State Consumer Disputes Redressal Commission
C.M.S & Other vs Pooran Chand Agarwal on 19 May, 2023
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of Institution: 01.05.2023
Date of hearing: 05.04.2023
Date of Decision: 19.05.2023
FIRST APPEAL NO.-7/2023
IN THE MATTER OF
1. CHIEF MEDICAL SUPERINTENDENT,
NORTHERN RAILWAY DIVISIONAL HOSPITAL,
S.P.M. MUKHERJEE MARG, DELHI-110006
2. The DIVISIONAL RAILWAY MANAGER,
(MR. S.C. JAIN)
NORTHERN RAILWAY DIVISIONAL OFFICE,
ESTATE ENTRY ROAD, NEW DELHI-110055
3. THE CHIEF MEDICAL DIRECTOR,
(DR. N.K. YADAV),
NORTHERN RAILWAY HEAD QUARTER OFFICE,
BARODA HOUSE, NEW DELHI-110001
4. THE GENERAL MANAGER,
(MR. ASHUTOSH GANGAL),
NORTHERN RAILWAY HEAD QUARTER OFFICE,
BARODA HOUSE, NEW DELHI-110001
5. THE CHAIRMAN/CEO,
(MR. VINOD KUMAR YADAV),
RAILWAY BOARD/MINISTRY OF RAILWAY,
RAIL BHAWAN,
DISMISSED PAGE 1 OF 15
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
NEW DELHI-110001.
(Through: Ms. Sareeka Sharma, Advocate)
...Appellants
VERSUS
POORAN CHAND AGARWAL,
S/o LATE MR. SHANKAR LAL,
R/o A-3/98, JANAKPURI,
NEW DELHI-110058.
(Through: Respondent in person)
...Respondent
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON'BLE PINKI, MEMBER (JUDICIAL)
Present: Ms. Sareeka (Enrl.D/892/2001), counsel for appellant, along with Dr.
S.K. Nagar in person, Northern Railway, Divisional Hospital, Delhi.
Respondent in person along with Mr. Om Prakash (Mob.
9891358325), AR/one of the neighbors of 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:
DISMISSED PAGE 2 OF 15
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
"The complainant was retired employee from the designation Parcel Supervisor with the Northern Railways, retired from PS Delhi Main, N. Railway. Holding Medical Card under RELHS-
97. His wife namely Smt. Shakuntla Devi Agarwal, under regular treatment for Thyroid-Cardiac Ailments continuous knee pain for the last fifteen years. She felt sever pain & swelling over both knees. After sudden fall unable to Stand and walk at her own, taken to BLK Hospital on 06.08.2019, after examination & diagnoses on spectral CT. scan shows minimally displayed condyler fracture in right femur.
2. It is stated that on 07.08.2019 she completely became bed- ridden taken to SIR Ganga Ram Hospital, New Delhi, on an emergency and admitted on 07.08.2019 and discharged on 19.08.2019. The treatment entailed hospital expenses of Rs.5,02,632/- paid by the complainant and a sum of Rs. 2,00,000/- from OIC. The wife of complainant further admitted on 06.09.2019 and discharge on 10.09.2019, further the hospital entailed total bill of Rs.1,20,843/-.
3. It is stated that the wife of the complainant Smt. Sakuntala Devi Agrawal having PNB Oriental Mediclaim Policy of Oriental Insurance Company Ltd for bank account holder only. Policy no. 2729000/48/2019-15918, period of insurance start from 14.11.2018 to 13.11.2019 as sum insured Rs.2,00,000/-from OIC / MEDI-ASSIST Share has already paid the sum insured of Rs.1,99,998/- directly to the hospital as adjusted in the first bill dated 07.08.2019. It is stated that a sum of Rs.4,23,477/- paid by the complainant to the hospital spending for reimbursement claim.
4. It is stated that complainant filed claim form RELHS Scheme-97 along with one bill no. 2019/2020/CR/I/0011573, for a sum of Rs.5,02,632/- and second subsequent bill no. 2019/2020/CR/1/0031806 for a sum of Rs.1,20,843/- alongwith DISMISSED PAGE 3 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL relevant documents. It is stated that the complainant claims total sum of Rs.5,02,634 &Rs.1,99,980/- paid by MEDI - ASSIST SHARE directly paid to the hospital and a sum of Rs.3,02,634/- paid by the complainant and a sum of Rs.1,20,843/- remaining from the subsequent bill dated 06.09.2019. The complainant claims total sum of Rs.4,23,477/- from the OP's under RELHS -97 Scheme.
