State Consumer Disputes Redressal Commission
The Chairman-Cum-Managing Director ... vs R. Bhaskaran S/O. V,. Rangan No.384/6, ... on 28 February, 2011
BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI BEFORE : Honble Thiru Justice M.THANIKACHALAM PRESIDENT Thiru J. JAYARAM, M.A.,M.L., MEMBER (JUDICIAL) Thiru S. SAMBANDAM MEMBER II F.A.NO.221/2010 (Against order in CC.NO.246/2009 on the file of the DCDRF, Chennai (North) DATED THIS THE 28th DAY OF FEBRUARY 2011 1.
The Chairman-cum-Managing Director Food Corporation of India 16-20, Barakamba Lane New Delhi
2. The Executive Director (South) Food Corporation of India Zonal Office, Haddows Road Chenai- 600 006 Appellant/ Opposite parties Vs. R. Bhaskaran S/o. V,.
Rangan Permanently residing at No.384/6, East Main Road Anna Nagar West Extension (In person) Chennai 600 101 Respondent/ Complainant The Respondent as complainants filed a complaint before the District Forum against the opposite parties praying for the direction to the opposite parties to pay Rs.7232/- alongwith compensation of Rs.2,00,000/-. The District Forum allowed the complaint. Against the said order, this appeal is preferred praying to set aside the order of the District Forum dt.8.2.2010 in OP.No.246/2009.
This petition coming before us for hearing finally on 17.2.2011. Upon hearing the arguments of the counsels on both sides, perusing the documents, lower court records, and the order passed by the District Forum, this commission made the following order:
Counsel for the Appellants/Opposite parties :
M/s. M. Imthias M. THANIKACHALAM J, PRESIDENT
1. This appeal, by the opposite parties, aims to set aside the order of the District Forum dt.8.2.2010, wherein a direction has been issued to refund a sum of Rs.7232/-, in addition to pay a sum of Rs.25000/- towards compensation for mental agony, alongwith cost of Rs.5000/-, which is based upon deficiency in service, as per the complaint made by the complainant.
2. The respondent, in this appeal, the complainant, is a retired employee of Food Corporation of India, covered by the Retired Employees Medical Health Scheme (MHS), wherein certain facilities were provided to the ex-employees, of the Food Corporation of India, having some ceiling limit. On 15.6.2008, due to severe fall, the complainant was unable to move, and under the said situation, he was rushed to Vijaya Ortho Hospital, Vadapalani, which is one of the empanelled hospital, where he was admitted for treatment, which was informed to the Food Corporation of India, personally by the complainant, through a friend, for formal approval.
3. The hospital informed the complainant, that he required major surgery of hip replacement, for which the complainant was not prepared, and therefore he wanted himself to be discharged from the hospital. The hospital, contacting the FCI for approval, failed, because of the inhuman treatment of Dr.Ramachandran, who failed to perform his duty. The request of the complainant to pay the amount, after discharge, since he had no amount at that time, also not conceded, thereby virtually he was imprisoned. Thereafter, the bill for Rs.7232/- was paid by a friend, thereby causing mental agony and deficiency of service, on the part of the opposite party.
It is the duty of the opposite party to see, that the approval was given, taking into the balance amount available in the member-patients credit, as per the eligibility. Because of the inhuman and illegal treatment, meted out to the complainant/ patient, the very purpose and objective of MHS, is questionable, for which the complainant is entitled to not only refund of expenses incurred by him viz. Rs.7232/-, but also a sum of Rs.2 lakhs, and above, as compensation with interest. Thus alleging/ leveling many allegations, against the opposite party, a consumer complaint came to be filed.
4. The opposite parties, admitting the medical health scheme, for retirees in 1999, as well as their eligibility, opposed the case of the complainant, interalia contending, that pre-authorisation letter, for admission, report by the hospital has to be sent, to the opposite party, alongwith representation and other particulars, which was not sent by the hospital, or the complainant, and therefore, they were unable to issue an authorization letter to the hospital, which cannot be labeled or treated as negligent act, or deficiency in service, that the complainant having failed to obtain approval for treatment, informing forthwith, when made a claim, he was requested to fulfill the formalities, as prescribed, for availing the medical benefits, but he failed to do so, and that when the complainant has failed to follow the procedure prescribed under the scheme, amount was not paid, requesting him to follow the procedure, which cannot be termed as negligence, or deficiency in service, thereby praying for the dismissal of the complaint, denying other averments also.
5. The District Forum, considering the admitted medical health scheme, as well as moved by the plea of the senior citizen, concluding as if the opposite parties have committed deficiency in service, directed not only to pay the medical expenses, but also a compensation of Rs.2500/-, with cost of Rs.5000/-, which is impugned in this appeal on various grounds.
