Chandigarh

StateCommission

CC/126/2020

Yash Pal Wadhwa - Complainant(s)

Versus

Employees State Insurance Dispensary - Opp.Party(s)

Devinder Kumar

23 Sep 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/126/2020
Date  of  Institution	:	16/07/2020
Date   of   Decision	:	23/09/2022

 

 

 

 

 

Yash Pal Wadhwa S/o Late Sh. Gobind Ram, resident of House No. 3138, Sector 27-D, Chandigarh.

…. Complainant

 

Vs.

 

 

1.     Employees State Insurance Dispensary, Sector 29, Chandigarh, through its Senior Medical Officer.

 

2.     The Director Health & Family Welfare, Chandigarh Administration, Sector 16, Chandigarh.

 

3.     Senior State Medical Commissioner, Employees State Insurance Corporation (Ministry of Labour & Employment (Govt. of India), Regional Office: Panchdeep Bhawan, Madhya Marg, Sector 19-A, Chandigarh.

…… Opposite Parties

 

 

BEFORE: JUSTICE RAJ SHEKHAR ATTRI   PRESIDENT

PADMA PANDEY                             MEMBER

                RAJESH K. ARYA                           MEMBER

 

PRESENT	:	Sh. Devinder Kumar, Advocate for the Complainant.
		Sh. Rajinder Singh, Govt. Pleader for OPs No.1 & 2.
		Sh. Anil Gogna, Advocate for Opposite Party No.3.

 

PER PADMA PANDEY, MEMBER

 

 

 

                In brief, the facts necessary for the disposal of the instant Consumer Complaint are, the Complainant by virtue of his employment with M/s Zeto Engineers and Fabricators, Industrial Area, Phase-I, Chandigarh, was enrolled with the ESIC for getting medical facilities by the ESI Dispensary/Hospital. The Complainant was suffering from Liver Cirrhosis and approached Opposite Party No.1 for its treatment, who referred him to the Department of Hepatology, PGI, Chandigarh where the Complainant was advised liver transplant. Thereafter, the Opposite Party No.3 referred the Complainant to SSMC, Chennai vide letter dated 30.01.2015. Since the condition of the Complainant was very serious, he was admitted to Apollo Hospital, where liver transplant surgery was done on 11.04.2015. In all, the Complainant spent an amount of Rs.35,27,844/- for his treatment aforesaid. Accordingly, for reimbursement of the said amount, the Complainant lodged his claim with the Opposite Party No.1. However, Opposite Parties took nearly five years to partially settle the claim and transferred an amount of Rs.13,62,072/- in the account of the Complainant, thereby withholding an amount of Rs.21,62,772/- without any rhyme and reason. The Complainant approached the Opposite Parties a number of times to release the remaining claim amount, but to no avail. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the Complainant has preferred the instant Consumer Complaint.

 

2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case. 

 

3.         Opposite Parties No.1 & 2 filed their joint reply, inter alia, admitting the factual matrix of the case. It has been pleaded that the Complainant was registered with ESIC vide Insurance Person (I.P) No. 1708284350. He visited the OPD at ESI Dispensary, Sector 29, Chandigarh and was medically examined and referred to ESI Hospital, Ramdarbar, Chandigarh. On 29.10.2014, the Complainant visited the ESI Hospital and after examination he was diagnosed to be suffering with Liver Cirrhosis with Diabetes Mellitus and Hyper Tension. For further treatment and management, the Complainant was referred to PGIMER, Chandigarh. On 30.01.2015, on the request of the Complainant, a referral certificate with respect to approval for providing treatment to him at Central Government Health Scheme (CGHS/ESIC) rates was given to the Complainant by Opposite Party No.3. On 16.06.2015, the Complainant submitted his medical bills to the tune of Rs.35,27,844/- for its reimbursement with ESI Dispensary, Sector 29, Chandigarh which were thoroughly verified in accordance with rates of Central Government Health Scheme rates (CGHS) and ESI Operational Manual 2014. After considering the aforesaid bills, the permissible amount of Rs.13,65,072/- had been sanctioned and paid to the Complainant. Pleading that there was no deficiency in service or unfair trade practice on their part, a prayer has been made for dismissal of the complaint.

 

4.         Opposite Party No.3 filed its separate reply, inter alia, admitting the basic facts of the case. It has been pleaded that no cause of action has arisen in favour of the Complainant against Opposite Party No.3. In the present case of Complainant, the reimbursement of medical expenditure was to be done by the Govt. of U.T., Chandigarh and it was to be paid by ESIC Dispensary, Sector 29, Chandigarh (Opposite Party No.1). Moreover, the Complainant was thoroughly guided to submit the bills in the office of Opposite Party No.1 and about the reimbursement process. Pleading that there was no deficiency in service or unfair trade practice on its part, a prayer has been made for dismissal of the complaint.

 

5.         Parties led evidence by way of affidavits and documents.

 

6.         We have heard the Learned Counsel  for the Complainant, Ld. Govt. Pleader for the Opposite Parties No.1 & 2 & Learned Counsel for Opposite Party No.3 and had gone through the record of the case, including the written arguments advanced on behalf of the parties.

 

7.         After scanning of record, including written arguments, our findings are as under:-

 

8.         On perusing the records of the case, this Commission finds that the Complainant was suffering from Liver Cirrhosis and he approached Opposite Party No.1 for its treatment. The Complainant was referred to the Department of Hepatology, PGI, Chandigarh where he was advised liver transplant. The Complainant was further advised by Opposite Party No.3 to SSMC, Chennai vide letter dated 30.01.2015. But, since the condition of the Complainant was very serious, he was admitted to Apollo Hospital where he got his liver transplant done on 11.04.2015. The Complainant incurred an amount of Rs.35,27,844/- for his treatment. However, upon lodging reimbursement claim, the Opposite Party took nearly five years to partially settle the claim and transferred only an amount of Rs.13,62,072/- in the account of the Complainant deducting an amount of Rs.21,62,772/-.    

