DISTRICT CONSUMER DISPUTES REDRESSAL FORUM Civil Station, Palakkad – 678001, Kerala Dated this the 23rd day of July, 2010 Present: Smt.Seena.H, President Smt.Preetha.G.Nair, Member Smt.Bhanumathi.A.K, Member CC No.36/2008 T.P.Mohandas, S/o.A.Gopalapisharady, Vrindavan, Kalluvazhy.P.O, Thiruvazhiyode, Via Palakkad Now residing at: Ashiana, Hill View Nagar, Kanjikode, Palakkad. - Complainant (By Adv.R.Sreevalsan) Vs 1. V.K.Prabhakaran Col (Rtd), Officer in charge, ECHS Polyclinic, Chandranagar, Palakkad. (By Govt. Pleader, Vinod K.Kayanat) 2. Sudhakar Pillai Major (Rtd), Officer in charge, ECHS Polyclinic, 6 AF Hospital, Race course Road, Sungam.P.O, Coimbatore. - Opposite parties (Party in person) O R D E R By Smt.Seena.H, President Case of the complainant in brief: Complainant is an ex-service man and is a member of Ex-service men Contributory Health Scheme. As per the terms and conditions of the scheme he has remitted Rs.4,800/- as one time contribution to ECHS. In the terms and conditions of the scheme supplied by the opposite parties to the complainant, it was agreed by the opposite parties that in case further treatment or investigations are required, the Polyclinic Doctors will refer the patient to service hospital/empanelled hospital. It is also informed that a list of empanelled hospitals etc will be available in the Polyclinic for the guidance of the patients. Further as per the scheme the patient will be required to report to the empanelled facility of his choice along with his ECHS membership card and referred from ECHS Polyclinic. On completion of treatment he is not required to make any payment. Bill will be cleared by ECHS. Further as per the scheme, in an emergency situation where the ECHS member may not be able to follow the normal referral procedure, he can report to a convenient hospital preferably to a service hospital or an empanelled hospital. In such cases no payment is required to be made and the bill of empanelled hospital will be cleared by the ECHS. In case a member goes to a non-empanelled hospital he has to pay the bill and submit a claim for reimbursement to the ECHS Polyclinic subsequently. In all cases of emergency admissions the nearest ECHS Polyclinic must be informed within 48 hours of admission. The reimbursement will be limited to approved CGHS rates. Complainant submits that his vision became bleak during the month of November 2007. He approached Aravind Eye Hospital, Coimbatore as he had undergone treatment in the above hospital through ECHS. The Doctors attached to Aravind Hospital, Coimbatore adviced him to undergo right eye silicone oil removal with cataract extraction and trabeculectomy. Accordingly complainant approached the 1st opposite party for obtaining a referral letter to the above hospital to get the surgery done through ECHS. It was told by the 1st opposite party that the Aravind Eye Hospital is not an empanelled hospital and he has approached the Eye Foundation, Coimbatore. Complainant submits that the Aravind Hospital is an empanelled hospital and he has previously undergone treatment through ECHS. As per the direction of the 1st opposite party complainant went to the Eye Foundation, Coimbatore and from there it was adviced to undergo right eye silicone oil removal with cataract extraction with IOL implantation and trabeculectomy. Receiving this certificate, the Doctor attached to the 1st opposite party issued a referral letter to ECHS Polyclinic, Coimbatore. As directed by the 1st opposite party, complainant approached the 2nd opposite party with the referral letter duly issued by the 1st opposite party and certificate issued by Eye Foundation. Complainant submits that 2nd opposite party acted in a very rude manner shouted at the complainant and said that he was not bound to accept any referral letter from 1st opposite party. At the time of this incident two another Ex-service man was also present at the 2nd opposite party’s office. Further complainant submits that when complained to the 1st opposite party regarding the attitude of the 2nd opposite party, they did not give any proper answer. Complainant decided to get the surgery done at his own cost. Surgery was conducted from Aravind Eye Hospital. Altogether complainant incurred an expense of Rs.10,000/-. Medical bills comes around Rs.3,975.45. According to the complainant, opposite parties are bound to provide definite free service to the complainant as he beingthe subscriber of the scheme. Complainant prays for refund of Rs.10,000/- along with compensation of Rs.1,00,000/- from 2nd opposite party and Rs.1,50,000/- compensation from both parties. Both opposite parties entered appearance and filed version contending the following. The main contention raised is that complainant is not a consumer since the service provided to the consumer is not based on payment of consideration and is only a free service for the retired defense personnel. Opposite parties submit that the referral procedure as stated by the complainant is not correct. When a medical problem arises, the ex-service man is required to report to his parent Polyclinic viz Palakkad and take the treatment either from Polyclinic or from service facility or empanelled facility. Whereas in this case, the ex-service man first went to a civil hospital in another station and demanded a referral to that hospital which is against the rules of the scheme. When an ECHS member reports to another Polyclinic for specialized treatment the referral is accepted if the required specialized facility is available at the service hospital or empanelled hospital. A fresh referral from the Polyclinic is prepared and given to the ECHS member to report to the empanelled hospital. When the facility is not available, the referral is not accepted and the ex-service man is given briefing about further action. 