Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.07/06.01.2015
Bharat Bhushan R/o A-18, D.D.A. Flats,
Vivekanand Puri,Sarai Rohilla, Delhi-110007 …Complainant
Versus
OP1. Union of India,
[through Ministry of Health and Family Welfare],
Nirman Bhawan, New Delhi - 110001
OP2. Additional Secretary & DG (CGHS),
Ministry of Health and Family Welfare,
Nirman Bhawan, New Delhi -110001
OP3. Additional Director (NZ), CGHS,
New Rajender Nagar, New Delhi-110068.
OP4. DR. K K Sethi, Chairman & Managing Director,
Delhi Heart & Lungs institute, 3 MM-II, Panchkuian Road,
New Delhi-110055.
OP5. Director Administration, Sir Ganga Ram Hospital,
Sir Ganga Ram Hospital Marg, Rajender Nagar,
New Delhi-110006 Opposite Parties
Senior Citizen Case
Order Reserved on: 15.02.2023
Date of Order: 12.05.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Inder Jeet Singh
ORDER
1.1. (Introduction to parties and their status) : The complainant/Bharat Bhushan is a pensioner. He was working as Assistant Director in Ministry of Panchyati Raj and retired from Ministry of Panchyati Raj, Patel Chowk, Delhi on 30.04 2012. He holds Pensioner CGHS Card No. 702113 for his entitlement for Private Ward with validity upto whole life to avail said comprehensive health care facilities under CGHS Scheme.
Union of India/OP1 is the Controlling Authority to OP2/Addl Secretary & DG (CGHS) and of OP3/Addl Director (North Zone). OP2 is Head of Central Government Health Scheme (CGHS) and OP3 is Head of North Zone of CGHS in Delhi. The OP4 is Chairman & Managing Director of Delhi Heart Lung Institute, New Delhi and the OP5/Sir Ganga Ram Hospital are the hospitals, who diagnosed, then conducted/given treatment to complainant and raised the bills. However, OP5 is just a pro-forma party for the purpose of proper adjudication of the case.
The OP1 to OP3 provide comprehensive health care facilities for the Central Govt. employees, pensioners and their dependents residing in CGHS covered cities in India through Wellness Centers (previously known as CGHS Dispensaries/ polyclinics under Allopathic, Ayurveda, Yoga, Unani, Sidha, Homeopathic systems of medicines and empanelled Hospitals, Diagnostic Labs and Imaging Centers).
1.2. (Introduction to dispute of parties) : The complainant alleges deficiency of services and unfair trade practice against OP1 to OP3 & OP4 for want to making available cashless facilities despite entitlement despite a fit case as well as when complainant had approached OP1 to OP3 for appropriate sanctions, after his discharge without treatment from hospital for want of extending cashless facilities, the sanction was delayed and during delay of sanction by OP1 to OP3, emergent situation arisen, he was treated and operated in hospital of OP5; he had to arrange and pay the bills of Rs.7,29,354/-. When the claim was lodged and he was made to run from post to pillar, even then partly amount of Rs.3,00,611/- was settled without assigning reasons for not settling remaining amount of Rs.4,29,743.35p for which complaint is filed.
The complainant seeks directions to (i) pay him remaining amount of Rs. 4,28,743/- along-with 18% interest from the date of the treatment/payment made by the complainant to OP5 (ii) compensate the complainant for Rs. 80,000/- against interest required to be paid by the complainant on the amount taken from friends and relatives for the purpose of making payment of his operation expenditure in March 2013; (iii) compensate the complainant to the extent of Rs. 10,00,000/- as a compensation, damages, expenditure made by the complainant and his wife in pursuing permission/sanction letter, reimbursement of claim, representations/RTI applications to different authorities regarding his claim and harassment caused by the acts of the OPs.
1.3: Whereas, OP1, OP2 & OP3 denied the allegations stating that neither there is any deficiency in services nor unfair trade practice, since there are various norms, practice, circular and rules to be followed in the hierarchy for approval or sanction of medical bills that too within the parameters of pecuniary authority of each level. The case of complainant was also considered as per norms, rules, circulars etc apart from Standing Technical Committee. The allowable medical claim was sanctioned and disbursed to complainant.
1.4: Similarly, OP4 also opposed the complaint that factually the grievances of complainant are against OP1, OP2 & OP3, being his erstwhile employers as well as CGHS of complainant and not against OP4. The empanelled hospitals are under CGHS Scheme, they are governed and bound by the terms and guidelines issued by Ministry of Health and Family Welfare and the OP4 is also bound by circulars dated 12.06.1996 and 22.07.2014, accordingly the complainant was dealt under such norms and practice. There is no deficiency of services or unfair trade practice by OP4.
1.5: (development took place during pending of case) – The complainant filed complaint seeking reimbursement of balance amount of Rs. 4,28,743/- along with interest qua medical expenditure of his treatment. However, during the pending of complaint the complainant was further paid amount by the OP1, OP2 & OP3 as per proceedings dated 27.09.2018 and total amount paid was Rs. 5,47,563/- out of Rs. 7,29,354/-. However, till that date the evidence of parties was over. Consequently, medical claim is of balance amount of Rs. 1,81,791/-, apart from the other issues.
1.6. (Introduction to other details): . The record is voluminous, the complainant has narrated in detail the facts, features and figures in a chronological way, it would be appropriate to maintain that sequence and accordingly relevant facts will be mentioned in a chronological way to maintain the symmetry. The OPs have also mentioned their cases in the form of preliminary objections as well as on merits, the relevant facts will be mentioned , without their repetitions.
