IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 21st day of June, 2014.
Present : Sri. Jacob Stephen (President)
Smt. K.P. Padmasree (Member-I)
Smt. Sheela Jacob (Member-II)
C.C. No. 40/2014 (Filed on 26.03.2014)
Between:
Abraham. T. Thomas,
Thuruthiyil Puthen Veedu,
(Chitralayam), Edayaranmula P.O.,
Pathanamthitta District, represented
by Power of Attorney Holder Smt.
Mariamma Varghese, Mattathuvadakkethil-
House, Cherimukku, Konni P.O.,
Pathanamthitta. … Complainant.
(By Adv. Susanna Geroge)
And:
The Joint Director,
Office of the Joint Director,
Central Govt. Health Scheme,
2/117, Mosque Lane,
Kesavadasapuram,
Thiruvananthapuram – 695 004. … Opposite parties.
ORDER
Sri. Jacob Stephen (President):
The complainants have filed this complaint against the opposite party for getting a relief from the Forum.
2. The brief facts of this complaint is as follows: The complainants are the children of late T.A. Thomas and late Rajamma Thomas. The complainant’s father T.A. Thomas died on 06.01.2008 and the complainant’s mother died on 18.01.2014. This complaint is filed by the Power of Attorney Holder Smt. Mariamma Varghese for and on behalf of the complainants. Late Mr. T.A. Thomas, the father of the complainants was a permanent member of Central Government Health Scheme (CGHS) vide CGHS card No. 23587/TVM. Being the sole dependent of late T.A. Thomas, his wife and the mother of the complainants Smt. Rajamma Thomas is entitled to get her treatment expenses of Rs. 3,69,525-00, in respect of her treatment on 04.03.2013 and 01.12.2013 re-imbursed from Central Government Health Scheme and the opposite party is responsible for allowing the said reimbursement. Though the claim was submitted, opposite party rejected the claim on the following grounds vide their letters dated 10.05.2013, 04.02.2014 and 24.02.2014:
- The claim is time barred.
- IFSC code/MICR not mentioned in MRC proforma.
- Signature of card holder and duplicate application are required.
- Affidavit/Legal heirship certificate are required.
- Separate claims are required for each admission to discharge.
Since the claimant Rajamma Thomas was bed-ridden, the repudiation of the above said claim is illegal and is a clear deficiency in service which caused financial loss and mental agony to the complainants being the claimants of the above said claim and hence opposite party is liable to the complainants for the same. Hence this complaint for an order directing the opposite party to allow the above said reimbursement claim of Rs. 3,69,525-00 and compensation of Rs. 5,000/- and cost of this proceedings.
3. An authorized officer of the opposite party appeared and submitted their counter as a statement before this Forum, in which it is stated that they have received more than one claim as a bunch in respect of the aforesaid reimbursement on 31.12.2013. One of the claims was time barred and the other was not time barred. So they returned the claim with the following remarks:
- Claim may be separated as time barred and non time barred.
- IFSC code/MICR code may written.
- Signature of the claimant/card holder and duplicate claim may be enclosed.
- Affidavit/legal heirship certificate may be enclosed with the claim.
- Claim may be separated for each admission to discharge.
It is also stated in their counter that they have intimated the claimant that the claimant can resubmit the medical reimbursement claim after fulfilling the above mentioned remarks and thereafter the medical reimbursement claim will be settled as per rules. Apart from the above statement, opposite party has not filed any separate version. So this Forum accepted the said statement as their version.
4. On the basis of the pleadings of the parties, the only point to be considered is whether this complaint can be allowed or not?
5. The evidence of this complaint consists of the oral deposition of the Power of Attorney Holder of the complainants as PW1 and Exts. A1 to A5. After closure of evidence, complainant was heard as opposite party did not turned up subsequent to the closing of the complainant’s evidence.
6. The Point: The complainants’ case is that the medical reimbursement entitled to them under CGHS in respect of their deceased mother’s treatment was denied by the opposite party illegally. Because of the above said act of the opposite party, complainants are put to mental agony and financial loss and the act of the opposite party is a clear deficiency in service and hence opposite party is liable to the complainants for the same and the complainants prays for allowing the complaint.
7. In order to prove the case of the complainants, Power of Attorney Holder of the complainants filed a proof affidavit in lieu of her chief examination along with certain documents. On the basis of the proof affidavit, she was examined as PW1 and the documents produced are marked as Exts. A1 to A5. Ext. A1 is the Power of Attorney executed by the complainants in favour of PW1. Ext. A2 is the copy of the permanent membership card issued under Central Government Health Scheme in the name of the complainants’ parents. Ext. A3 series are the bundle of hospital bills for Rs. 3,69,525-00 as per the statement attached therein. Ext. A4 series (A4 to A4(b) are the letters dated 10.05.2013, 17.01.2013 and 04.02.2014 sent by the opposite party in the name of the original card holder Mr. T.A. Thomas for curing the defects of the claim. Ext. A5 is the copy of the death certificate dated 27.01.2014 in respect of the death of Smt. Rajamma Thomas, the mother of the complainants, issued from Aranmula Grama Panchayat.