5. The complainant claims reimbursement of the aforesaid payment from the Chief Medical Superintendent of the Northern Railways/OP's. It is stated by the complainant that OP's seeking reasons for entertaining reimbursement bills exceeding its empowerment (SOP) of Rs.2,00,000/- part payment of Rs.1,98,064/-on 17.08.2020 had been reimbursed. It is alleged that the OP illegally curtailed Rs.2,30,767/- on the ground that the complainant / Railway beneficiary to go any private hospital on their own violation except in case of real emergency situation.
6. It is stated that the complainant regularly and diligently kept following up the status of the claims, but no avail. Feeling aggrieved, complainant has filed the present complaint alleging deficiency in service and unfair trade practice on the part of the OP's and seeking relief that OP's be directed to pay a sum of Rs.5,02,632 &Rs.1,99,998/- paid directly by MEDI - ASSIST SHARE, to the hospital and a sum of Rs.3,02,634/- paid by the complainant and a sum of Rs.1,20,843/- remaining from the subsequent bill dated 06.09.2019. The complainant claims total sum of Rs.4,23,477/- from the Ops under RELHS - 97 Scheme, along with compensation amounting to sum of Rs.1,00,000/-(Rupees One Lakh Only) on account of mental agony, harassment, pains and sufferings and also litigation charges."
DISMISSED PAGE 4 OF 15
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
2. The District Forum after taking into consideration the material available on record passed the order dated 22.11.2022, whereby it held as under:
"12......It is undisputed that complainant was retired employee from the designation Parcel Supervisor with the Northern Railways, retired from PS Delhi Main, Northern Railway, holding Medical Card under RELHS-97. Ld. Counsel for OP's submits that the Op's do not dispute the fact that the wife of the complainant, under regular treatment for Thyroid-Cardiac Ailments continuous knee pain for the last fifteen years, taken to BLK Hospital on 06.08.2019, after examination & diagnoses on spectral CT. scan shows minimally displayed condyler fracture in right femur, further the complainant and his wife had to rushed to Sir Ganga Ram Hospital, New Delhi, on an emergency and discharge on 19.08.2019. The treatment entailed hospital expenses of Rs.5,02,634/- paid by the complainant and a sum of Rs.1,99,998/- from OIC. The wife of complainant further admitted on 06.09.2019 and discharge on 10.09.2019, further the hospital entailed a bill of Rs.1,20,843/-.
13.The complainant filed claim form RELHS Scheme-97 along with bill no. 2019/2020/CR/1/0011573 for a sum of Rs.5,02,634/- and bill no 2019/2020/CR/1/0031806 for a sum of Rs.1,20,843/- alongwith relevant documents. It is stated that the complainant claims total amount of Rs.5,02,63 & Rs.1,99,980/- paid by MEDI -ASSIST SHARE directly paid to the hospital and a sum of Rs.3,02,634/- paid by the complainant and a sum of Rs.1,20,843/- remaining from the subsequent bill dated 06.09.2019. The complainant claims total sum of Rs.4,23,477/- from the op's under RELHS -97 Scheme, which including Rs.1,99,980/- paid by MEDI -ASSIST Share directly to the hospital, under Oriental Insurance Co. Ltd for Group Health Insurance Product (Policy for Bank Account Holders of PNB). The OP's have however, on the basis of the recommendations DISMISSED PAGE 5 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL made by Committee, reimbursed only a sum of Rs.1,98,064/-on 17.08.2020. The OP's have refused to pay balance of Rs.2,25,413/- (Rupees Two Lakh Twenty Five Thousand Four Hundred Thirteen only) to the complainant on the ground that the complainant/Railway beneficiary to go any private hospital on their own violation except in case of real emergency situation.
14. We, found that OP's are not really disputing that the complainant's wife was in compelling circumstances, and in a grave medical emergency forced to take treatment from Sir Ganga Ram Hospital, and has paid claim amount for her wife treatment between 07.08.2019 and discharged on 19.08.2019 and further from 06.09.2019 and discharge on 10.09.2019 and the Op's have however, on the basis of the recommendations made by Committee, reimbursed only a sum of Rs.1,98,064/- on 17.08.2020. The OP's have refused to pay balance of Rs.2,30,767/- to the complainant.
15. From the foregoing discussion would lead to the only irresistible conclusion that the repudiation of the claim of the complaint was unjustified and the complainant had filed his evidence by affidavit and filed and relied upon the discharged summary and final discharged bills issued by doctor of Sir Ganga Ram Hospital. The complainant aged about 84 years old, who had to spend his hard-earned savings, while undergoing treatment to save his as well his wife life, cannot be simply told that, since the complainant has failed to abide by the Railway Board Policy dated 31.01.2007, issued by competent authority with the consultation of experts that "CMD of Zone railway can obtain special permission from railway board for treatment in private hospital of a beneficiary who is under treatment (since last 15 years and there is no scope available for railway beneficiaries to go any private hospital on DISMISSED PAGE 6 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL their own violation except in case of real emergency situation."