2.1 (Case of complainant) : The complainant has been suffering with heart diseases. In September, 1987 he had an acute and extensive myocardial infarction (a severe heart attack) at the age of 36 years. The said heart attack substantially reduced the efficiency of his heart and put him under constant medical supervision follows the proper medical treatment direct by the registered practitioner, thus, the complainant started taking medicine and precautions regularly. Then in the year 2007, he again suffered a heart attack and admitted to Sir Ganga Ram Hospital, New Delhi and this time severe blockage was detected in his cardiac arteries. He had undergone an operation containing a procedure called Stenting (Net pipes were planted in the artery), [the discharge summary is now Ex.CW-1/2 (Annexure-2)]. 2.2 In the December 2011, his heart beats rate got increased to almost double the normal rate and was hospitalized in B. L. Kapur Hospital, Rajender Nagar, New Delhi. They tried to control it with medicines but could not succeeded and finally he was cardioverted to normal sinus rhythm (electric shock/shocks were given to stop and restart the heart beat), which was a life threatening procedure. He remained hospitalised w.e.f. 13.12.2011 to 15.12.2011, [the discharge summary is now Ex.CW-1/3A to 1/3C (Annexure-3 Colly)]. Again in December 2011, the same problem re-occurred and this time he was hospitalised in Sir Ganga Ram Hospital, New Delhi where Atrial fibrillation and severe LV dysfunction was diagnosed. He remained hospitalized w.e.f. 19.12.2011 to 23.12.2011 and this time his heart beats were controlled with medicines, [the discharge summary is now Ex.CW-1/4A to 1/4B (Annexure-4 Colly)].
2.3 On 09.02.2013, he again faced the same problem increased heart beats and he rushed immediately to Delhi Heart and Lungs Institute, 3 MM-II, Panchkuian Road, New Delhi, being a CGHS empanelled Hospital for the similar medical treatment. He was advised (Dual Chamber ICD implant at the earliest to prevent sudden cardiac death" and asked to deposit a sum of Rs.6,36,250/- or get a sanction letter for this amount from CGHS Authorities for the above mentioned treatment, whereas the complainant was not in a financial position to arrange amount at that time and he requested hospital authorities for treatment since he (being a pensioner CGHS beneficiary) was entitled for cashless medical treatment in an empanelled Hospital but they refused since CGHS authorities make unnecessary objections and also delay reimbursement of amounts. They advised the complainant to bring approval from CGHS authorities in advance. Since no one was available in his family to obtain the approval, the complainant was constrained to get him discharged on 10.02.2013 on request, the record also shows so, with an advice to either arrange the said amount or get approval from CGHS authorities for implant of Dual Chamber ICD at to prevent sudden cardiac death, [the discharge at request is Ex.CW-1/5A to 1/5E (Annexure-5 Colly)], whereas the complainant was entitled to cashless medical treatment in an empanelled hospital being a pensioner CGHS beneficiary. There is gross violation of agreement by an empanelled Hospital under CGHS Scheme and severe negligence on the part of hospital authorities at the cost of the life of a patient who was in such a critical condition, [the Circular is now Ex.CW-1/6A to 1/6C (Annexure-6 Colly)].
2.4 The complainant was feeling very weak and restless. He was too weak to move freely. His wife Smt. Hemlata, was constraint to visit at different place being urgent, the complainant explains how from 11.2.2013 to 21.02.2013, his wife moved at different locations and authorities for appropriate approvals or sanction letter etc, which is compiled as follows:-
(i) She visited CGHS Dispensary, Dev Nagar, Delhi on 11-02-2013 and requested to issue required sanction letter for the said treatment but she was informed that Chief Medical Officer (CMO) of the Dispensary was not available and she was also instructed to visit Dr. Ram Manohar Lohia Hospital for its advices,
(ii) she visited to Dr. Ram Manohar Lohia Hospital, New Delhi on 12-02-2013 and contacted Dr. Niruta Sharma with request to give advice on the treatment of the complainant as advised by the CGHS authorities but after having gone through the papers of medical treatment of the complainant, she was instructed to approach Dr. Pandit
(iii) on 13-02-2013, she again visited there and after a wait, of three hours, she managed to approach Dr. Pandit, but he behaved in a very rude manner and instructed her to go back and approach the Chief Medical Officer of CGHS Dispensary, Dev Nagar, Delhi.
(iv) on 13-02-2013, the complainant sent e-mails to Shri R K Jain, Addl. Secy & DG (CGHS) and Dr. Bindu Bhushan, Jt. Director (Grievance) at their e-mail addresses regarding difficulties faced by him in getting treatment being a pensioner CGHS beneficiary in emergency case and requested to take immediate action in that regard, [emails are Ex.CW-1/7A to 1/7B (Annexure-7 Colly)].
(v) on 14-02-2013, she visited to CGHS Dispensary, Dev Nagar, Delhi and approached CMO. they were apprised with whole case of medical treatment of the complainant, his difficulties in obtaining the required sanction letter from CGHS authorities and Dr. Ram Manohar Lohia Hospital, New Delhi. The CMO referred the case in writing to Dr. Ram Manohar Lohia Hospital, New Delhi for further advice as the requirement of Dual Chamber ID implant, which was advised by the doctor of Delhi Heart and Lungs Institute, New Delhi can only be confirmed by a Cardiologist of Dr. Ram Manohar Lohia Hospital, New Delhi.
(vi) on 14-02-2013, the complainant sent an e-mail to In-charge, CGHS Helpline at e-mail address helpline-cghscamie.in and requested for immediate action or advise the complainant that how he would get treatment in these circumstances, [the email is now Ex.CW-1/8 (Annexure-8)].
