Orissa

Sundargarh

CC/118/2019

Randhir Singh - Complainant(s)

Versus

The Insurance Medical Officer, I/c, ESI Dispensary, Rajgangpur - Opp.Party(s)

Sri Satyajit Panda, Adv. & Associates

03 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: SUNDARGARH-1

CONSUMER COMPLAINT CASE NO. 118 OF 2019

Randhir Singh, aged about 52 years,

S/o: Umesh Prasad Singh,

Occupation: - Service,

Ro: - Cinema Pada, Rajgangpur,

Po/Ps: - Rajgangpur,

Dist: Sundargarh, Odisha.                   ….        ….        ….        ….        ….        .Complainant.

Versus

1. The Insurance Medical Officer,

I/c, ESI Dispensary, Rajgangpur,

Po: - Rajgangpur,

Dist: - Sundargarh, Pin-770017.

2. Directorate of Employees State Insurance Scheme,

Bhubaneswar, Odisha, Pin-751001.                ….        ….        ….        .Opposite Parties.

Counsel for the Parties:-

For the Complainant                           : - Sri Nimai  Naik, Adv. & Associates.           

For the Op No. 1 & 2                           : - None.   

.

Date of Order: 03.11.2022

Present

      1. Sri Dr. Ramakanta Satapathy,President.

                    2. Sri Sadananda Tripathy, Member.

Presented by Sri Sadananda Tripathy, Member.

1. The Brief fact of the Complainant is that the Complainant is an employee of Hari Machines limited . He is covered both the claim and medical benefits under the ESI Corporation for which he is issued the e-Pehchan Card whose insurance no is 440155152 registered on 23.06.2007. In that Card he is entitled to get same benefit of his family members which are as many as six dependent members being his spouse Sanju Singh, father Umesh Prasad Singh, Puja Singh Unmarried daughter, Ankesh Singh minor son and Anuska Singh unmarried daughter. On 13.03.2018 his unmarried daughter Anuska Singh suffering from I.T.P was checked up at ESI Dispensary, Rajgangpur on 13.03.2018. The O.P No. 1 then referred her to JD  ESI Hospital, Rourkela and on the same day she was referred to SCB, Cuttack for better and proper treatment. She was admitted as indoor patient into SCB, Cuttack on 16.03.2018 and was discharged on 17.03.2018. During which the Complainant spent on medicine amounting to Rs. 5,543.72, Total no of bill is 14 duly attested by Dr. R. K Nayak Asst. Professor SCB, Cuttack who then the Complainant sent the same to the office of the O.P No. 2 for needful. After a prolonged period of more than one year the O.P No. 2 sent a letter to the Complainant denying the reimbursement of the expenses spent on the treatment of his unmarried daughter in SCB, Cuttack of the period 16.03.2018. In that letter the Joint Director in consultation of his Standing Committee members of the ESI Scheme, Odisha alleged to have returned back the original bills along with other documents as the medicines were purchased after the treatment period is over. Further objection is that the discharge ticket has been tampered. To this the complainant adds that he is not yet issued the original bills and other documents which he ought to have been issued nextpoint which the Complainant likes to draw the attention of the Hon’ble Commission is that the medicines are purchased under the treatment of Dr. R.K.Nayak who has duly certified the same. Besides the O.P No. 2 taking the plea that the discharge ticket has been tampered may be viewed seriously. The O.P No. 2 cannot be spared to be punished heavy fine for the deficiency of service rendered to the Complainant. The Complainant is undergoing acute torture of mental, physical, moral, social, financial just after the discharge from the hospital till date.
2. The written statements/reply show cause notice of the O.P No. 1 on behalf of O.Ps is that the Complainant bearing insurance Number 4401555152 has submitted the R.C.M claim for Rs. 5543.72 incurred during treatment of his daughter Ms. Anuska Singh at S.C.B Medical College and Hospital, Cuttack vide R.C.M receipt no- 94 dtd. 8.6.2018 of ESI Dispensary, Rajgangpur. The patient was referred on dtd. 14.03.2018 to S.C.B medical college and Hospital, Cuttack where she was admitted from dtd. 16.03.2018 to 17.03.2018. But the cash memos submitted by the I.P were from dtd. 20.03.2018 to 27.03.2018, so the said claim had been sent to the Director, ESI Scheme, Odisha for necessary sanction after approval of standing committee vide letter No- 565 dtd. 14.08.2018. On dtd. 28.01.2019 the claim of the Complainant was placed before the Standing Committee, the Committee Members after examining the treatment record opined that the Medicines were purchased after the treatment period is over. Besides it is seen that the discharge ticket has been tampered. Hence, the Committee Members decided not to reimburse the claim. The Complainant has been intimated vide letter no. 444 dtd 02.07.2019 of ESI Dispensary, Rajgangpur. Further, the Essentiality Certificate issued by Asst. Professor, Dept of Clinical Haematolgy, S.C.B medical College, Cuttack is tampered in the treatment period. In the Discharge record Issued by Dept of Clinical Haematolgy, S.C.B Medical College, Cuttack is also tampered in the date of admission and date of discharge.​                                                                                                        From the above mentioned observations, it is clear that the decision of Standing Committee not to reimburse the R.C.M claim of the Complainant is justifiable.
3. Perused the allegation made by the Complainant in the Petition and the objection filed by the O.P. As per the provision ESI (General Regulations, 1950 U/S. 95-A (2) Medical benefit to families of insured persons, it is clearly said that the family of an insured person shall become entitled to medical (from the day the insured person himself) benefit and shall continue to be so entitled so long as the insured person is entitled to receive medical benefit for himself. However the allegation of tampering is not proved but all the medicines are purchased by the Complainant is proved. So the case is disposed of accordingly. 

Issues

1. Is the Complainant a Consumer of the O.Ps?
2. Is there any deficiency of service in part of O.Ps?
3. Whether the Complainant is entitled for getting any relief from the OPs?

Issue No. 1

Is the Complainant a consumer of the O.Ps?

The Complainant is an employee of Hari Machines limited. He is covered both the claim and medical benefits under the ESI Corporation for which he is issued the e-Pehchan Card whose insurance no is 440155152 registered on 23.06.2007. In that Card he is entitled to get same benefit of his family members which are as many as six dependent members. So the Complainant is the consumer of the O.Ps as per the CP Act.

Issue No. 2

Is there any deficiency of service in part of O.Ps?

The OPs have failed to proved the allegation of tampering mentioned in their objection but all the medicines are purchased by the Complainant is proved however in the later stage or in the same day and as per the ESI Act and regulations, the insured person becomes entitled to get medical benefit and shall continue to be so entitled so long as the insured person is entitled to receive medical benefit for himself.  Hence the O.Ps are deficient in service.

Issue No. 3

Whether the Complainant is entitled for getting any relief from the OPs?

From all the facts of the parties, the Complainant is entitled for getting reliefs what he claims in his complaint petition from the Ops.

Order

The case is disposed of on contest. The Ops are directed to give Rs. 5,543.72 towards cost of the medicines with 9% interest from the date of filling of the case to the date of given to the Complainant, Rs. 20,000/- towards deficiency of service and Rs. 5,000/- towards cost & litigation expenses of the petition to the Complainant within 30 days from the date of order, failing which the amount will further carry with 9% interest per annum till realization to the Complainant.

Order pronounced in the open Court today on 3^rd day of Nov’2022.

Free copies of this order to the parties are supplied.

 I agree.                                                                                                                                  

                                         

          Dr. Ramakanta Satapathy, President                                                       Sadananda Tripathy    

                       Member

 

                                                Dictated and corrected by me

 

                                                              Sadananda Tripathy, Member