BEFORE THE PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

C.C NO-68/2014

Present-Sri Dipak Kumar Mahapatra, President, Smt. Smita Tripathy, Member (W).

Subash Kumar Nag,aged about 57 years,

S/O- Late Dinu Kumar Nag,Qtr No- E-180, HIndalco Colony,

P.O/P.S-Hirakud,Dist- Sambalpur.                                                                       …..Complainant

Vrs.

1. The Insurance MedicalOfficer,

ESI Dispensary Hirakud,

2. The Director,

ESI Scheme,Bhubaneswar,Orissa.……O.Ps

Counsels:-

1. For the Complainant:-        Sri S.K.Mishra, Advocate & Associates.
2. For the O.P-1            &2       :-         Sri A.K.Senapat, Govt. Pleader.

DATE OF HEARING : 08.03.2021, DATE OF ORDER : 12.04.2021

SRI DIPAK KUMAR MAHAPATRA,PRESIDENT:-Brief facts of the case is that the Complainant is an employee of Hindalco,  Hirakud and  was insured with the O.P vide policy no-530168. The Complainant had a chest pain on dtd. 23.01.2008 and reported the matter to the O.P-1. The O.P-1 advised him to go to VSS Medical College Hospital, Burla for better treatment and the Complainant did accordingly. He admitted there for two days  and the treating doctors examined him  and found WPE syndrome  and they referred to AIMS Delhi for higher medical treatment. The O.P-1 wrote O.P-2 to take necessary steps for treatment of the Complainant at AIIMS. Vide letter no-264 dtd. 21.04.2008. The O.P-2 arranged finance for the treatment of the Complainant  and the sanction letter was communicated to the Complainant on dtd. 15.05.2009 vide letter no-4183.  The Complainant was admitted in AIIMS on dtd. 20.06.20009 and surgery was conducted on dtd. 25.06.2009 and he was discharged on dtd.03.07.2009. He stayed in Delhi for pre and post check up for 67 days. Thereafter the Complainant availed fitness certificate and joined in his duty and submitted all the medical prescription, medicine bills tickets of travelling and bills of expenditure at Delhi to the O.P-1 for reimbursement. But the O.Ps failed to settle the bills in spite of the payment f insurance premium to the O.Ps time to time. The complainant has faced heavy financial loss ,mental agony and pain due to mischief and unfair trade practice of the O.Ps for which the Complainant has prayed for certain relief as prayed.

The claim of the Complainant comes under Employees State Insurance Act. The Professor  and HOD of Cardiology  Department VSS Medical College Hospital, Burla has referred the Complainant to the Department of Cardiology AIIMS New Delhi as a case of WPW SYNDROME. With an estimation certificate of Rs.25,000/- vide letter no-3090/MCH dtd. 20.03.2008. The letter of treatment for the Complainant for treatment was forwarded to the Directorate of ESI Scheme Orissa, Bhubaneswar on 21.04.2008 by the O.P-1. The Govt. of India in Labour and Employment Department  in the memo no-9151(4)LE dtd. 27.08.2008  sanctioned a sum of Rs.20,000/- to AIIMS Delhi and accordingly the Directorate of ESI Scheme Orissa  issue and transmitted  an A/C- payee cheque   vide no-669207  dtd. 01.10.2008 amounting to Rs. 20,000/- to the accounts Officer  CN Centre  AIIMS New Delhi  with a request letter  to provide  medical treatment  to the Complainant.  After receipt of first phase treatment the Complainant has applied for the 2^nd phase of treatment  as per the recommendation  of professor and HOD Cardiology Department IIMS Delhi  for surgery with estimation of Rs80,000/- and an account payee  cheque bearing no-344260 dtd. 06.05.2009 was issued accordingly. After receipt of treatment the Complainant neither submitted the treatment record to the O.Ps nor the CN Centre AIIMS New Delhi  submitted the utilization certificate to the Directorate ESI, Odisha , Bhubaneswar. The Complainant submitted RCM Claim bill amounting to Rs.63,072/- and submitted T.A bill, Train Fare Bill and lodging charges Rs. 23,384/- for necessary sanction but they were not in order and not supported by required documents for which those were objected at Dispensary level. The Complainant was asked to comply the objection to get the RCM bill but the Complainant was failed to so. The bill was not settled due to the negligence of the Complainant himself. The Complainant has already received a sum of Rs.1,00,000/- through CN centres AIIMS New Delhi  but he has not disclosed the fact to the Forum. Hence he is not committed any deficiency in service and shall not be penalised.

As the case is a “YEAR OLD CASE”, this Commission has rightly decided to dispose the case on merit basis.

POINTS OF DETERMINATION:-

1. Whether the Complainant is comes under the purview of Consumer Protection Act-2019?
2. Whether the O.Ps has committed any Deficiency in Service to the Complainant?

From the above discussion and materials available on records we inferred that the Complainant comes under the purview of Consumers as being an employee of Hindalco,  Hirakud and  was insured with the O.P vide policy no-530168. During the service period he fell ill and he was sent to AIIMS Delhi to avail higher medical facilities by the O.Ps. After his recovery from illness he availed fitness certificate and joined in his duty and submitted all the medical prescription, medicine bills tickets of travelling and bills of expenditure at Delhi to the O.P-1 for reimbursement but the claim was not settled. The claim was not settled as the relevant documents filed by the Complainant were remain pending for necessary sanction as but they were not in order and not supported by required documents for which those were objected at Dispensary level. The Complainant was asked to comply the objection to get the RCM bill but the Complainant was failed to do so. Basing on the above observation we order as follows:-

ORDER

That the Complaint petition is allowed. The O.P-1 & 2 are jointly and severally  directed to settle the claim and reimburse the amount which were incurred during the treatment of the Complainant along with interest @ of 5% p.a from the date of filing of this case dtd. 12.12.2014. Further the O.P-1 & 2 are jointly and severally directed to pay Rs.5,000/-(Rupees Five Thousand) by way of compensation to the Complainant for causing him mental, physical and financial loss and agony and Rs. 5,000/-(Rupees Five Thousand) as litigation costs. This amount shall be paid by the OP to the Complainant within a period of one month from the date of receipt of a certified copy of this order, failing which the OPs shall pay interest @ 5% per annum on this amount from the date of order till its realisation."

Order pronounced in the open Court today i.e, on 12^th day of April 2021 under my hand and seal of this Commission.

Office is directed to supply copies of the Order to the parties free of costs receiving acknowledgement of the delivery thereof.

I agree,                                                                                            

-Sd/-                                                                                                   -Sd/-

MEMBER(W)                                                                                                PRESIDENT  

                                                            Dictated and Corrected

                                                                             by me.

                                                                               -Sd/-

   PRESIDENT