alipiri P.S., on which a case in Crime No.210/2014 under Section-337 IPC was registered and took-up investigation, charge sheet also filed in this case. C.C.No.3/2015 is pending on the file of IV Additional Judicial 1^st Class Magistrate, Tirupati, under Section-338 IPC, r/w Section-134A & B of M.V.Act. That the complainant’s father sustained fractures viz. 1) Right Tibia Priximal 1/3 and Mid 1/3 junction fracture, 2) Right Fibula Neck fracture, right Distal Fibula Fracture, and for the said fractures, injured was advised to undergo surgery at Apollo hospital, Chennai. Accordingly, he underwent surgery and he was discharged on 09.08.2014, advising the injured to visit Apollo hospital, for periodical checkup every month till the problem is set right

            6.  That the complainant spent Rs.2,82,969/- for the injured apart from nutrition and attendant charges in Apollo hospital. That after discharge of his father from Apollo hospital, the complainant approached opposite party No.1 with all medical bills along with his representation on 01.09.2014 for reimbursement. After lapse of one year, the complainant received an intimation from opposite party No.1 stating that as per the proceedings of opposite party No.3 dt:06.04.2015, the claim of complainant was returned for the reason that “Facilities are available in ESI institutions”. As per ESI Medical Manual 23.04 under Regulations No.96-A (No.7 and 8) in page.36, it clearly stated that in serious cases of accident or illness to the patients, they may be admitted directly into any recognized hospitals or non-recognised hospitals or any private hospital where owing to the clinical condition of the patient being unconscious or otherwise it was not possible to reveal his identity as an ESI patient or to the member of the ESI employee and the hospital authorities may recover the hospital expenses and bills recovered directly from the employee / patient (ESI member) or the employer of the ESI member. Contrary to the said rule position, the opposite parties return the claim of reimbursement; as such the opposite parties are committed deficiency in service. The complainant got issued legal notice to opposite parties 1 to 4 on 14.10.2015 requesting them to settle the claim to the complainant. Though the opposite parties 1 to 4 received the said notice neither gave reply no settle the claim. Hence the complaint.

            7.  Opposite party No.1, filed his written version and the same is adopted by opposite parties 2 to 4. In the written version of opposite parties, they have admitted that the complainant approached opposite party No.1 with representation on 01.09.2014 and the same was returned on 10.04.2015 and also admitted that the complainant got issued legal notice to opposite parties 1 to 4. The parawise allegations in the complaint including the employment of the complainant in Municipal Corporation, Tirupati, and his subscription to ESI and the accident dt:02.08.2014, were denied and put the complainant to strict proof of the same.

            8.  The opposite parties further contended that all ESI hospitals are working    24 hours. If any patient is admitted in any other hospital due to emergency, he has to intimate the same to the nearby ESI dispensary or hospital or to bring the patient to ESI hospital as early as possible. The opposite parties have admitted that as per ESI Medical Manual and other rules, the ESI covered employee or his dependents are eligible for medical reimbursement provided it is properly channelized. That the complainant has admitted his father in Suraksha hospital, Tirupati, and later shifted to Apollo hospital, Chennai, instead of ESI hospital, Tirupati, or any other hospital at Tirupati. That the complainant has taken complete treatment to his father in Apollo hospital, Chennai. If the complainant shifted his father to ESI hospital, Tirupati, he would have given treatment here. If facilities are not available, the ESI should have referred to tie-up hospitals at Hyderabad or any other hospital in the State. As the patient was not brought to ESI hospital for treatment, he is not entitled for reimbursement, that the complainant did not bring his father to ESI hospital where facilities are available. His claim for reimbursement as such was returned. The version of complainant from his complaint and legal notice are self-contradictory. There is no deficiency in service on the part of opposite parties. There is no cause of action for filing the complaint and prays the Forum to dismiss the complaint with costs.

