State Consumer Disputes Redressal Commission
Esi Corporation & Anr. vs Susanta Kumar Panda on 3 July, 2023
FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of hearing: 05.04.2023
Date of Decision: 03.07.2023
FIRST APPEAL NO.-20/2017
IN THE MATTER OF
1. EMPLOYEES STATE INSURANCE CORPORATION,
THROUGH ITS DIRECTOR GENERAL
PANCHDEEP BHAWAN,
CIG MARG, NEW DELHI-110002.
2. DIRECTORATE (MEDICAL) DELHI,
ESI SCHEME DISPENSARY COMPLEX,
TILAK VIHAR, TILAK NAGAR,
NEW DELHI-110018.
(Through: Mr. Yakesh Anand &
Mr. Prateek Kumar, Advocates)
...Appellants
VERSUS
MR. SUSANTA KUMAR PANDA,
H.NO. 304, I-IIND- 304, MADANGIR,
NEW DELHI-110062.
(Through: Mr. Sandeep Vishnu, Advocate)
...Respondent
DISMISSED PAGE 1 OF 9
FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON'BLE PINKI, MEMBER (JUDICIAL)
Present: Mr. Yakesh Anand and Mr. Akshay Thakur, counsel for the
Appellant.
None for the Respondent.
PER : HON'BLE JUSTICE SANGITA DHINGRA SEHGAL, PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are as under:
"The complainant has been working with M/s Lark Labs India Ltd., Okhla Industrial Area Phase - II, He has been regularly depositing ESI Contribution at the rate of 1.75% from his salary along with the Employee's Contribution at the rate of 4.75%. He is thus a consumer of OP1 who is rendering medical services under the ESI Scheme. He was suffering from Acute with Chronic problem of fissure and piles and on 4th March 2014 had visited ESIC Hospital Tigri New Delhi. He was referred to OPD of ESIC Hospital Sreemaa Anand Mayee Marg Okhla, where he went on 23/04/14 and 21/05/14 but his problem persisted and could not be cured. On 30/05/14 suddenly his condition became very serious and was rushed to Batra Hospital, New Delhi. He was diagnosed as a case of Fistula in ANO with Abscess with Hemorrhoidectomy with Anal Spasm and Ulcerative Colitis with large bowl perforation with gangrene of Caccum. Fistulectomy with abscess drainage with Hemorridectomy with Anal Dilation was carried out after admission in surgery of said hospital. On the same day he was admitted in ESI Hospital, Okhla from where he was discharged on 21/06/2014. He was again admitted to Batra Hospital on 21/06/14 with complaints of wound dehiscence of anterior abdominal wall prolapse ileostomy with fistula between ileostomy and skin. He was operated by debridement repair of burst abdomen resection with repair of ileostomy and closure DISMISSED PAGE 2 OF 9 FA/20/2017 D.O.D.: 03.07.2023 ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA of abdominal flap on 26/06/2014. Again a repair of burst abdomen was carried out on 27/06/14 before he was discharged on 17/07/14.
The complainant had incurred an expense of Rs. 232434/- (Two Lacs Thirty Two Thousand Four Hundred Thirty Four) Hospital from 30/05/2014 to 15/06/14. He had also paid a sum of Rs. 3843/- (Three Thousand Eight Hundred Forty Three) for Medicines/OPD Card, in respect of his on account of his treatment in Batra treatment in Batra Hospital for the second time i.e. from 21/06/14 to 17/07/14 the expenses was directly borne by OP1.
The complainant lodged a claim for reimbursement of a sum of Rs. 236277/- (Two Lacs Thirty Six Thousand Two Hundred Seventy Seven) in respect of his treatment at Batra Hospital from 30/05/14 to 15/06/14. The claim however, was rejected by OP2 vide its letter no. 3184 dt 21/08/2015. The complainant has alleged deficiency in service on the part of OPs and has sought a direction for payment of claim along with compensation and cost of litigation."