(vii) on 15.02.013, she visited Dr. Ramonhar Lohia Hospital Delhi despite she was not well, having physical weakness and difficulties in walking being patient of knee joint pains and other old age related problems. She stood for hours and contacted Dr. Ajay Sharma, Sr. Specialist, Department of Cardiology, who finally confirmed in writing that Dual Chamber ICD implant was advisable for the complainant and asked to make an arrangement of Rs. 5,25,000/- as estimated cost towards the Dual Chamber ICD implant and to start the treatment at Dr. Ram Manohar Lohia Hospital, New Delhi, [the advices are now Ex.CW-1/9A to 1/9B (Annexure-9 Colly)].
(viii). on 16-02-2013, the complainant applied to CMO CGHS, Dev Nagar Delhi [for permission/sanction letter for Dual Chamber ICD implant at Delhi Heart and Lungs Institute as CGHS empanelled hospital], who forwarded the application to OP3, [the application with forwarding notes is now Ex.CW-1/10 (Annexure-10)].
(ix) on 16-02-2013, the complainant again sent an e-mail to In-charge, CGHS Helpline at e-mail address with all relevant documents with request to permit him for treatment at Delhi Heart and Lung Institute, Delhi, [the letter is now Ex.CW-1/11 (Annexure-11)].
(x) on 17-02-2013, complainant's wife personally took photocopy of application [bearing forwarded note of CMO CGHS, Dev Nagar Delhi] to OP3 with request to expedite the required permission/sanction letter but she was asked to come next day as the concerned Medical Officer was not available. However, on 18-02-2013, she again visited there but she was told that permission/sanction letter would not be issued immediately as some expert would examine the case and only then permission/sanction letter would be issued in two/three days.
(xi) on 19-02-2013, again an e-mail was sent to In-charge, CGHS Helpline at e-mail address with copy of letter dt. 16-02-2013 for permission for implant at Delhi Heart and Lung Institute, Delhi and the same was forwarded to OP as enclosure and it was requested to permit the complainant for treatment at Delhi Heart and Lung Institute, Delhi and he was ready to bear the cost difference between costs of Dr. Ram Manohar Lohia Hospital and Delhi Heart and Lung Institute, Delhi, [the email is Ex.CW-1/12 (Annexure-12)].
On 21-02-2013, the complainant sent the same e-mail to the Nodal Officer, North Zone, CGHS, Delhi at his e-mail address and requested for the same, [the email is Ex.CW-1/134 to 1/13B (Annexure-13)].
2.5. After 2 or 3 days, complainant's wife again visited to the office of OP3 to collect permission/sanction letter but she was told since the cost of the implant is very high, so matter would be forwarded to CGHS Head Quarter or the Ministry of Health and Family Welfare. It was also told that it is a long and time consuming process, she was also instructed to approach the Hospital Cell of the CGHS Head quarter at R K Puram, New Delhi. She also went to the office of CGHS, R K Puram, Delhi and requested to expedite it, since complainant requires Dual Chamber ICD implant urgently but it shocked her to know that application was not forwarded there nor received in the office of CGHS, R K Puram, Delhi till that time. Thus on next day, she went to the office of the Additional Director (NZ), CGHS, New Rajender Nagar, New Delhi but it was told that complainant's case would be discussed in the meeting of experts and thence decision would be taken. Since then, she has been regularly visiting to the offices of OP3 and CGHS (HQ), to consider the matter but nothing was done.
2.6 During the phase of aforementioned process, it was 04.03.2013 when all of sudden complainant's condition started deteriorating, he was about to faint, he was not in position to speak or do anything; he was fell down and became unconscious for which he was immediately taken to Sir Ganga Ram Hospital, Rajinder Nagar, Delhi/OP5 by his brother in law , who happens to be residing in neighborhood. The complainant was admitted in emergency of OP5, he was thoroughly checkup and after other test reports, he was advised for Dual Chamber ICD implant, which was also advised earlier by the Cardiologist of Delhi Heart and Lungs Institute, New Delhi and Cardiologist of Dr. Ram Manohar Lohia Hospital, New Delhi. Thus, ultimately the required implant was done in Sir Ganga Ram Hospital, Rajinder Nagar, Delhi. The complainant remained hospitalised from. 04.03.2013 to 08.03.2013 and was discharged after making an payment of Rs. 7,29,354/- which was arranged by his family either from own limited resources, loan from relatives and friends, [the record admission in emergency, treatment, ICD Implant, bills and discharge, are Ex.CW-1/144 to 1/14N (Annexure-14 Colly)]. On 14.03.2013, the complainant applied for reimbursement for medical bill amount of Rs. 7,29,354/- with the CMO, CGHS, Wellness Centre, Dev Nagar, Delhi, [application wit record Ex.CW-1/15/1 to 1/15/32 (Annexure-15 Colly)]. The complainant further narrates the event and trauma faced for reimbursement of bills, it is compiled as follows:-
(a) on 08.04.2013, the CMO/OSD to OP3 asked to make clarifications, which were accordingly furnished to OP3 through the CMO, CGHS, Wellness Centre, Dev Nagar, Delhi on 25.04.2013, [the clarifications along-with documents is Ex.CW-1/164 to 1/16M (Annexure-16 Colly)].