2nd opposite party submits that complainant was informed about non-availability of specialized treatment under the scheme at Coimbatore and he was also briefed about further action. Opposite parties further submits that an emergency admission within the scheme is also permitted. The onus of proving the emergency lies with the ECHS member. As per procedure once the beneficiary is admitted in a hospital, a report along with an emergency admission letter from the specialist Doctor of the hospital where he is admitted to the nearby Polyclinic, Coimbatore in this case has to be given. This can be given by any of the friends/relatives/hospital authorities etc. In case of admission to a non-empanelled hospital, the ECHS beneficiary or his representatives should inform nearest Polyclinic within 48 hrs of such admission. The responsibility for clearing bills rests with the ECHS patient. The bills along with the summary of the case and other documents are to be submitted to the Polyclinic. Sanction will be accorded by ECHS as per approved rates. Opposite parties submit that in this case, the complainant has neither informed the nearby Polyclinic nor preferred a claim for emergency treatment so far. Opposite parties further submits that the status of empanelment of hospital varies from time to time as per change in policies, rates etc. It is the duty of the ex-service man to check the current status of the hospital. 2nd opposite party specifically denies the allegation of rude behavior towards the complainant. 2nd opposite party submits that the complainant approached him with the referral letter issued to him from Polyclinic, Palakkad but the referral was addressed to Air Force Hospital. Since opposite party knew that the facility is not available with the Air Force Hospital, he was told either to report back to ECHS Polyclinic or go to CHAF, Bangalore for treatment. Since the ex-service man has not followed the procedure laid down in the scheme, there is no deficiency in service on the part of opposite parties. Complainant and opposite parties has led evidence in the form of affidavit. Ext.A1 to A17 marked on the side of complainant. 2nd opposite party was cross examined as DW1. Witnesses from the side of the complainant was examined as Ext.PW2 and PW3. The issues that arise for our consideration are; 1. Whether there is any deficiency in service on the part of opposite parties? 2. If so, what is the relief and cost complainant is entitled to? Issues No.1 & 2: The specific allegations of the complainant is regarding the attitude and behavior of the opposite parties especially 2nd opposite party towards the complainant. Complainant also prays for reimbursement of the medical expenses incurred by the complainant being an member of ECHS. Opposite parties on the other hand contented that complainant is not a consumer as there is no consideration for the service and further opposite parties has acted only as per the rules of the scheme and there is no deficiency in service on their part. Further complainant has never approached the opposite parties claiming medical expenses he has incurred. Heard both parties. Perused all documents produced by both parties. On going through the information brochure produced by the complainant for reference, we came to know that for claiming benefits under the ECHS scheme, there is a step by step procedure laid down in it. Some procedures are seen mandatory as per the scheme. Here the complainant has stated that opposite party has not referred him to Aravind Eye Hospital which in his knowledge was an empanelled hospital and if not the fact was not informed to him by the opposite parties through letter. Chapter 7 of ECHS specifically provides the procedure for availing treatment. It is stated that for availing treatment facilities ECHS member is required to go to the nearest Polyclinic carrying his ECHS membership card. The Doctors in the Polyclinic will provide the required initial treatment and medicines free of cost. In case further treatment is required, the patient will be referred to the nearest service hospital or empanelled hospital. It is also specifically stated that a mandatory requirement to avail of ECHS treatment in each case is that the patient has to first go to an ECHS Polyclinic. They are the only ones who are permitted to refer a patient to a service hospital or to a civil empanelled hospital. So it is clear from the provisions of the ECHS Scheme that an ECHS member has to approach the Polyclinic first whether to avail treatment from the clinic or elsewhere. So we are of the view that the allegation of the complainant that the empanelment of hospitals is to be informed to the members directly is of no substance. Complainant can very well enquire the same directly when he approaches the polyclinic or refer notice board for information. Another allegation leveled against 2nd opposite party is that he behaved indifferently and in a rude manner when the complainant approached him with the referral letter of 1st opposite party. 