IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,
Dated this the 20th day of December, 2011.
Present : Sri. Jacob Stephen (President).
Sri. N. Premkumar (Member)
C.C.No. 96/2010 (Filed on 03.07.2010)
Between:
Rajamma Thomas,
Thuruthiyil Puthen Veedu,
(Chithralayam),
Edayaranmula.P.O.,
Pathanamthitta.
(By Adv. Susanna George) ….. Complainant
And:
The Joint Director,
O/o the Joint Director,
Central Government, 2/117,
Mosque Lane,
Kesavadasapuram,
Thiruvananthapuram – 695 004.
(By Adv. N.K. Balasubrahmaniyam) ….. Opposite party
O R D E R
Sri. N. Premkumar (Member):
Complainant filed this complaint for getting a relief from the Forum.
2. Facts of the case in brief is as follows: Complainant is a permanent member of Central Government Health Scheme and she is holding C.G.H.S Card No.235871/Thiruvananthapuram. Her husband T.A. Thomas was employed in the Defence service. He expired on 06.01.2008. She is a dependent of T.A. Thomas. He had contributed a sum of `4,830 towards permanent membership of C.G.H.S, Thiruvananthapuram. This health scheme is to provide comprehensive medical care facilities to Central Government employees, pensioners and members of their families.
3. The complainant was admitted in Poyyanil Hospital, Kozhencherry due to fracture of her left hand. She was treated there from 2.6.09 to 5.8.09. After that, she continued treatment still now. She is aged about 82 years. She is not in a position to live without the help of others. Complainant has claimed the reimbursement of medical expenses incurred for her treatment on February 2010. The same was rejected by opposite party stating that claim has not been submitted within time, some vouchers are not in connection with the discharge bill and outpatient treatment is not reimbursable. Opposite party’s rejection of claim is quite unreasonable and against all principles of natural justice. She is in need of somebody’s help even to move about and follow her ordinary perusals. Hence this complaint for getting the claim amount, compensation and cost.
4. Opposite party entered appearance and filed version stating that complaint is not maintainable either in law or on facts. According to them, this Forum has no jurisdiction to entertain this case. The Central Administrative Tribunal is having jurisdiction to entertain this matter. The complainant is not a consumer coming within the definition of a consumer.
5. Opposite party admit that complainant is a permanent card holder under General Ward category having C.G.H.S Card No.23587. Complainant is alleged to have undergone treatment in a private hospital for fracture of left hand. She taken treatment in June, 2009 and continued follow up treatment without informing C.G.H.S Dispensary at Thiruvananthapuram. She submitted a claim on 15.2.2010 after a period of nine months. This shows that complainant’s alleged fracture and claim made by her is not bonafide. As per the norms prescribed a claim under MRC has to be preferred within a period of 90 days. As per the norms complainant has to seek opposite party treatment from C.G.H.S Dispensary or Government Hospital as advised by C.M.O of C.G.H.S Dispensary. Complainant has taken treatment in a hospital which is not at all recognized.
6. According to them, many bills and dates of bills are not matching with date of admission and discharge made in the discharge summary. Therefore, claims made by the complainant is illusory and bogus. Complainant at the time of joining the scheme given an undertaking that she would abide by the rules and regulations and modification of services which may be issued from time to time. It is prescribed in the C.G.H.S Scheme that for O.P.D treatment beneficiaries should get the medicines only from CGHS Dispensary concerned and cost of medicines purchased from outside is not reimbursable. Hence they canvassed for the dismissal of the complaint.
7. From the above pleadings, following points are raised for consideration:
(1) Whether the complaint is maintainable before the Forum?
(2) Whether the reliefs sought for in the complaint are allowable?
(3) Reliefs and Costs?
8. Evidence of the complaint consists of the oral deposition of PW1 and Exts.A1 to A6 series. After the closure of evidence, both parties were heard.
9. Point Nos.1 to 3:- In order to prove the complainant’s case, complainant filed proof affidavit along with documents. Complainant’s power of attorney holder is examined as PW1 and the documents produced were marked as Exts.A1 to A6. Ext.A1 is the copy of power of attorney executed by the complainant. Ext.A2 is the copy of legal notice sent to opposite party. Ext.A3 is the reply notice of Ext.A2. Ext.A4 is the attested copy of Central Govt. Health Scheme Card No.23587. Ext.A5 is the letter issued by opposite party to complainant. Ext.A6 series are the medical bills of the complainant.