(b) on 14.08.2013, the complainant made representations to OP3 and to Nodal Officer, North Zone, CGHS, New Rajinder Nagar, New Delhi about the status of his claim since the staff of North Zone, CGHS, New Rajinder Nagar, New Delhi informed that his medical Reimbursement claim was forwarded to CGHS (HQ), but the Claim Tracking System of CGHS was showing that the claim was pending with the OP3 [the representation is Ex.CW-1/17A to 1/17B (Annexure-17 Colly)].
(c) on 05-09-2013, complainant wrote a reminder letter and sent it to the Addl. Director (HQ), CGHS, Bikaner House, New Delhi by the complainant regarding status of his claim but no reply was received, the same is Ex.CW-1/18 (Annx-18).
(d) on 28-09-2013, complainant applied under RTI to the CMO (RTI), CGHS (HO), Bikaner House, New Delhi to provide information including the status of his medical reimbursement claim but no reply except a communication regarding forwarding his RIT letter to CPIO, CMO (Hospital Cell), CGHS (HO), Bikaner House, Delhi and CPIO/Office of OP#. The complainant further narrates further process adopted under RTI Act, inclusive of appeals etc. [ which are Ex.CW-1/19A to 1/19E Annexure-19 Colly) to Ex.CW-1/27A to 1/27B (Annexure-27 Colly)].
It was 27.02.2014, when the complainant received reply by Dr. S. C. Kapoor, Joint Director (R&H), CGHS (HQ), Bikaner House, New Delhi on his RTI application dated 17-12-2013 (Ex CW1/25A to Ex CW1/25C), while informing that the requisite information was not dealt by his office and same would be provided by the CPIO, office of the CGHS, OP3and other reply letter sent by CPIO/CGHS/OP3, [which are Ex.CW-1/30A to 1/30E (Annex-30 Colly)].
(e) on 11-02-2014, the complainant received a letter dated 07-02-2014 from Sr. CMO (SAG)/NZ, CGHS, New Rajinder Nagar, New Delhi that complainant's claim was approved for an amount of Rs.3,00,61/-, [the letter is Ex.CW-1/28A to 1/28B (Annexure-28 Colly)].
(f) on 18-02-2014, the complainant, while feeling aggrieved, made a representation to the Sr. CMO (SAG)NZ, CGHS, New Rajinder Nagar, New Delhi on his partly reimbursement of claim for an amount of Rs. 3,00,611/- against claim of Rs.7,29,3541- and he also requested to settle remaining of Rs. 4,28,743/- but no response [the representation is Ex.CW-1/29A to 1/29C (Annexure-29 Colly)].
2.7. On 22-05-2014, complainant sent legal notice u/s 80 CPC to the Secretary, Govt. of India, Ministry of Panchyati Raj, Sardar Patel Bhawan, Patel Chowk, Parliament Street, New Delhi CMO, CGHS Head Quarters, Bikaner House, Shah Jahan Road, New Delhi to pay balance medical treatment expenses/charges of Rs. 4,28,743/- along with interest @18% per annum, (it is now Ex.CW-1/314 to 1/31C (Annexure-31 Colly), which was replied on 08-07-2014 by Dr. Seema Arya, CMO (R&H), CGHS, North Zone, New Rajinder Nagar, New Delhi stating that "as per para 6 of OM dated 12.6.1996, 'permanent pacemakers are not implanted in emergencies, which is always tackled by inserting temporary pacing system; in all such cases prior permission of Director, CGHS will have to be obtained.' Medical Reimbursement Claim of Shri Bharat Bhushan, CGHS ID 702113, was received on 22-03-2013 for the amount of Rs. 7,29,354/-, his claim was earlier regretted since AICD implantation through emergency admission at private non-empanelled SGRH without prior permission from competent authority were not found justified. The beneficiary had re-submitted the claim for reconsideration on humanitarian grounds. Thus, for reconsideration an Expert Committee was constituted under the chairmanship of Special DG(SYK) who met on 05-09-2013 and recommended as "in view of intermittent Atial Flutter/Fibrillation severe LVD (EF=33%), documented ventricular tachycardia and non-critical CAD Single Chamber ID Implant is justified" Single Chamber AICD implant has been justified which is of lower cost compared to Dual Chamber AID implanted in instant case. Since CGHS does not have published rates for AICD implants, reference is invited to published rates of GB Pant Hospital, Delhi and Dr. R.M.L. Hospital, Delhi and Single Chamber AICD rates, which have been tabulated/reproduced in para 45 of the complaint, package charges of Rs.33,062.50/-, the total amount of Rs.3,00,610.90p was considered as admissible amount, it was approved and submitted to Pay & Accounts Office vide bill no. 4602 dt 2.2.2014 ( the record is Ex.CW1/32A to Ex CW1/32C), the pharmacy charges of Rs.906.25p & blood bank services charges of Rs.140/- were not admissible.