2. The District Forum after taking into consideration the material available on record passed the order dated 21.09.2016, whereby it held as under:
"Learned Counsel for the complainant has forcefully contended that the Complainant was admitted in Batra Hospital in an emergency and he was entitled to reimbursement of the expenses incurred on the treatment as per the guidelines issued for reimbursement of expenses by the OPs. He has referred to discharge summary dated 15/06/14 in this regard. On the other hand the Learned Counsel of the OPs has contended that the Complainant had visited the hospital on his own and had failed to get his case referred from an ESI Hospital/Dispensary. He had contended that the claim of the complainant has been rightly rejected by the OPs. We have given our thoughtful consideration to the contentions raised.
DISMISSED PAGE 3 OF 9 FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA A careful consideration of medical record placed on the file specially the discharge summary dated 15/06/14 makes it amply clear that the complainant was admitted in Batra Hospital in an emergent condition. He was diagnosed as a case of fistule in Ano with Abscess with Hemorrhoids with Anal Spasm with ulcerative Colitis with large bowl perforation with gangrene of Caccum. Operation was performed on him to relieve him of the agony.
The fact that gangrene had already set in lends credence to our opinion. The onset of gangrene is life threatening and has to be treated immediately without any loss of time. In our considered opinion therefore it was an emergent condition where the complainant had got himself admitted in Batra Hospital which was on the panel of ESI. We therefore, hold that the rejection of the claim by the OPI was unjustified. We hold OPs deficient in rendering services to the complainant and direct them as under:
Pay to the complainant a sum of Rs. 2,36,277 (Two Lacs Thirty Six Thousand Two Hundred Seventy Seven) along with interest @ 10% per annum with effect from 16/12/15 (from the date of filing of the complainant ) till payment;
We direct OPS to pay a sum of Rs. 25000/- (Twenty Five Thousand) to the complainant as compensation for pain and agony suffered by him;
Pay to the complainant a sum of Rs. 5,000/-as cost of litigation.
This order shall be complied with by the OP within a period of 30 days from the date of receipt of this order failing which interest @ 12% shall be payable on the entire above mentioned amount till realisation. Copy of this order is sent to all the parties free of cost. File be consigned to Record Room."
3. Aggrieved by the aforesaid Judgment of the District Commission, the Appellants have preferred the present appeal, contending that Commission erred in DISMISSED PAGE 4 OF 9 FA/20/2017 D.O.D.: 03.07.2023 ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA establishing in deficiency in services on the part of the Appellants as the Respondent visited the Private hospital without taking prior permission from the ESIC and it was a planned surgery. The counsel for the Appellants further submitted that the Respondent can only get benefit of medical reimbursement from empanelled/non-empanelled private hospitals only for his/her treatment only in a case of emergency hospitalization and treatment but the patient at the time of admission was conscious, therefore it was not a case of emergency as his surgery was planned.
4. Respondent has the reply to the appeal, wherein, he submitted that there is no error in the impugned judgment as the entire material available on record was properly scrutinized before passing the said order.
5. Written Arguments of both the parties is on record.
6. We have perused the material available on record.
7. The main question for consideration before us is whether the District Commission erred in establishing in deficiency in services on the part of the Appellants?
8. It is not disputed by the parties that the Respondent has been working with M/s Lark Labs India Ltd., Okhla and was covered under the ESI Scheme under the ESI Act. The Respondent was suffering from acute and chronic problems of fissures and piles, so he visited ESIC Hospital Tigri, New Delhi on 04.03.2014. Thereafter, he was referred to the OPD of ESIC, Okhla. Accordingly, the Respondent visited the ESIC hospital on 23.04.2014 and 21.05.2014 but his problem persisted and could not be cured. Therefore, he treated in the Batra Hospital, where he incurred an expense of Rs.2,36,277/- which was rejected by the Appellants vide letter dated 21.08.2015 as the situation under which the respondent was treated was not emergency one.
DISMISSED PAGE 5 OF 9 FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA
9. Therefore, it is imperative to refer discharge summary issued by the Batra Hospital & Medical Research Centre (Annexure A-2):
Course in Hospital: - Patient was admitted evaluated & taken for surgery Fistulectomy with abscess drainage with haemorrhoidectomy with anal dilatation on 30.05.14: On POD 2 he developed sudden onset abdominal distension and pain. X ray abdomen s/o air under diaphragm thus s/o perforation. He was taken to OT and planned for emergency surgery. Exploratory laparotomy with subtotal colectomy with ileostomy with sigmoid colon mucus fistula done Findings: - Transverse colon perforated caecum gangrene. After surgery patient developed abdominal distension due to hypokalemia which was manager conservatively. now distension is settling but attendants want to take patient to other hospital. all risk pros and cons have been explained in detail.