            9.  In support of the case of the complainant, the evidence affidavit of complainant was filed as P.W.1 and got marked Exs.A1 to A18. On the other hand, for the opposite parties one K.Venkata Subramanyam, filed his evidence affidavit as R.W.1 and got marked Exs.B1 and B2. Both parties have filed their respective written arguments. Heard the counsel for both parties.

            10.  Now the point for consideration is whether there is deficiency of service on the part of opposite parties in not reimbursing medical bills? If so, to what extent the complainant is entitled for the reliefs sought in the complaint?

            11.  Point No.(i):- This Forum has disposed of this case by holding that the complainant is entitled to reimbursement as prayed for and opposite parties are under obligation to reimburse the same, in view of the provisions of Regulation-96A (7&8) and Section-56 of Employees State Insurance Act 1948, and also placed reliance on a decision of Hon’ble Kerala High Court in Insurance Appeal No.14/2012 dt:30.01.2013. Further, this Forum also relied on a decision of Maharashtra State Consumer Disputes Redressal Commission, Mumbai, in First Appeal No.1016/2008, wherein it is held that “the treatment was taken in a private hospital for the son of employee and claimed medical bills for Rs.28,587/-, but ESI gave only Rs.4,710/-. Therefore, the claimant filed complaint before the District Forum. The District Forum allowed the complaint in part and directed the respondent to pay Rs.23,877/- by deducting Rs.4,710/-, which was received by the complainant as part of reimbursement”. The Hon’ble State Commission upheld the order of the District Forum.      

            12.  The opposite parties preferred an appeal before the State Commission against the orders passed by this Forum on 22.07.2016. The Hon’ble State Commission after hearing both sides allowed the appeal by setting aside the impugned order passed by the District Consumer Forum and remanded the matter to this Forum for fresh disposal after offering reasonable opportunity to both sides. The reason for remanding the matter by the State Commission is that the counsel appearing before the District Forum has not brought to the notice of the District Forum about the ESI Medical Manual, and had the counsel produced the ESI Medical Manual before the District Forum, its finding would be otherwise. Whether the claim submitted by the complainant falls within the ambit of Clause-3.30 of the ESI Medical Manual or not could have to be considered in detail.

            13.  It is an admitted fact that ESI Corporation has issued I.P.No.5203666915 to the complainant. The complainant is working in Telugu Ganga Water Works in Municipal Corporation, Tirupati, and an amount of Rs.400/- per month had been deducted from the salary of the complainant and remitting the same to ESI Corporation. It is not the case of the opposite parties that the complainant is not a member of ESI Corporation, as per the provisions of ESI Act. The complainant and his family members are entitled for medical reimbursement subject to taking of treatment in ESI hospitals or any other recognized hospitals. The father of the complainant met with an accident on 02.08.2014 at Alipiri of Tirupati town. The Station House Officer, Alipiri, registered a case in Crime No.210/2014, under Sectoin-337 IPC against the driver of the offending vehicle. The Station House Officer investigated into the matter and laid charge sheet. The IV Additional Judicial I Class Magistrate, Tirupati, altered the Section of Law from 337 to 338 IPC r/w Section-134 A and B of MV Act and numbered the same as C.C.No.03/2015. A perusal of Exs.A3 and A7 clearly reveals that the father of the complainant had taken treatment in Apollo Hospitals, Chennai, for the fractures sustained by him in the road accident. The complainant submitted Ex.A10 application to the ESI Corporation on 01.09.2014. The opposite parties did not sanction the reimbursement on the ground that the father of the complainant had not taken treatment in nearby ESI hospital. The Hon’ble State Commission held that the finding of the District Consumer Forum that a member of the ESI is entitled for medical reimbursement even if he had taken treatment in any private hospital is not sustainable.

 

14. It is relevant to extract Regulation 96-A of ESI Act 1948, which reads as follows:-

“Claims for reimbursement of expenses incurred in respect of medical treatment of insured person and (where such medical benefit is extended to his family) his family may be accepted in circumstances and subject to such conditions as the Corporation may by general or special order specify”.

