Chandigarh

DF-II

CC/403/2022

Sahdev Kaushik - Complainant(s)

Versus

Union of India - Opp.Party(s)

Adv. Manoj Chahal

22 Nov 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	403 of 2022
Date  of  Institution	:	05.05.2022
Date   of   Decision	:	22.11.2022

 

 

 

 

Sahdev Kaushik s/o Sh.Radhey Shyam, R/o H.No.3102, Sector 44-D, Chandigarh, presently posted as Superintendent in the office of Regional Passport Office, Sector 34-A, Chandigarh

             …..Complainant

Versus

1]  Union of India, Ministry of External Affairs through its Regional Passport Officer, Regional Passport Office, SCO 28-32, Sector 34, Chandigarh.

2]  Central Government Health Scheme through its Additional Director, Room No.427, 4^th Floor, Kendriya Sadan, Sector 9-A, Chandigarh 160009

   ….. Opposite Parties 

 

BEFORE:  SMT.PRITI MALHOTRA      PRESIDING MEMBER

         SH.B.M.SHARMA                     MEMBER 

                               

 

 

Argued by :- Sh.Manoj Chahal, Adv. for complainant.

  None for OPs

 

PER B.M.SHARMA, MEMBER

 

         The case of the complainant precisely is that the complainant, a member of Central Government Health Scheme and is having Health Card under CGHS issued by OP No.2.   It is stated that the wife of complainant namely Partigya Kaushik developed Strangulated Ventral hernia for which she initially taken to Dr.(Ms.) Vinod Bala, MBBS, clinic at SCO No.79, Sector 40-C, Chandigarh and then to CGHS Dispensary No.1, Sector 45 (Old Polyclinic), Chandigarh (Ann.C-4 & C-5), but as no relief was got from the treatment there, she visited Max Super Speciality Hospital, Mohali (an empanelled Hospital under CGHS Chandigarh) and underwent emergency exploratory laprotomy and anatomical repair of hernia defect on 22.6.2017 and discharged on 25.6.2017. The total medical bill/expenses incurred on said treatment to the tune of Rs.1,64,069.61 (Ann.C-6) was paid by complainant.  Thereafter, the complainant lodged claim for reimbursement of said medical bill with OP No.1, who in turn sanctioned only an amount of Rs.33,868/- vide order dated 28.7.2017.  It is stated that once the complainant and his family members are duly covered under CGHS (Central Govt. Health Scheme) and got treatment at their empanelled Hospital, then any deduction made from the medical bill raised by empanel hospital is wrong & illegal. Hence, this complaint has been preferred.

 

2]       The OP No.1 – Regional Passport Office, Chandigarh has filed reply wrongly mentioning it as OP No.2 and while admitting the factual matrix of the case about complainant and his wife covered under CGHS, treatment taken by his wife and expenditure spent thereon as claimed being matter of record, have stated that an employee who is covered under the Health Benefit scheme can directly approach the Super Speciality Hospital, if there is a severe urgency or there is any recommendation regarding the same.  It is submitted that the complainant had submitted his claim in time for reimbursement of incurred expenditure on treatment of his wife, but as per the policy of Govt., medical bills have been restricted as per CGHS rates.  It is submitted that CGHS covers the family and spouse of an employee, who can get treatment in emergency from list of empanelled doctor/hospitals for which he will be reimbursed for the expenses incurred on such treatment.  Denying other averments, the OP- Regional Passport Office, Chandigarh has prayed for dismissal of complaint qua.    

         The OP NO.2-CGHS, Chandigarh has also filed short reply stating that mere CGHS Card does not makes an individual entitled to treatment at CGHS rate from any CGHS empanelled Hospital.  It is stated that complainant took treatment from Max Hospital, Mohali (a private hospital empanelled under CGHS Chandigarh for the period from 22.6.2017 to 25.6.2017 and underwent emergency treatment for Emploratory laprotomy and Anatomical repair of hernia defect, for which the admissible amount as per CGHS Rates is Rs.28,663/- (Ann.OP-1).  It is submitted that it appears that OP No.1 had reimbursed the medical claim for Rs.33,868/- more and above CGHS approved rates of Rs.28,663/- under delegation of powers to HOD/HOO.  It is also submitted that the responsibility for settlement of medical bills of serving employee is of HOD/HOO, hence the name of OP No.2 be dropped from the complaint. 