3.1 (Case of OP 1 to OP3) : The OP1, OP2 & OP3 opposed the complaint vehemently that it is not maintainable, since the same is without cause of action and complainant came without clean hands. The beneficiary had undergone AICD implantation which is listed procedure, the procedure is not an emergency and prior permission is required from competent authority before it is undertaken; the permission is to be issued by AS & DG in concurrence with AFD and a prescription is required from a government specialist. The beneficiary underwent the procedure in non-empanelled hospital, who charges at its own rate. Moreover, as per discharge summary of 08.03.2013, the beneficiary/complainant was examined at the time of his admission, he had higher mental functions as well as sensory and motor functions were also normal at the time of admission. His case was put up before STC (Standing Technical Committee) comprising cardiologists from Dr. Ram Manohar Lohia Hospital & Safdarjung Hospital and additional Director CGHS (Headquarters), Director CGHS under the Chairmanship of Special DG-PH Chairman, Dr. S.Y. Kothari on 08.03.2013, who opined “in view of intermittent Atrial Flutter/ Fibrillation severe LVD (EF=33%), documented ventricular tachycardia and non-critical CAD Single Chamber ICD Implant is justified”. Accordingly, reimbursement was done to the beneficiary as per opinion of STC for single chamber AICD at G.B. Pant Hospital approved list and as per CGHS rates and guidelines, the complainant was reimbursed Rs. 3,00,611/-, it was confirmed by email dated 28.02.2014 of receipt of admissible amount in the account of beneficiary. As per CGHS guidelines, prior permission for procedure has to be taken from competent authority in all non-emergency cases. But in case of emergency empanelled hospitals is to be provided credit facility on production of valid CGHS card. The paragraph 21 of the reply, refers OM no.S-11016/16/2010-CGHS(P) dated 2.1.2011 in respect of delegation of powers with specific pecuniary limits in respect of competency to give permission for un-list procedure, investigations, implants etc.
Since the beneficiary had undergone AICD implantation, which is listed procedure but not an emergency and was performed at non-empanelled hospital without permission from competent authority, the case was examined by Joint Director, (R&H) and it was sent to STC for justification for emergency case. The expert committee had met on 05.09.2013 under the chairmanship of special DG (SYK) who appoint “ In view of intermittent Atrial Flutter/ Fibrillation severe LVD (EE=33%) documented ventricular tachycardia and non- critical CAD Single Chamber ICD implant is justified”. The reimbursement of unlisted implant is to be done at the rates approved by AIIMS/ G.B. Pant Hospital/ actual whichever is less. The reimbursement of Rs. 3,00,611/- was as per opinion of STC for single chamber of AICD at G.B. Pant Hospital rates. The OPs denied other allegations and claims of complainant.
3.2. (Case of OP4)- OP4 opposes complaint that there is no liability or deficiency of any services on its part. It is an empanelled hospitals under CGHS Scheme, it is governed by terms and guidelines issued by the Ministry of Health and Family Welfare (CGHS). Circulars dated 12.06.1996 ( now Exh.-OP4/1) and 22.07.2014 (Exh.-OP4 /2) issued by Director General of CGHS are binding upon the empanelled Hospital. Accordingly in view of circulars and its standard policies, CGHS mandates that for procedure of ICD implant, prior approval from Director CGHS shall be obtained which approval is granted by CGHS on the basis of advice of Government Cardiologist. It was also explained to complainant that for dual chamber ICD, prior approval of Director CGHS was mandatory by CGHS itself. It was further pointed out that pacemaker, ICD Implant etc. is an elective procedure and is not done as an emergency procedure. In the instant case the Dual Chamber ICD Implant was done and the circular dated 12.06.1996 did not speak about ID implantation, it only speaks about Coronary Stent, Rotablator and Pacemaker.
3.3. The complainant was presented with complaint of Chest Heaviness referred to left shoulder associated with palpitation on 09.02.2013. He was admitted in HDU for evaluation and further management. After routine medication and investigation and after achieving stabilization, he underwent coronary angiography which showed insignificant CAD with patent stent in RCA. However in view of severe LV systolic dysfunction associated with Ventricular Tachcardia, he required dual chamber ICD implant. Estimate of expenses as per CGHS rates for ICD implant was provided to the patient's attendant and who was also advised to obtain approval from Director CGHS as per the standard practice being followed for implantation of other cardiac devices e.g. Rotablator, Pacemaker where prior permission from Director CGHS is required in view of above mentioned Circulars dated 12.06.1996 and 22.07.2014. However the attendant of the patient requested to get the patient discharged after assuring that the patient will be admitted in the hospital after obtaining the required sanction letter from CGHS for implantation of ICD. Accordingly the patient was discharged by the hospital on 10.02.2013; OP4 also refers reply dated 8.7.2014 (Ex OP4/3) to the notice u/s 80 CPC, apart from copy of bill dated 10.4.201(Ex OP4/4).
4. (Replication of complainant)- Complainant filed rejoinder to reply of OP1 to OP3 the complainant denies allegations of reply of OP1 to OP3 and he reaffirms his complaint as correct vis-à-vis there are many admitted facts by OP1 to OP3 in their reply. The complainant also filed separate replication to the reply of OP4, complainant re-affirms his case.
Briefly, the OP 1 to 3 admit in case there is an emergency, empanelled hospital is to provide credit facility on production of a valid CGHS card but OP-4 overlooked it and violated the provisions for which he was bound to comply. They also admit that CMO
In-charge is authority to give permission of procedures/investigation which are listed in CGHS rate list 2010 but Dual Chamber ICD implant is unlisted in
CGHS published rate list 2010, thus permission was not issued by CMO
In-charge and he forwarded the complainant's application to OP3. Moreover, complainant’s application was not furnished in the office of AD North Zone). The contention of OP-1 to 3 that complainant was required to take prior permission of the Dual Chamber ICD implant is absolutely wrong and mischievous, whereas the prior permission was not at all required as per para 6 of circular dated 22.07.2014 (now Exh.-OP4/2). It is also admitted by the OP1 to OP3 that for unlisted procedure/investigation implants costing more then Rs. 1,50,000/- the permission has to be given by AS & DG in concurrence with ID of MoFHW. The permission was not granted on the same date. It also supported the claim of the complainant that he applied for prior permission in due course and the same has never been given to the complaint for the reasons best known to OP. It is admitted by them that reimbursement of the unlisted implants is to be done at the rates approved by AIIMS/GB Pant Hospital/actual whichever is less. The OP decided the claim rate by comparing rates of GBP Hospital and RML Hospital in an arbitrarily manner which was not at all required as per provisions of ExCW-1/33A to 1/33B (Annexure-33 Colly).