6. The respondent/complainant, appeared in person, filed written arguments, as well issued a telegram also, questioning the conduct of the opposite party, as well as questioning the order of this commission, in granting stay, as illegal.
The written submissions, as well as relevant documents are perused, and order is passed on merit.
7. The learned counsel for the appellants, urged before us, that as per the circular dt.28.7.2003, which is binding upon the complainant also, on which basis he had claimed the amount, the complainant failed to follow the procedures, when insisted, he declined to comply the same, and such a person is not entitled to accuse the opposite parties, under the guise of senior citizen, though he may be a senior retired employee of the FCI, which submission, we are unable to ignore, considering the admitted facts, as well as the conduct of the complainant.
8. The complainant was admitted in the Vijaya Ortho Hospital, Vadapalani, on 15.6.2008, for the injury sustained by him, due to severe fall, though it is Sunday. Because of the fact, he was having the health card, covered by the Retired Employees Medical Scheme, the Vijaya Hospital, being an empanelled hospital, without insisting payments, as advance, they admitted him for treatment. It is also an admitted fact, nor seriously under challenge, that the fact of admission was informed to the FCI, and it is not known, who had received, being Sunday. As seen from paragraph 8 of the complaint, after 3 days, the hospital authorities informed him, he requires major surgery of hip replacement, for which the complainant was not willing, thereby, he wanted to discharge himself from the hospital. It is also an admitted fact, that an approval is necessary, by the opposite party, for taking treatment, whether it is an ordinary treatment or emergency treatment, with some exemptions. In this case, when the complainant wanted to be discharged from the hospital, approval not reached to the hospital, and therefore the concerned hospital, insisted the complainant to pay the bill of Rs.7232/-, which is not in dispute. The complainant, who had been to the hospital under the hope of getting cashless treatment, under MHS, was constrained to pay the amount, through his friend, which certainly should have caused some problem, that too, in the old age, that does not mean, he should accuse each and everyone, including the scheme itself, and the procedure prescribed therein, which he attempted to do so, as seen from the written version, as well as in the pleadings. After payment and discharge from the hospital, having suffered some mental agony, or sufferings, when the complainant claimed the amount, the authorities viz. the opposite parties, declined to accept the claim, as such, and they have advised or directed to submit the reimbursement bill, for which the complainant was not willing, insisting that he should be paid as of right, without any query, which was not conceded, resulting this complaint. In this context, we have to see the procedure prescribed under the MHS, for claiming the amount.
9. Under the MHS, as per the circular, a retiree of FCI, is entitled to take treatment, in the empanelled hospital. Under the scheme the patient shall be admitted to any hospital on the recommendation from Medical Officer, FCI/ Consultant of concerned hospital/ CMO in the prescribed proforma as per specimen enclosed (Annexure 1). Annexure 1, is the prescribed form, for 1st admission report/free authorization.
Based upon annexure 1, authorization letter, as contemplated under annexure II of the circular, will be issued, thereby entitling the ex-employee of the FCI, to take treatment, not to pay the amount, the FCI will pay the amount, on production of the claim, by the hospital concerned, under the understanding. In this case, neither annexure 1, was given, nor annexure II, approval was given to the hospital. Therefore, the hospital insisted the complainant to pay the medical expenses, in which we cannot find fault.
10. The learned counsel for the appellant argued, that in case of emergency, the patients can be admitted, even without pre-approval, and in that case also, subsequently, annexure1 should be forwarded, then followed by approval viz.
under Annexure 2, which is not undertaken in this case, which is the duty of the complainant, since failed, he is not entitled to accuse the opposite party, which submission is supported by conditions, available in the circular, which reads In case of emergencies, patient can be admitted to the hospital on production of valid Family Health Identity Card and the hospital will give pre-authorisation letter from FCI immediately or on the following day. The empanelled hospital shall not demand any advance from the beneficiary, and shall provide credit facilities to the concerned patient till authoristion letter received from the corporation. In an emergent situation, when a patient is away from local station, he/she may avail the treatment, where he has fallen ill from the empanelled hospital, on submission of authorization from the FCI office, within 24 hours. As stated therein, without demanding any advance, credit facilities was extended to the complainant, based upon family health card. But hospital has not given pre-authorisation letter, under annexure 1, and that is why the authorities have also not authorized the treatment, as available under Annexure II, for which we feel the opposite parties cannot be held responsible. When the complainant has made representation on 2.6.2008, and 30.6.2008, the FCI has informed the complainant, that authorisation letter is a must, before admission, and in this case, since authorization letter is not available or obtained, the complainant is entitled to only for reimbursement, subject to FCI/CSMA Rules, in which communication we are unable to find any irregularity. The complainant instead of sticking on the prestige, should have submitted the bill, and obtained the amount, by way of reimbursement, which he failed, for which we cannot accuse the opposite parties.