 

            The reading of the above provisions clearly shows that the Corporation may accept the medical reimbursement subject to certain conditions. The ESI Medical Manual Clause-3.30 deals with reimbursement of expenses in respect of medical treatment under Regulation -96A.

A.	The following conditions have been laid down under this Regulation:-
a.	Full authority is vested with the State Government concerned to reimburse expenditure in respect of medical treatment of IP and his family.
b.	It may be left to the discretion of the State Government to decide the Authority within their machinery who will approve the expenditure in question; and
c.	Time limit for submission of the claims for reimbursement is one year.
B.	The State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on Medical Care:
i.	Whether such facilities for which reimbursement is recommended are not available with the State;
ii.	Whether the hospital where the IP was sent or proposed to be set was / is the nearest hospital having required facilities / services.
C.	A list of types of cases for which reimbursement is permitted is given below:
1.	Reimbursement is permissible in case of failure of the mobile dispensary van due to technical defects or otherwise to adhere to its schedule timings or where IP attached to such a dispensary sustained serious injuries or suffered from serious illness during off hours of the dispensary.
2.	IPs and their family members had to resort to private treatment during the off hours of ESI dispensary / Emergency Centre due to unavoidable circumstances.
3.	Medicines prescribed by IMO / Specialist were out of stock in the ESI Dispensary / Approved Chemist thereby compelling the IPs to make purchases from the market.
4.	Medicines prescribed by Specialist and not provided by the IMO/IMP and where specialist considered such special medicines absolutely necessary for the treatment of the beneficiaries as no substitute medicine was considered equally efficacious whether as an outpatient or in patient.
5.	Special appliances prescribed by Specialist such as Spinal supports, Cervical Collars, Walking Calipers, and Crutches, etc. if considered necessary as part of the treatment.
6.	Where an IMO / IMP failed to make domiciliary visit requested by an IP thereby compelling the IP to make private arrangement for treatment. Under the panel system such cost is recoverable from the IMP if recommended after investigation by the Medical Service Committee.
7.	Serious cases of accident or illness admitted directly into recognized hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer.
8.	Serious cases of accident / illness where a beneficiaries was admitted directly at a private hospital or in a non-recognized hospital where admission in a hospital recognized under the scheme would have serious jeopardized his health like sudden heart attacks, fracture of the spine, cerebral hemorrhage, etc.
9.	Serious cases of accident and illness admitted to recognized hospitals where all the reserved ESI beds were occupied.
10.	Mental cases that may have incurred expenditure either as an outpatient on specialized therapy such as ECT etc.
11.	In respect of specialized examination, laboratory test, X-ray, other imaging services etc., recommended by specialist, but where the IP either due to the break down in the machinery or where the nature of the examination of the Laboratory Tests was such that it was beyond the scope of the facilities available in the recognized laboratory / hospital.
12.	Expenditure incurred on investigation for blood transfusion.
13.	Reimbursement of conveyance charges incurred by IP where ambulance or any other transport under the scheme is not available owing to some reason or the other and where in the opinion of the IMO / IMP such a patient was non-ambulatory.
14.	In addition to above types of cases, reimbursement may also be allowed in other cases depending upon the merits of each case and the circumstances under which expenditure was incurred”.