5.1 (Evidence of parties)- Complainant Sh. Bharat Bhushan filed his detailed affidavit of evidence, it is replica of complaint and documents filed thereto.
5.2: OP1 to OP3 filed detailed affidavit of Dr. S.K. Narula (Dr. Sunil Kumar Narula), Addl. Director, CGHS (NZ), which is also on the lines of reply.
5.3. OP4 filed affidavit of Sh. S.R. Khurana, Executive Director of M/s Heartcare Pvt. Ltd., the affidavit is on the pattern of written statement coupled with documentary record of circulars, office memorandum dated 22.07.2014, reply to legal notice, record of admissible amount of Rs. 3,00610.90p on the recommendation of expert committee and bill.
5.4. Since OP5 is a pro-forma party, there was appearance on its behalf, however, no reply or evidence was filed on its behalf as per the proceedings.
6.1 (Final hearing) : At this final phase of case, the complainant, the OP1 to OP3 and OP4 filed their respective arguments, the written arguments are mirror image of the pleadings and documents by compiling them together and in fact they have already been referred while giving and narrating the case of each party in the aforementioned paragraphs.
6.2. When occasion came for making oral submissions, complainant's counsel Sh. Abhinash Kumar, Advocate along with Sh. H. L. Rai and Sh. Prabhakar Pandey, Advocate for OP4 made the submission, the remaining OPs, OP1 to OP3 have not made any oral submission. OP5 has not been regular in appearance being pro-forma party, however, despite no oral submission by them, the case of each party will be considered.
6.3. It is submitted on behalf of complainant that despite his entitlement for medical reimbursement, the amount was intentionally not reimbursed, whereas at the initial stage of case the cashless facility supposed to have been extended. There is clear violation of guidelines as well as non-compliance of circulars, which clearly makes out case of deficiency of services and negligence on the part of OP1 to OP3, apart from OP4 failed followed to extend cashless facilities immediately after reporting for treatment. The submissions of complainant are on the line of complaint along with documents annexed thereto, apart from the further development taken place. The complainant relies upon Shiva Kant Jha vs Union of India W.P. (c) no. 694/2015 dod 13.04.2018(SC) that there were similar circumstances and directions were given for payment of balance amount to the petitioner therein, besides certain other directions with regard to timely MRC by CGHS in cases of pensioner beneficiaries. (however, at the outset, the complainant contends to consider it in his case, however, in paragraph no. 15 of Order in the said W.P. no. 694/2015, it was clearly stated and directed that the decision is confined to only that writ petition. Therefore, that decision is only for that case).
The complainant presented his grievances by narration as well as documentary record, which have already been referred with that circumstances in a chronological way in para no. 2 above of this final order. The complainant also made his submission to counter the case of other OPs that OP1 to OP3 have taken wrong and passive stand to deny his valid claim, despite he had a valid and fit case of cashless facility. On 09.02.2013 there was opinion by Delhi Heart and Lungs Institute for dual chambers ICD implant, which was also subsequently opined by Dr. Ram Manohar Lohia Hospital on 15.2.2013 and in March 2013 he was operated for dual chambers ICD implant in Sir Ganga Ram Hospital, despite such opinion firstly cashless facility was not extended and subsequently medical bill of single chamber ICD implant was approved, which is contrary to the norms, practice and guidelines. Subsequently, during the pending of complaint some portion of bill amount was sanctioned/ approved but without details. It establishes the case of complainant on all counts.
So far OP-4 is concerned, it deliberately with wrong intention trying to justify its wrong action with the instructions for pacemaker only with ID implantation. However the circular dated 22.07.2014 vide para 6 states that "in case of implantation of any of the devices in emergency, reimbursement shall be subject to ex-post facto approval by Addl. Director/Joint Director CGHS of city, in consultation with experts, if necessary". This clearly states that prior permission is not required in of implantation of ICD in emergency which was the case of the complainant.
The complainant concludes that he has established his grievances and claims against the OPs, however, the partly paid amount may be considered and he is also entitled for compensation for long trauma of harassment faced by him and his wife for his justified valid claim.
6.5. In fact, OP1 to OP3 and also OP4 admits the case of complainant substantially and the complaint was opposed just for the sake of opposition.
6.6. OP1 to OP3 have not made their oral submission, however, their written submissions are replica of the reply and document, which have already been referred and narrated in paragraph no. 3.1 above. OP1 to OP3 maintain that reimbursement of Rs. 3,00,611/- was on the recommendation of STC and that amount was also disbursed to the complainant. It has already been stated that complainant was paid further amount by OP1 to OP3, which find mentioned in the proceedings dated 27.09.2018.
6.7. Similarly, OP4, has submitted that neither there is any negligence or omission or deficiency of services, since OP4 is bound by the guidelines and other circulars issued by Ministry of Health and Family Welfare and it is also clear from the case of OP1 to OP3 that those norms are to be followed strictly, for which OP4 cannot be accounted. The submissions of OP4 are based on record of circulars, guidelines and other material filed in support of evidence.
7.1 (Findings) : The contentions of both the sides are considered analytically and also assessed them, coupled with the narrations of evidence of the parties, apart from the proceedings during the pending of the complaint. The core issues emerged from the rival claims are, whether it was case of emergency or non-emergency; case of single chamber ICD implant or of double chamber ICD implant and consequently what amount is to be reimbursed?