10. It is clear from the discharge summary dated 15.06.2014 that the Respondent was admitted, evaluated and taken for surgery for Fistulectomy with abscess drainage, haemorrhoidectomy and anal dilatation on 30.05.14. Furthermore, on the second day of recovery, the Respondent experienced sudden abdominal distension and pain. Subsequently, an X-ray of the abdomen was conducted, which revealed the presence of air under the diaphragm, indicating a perforation in the digestive tract. This was a serious condition that required immediate attention, so the patient was taken back to the operating theatre for emergency surgery to address the perforation. He was again admitted on 21.06.2014 and operated by debridement repair of burst abdomen resection with repair of ileostomy and closure of abdominal flap on 26.06.2015 and again repair of burst abdomen on 27.06.2014 as evident from discharge summary dated 17.07.2014.
DISMISSED PAGE 6 OF 9 FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA
11. Therefore, it is evident that the Respondent was brought in an emergency condition as the surgery occurred on the same day. Additionally, despite regularly visiting the empanelled hospital, the Respondent's condition could not be cured, leading to the decision to seek treatment at a private hospital in an emergency situation.
12. We also deem it appropriate refer WRIT PETITION (CIVIL) NO. 694 OF 2015 titled as Shiva Kant Jha vs. Union of India decided on 13.04.2018, wherein, the Apex court held that:
".......In the facts of the present case, it cannot be denied that the writ petitioner was admitted in the above said hospitals in emergency conditions. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. It also cannot be denied that the petitioner was taken to hospital under emergency conditions for survival of his life which requirement was above the sanctions and treatment in empanelled hospitals.
..In the present view of the matter, we are of the considered opinion that the CGHS is responsible for taking care of healthcare needs and wellbeing of the central government employees and pensioners. In the facts and circumstances of the case, we are of opinion that the treatment of the petitioner in non-empanelled hospital was genuine because there was no option left with him at the relevant time. We, therefore, direct the respondent-State to pay the balance amount of Rs. 4,99,555/- to the writ petitioner. We also make it clear that the said decision is confined to this case only. We further direct the concerned Ministry to take steps to form the Committee as expeditiously as possible. Further, the above exercise would be futile if the delay DISMISSED PAGE 7 OF 9 FA/20/2017 D.O.D.: 03.07.2023 ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA occasioned at the very initial stage, i.e., after submitting the relevant claim papers to the CMO-I/C, therefore, we are of the opinion that there shall be a timeframe for finalization and disbursement of the claim amounts of pensioners. In this view, we are of the opinion that after submitting the relevant papers for claim by a pensioner, the same shall be reimbursed within a period of 1 (one) month..."
13. Above dicta reflects that in an emergency situation the Respondent can be treated in non-empanelled hospital and he does not require prior permission in any such situations. In situations like this, before reimbursing any medical claim, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned.
14. Returning to the facts of the present case, it is clear from the record that the Respondent was treated for Fistulectomy with abscess drainage with haemorrhoidectomy with anal dilatation and thereafter, abdominal distension & pain, which happened after the surgery in the Batra hospital in an emergency condition and entailed the total bill of Rs. 2,36,277/-. However, the Appellants failed to reimburse the total claimed amount.
15. In view of the forgoing, we are in agreement with the reasons given by the District Commission and fail to find any cause or reason to reverse the findings of the District Commission. Consequently, we uphold the Judgment dated 21.09.2016 passed by the District Consumer Disputes Redressal Forum, (Central), ISBT Kashmere Gate Delhi.
16. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
DISMISSED PAGE 8 OF 9 FA/20/2017 D.O.D.: 03.07.2023
ESI CORPORATION & ANR. VS. MR. SUSANTA KUMAR PANDA
17. The Judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
18. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
03.07.2023 DISMISSED PAGE 9 OF 9