The OP's have however, on the basis of the recommendations made by Committee, reimbursed only a sum of Rs.1,98,064/- on 17.08.2020 as the claim was examined scrutinized and justified as emergency case by the authority i.e., OP No. 1, as per procedure contained in Railway Board letter no. 2005/H/6.4/Policy-II/New Delhi dated 31.01.2007.
16. Under Article 21 of The Constitution of India, the State have a Constitutional obligation to bear the medical expenses of Government employees while in service and also after they are retired. The OP's have on the basis of the recommendations made by Committee, reimbursed only a sum of Rs.1,98,064/-on 17.08.2020 as the claim was examined scrutinized and justified as emergency case by the authority i.e. OP No. 1, as per procedure contained in Railway Board letter no. 2005/H/6- 4/Policy-II/New Delhi dated 31.01.2007. Clearly in the present case by taking a very inhuman approach, OP's official have denied , full claim, the grant of medical reimbursement to the complainant forcing him to approach the Forum/Commission.
17. There is no dispute in respect of RELHS-97 Scheme and the complainant is the beneficiary of the scheme. It is case of emergency "Rule allow reimbursement". The OP place reliance on the Railway Board Policy / Circular dated 31.01.2007 relevant portion which read as under :-
"In exceptional situations, CMDs of Zonal Railways can obtain special permission from Railway Board for treatment in any Private Hospital on case to case basis. Hence, there is no scope available for any railway beneficiary to go to any private hospital himself/ herself or their dependents on their own volition, except in case of real emergency situation."
DISMISSED PAGE 7 OF 15
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
18.In the above facts and circumstances, we accordingly hold that OP's were guilty of deficiency in service as its arbitrarily repudiated the entire claim, since the finding of the concerned authority was not supported or substantiated by any conclusive documents.
19. In the light of the aforesaid, We, have no hesitation in holding that the Op's ought to forthwith reimburse the complainant by paying him the differential amount of Rs.2,25,413/- (Rupees Two Lakh Twenty Five Thousand Four Hundred thirteen only). The complainant should not claim a sum of Rs.1,99,998/- paid by Medi assist Share paid to the Hospital under Oriental Insurance Co. Ltd for group Health Insurance Product (Policy for Bank Account Holders of PNB). The complaint is accordingly allowed by directing the Op's to pay the balance amount of Rs.2,25,413/- (Rupees Two Lakh Twenty Five Thousand Four Hundred thirteen only), with interest @ 7% per annum since lodging of claim and as well as compensation of Rs.1,00,000/- (Rupees One lakh Only) for mental agony Rs.25,000/- (Rupees Twenty Five Thousand) as cost of litigation from the date of filing of complaint within 4 weeks of the receipt of the order, failing which OP will be liable to pay interest @ 12 % p.a. till realization."
3. Aggrieved by the aforesaid Judgment of the District Commission, the Appellant has preferred the present appeal, contending that, that as per CGHS guidelines prevailing at the time, treatment expenses at private hospitals are admissible for reimbursement, only in the event of emergencies. Secondly, the respondent seeking for entertaining reimbursement bills exceeding its empowerment (SOP) of Rs. 2,00,000/- part payment of Rs. 1,98,064/- had been reimbursed on 17.08.2020 as per as per Central Government Health Scheme (CGHS) rates and appellant DISMISSED PAGE 8 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL illegally curtailed Rs. 2,30,767/- on the ground that the respondent goes any private hospital on their own violation except in the case of real emergency situation.
4. Respondent has the written submitted, 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. We have perused the material available on record and heard the counsel for both the parties.
6. 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.
7. It is not disputed by the parties that the Respondent was the retired employee from the designation parcel supervisor and holding medical card under scheme RELHS -97. On 06.08.2019, wife of the respondent felt sever pain and swelling to both knees and was taken to BLK hospital. Thereafter, examination & diagnosis on spectral CT, Scan shows minimally displayed condyler frature in right femur. Subsequently, she was taken to the SIR Ganga Ram Hospital (private) on an emergency condition and treated for said fracture from 7.08.2009 to 19.08.2019 and 06.09.2019 to 10.09.2019. The hospital entailed total bill of Rs. 5,02,632/- on first visit and Rs. 1,20,843/- on second visit. Further, it is admitted by the Appellants that the case was scrutinized and justified as emergency case by the competent authority and accordingly, the Appellants reimburse the claim of the Respondent to Rs.1,98,063.90/- as rules of CGHS instead of Rs. 4,28,830.89/- as claimed by the Respondent.
