IN THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KOLLAM
C.C.No. 344/2022
PRESENT
SMT. S.K.SREELA, B.A.L, LL.B, PRESIDENT
SRI. STANLY HAROLD, B.A.LL.B, MEMBER
ORDER DATED: 30.10.2024.
BETWEEN
Dr.N.Bahuleyan,
DHM, Reg.No.25284, BA, LLB
(Member of Indian Council of Alt.Medicines),
PG Diploma in Personnel Management,
Residence Address:-Pazhaniyil Puthen Veedu,
South Monkuzhi,
Pullikkanakku P.O., Mavelikkara, Alappuzha. : Complainant
AND
1. Addl.Director General CGHS,
Vanchiyur Wellness Centre , Pin 695 004.
(By Adv.Nisa Fasil)
2. The Secretary & Director General of CGHS,
New Delhi, CGHS Directorate, Sector 13,
R.K.Puram, New Delhi 110022. : Opposite parties
ORDER
Stanly Harold, B.A.LLB, Member
This complaint is filed U/s 35 of the Consumer Protection Act 2019.
The averments in the complaint in short are as follows:-
Complainant is a beneficiary of Central Government Health Scheme for free treatment for all treatments like Laparoscopic Surgery or any other advanced treatment except expenses of food. On 24.02.2022 vide Sl.No.7, Token No.43203 Reference ID:TR3/24FEB2022/0842, as per the direction of the CGHS authorities complainant was referred by CGHS Vanchiyur to SK Hospital for key hole surgery of Hernia. But SK Hospital authorities refused to conduct the surgery disclosing that Central Government Health Scheme had failed to make payment to them and operation can be done only by cash payment by the complainant. Thereafter the complainant reported the same day at Gokulam Medical College. They also refused to make laparoscopic surgery saying that CGHS had not paid for their earlier operations. They prepared for conducting a general surgery (Open Surgery) for which the complainant had not agreed. They had not agreed for Laparoscopic surgery on CGHS credit facility, they also informed that laparoscopic hernia surgery can only be done on full payment. But they also prepared for open surgery for which complainant was not amenable the reason is that complainant had nobody to assist for longer period as he is living alone in his house. The Central Government Health Scheme, Trivandrum was instrumental for nor making free treatment to the complainant by not making payment to the empaneled hospitals SK Hospital and Gokulam Medical College. As Central Government Health Scheme denied the complainant free treatment from empaneled hospitals, CGHS was instrumental for the complainant’s admission to non-empaneled hospital Padmavathy Medical Foundation at Sasthamcotta, Kollam by paying a huge amount of Rs.60,166/-(Sixty thousand one hundred sixty six) and the bill was produced before CGHS on 04.04.2022. But the Central Government Health Scheme at Trivandrum had passed only Rs.20,995/-(Twenty thousand nine hundred and ninety five) to the complainant which is not even sufficient for a piles operation which shows the deficiency in service of the officials. CGHS had denied the complainant’s free treatment by way of making not payment to the empaneled hospital and the mode of Medical Reimbursement is not at all applicable to the complainant who was forced to Private Hospital and claim was instrumental of CGHS false policy of Bania Profiteering business which is a heinous act of the part of department. Due to this the complainant who is a beneficiary of CGHS had to take the treatment of non-empanelled hospital. Thereafter CGHS offered partial payment as Medical Reimbursement, instead of giving beneficiary service to the card holder. The above said act of the opposite parties clearly amounts to deficiency in service and unfair trade practice. Hence the complaint.
Notice was issued to the opposite parties and they failed to appear before the Commission. Hence, they were set exparte. Though the 1st opposite party filed the version after setting them exparte, the same was not admissible as the same was filed beyond the statutory time limit.
The complainant filed affidavit in lieu of chief examination and has been examined as PW1 marked Exts.P1 to P7 documents. Ext.P1 is the token No.432003 dated 24.02.2022 issued from Central Government Health Scheme, Trivandrum. Ext.P2 is the letter issued to Additional Director, CGHS dated 23.08.2013. Ext.P3 is the letter issued to the Additional Director, CGHS Welfare Centre, Trivandrum dated 11.07.2022. Ext.P4 series (4 Nos.) Medical Records issued from Sree Gokulam Medical College and Research Foundation. Ext.P5 is the letter issued to the Additional Director, CGHS Welfare Centre, Trivandrum dated 04.04.2022. Ext.P6 is consultation bill for Rs.60,166/- issued from Padmavathy Medical Foundation dated 13.03.2022. Ext.P7 is the emergency certificate issued from Padmavathy Medical Foundation dated 16.03.2022.
The complainant, an ex-serviceman, is entitled to free treatment in empaneled hospitals for major ailments, as a beneficiary of the Central Government Health Scheme (CGHS). He had paid Rs. 48,000 for this scheme, which provides free treatment for advanced medical procedures in empaneled hospitals. He also holds a CGHS beneficiary card (No. 3697975), entitling him to advanced treatments, including laparoscopic surgery for a left inguinal hernia, in empaneled hospitals, along with accommodation as per his status, excluding food.
The complainant was admitted to Padmavathy Medical Foundation, a non-empaneled hospital, due to an emergency. Following this, he sought treatment at empaneled hospitals S.K. Hospital and Gokulam Medical College, as per Ext. P1, which referenced him to these facilities for laparoscopic surgery. However, these hospitals denied him the CGHS-covered free treatment, citing non-payment by CGHS, Trivandrum, for previous treatments.
The complainant incurred Rs. 60,166 for the surgery, but CGHS only reimbursed Rs. 20,995, leaving a significant shortfall. This denial of full reimbursement is a deficiency in service by the CGHS authorities, as the complainant had relied on the scheme's assurance of full coverage for such procedures.
Upon reviewing the uncontroverted testimony and supporting documents (Exhibits P1 to P7), it is clear that the opposite parties failed to provide full reimbursement, resulting in financial loss and mental distress to the complainant.
In the result the complaint is allowed. The opposite parties 1 and 2 shall jointly and severally pay the complainant Rs. 39,171 as the balance of the total bill incurred for the laparoscopic surgery and Rs. 5,000 as compensation for mental agony and financial hardship due to the service deficiency. The opposite parties shall also pay Rs. 2,000 as costs of the proceedings. Time for compliance within 45 days from the date of receipt of the order; otherwise, the complainant may initiate execution proceedings.
Dictated to the Confidential Assistant Smt.Minimol S.transcribed and typed by her corrected by me and pronounced in the Open Commission this the 30th day of October 2024.
Sd/-
STANLY HAROLD
MEMBER
Sd/-
S.K.SREELA
PRESIDENT
Forwarded/by Order
Senior superintendent
INDEX
Witness Examined for the complainant:-
PW1 : Dr.N.Bahuleyan
Document marked for the complainant:
Ext.P1 : Token No.432002 dated 24.02.2022
Ext.P2 : Letter issued to Additional Director, CGHS
Ext.P3 : Letter issued to Additional Director, CGHS
Ext.P4 : Medical Records
Ext.P5 : Letter issued to Additional Director, CGHS
Ext.P6 : Consultation bill for Rs.60,166/-
Ext.P7 : Emergency certificate
Witness Examined for the opposite parties:-Nil
Documents marked for opposite parties:-Nil
Sd/-
PRESIDENT