11. In paragraph 8 of the complaint, though it is said the hospital desperately contacting the FCI, for conveying the approval by fax, needed approval, was not coming forth, and this had happened because of the inhuman treatment of Dr.Ramachandran, probably the man incharge to give approval. The person, who can speak about this is the hospital concerned. The hospital authorities have not filed any affidavit, as if they have given annexure AI, and despite that fact, the FCI authorities failed to give approval.
It is also not the case of the complainant, or hospital that they have given fax message about the admission of the complainant, and on that basis also, approval should have been granted.
In the absence of any such plea, unfortunately, the District Forum has come to the conclusion, as if the hospital authorities have intimated the facts of admission, and the opposite parties have failed to give approval, which should be construed as negligent act, which finding is based upon the misunderstanding of the facts, as rightly pointed out by the learned counsel for the opposite parties.
12. In the previous occasions, it seems, when the complainant was admitted in the hospital, fax message was given from the hospital, and treating the same has Annexure 1, probably approval was given, which is pleaded in paragraph 6 of the written version. The District Forum, has also relied upon the passage available in paragraph 6 of the written version, on which basis alone, finding regarding deficiency of service is recorded, which reads The opposite parties admitted in his written version that the hospital faxed the first admission report on the request of the corporation for necessary approval, then automatically the Zonal Medical Officer or the concerned officer of the Food Corporation of India is supposed to send that approval enabling the complainant to discharge. Having failed to do their service... This is not the case, as seen from paragraph 6 of the written version. The entire reading of paragraph 6 of the written version, would make it clear, that in the year 2006, also the complainant followed the same irregularity, and in order to help the retired officials, failing to send FAR of hospital, in order to help the retired official, the hospital only faxed the FAR, on the request of the respondent corporation for necessary approval, and the medical officer was kind enough to recommend the treatment, for 4 days, to the said hospital, as per the MHS scheme. These allegations relates to the treatment taken by the complainant in 2006, elsewhere, since that is for 4 days, this case is only for 3 days. Here, even it is not the case of the complainant, that the hospital had sent any fax message. Therefore, the finding of the District Forum, based upon certain things, described in paragraph 6, during the year 2006, was taken as if had happened, for this treatment, which is most, unfortunate. In this case, admittedly annexure 1 was not sent to the FCI officials, resulting no pre-approval, and in this way alone, hospital insisted for the payment, which cannot be termed as negligent act, or deficiency in service, or inhuman act, something like that, which is said so, in different form by the complainant. The entire reading of the complaint, as well as written submission, aim to say that the complainant should not be insisted by the procedure, which is not possible.
Under a scheme, complainant claims benefit, and therefore he is bound to follow the procedure, eventhough he is a senior citizen. It is not for the consumer forum, to frame rules, for senior citizen, and if at all they have to approach the concerned authorities, seeking exemption for this kind of senior citizens, which we cannot do. Thus, as such when there are rules and regulations, for claiming medical reimbursement, or claiming benefits under MHS, that should be scrupulously followed and having followed, if the opposite parties have committed any deficiency or negligence, then only we can call upon them, not otherwise. In this case, the complainant alone had committed deficiency in service, and if at all he had sustained any mental agony, by the insistence of the hospital to pay the amount, he should be blamed, not the opposite party. Without considering, all these things, the District Forum, has affixed deficiency in service, upon the opposite parties, which finding, we are unable to endorse.
Hence the appeal deserves acceptance, and the order of the District Forum is liable to set aside.
13. In this case, though the complainant is not entitled to get the refund, as well as compensation, as of right, considering the age of the complainant, as well as his health condition, we are inclined to direct the opposite parties to pay the actual expenses, incurred by him viz. Rs.7232/- alone, and this gesture shown by this commission, should not be taken as a precedent, by other retirees. Having regard to the facts and circumstances of the case, to this extent, the order of the District Forum is to be modified, though the appeal deserves to be accepted in toto.
14. In the result, the appeal is allowed in part, modifying the order of the District Forum in CC.No.246/2009 dt.8.2.2010, setting aside the grant of compensation and cost, directing the opposite party/ appellant, to pay a sum of Rs.7232/- alone.
Registry is directed to release the above said sum of Rs.7232/- from the mandatory deposit of Rs.18,650/-, in favour of the Respondent /complainant, on his filing memo, and discharge the balance amount, to the appellants/opposite parties, with accrued interest.
This should not be treated as precedent by anyother retired employees of the Food Corporation of India.
S.SAMBANDAM J. JAYARAM M. THANIKACHALAM MEMBER II JUDICIALMEMBER I PRESIDENT INDEX : YES / NO Rsh/d/mtj/Bench-1/Miscellaneous