 

3]       Rejoinder has also been filed by the complainant reiterating the assertion as made in complaint and controverting that of OPs No.1 & 2 made in their respective reply. 

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the complainant and have also perused the entire record.

 

 

6]       The thorough perusal of the record reveals that the complainant’s wife covered under Central Govt. Health Scheme (CGHS), was treated for Exploratory Laparotomy and surgery for strangulated hernia repair at an Empanelled Hospital of OPs i.e. Max Super Specilaity Hospital, Mohali and incurred a total expenditure of Rs.1,64,069.61/-.  The OPs have reimbursed only an amount of Rs.33,868/- against the bill of Rs.1,64,069.61/- as per CGHS rates and denied balance claim amount.

 

7]       We are of the view that when the CGHS beneficiary (complainant’s wife) has taken treatment from the Hospital empanelled by the OPs, then there is no justification for them to deny full reimbursement of the medical expenses incurred on such treatment on the ground of package or fixed rates.  In our view, in case the amount exceeds than the fixed package or rates of CGHS, then it is for the OPs to take such matter with concerned hospital or authorities and the consumer/beneficiary should not be made to suffer. The complainant cannot be denied his genuine right to get reimbursement of entire amount paid by him towards the treatment at an empanelled hospital of OPs.  The OPs are under obligation to reimburse entire medical expenses incurred by the complainant or his dependent on the treatment availed at an empanelled hospital. The restriction clause, if any, must be taken up & settled with empanelled hospital to make the medical coverage under CGHS a viable health cover for the Govt. Employee with clear guidelines/parameters so that the entitled person is not put to hardship & inconvenience.  Therefore, there is clear cut deficiency in service on the part of the OPs in denying full reimbursement of medical claim incurred by the complainant on treatment of his wife, which certainly caused physical harassment, mental agony and financial loss. 

 

8]       It is a settled law that right to health is an integral part of the right to life and that it is duty of the State to bear the expenditure incurred by a Government servant suffering from ailments which require treatment at approved speciality hospital.

 

9]       The Hon’ble Supreme Court of India in case of State of Punjab & Ors. Vs. Mohinder Singh  Chawla Etc. (CA No.16979/96 @ SLP (c) No.12472/96, decided on 17.12.1996, has held that :- 

 

It is now settled law that right to health is an integral to right to life. Government has constitutional obligation to provide the health facilities. If the Government servant has suffered an ailment which requires treatment at a specialised approved hospital and on reference whereat the Government servant had undergone such treatment therein, it is but the duty of the State to bear the expenditure incurred by the Government servant. Expenditure, thus, incurred requires to be reimbursed by the State to the employee. The High Court was, therefore, right in giving direction to reimburse the expenses incurred towards room rent by the respondent during his stay in the hospital as an inpatient.

 

 

         The Hon’ble Delhi High Court in case Jai Prakash vs. Union of India (Uoi) dated on 14.5.2007 reported 141 (2007) DLT 78 has also held, in such like case, that “The petitioner cannot be deprived of his right to the reimbursement of the entire amount paid by him on account of his surgery.”

 

10]      Taking into consideration the above discussion, findings and law, the deficiency in service on the part of OPs is proved. Therefore, present complaint is allowed with directions to the Opposite Parties No.1 & 2 to reimburse the balance amount of Rs.1,30,202/- to the complainant along with interest @10% p.a. from the date of discharge i.e. 25.6.2017 till its realization. The Opposite Parties No.1 & 2 are also directed to pay compensation of Rs.50,000/- to the complainant for causing mental agony & harassment due to their deficient act along with litigation cost of Rs.20,000/-.

         This order shall be complied with by the Opposite Parties No.1 & 2 within a period of 45 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.25,000/- apart from the above relief.

         The complaint has been filed under The Consumer Protection Act, 2019, as such we direct the Opposite Parties No.1 & 2, per Section 39(g) of The Consumer Protection Act, 2019 to reimburse/pay the entire medical expenses/claims of CGHS Card Holder/Beneficiary while being treated at their Empanelled Hospital/Doctor and must create a procedure/specific guidelines to help the consumer at their end and to finalize/prepare guidelines in this regard within a period of 3 months.    

         Pending application(s), if any, also stands disposed of accordingly.

        The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

22^nd November, 2022                                                                                                                                                                        sd/-

                                                (PRITI MALHOTRA)

PRESIDING MEMBER

 

 

 

Sd/-

 (B.M.SHARMA)

MEMBER