10. Apart from version, opposite party has not adduced any oral or documentary evidence to prove their case.
11. On the basis of the contention and averment of the parties, we have perused the entire material on record. Complainant’s case is that, she is an aged widow and a permanent member of Central Government Health Scheme. The said scheme provides comprehensive medical care facilities to its members. Complainant sustained fracture and hospitalized and her claim for reimbursement of medical bill was rejected on flimsy ground. Opposite party’s contention is that complainant has not submitted the claim within 90 days and the treatment taken by the hospital is not recognized. Moreover, complainant violates the rules and regulations and the modification of the scheme that the beneficiaries should get the medicine only from the C.G.H.S Dispensary and the cost of medicines purchased from outside is not reimbursable.
12. There is no dispute that complainant is not a beneficiary of the C.G.H Scheme and her ailment. One of the contentions of opposite party is that the claim of complainant is time barred. But evidence on record shows that she is aged and bed ridden and has undergone continuous treatment due to fracture and allied ailment. She has been weak and disabled and during the period of continuous treatment she submitted the claim. As per Ext.A6, complainant has been under treatment on 2.6.09 and a bill from Poyyanil Hospital dated 15.02.2010 shows that she has continuing the treatment even after filing the claim. Even any delay in claiming the benefit it is based on sufficient cause and hence delay is condonable as per humanitarian ground. Since it is a beneficiary scheme for the dependent of the pensioners, opposite party should act as per good conscience not mechanically.
13. On a perusal of Ext.A4, it is recorded as “Indoor & Outdoor treatment”. It means that complainant is allowed to reimburse inpatient and outpatient treatment claims. Therefore opposite party stand an outpatient treatment is not reimbursable” is not sustainable. Moreover, if any modification in the rules and regulations of the scheme, material on record shows that such modification has not been informed to complainant.
14. It is pertinent to note that complainant is admitted and treated for fracture and allied ailment. Evidence on record shows that it is a continuous treatment. According to opposite parties, some vouchers enclosed in the claim are from 2008-09 and no connection with the discharge bill. But they failed to point out any particular bill or vouchers. Since the complainant is aged and the treatment is continuous, there may have some other ailment not closely connected with the discharge bill. That does not mean that she is not entitled to get the benefit of the C.G.H Scheme. Therefore, opposite party’s contention of bill period in Ext.A5 is not sustainable. Moreover opposite party has not a case that complainant has not such an ailment as claimed. Therefore denying claim without valid reason is irregular, irrational, illegal and against the spirit of consumer justice. Moreover, opposite party has not adduced any material either to prove their contention or to disprove the complainant’s case.
15. From the above facts and circumstances of this case and on the basis of the available evidence on record the denial of medical claim of complainant is not only a clear deficiency of service but also a breach of contract as reposed by the complainant. Since the principle of C.G.H Scheme is for the welfare and benefit of its members, the interest of justice, we are of the view that complainant’s claim is allowable and maintainable before this Forum. Considering the facts and circumstances of the case, no amount is allowable for compensation and cost.
16. In the result, complaint is allowed thereby the opposite party is directed to pay Ext.A6 series bill amount to the complainant within one month from the date of receipt of this order, failing which the complainant is allowed to realize the whole amount with 10% interest from this date till the realization of the whole amount.
Declared in the Open Forum on this the 20th day of December, 2011.
(Sd/-)
N. Premkumar,
(Member)
Sri. Jacob Stephen (President) : (Sd/-)
Appendix:
Witness examined on the side of the complainant:
PW1 : Maniyamma Kurian
Exhibits marked on the side of the complainant:
A1 : Photocopy of power or attorney executed by the complainant.
A2 : Photocopy of advocate notice dated 15.5.2010 sent by the complainant
to opposite party.
A3 : Reply letter dated 18.5.2010 sent by the opposite party to the
complainant.
A4 : Attested copy of Central Govt. Health Scheme Card No.23587.
A5 : Letter dated 31.3.2010 issued by opposite party to complainant.
A6 series : Medical bills of the complainant.
Witness examined on the side of the opposite party:
Exhibits marked on the side of the opposite party:
(By Order) (Sd/-)
Senior Superintendent.
Copy to:- (1) Rajamma Thomas, Thuruthiyil Puthen Veedu, (Chithralayam),
Edayaranmula.P.O., Pathanamthitta.
(2) The Joint Director,O/o the Joint Director, Central Government,
2/117, Mosque Lane, Kesavadasapuram,
Thiruvananthapuram – 695 004.
(3) The Stock File.