7.2: By taking stock of all the circumstances, as well as by looking them in sequence, the complainant's case is based on documentary record,; similarly the cases of OP1 to OP3 and of OP4 are also based on documentary records. Whereas, the complainant on the one side and OPs on the other side have reservations with the meaning and implications of those letters, circulars, guidelines etc. As such the documentary record is not disputed, which have already been referred.
7.3 It is relevant and material to mention that initially complainant was reimbursed amount of Rs. 3,00,611/- in February 2014 as single chamber ICD implant and other admissible charges, which is prior to filing of complaint on 06.01.2015. The complainant was paid further amount during the pending of complaint, it was apprised to the Commission, that total amount of Rs. 5,47,563/- (inclusive of previous payment of Rs.3,00,611/-) has been paid by them to the complainant, it was recorded in the proceedings dated 27.09.2018, which is mentioned in the proceedings. The OPs were asked to justify as to how this amount was calculated and paid. However, the matter remained sub-judice and pandemic Covid-19 intervened. Thereafter, certain records were filed, which were also supplied to the complainant and there were reservations that the record being filed was already part of reply of OPs as well as it is also the part of record of Annexure-32 of the complaint.
This record is perused. It is consisting 3 pages, out of them the first two pages were part of record filed by the complainant ( as Ex CW/28) as well as part of the record filed by the OPs in respect of sanction of amount of Rs.3,00,611/- being for single chamber ICD implant & other allowable amount but the third sheet is in respect of consideration of representation of the complainant-beneficiary. This third sheet was not earlier part of record of either side. The representation was re-examined by Standing Technical Committee on 10.03.2016, whereby the case of complainant for double chamber ICD by cardiologist was considered and the amount as per scheduled G.B. Pant rate of double chamber for Rs. 5,14,500/- was opined in place of G.B. Pant rate of single chamber ICD for Rs. 2,67,548/- and the difference amount was sanctioned in favour of beneficiary-complainant and it was paid. Consequent to this development, the complainant has received total amount of Rs.5,47,563/- out of total bill amount of Rs.7,29,354.25p/-, consequently the complaint results to the balance amount of Rs. 1,81,791/- with regard to medical bills, because of these developments.
7.4. By taking stock of all these circumstances including the development on the eve of further payment of additional amount of Rs. 2,46,952/- pursuant to approval by STC on 10.03.2016, took, some of the important relevant aspects need to be mentioned, which are:
(i) it was 09.02.2013 when Delhi Heart and Lungs Institute advised double chamber ICD implant, however, complainant was discharged for want of extend of cashless facility; double chamber ICD implant was also opined by Dr. Ram Manohar Lohia Hospital on 15.2.2013 and on 05.03.2013 he was operated for dual chambers ICD implant in Sir Ganga Ram Hospital being indoor patient from 04.03.2013 to 08.03.2013,
(ii) on the one side complainant claims that he was taken to hospital in emergent situation, but on the other side, OP1 to OP3 has reservation that as per discharge summary of 08.03.2013 (page 54 of paper book) issued by Sir Ganga Ram Hospital, the beneficiary/complainant was examined at the time of his admission, he had higher mental functions as well as sensory and motor functions were also normal at the time of admission. But complainant relies upon certificate (page 52 of the paper book) that treating doctor certifies that complainant-patient was admitted as an emergency in the hospital on 04.03.2013,
(iii) the OP3 approved claim of Rs. 3,00,611/- out of total bill amount of Rs. 7,29,354/- on the recommendation of Expert Committee,
(iv) approval the amount of Rs. 3,00,611/- was informed to complainant on 8.07.2014 (annexture-32, page 159 of paper book; with details at pages 160-161) that case of non-critical CAD single chamber ICD implant is justified and was approved to case of dual chamber ICD implanted,
(v) the complainant made a representation for reconsideration of his case for approval of dual chamber ICD implant as advised earlier and STC committee in its meeting on 10.03.2016 reconsidered the case and came to the conclusion which reads as “ the case was reviewed as per the opinion of the Expert Committee held on 05.09.2013. The beneficiary has already been reimbursed as per G.B. Pant Hospital rates of Single Chamber ICD. Before the procedure the patient had been advised Dual Chamber ICD by the Cardiologist, RML hospital as per prescription dated 15.02.2013. After perusal of the records and the clinical condition mentioned in the documents the Committee concurs with the opinion of Dual Chamber ICD advised by the Cardiologist RML Hospital.”
On the basis of comments of the STC on 10.03.2016, the complainant case for double chamber ICD at G.B. Pant rates was allowed for Rs. 5,14,500/- in place of earlier single chamber ICD of G.B. Pant rate of Rs. 2,67,548.40p, consequently the difference amount of Rs. 2,46,952/- was allowed,
(vi) the conclusion drawn on (i) to (v) above, clearly spells out that it was expert committee who had earlier approved/opined single chamber ICD and later on STC reconsidered it and concurred opinion of double chamber ICD implant in respect of treatment rendered to the complainant.
Therefore, it dispels all the clouds that complainant was deserving from the very inception double chamber ICD implant as advised so twice, STC concurred its opinion 10.03.2016. But in order to reach this stage, the complainant faced all administrative and other trauma by running from post to pillar as well as approaching the concerned offices & Authority, for appropriate sanctions, cashless facilities before implant as well as for reimbursement of bills after implant and
(vii) Simultaneously, G.B. Pant rate of double chamber ICD for Rs. 5,14,500/- is as per allowable amount under the Scheme for pensioners beneficiaries. The development so taken place, has already been referred in above 7.3 above.