 

9.         Opposite Parties No.1 & 2 maintained that reimbursement of Rs.13,65,072/- had been sanctioned and paid to the Complainant in terms of CGHS/ESI Operational Manual. A schedule with respect to medical expenses incurred/claimed and medical expenses allowed in terms of CGHS/ESI Operational Manual has been annexed with their written version as Annexure R-1/1. The allegation of the Complainant that OP No.1 took a long time i.e. five years to settle the claim, has been rebutted by Opposite Parties No.1 & 2 on the ground that there were many irregularities in the bills raised by the Complainant and it took a considerable time for them to scrutinize the same and find out deficiencies therein before releasing the permissible amount to the Complainant in terms of CGHS/ESI Operational Manual.

 

10.         On analyzing the details of deductions made in the bills submitted by the Complainant to the Opposite Parties [Annexure R-1/1], we find that against every itinerary i.e. consultation, equipments, investigation, medical records, nursing charges, lab investigations, x-ray etc. the Opposite Parties have applied the prevailing rate according to their rules and made deductions out of the total amount claimed by the Complainant against each itinerary. For example, against the Consultation out of the claimed amount of Rs.4800/- as per CGHS approved rates, deduction of Rs.4296/- has been made. There are certain columns, where no provision has been shown against the CGHS rate. Accordingly, Opposite Parties No.1 & 2 had applied the rates according to their rules and arrived at the total amount payable as Rs.13,65,072/- after deducting an amount of Rs.21,62,772/-. In this back drop, the Opposite Parties No.1 & 2 have maintained that since due amount was sanctioned and paid to the Complainant as per the approved rates of CGHS/ESIC Operational Manual, thus, nothing is payable to the Complainant.

 

11.         In the wake of aforesaid, it is apparent the medical bills were reimbursed by the Opposite Parties No.1 & 2 in terms of provisions under approved rates of CGHS/ESI Manual. To our mind, nothing was withheld by the Opposite Parties No.1 & 2, which was otherwise payable according to the Manual. The prayer of the complainant qua releasing of the alleged withheld amount of Rs.21,62,772/- is, therefore, declined. However, there is no denying the fact that Opposite Parties No.1 & 2 took almost five years to transfer an amount of Rs.13,65,072/-in the account of the Complainant, which not only amounts to deficiency in service, but is a grave malpractice under the Consumer Protection Act. Had, Opposite Parties No.1 & 2 been vigilant in releasing/refunding the amount promptly, complainant would not have been put to unnecessary harassment and mental tension, forcing him to knock the doors of this Commission for seeking redressal by spending money on litigation. So, for the inconvenience and expenditure incurred by the complainant, it would be just and reasonable to award a suitable compensation to the Complainant and cost of present proceedings which is quantified at Rs.25,000/-.

 

12.         Now coming to the quantum of compensation, it would be appropriate for us to refer the judgment of the Hon'ble Supreme Court of India in the case of Ghaziabad Development vs Balbir Singh reported (2004) 5 SCC 65 wherein the court has held that ―The word compensation is of a very wide connotation. It may constitute actual loss or expected loss and may extend to compensation for physical, mental or even emotional suffering, insult or injury or loss. The provisions of the Consumer Protection Act enable a consumer to claim and empower the Commission to redress any injustice done. The Commission or the Forum is entitled to award not only value of goods or services but also to compensate a consumer for injustice suffered by him. The Commission/ Forum must determine that such sufferance is due to malafide or capricious or oppressive act. It can then determine the amount for which the authority is liable to compensate the consumer for his sufferance due to misfeasance in public office by the officers. Such compensation is for vindicating the strength of law. We find the above judgement appropriate for us to arrive at the quantum of compensation. In view of the discussion made above and considering the facts and circumstances of the complaint, we feel that a sum of Rs.2,00,000/- as compensation for deficiency in service, mental agony, harassment & unfair trade practice would be just and reasonable.

 

13.         Since reimbursement of medical expenditure was to be done by the Opposite Party No.2 and it was to be paid by ESIC Dispensary, Sector 29, Chandigarh (Opposite Party No.1), we feel that the instant Consumer Complaint qua Opposite Party No.3 deserves to be dismissed.

 

14.         In the light of above discussion, this consumer complaint deserves to succeed. The same is accordingly partly allowed.  Opposite Parties No.1 & 2 are, jointly and severally, directed as under:-

[a]    To pay Rs.2,00,000/- to the Complainant as compensation for deficiency in service, mental agony, harassment suffered by him; 

[b]     To pay cost of litigation to the tune of Rs.25,000/- to the Complainant.

                The complaint against Opposite Party No.3 fails and is accordingly dismissed with no order as to costs. 

15.         The above said order shall be complied within 30 days of its receipt by the Opposite Parties No.1 & 2; thereafter, they shall be liable for an interest @8% p.a. on the amounts mentioned in sub-paras [a] & [b] above from the date of institution of this complaint, till the same are paid.  

 

16.         Certified copies of this order, be sent to the parties, free of charge.

 

17.         The file be consigned to Record Room, after completion.

 

Pronounced

23^rd Sept., 2022                                                   

Sd/-

                                                (RAJ SHEKHAR ATTRI)

PRESIDENT

 

 

Sd/-

                                                        (PADMA PANDEY)

MEMBER

 

 

Sd/-

                                                        (RAJESH K. ARYA)

MEMBER

“Dutt”