8. On the other hand, the gist of the contentions of the opposite party as per their statement/version is that the claim in respect of the reimbursement in question received by them was not proper and for processing the claim, certain documents and clarification are required and they have properly communicated the same to the claimants vide their letters and they are prepared to settle the claim on getting the required documents and clarifications from the claimants as requested by the opposite party and the same was not submitted by the claimants so far. But they have not adduced any oral or documentary evidence in their favour and not even cross examined PW1.
9. On the basis of the contentions of the parties and on the basis of the available materials on record, it is seen that late Rajamma Thomas, the mother of the complainants is entitled to get her treatment expensed reimbursed under Central Government Health Scheme being the dependent of late T.A. Thomas who was a permanent member of the said scheme and the claimants are entitled to get the reimbursement in question as per the terms and conditions of the said scheme being the legal heirs of the deceased claimant. The allegation of the complainants is that the opposite party repudiated their claim illegally. But on a perusal of Exts. A4 to A4(b) dated 10.05.2013, 04.02.2014 and 24.02.2014 it is seen that the claim of the complainants is not rejected and is further seen that the claim of the complainants is returned by the opposite party for want of certain documents and clarifications. Further in the statement submitted by the opposite party, they have clearly stated that they are prepared to settle the claim on getting the required documents and clarifications. So it is clear that the claim of the complainants is not said to be rejected so far. At the same time, there is no evidence from the side of the complainants showing either they have submitted their claim in proper way or they have furnished all the required documents and clarifications as requested by the opposite party. Further, the evidence adduced by the complainants before this Forum is also not sufficient for this Forum for taking a decision against the opposite party for any deficiency in service. In the circumstances, we are constrained to disallow this complaint as this complaint is found as premature.
10. However, the above observation does not means that the complainants are not entitled to get their medical reimbursement claim.
11. In the result, this complaint is disposed with following directions:
- The complainants are directed to re-submit their reimbursement claim before the opposite party within 30 days from the date of receipt of this order, as per the directions given in Ext.A4 to A4(b) letters issued by the opposite party and as per the terms and conditions of the Central Government Health Scheme and, if the complainants submits their claim as directed herein above.
- The opposite party is directed to process the complainants’ claim within 30 days from the date of receipt of the claim and allow the amount entitled to the complainants without considering the question of time bar if the treatment records shows that the patient was continuing her treatment from 04.03.2013 onwards.
- In the circumstances, there will be no orders for cost.
Dictated to the Confidential Assistant transcribed and typed by him, corrected by me and pronounced in the Open Forum on this the 21st day of June, 2014.
(Sd/-)
Jacob Stephen,
(President)
Smt. K.P. Padmasree (Member-I) : (Sd/-)
Smt. Sheela Jacob (Member-II) : (Sd-)
Appendix:
Witness examined on the side of the complainants:
PW1 : Mariamma Varghese.
Exhibits marked on the side of the complainants:
A1 : Power of Attorney executed by the complainants in favour of PW1.
A2 : Copy of the permanent membership card issued under Central Government
Health Scheme in the name of the complainants’ parents.
A3 : Bundle of hospital bills for Rs. 3,69,525-00 as per the statement attached
therein.
A4 series (A4 to A4(b) : Letters dated 10.05.2013, 17.01.2013 and 04.02.2014 sent by the
opposite party in the name of the original card holder Mr. T.A. Thomas.
A5 : Copy of the death certificate dated 27.01.2014 of Smt. Rajamma Thomas, issued
from Aranmula Grama Panchayat.
Witness examined on the side of the opposite parties : Nil.
Exhibits marked on the side of the opposite parties : Nil.
(By Order)
(Sd/-)
Senior Superintendent
Copy to: (1) Abraham. T. Thomas, Thuruthiyil Puthen Veedu, (Chitralayam), Edayaranmula
P.O., Pathanamthitta District, represented by Power of Attorney Holder Smt.
Mariamma Varghese, Mattathuvadakkethil House, Cherimukku, Konni P.O.,
Pathanamthitta. …
(2)The Joint Director, Office of the Joint Director, Central Govt. Health Scheme,
2/117, Mosque Lane, Kesavadasapuram, Thiruvananthapuram – 695 004.
(3) Stock file.