2nd opposite party specifically denies the say of the complainant. Also submits that the 1st opposite party has not referred the complainant to him, but admits that the complainant has approached him with the referral letter. Ext.A7 shows that the referral letter is addressed to Six Air Force Hospital and not to 2nd opposite party. 2nd opposite party also has deposed while cross examining that polyclinic has the authority to make referral to service hospital. So the referral was addressed to 2nd opposite party seems to be wrong. But it is an admitted case that the complainant has approached 2nd opposite party. In order to substantiate the allegation that 2nd opposite party behaved in a rude manner and refused to accept the referral letter, complainant examined his wife and another ex-service man who were said to be present at the scene. PW2 has deposed to the effect that he has seen the complainant and his wife on that particular day in the 2nd opposite party office. He added that ]ns¶ AhnsS F´mWv kw`hn¨sX¶v Rm³ InÃ. ]n¶oSv ]pd¯v h¶t¸mÄ referral letter AhÀ hm§m³ XmXv]cyw ImWn¨nÃ. Xncn¨b¨p F¶p ]dªp . It is understood that the witness has not actually seen the alleged incident. Complainant further submits that there is provision in ECHS scheme for approaching non-empanelled hospital in case of emergency. Complainant being a beneficiary of the scheme is entitled to get the medical expenses reimbursed. Procedure to be followed in case of emergency as laid down in the ECHS scheme is as follows: In case he admits in an non-empanelled hospital, the ECHS member or his representatives should inform nearest Polyclinic within 48 hours of such admission. Further states that the onus or proving the emergency lies on the patient. Admittedly neither the complainant nor his representative has informed the Polyclinic regarding emergency admission. Complainant herein has approached a non-empanelled hospital for eye surgery. It is clear from the complaint itself that complainant never intended to conduct the surgery through ECHS. The specific statement in the complaint that ‘finally when the complainant realized that further expectation of getting the surgery done through ECHS Polyclinic is a mirage, it was decided by the complainant to get the surgery done at his own cost’ reveals the same. Whatever may be the reasons assigned, complainant ought to have intimated 1st opposite party regarding emergency admission. It is also an admitted fact that complainant has never approached the opposite parties claiming reimbursement. We are of the view that complainant ought to have followed the procedural formalities for claiming the amount. In view of the above discussions, we find that complainant miserably failed to prove his case. Without convincing and cogent evidence, it is not proper to attribute deficiency in service on the part of opposite parties. In the result complaint dismissed. Pronounced in the open court on this the 23rd day of July, 2010 Sd/- Seena.H President Sd/- Preetha.G.Nair, Member Sd/- Bhanumathi.A.K, Member Appendix Date of filing: 21/02/2008 Witnesses examined on the side of complainant PW1 – T.P.Mohandas PW2 – Shri.Premraj PW3 – Smt.K.P.Maheswari PW4 – Dr.V.Narendran PW5 – Dr.D.Ramamurthy Witnesses examined on the side of opposite parties DW1 – Major Sudhakar Pillai Exhibits marked on the side of complainant Ext.A1 – Photocopy of ex-service men card (Health card) Ext.A2 – Photocopy of Pension certificate Ext.A3 – Photocopy of record of pension disbursements Ext.A4 – Letter dt.15/12/2007 sent from Aravind Eye Hospital (with objection) Ext.A5 – Certificate issued from The Eye Foundation, Coimbatore (with objection) Ext.A6 – Book maintained by the complainant for the treatment Ext.A7 – Referral form – Part I issued by ECHS Polyclinic, Palakkad Ext.A8(Series) – Bills 5 in Nos. Ext.A9 – Advocate Notice dt.08/01/08 Ext.A10 – Postal receipt Ext.A11 – Acknowledgement cards Ext.A12 – Photocopy of ECHS Health card of Premraj and his dependents Ext.A13 – Photocopy of prescription form Ext.A14 – Address and rank of Premraj.P Ext.A15 - Photocopy of ECHS Health card of complainant and his dependent Ext.A16 – Photocopy of referral form – Part I Ext.A17 – Advocate notice dt.21/02/2008 Exhibits marked on the side of opposite parties Nil
| | [HONORABLE Smt.Bhanumathi.A.K] Member[HONORABLE Smt.Seena.H] PRESIDENT[HONORABLE Smt.Preetha.G.Nair] Member | | 