 

15.  The opposite parties in the written arguments contended that as per ESI Medical Manual and other rules, the employee or his dependents covered by ESI are eligible for medical reimbursement provided it is properly channelized. The employee has to bring the patient to any ESI hospital for treatment. All ESI hospitals are working 24 hours. If any patient is admitted in any other hospital due to emergency, he has to intimate the same to the nearby ESI dispensary or ESI hospital, as early as possible or to bring the patient to the ESI dispensary or ESI hospital. The complainant has admitted his father in Suraksha hospital, Tirupati, and later shifted him to Apollo hospital, Chennai, instead of ESI hospital, Tirupati, or any other place. The complainant has taken complete treatment in Apollo hospital, Chennai. If the complainant shifted his father to ESI hospital, Tirupati, he would be given treatment in the said hospital or if facilities are not available, he would have been referred to tie- up hospitals at Hyderabad or any other hospital in the state. But, the complainant did not bring the patient to ESI hospital and as such he is not liable for medical reimbursement. Further, it is contended that while submitting bills, the complainant has stated that his relatives have taken his father to Apollo hospital, Chennai, without his knowledge. But, in the legal notice dt:14.10.2015, complainant has stated that his father was taken to ESI hospital, Tirupati, and that no doctor was available to treat the injured and hence he was shifted to Apollo hospital, Chennai. But in the complaint he stated that immediately after the accident, the injured was shifted to nearby Suraksha Hospital, Tirupati, and later shifted to Apollo Hospital, Chennai. Thus, it is pointed out that the complainant has been stating different versions to suit his convenience. Finally, it is contended that complainant failed to follow the procedure in admitting his father for treatment and as such he is not entitled for reimbursement, and further question of deficiency in service on the part of opposite parties does not arise. Ex.B2 is list of tie-up arrangements with super specialty hospitals for IPs. In the said list Apollo hospitals did not find place. Ex.B1 is Clause-3.30 of ESI Medical Manual.

16.  Opposite party No.4, during hearing of this case, after disposal of the appeal by the State Commission, filed Memo enclosing the case status of MVOP No.46/2015, filed by the father of the complainant herein i.e . M.Nadhamuni Reddy, which shows that the matter was settled before the Lok Adalat. The opposite party counsel submitted that since the matter was settled before the Lok Adalat in respect of MVOP filed by the father of the complainant herein, and the medical bills were also considered by the Lok Adalat, question of again asking for reimbursement before this Forum on the same set of medical bills does not arise.

17.  The opposite party counsel invited our attention to Clauses - 7 and 8 and Regulation-3.30 of ESI Medical Manual and contended that these clauses are not applicable to the facts of the present case on hand, and as such the complainant is not entitled for medical reimbursement. Clause-7 reads as follows:-

“Serious cases of accident or illness admitted directly into recognized hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer”.

 

Clause-8 reads as follows:-

“Serious cases of accident / illness  where a beneficiary was admitted directly at a private hospital or in a non-recognized hospital, where admission in a hospital recognized under the scheme would have seriously jeopardized his health like sudden heart attacks, fracture of the spine, cerebral hemorrhage etc.

 

 18.  The complainant marked Ex.A4, which is Emergency Certificate issued by Apollo Hospital, Chennai, in which it is mentioned that Mr.Nadhamuni Reddy, father of the complainant had complaints of pain and swelling over right leg and right foot, abrasions over head because of history of road traffic accident and diagnosed right tibial proximal 1/3 and mid 1/3 junction fracture, right fibula neck fracture and distal fibula fracture. The opposite party counsel contended that by any stretch of imagination, it cannot be said that the fracture suffered by the injured was very serious in nature and therefore Clause-7 cannot be applied to the facts of the present case on hand. Similarly, the injury suffered by the complainant’s father in the accident will not seriously jeopardize his health like sudden heart attack, fracture of the spine or cerebral hemorrhage. After perusing the relevant Clauses and Regulation-96A of ESI Medical Manual, we agree with the counsel for the opposite party that claim submitted by the complainant does not fall within the ambit of Clause-3.30 of ESI Medical Manual.

19.  We, therefore, hold that there is no deficiency in service on the part of opposite parties, since the complainant is not entitled for medical reimbursement, as per the above Clauses and ESI Medical Manual. Further, the case status in MVOP No.46/2015 filed by opposite party No.4, shows that the father of the complainant claimed compensation including medical reimbursement and the matter was settled with the insurance company. Hence, this point is answered against the complainant holding that he is not entitled for medical reimbursement in view of Regulation-96A and Clause-3.30 of ESI Medical Manual.