DISMISSED PAGE 9 OF 15
FA/7/2023 D.O.D.: 19.05.2023
C.M.S. & ORS. VS. POORAN CHAND AGARWAL
8. At the stage, we 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:
"12) With a view to provide the medical facility to the retired/serving CGHS beneficiaries, the government has empanelled a large number of hospitals on CGHS panel, however, the rates charged for such facility shall be only at the CGHS rates and, hence, the same are paid as per the procedure. Though the respondent-State has pleaded that the CGHS has to deal with large number of such retired beneficiaries and if the petitioner is compensated beyond the policy, it would have large scale ramification as none would follow the procedure to approach the empanelled hospitals and would rather choose private hospital as per their own free will. It cannot be ignored that such private hospitals raise exorbitant bills subjecting the patient to various tests, procedures and treatment which may not be necessary at all times.
13) It is a settled legal position that the Government employee during his life time or after his retirement is entitled to get the benefit of the medical facilities and no fetters can be placed on his rights. It is acceptable to common sense, that ultimate decision as to how a patient should be treated vests only with the Doctor, who is well versed and expert both on academic qualification and experience gained. Very little scope is left to the patient or his relative to decide as to the manner in which the ailment should be treated. Speciality Hospitals are established for treatment of specified ailments and services of Doctors specialized in a discipline are availed by patients DISMISSED PAGE 10 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL only to ensure proper, required and safe treatment. Can it be said that taking treatment in Speciality Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, 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. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the officials of the CGHS have denied the grant of medical reimbursement in full to the petitioner forcing him to approach this Court.
14) This is hardly a satisfactory state of affairs. The relevant authorities are required to be more responsive and cannot in a mechanical manner deprive an employee of his legitimate reimbursement. The Central Government Health Scheme (CGHS) was propounded with a purpose of providing health facility scheme to the central government employees so that they are not left without medical care after retirement. It was in furtherance of the object of a welfare State, which must provide for such medical care that the scheme was brought in force. 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 DISMISSED PAGE 11 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. The doctors did his operation and had implanted CRT-D device and have done so as one essential and timely. Though it is the claim of the respondent-
State that the rates were exorbitant whereas the rates charged for such facility shall be only at the CGHS rates and that too after following a proper procedure given in the Circulars issued on time to time by the concerned Ministry, 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.
15) 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 well being 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.
16) Further, with regard to the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially, we are of the opinion that all such claims shall be attended by a Secretary level High Powered Committee in the concerned Ministry which DISMISSED PAGE 12 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL shall meet every month for quick disposal of such cases. We, hereby, direct the concerned Ministry to device a Committee for grievance redressal of the retired pensioners consisting of Special Directorate General, Directorate General, 2 (two) Additional Directors and 1 (one) Specialist in the field which shall ensure timely and hassle free disposal of the claims within a period of 7 (seven) days. 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 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.
9. Above dicta reflects that speciality hospitals are established to provide treatment for specific medical conditions, and patients can utilize their services to receive appropriate, secure, and efficient medical care. However, it is important to note that undergoing treatment in a speciality hospital does not exempt a person from seeking reimbursement based solely on the claim that the hospital in question is not included in the Government Order. Therefore, it is also clear that the right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. Moreover, aforesaid mentioned precedent also makes it clear that the person does not require prior permission in such situation where the survival of the person is the prime consideration. In situations like this, before DISMISSED PAGE 13 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL 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.
10. Apex court also raise a concerned about MRC (Medical Reimbursement Claim) in case of retired employee that the slow and tardy pace of disposal of MRC by the CGHS in case of pensioner beneficiaries and the unnecessary harassment meted out to pensioners who are senior citizens, affecting them mentally, physically and financially. Therefore, it cannot be denied that old persons taking benefits of pension scheme must not suffered and in an emergency condition their claim cannot be rejected on the ground of taking treatment in the private hospital. Further, it is crucial that the medical expenses must reimbursed promptly to ensure retire employees receive the care they need without facing financial hardships. It is the responsibility of the authorities to ensure that these retired employees receive the support they need to maintain their health and well-being.
11. Returning to the facts of the present case, it is clear from the record that the Respondent's wife was treated for a condylar fracture in her right femur in the Sir Ganga Ram hospital in an emergency condition and entailed the total bill of Rs. 6,23,474/-. Despite the Respondent holding a card under the REHLS-97 scheme, the Appellants failed to reimburse the total claimed amount, therefore, the deficiency on the part of the Appellants stand proved.
12. 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 22.11.2022 passed by the District Consumer Disputes Redressal DISMISSED PAGE 14 OF 15 FA/7/2023 D.O.D.: 19.05.2023 C.M.S. & ORS. VS. POORAN CHAND AGARWAL Forum-VI, (Distt. New Delhi), 'M' Block, 1st Floor, Vikas Bhawan, I.P. Estate, New Delhi-110002.
13. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
14. The Judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
15. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
19.05.2023 DISMISSED PAGE 15 OF 15