(viii) Then. what it culls out? In the beginning stage of pleading and then at the stage of evidence of parties, the disputes emerged on the issue of whether or not it is a emergency case, case of single chamber ICD implant or double chamber ICD implant and because of such disputes, the OPs had construed the complainant's case of non-emergency on the basis of discharge summary vis-à-vis the complainant had been issued a certificate that he reported in the emergency; the complainant was recommended/ approved amount of Rs. 3,00,611/- on the basis of expert opinion of 05.09.2013 that CAD single chamber implant is justified but later on the STC in its comment dated 10.06.2016 concurs its opinion with the expert committee that double chamber ICD implant is justified and appropriate. These series of events dispel when STC gave its comment on 10.03.2016 that it is a case of dual chamber ICD implant by concurring its opinion. This has shorten the entire controversy, when record was filed in three sheets, out of them first two sheets were already on record and third sheet is about reexamination of complainant/ beneficiary, already reproduced.
8.1. Had the OP1 to OP3, considered the case of complainant as initially put up but it was not considered at the beginning, however, as last it was considered. It establishes the case of complainant against OP1 to OP3 of deficiency of services.
8.2. The OP4 has proved circulars dated 12.06.1996 and 22.07.2014, which issued by Director General of CGHS and circulars are binding upon the empanelled Hospital and OP4 is not exception to it. The OP4 is feeling constrained to exercise its discretion because of norms laid down in such circulars as well as other instructions or D.O. letters. The evidence so led by OP1 to OP3 also proves that OP4 could exercise its functioning as per and within parameters to specified. Under these circumstances no fault could be found against OP4, who has been practicing the norms, guidelines and other instructions from time to time. The complainant could not prove his case against OP4.
9.1. Since the complainant is held entitled by the OP1 to OP3 for dual chamber ICD implant, the complainant had filed claim of Rs. 7,29,353/- out of which he has already received Rs. 3,00,611/- on 11.02.2014 and Rs. 2,46,952/- on 27.09.2018 and the balance amount left is of Rs. 1,81,791/-. Whether the complainant is entitled for balance amount of bills of Rs. 1,81,791/-?
A simple and straight answer is in negative since beneficiary can be reimbursed the amount as per Scheme and as per norms, guidelines and other practice. The amount of Rs.5,14,500/- was considered and allowed by STC on 10.03.2016 being G.B. Pant rate of double chamber ICD. The total amount of Rs.5,47,563/- was allowable amount as per those norms and rates. Therefore, complainant is not entitled for balance amount of Rs. 1,81,791/- being not allowable. The allowable amount was Rs. 5,14,500/-, it has already been disbursed along with other packages charges, that is why as per proceedings dated 27.09.2018 it was reported that total amount paid to complainant is Rs. 5,47,563/-.
9.2. But there is small question, since the complainant was entitled for cashless facility at the time of his admission, he had also wrote for appropriate sanction, when cashless facility was not extended but he was constrained to get him discharged and later on he was constrained to approach to medical emergency, where he was admitted, dual chamber ICD was implanted and he had paid total amount of Rs. 7,29,354/- inclusive of entitled amount of Rs.5,47,563/-. To say, he had parted with his money, which he could have by way of cashless facility of Rs. 5,47,563/-. He had received this amount later-on that too in two phases after much persuasions and representations to OPs.
Therefore, the complainant should receive interest on such amount, he had arranged and paid for his treatment, he is held entitled for interest, which is quantified as simple interest at the rate of 4% pa, which will be payable on Rs. 3,00,611/- for period of 11 month w.e.f. 08.03.2013 (date of discharge) to 11.02.2014 (date of reimbursement such amount), which was initially allowed as single chamber ICD implant, the interest comes to Rs.11,022.40p. Similarly, the complainant is also held entitled for interest at the rate of 4% pa on amount of Rs. 2,46,952/- for period of 5 years & 6 month w.e.f. 08.03.2013 (date of discharge) to 27.09.2018 (date of payment/proceedings), which come to Rs. 54,329.44p, the total amount comes to Rs, 65,352/- in favour of complainant and against OP1 to OP3 jointly or severally.
Considering the role of OP4 as well as OP4 was complying with the circulars, D.O. letters etc., the complaint against OP4 is dismissed. No directions are warranted against OP5 being pro-forma party.
9.3. The complainant has claimed compensation of Rs. 10,00,000/- in respect of harassment and trauma faced by him and his wife in order to secure his valid medical claim amount, therefore, considering his age of senior citizen as well as age of his spouse, who was assisting the complainant (as complainant was undergoing treatment and his wife was putting efforts by visiting the authorities for appropriate sanction and release of the amount) & keeping in view all these situations, compensation of Rs. 50,000/- will meet both ends, apart from costs of Rs. 10,000/- in favour of complainant and against OP1 to OP3.
9.4. Accordingly, the complaint is allowed in favour of complainant and against the OP1 to OP3 to pay jointly and/or severally an amount of Rs, 65,352/- interest component, especially detailed and calculated in para no. 9.2 above, apart from damages of Rs.50,000/- & costs of Rs.10,000/- to be payable within 30 days from the date of receipt of this order.
In case, OP1 to OP3 do not pay the amount within 30 days from date of receipt of this Order, then simple interest will @ 6% per annum (in place of 4% per annum) on the amount and period mentioned in paragraph 9.2 above.
10. Announced on this 12th May, 2023 [वैशाख 22 , साका 1945]. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[ Shahina] [Inder Jeet Singh]
Member (Female) President