20.  In the result, complaint is dismissed. No costs.        

              Dictated to the stenographer, transcribed and typed by him, corrected and pronounced by me in the Open Forum this the 6^th day of February, 2020.

 

       Sd/-                                                                                                                      Sd/-                                                                                                                             

Lady Member                                                                                               President (FAC)

 

APPENDIX OF EVIDENCE

 

 

Witnesses Examined on behalf of Complainant/s.

 

PW-1: M. Rajasekhar (Chief Affidavit filed).

 

Witnesses Examined on behalf of Opposite Party/s.

 

RW-1: K. Venkata Subramanyam Prasad (Chief Affidavit filed).

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT/s

 

Exhibits (Ex.A)	Description of Documents
	Photo copy of FIR in Crime No. 210/2014 of Alipiri PS, Tirupati. Dt: 16.08.2014.
	Photo copy of Charge Sheet in C.C.No.03 of 2015 on the file of IV Additional Judicial Magistrate of First Class, Tirupati.  Dt: 03.01.2015.
	Original copy of Discharge Summary issued by the Authorities of Apollo Hospitals, Chennai. Dt: 09.08.2014.
	Original copy of Emergency Certificate issued by the Authorities of Apollo Hospitals, Chennai. Dt: 14.08.2014.
	Original copy of Essential Certificate issued by the Authorities of Apollo Hospitals, Chennai. Dt: 20.08.2014.
	Original copy of Statement of Medical Bills containing 20 pages worth of Rs.2, 82,969/-. Dt: 22.08.2014.
	Original copy of Advance Stamp Receipt of Rs.2, 82,969/- signed by the complainant.
	Original copy of Details of  Bank Account for transfer of funds through online of the complainant. Dt: 26.08.2014.
	Original copy of Employees State Insurance Corporation (Certificate of Re-employment/ Continuing employment) issued by the Deputy Executive Engineer (Environmental) Municipal Corporation, Tirupati in favour of Complainant.
	Representation made by the complainant to the ESI Hospital Authorities. Dt: 01.09.2014 (Original copy).
	Original copy of Letter issued by the Branch Manager, ESI Corporation, Tirupati to the Superintendent, ESI Hospital, Tirupati.  Dt: 21.08.2014.
	Photo copy of ESIC Identity Card of the Complainant.
	Scrutiny Certificate issued by Incharge Medical Officer, ESI Dispensary, Tirupati (Original copy).
	Annexure (Checklist to be furnished by the Director of Insurance Medical Services, AP, Hyderabad along with proposal for Reimbursement of Medical Claims of I.P’s to Government.
	Photo copy of Return Memo issued by the Director of Insurance Medical Services, Hyderabad under the reason of “Facilities are available in E.S.I institutions”. Dt: 06.04.2015.
	Office copy of legal notice with postal receipts. Dt: 14.10.2015.
	Acknowledgements of Opposite Parties 1 to 3.
	List of Tie-Up arrangements with Super Specialty Hospitals only for IP’s in Andhra Pradesh.

 

EXHIBITS MARKED ON BEHALF OF THE OPPOSITE PARTY/s

 

Exhibits   (Ex.B)	Description of Documents
1.	Attested copy of ESI Medical manual extracts clause 3 (Containing Pages 56 to 60)
2.	Attested copy of List of Tie-Up arrangements with Super Specialty Hospitals only for IP’s.

 

 

                                                                                                                                          Sd/-                              

                                                                                                               President (FAC)

             

           // TRUE COPY //

// BY ORDER //

 

Head Clerk/Sheristadar,

                 Dist. Consumer Forum-II, Tirupati.

           

          

 

 Copies to:-    1. The complainant.

                       2. The opposite parties.