State Consumer Disputes Redressal Commission
Smt.Asha Khelwar vs Dr.Vibha Bajpai & Anr. on 14 June, 2018
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR (C.G).
Appeal No.FA/2018/263
Instituted on : 17.04.2018
Smt. Asha Khelwar, W/o Pradeep Kumar Khelwar,
Aged 42 years, R/o : Quarter No.1/B, Street 25, Zone - 1,
Khursipar,
Bhilai, Tehsil and District Durg (C.G.) ...... Appellant (Complainant)
Vs.
1. Dr. Vibha Bajpai,
Employees Insurance Medical Officer,
Employees State Insurance Services, Nandini Road,
Bhilai, Tehsil and District Durg (C.G.)
2. Director, Employees State Insurance Corporation,
Secretariate Building, Second Floor,
Naya Raipur (C.G.) ... Respondents (OPs)
PRESENT :
HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT
HON'BLE SHRI D.K. PODDAR, MEMBER
HON'BLE SMT. RUCHI GOEL, MEMBER
COUNSEL FOR THE PARTIES :
Shri Awadhesh Rai, Advocate for the appellant (complainant).
Shri Manish Sinha, Advocate for the respondents (OPs).
ORDER
DATED : 14/JUNE/2018 PER :- HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT.
This appeal is directed against the order dated 26.02.2018, passed by District Consumer Disputes Redressal Forum, Durg (C.G.) (henceforth "District Forum") in Complaint Case No.C.C.2017/516. By the impugned order, learned District Forum, has dismissed the complaint of the complainant.
2. Briefly stated the facts of the complaint of the complainant are the complainant is working in the post of Computer Operator in Krishna Public School, Nehru Nagar, Bhilai, District Durg (C.G.). The employer of the complainant, Krishna Public School, Bhilai, has deducted a sum of Rs.226/- per month from the salary of the complainant and the same was transmitted to the // 2 // O.P. No.2. The E.S.I. Employee Code of the complainant is 00454 and E.P.F. No. is C.G.R.A.I./0011591000/559 E.S.I.C. No.1100001/5915180478. The complainant is issueless/childless. For fulfillment of the desire of the child, the complainant obtained permission from the O.P. No.1 on 08.10.2015 and took treatment in another hospital. The complainant submitted bills amounting to Rs.1,89,246/- to the OPs for her treatment vide bills dated 13.01.2016, 20.01.2016, 25.04.2016 and 25.02.2017, which were returned by the OPs by saying that the age of the Insurance Card I.P. is 43 years. Therefore, the case was returned. The complainant several times written letters to the OPs and requested for payment of the above amount, but the OPs did not give reply to the above letters. On 03.04.2017, the complainant sent registered notice to the OPs to the effect that the OPs have not taken back the permission given on 08.10.2015 to the complainant in writing. The complainant took treatment from time to time as per Government rules and submitted bills for the same to the OPs and the OPs are legally bound to pay the same, because the OPs accepted the premium amount and did not return the amount. The Memorandum of Insurance Conditions has not been provided. In the notice, the complainant requested the OPs to pay a sum of Rs.1,89,246/- along with interest @ 24% p.a. and Rs.3,000/- towards notice expenses. The above notice was received by the OPs. The O.P. No.1 informed the advocate of the complainant that on being submission of the receipt, after examination of the documents, intimation will be given and the complainant was paid a sum of Rs.6,032/-, Rs.3,572/-, total Rs.12,144/- by the office of the O.P. No.1 from 21.01.2016 to 12.05.2016 on the basis of bills, as per government rules. The O.P. No.1 has no authority to pay the remaining amount to the complainant. Vide letter No. // 3 // Establishment/2017/443, dated 24.06.2017, the O.P. No.1 informed that Employees State Insurance Corporation is not maintaining the particulars mentioned in para 1. In para 2, the O.P.No.1 admitted that the employer is deducting premium amount and the same is transmitted to the Employees State Insurance Corporation. The O.P. No.1 has denied the permission given to the complainant and again returned the bill. In respect of objection, Page No.103 Chapter 6 of C.G.H.S. Rue (Nabi 2016) was referred but the copy of the same was not provided to the complainant, which is an act of deficiency in service. In her letter, the O.P. No.1 also mentioned that treatment cannot be provided to the ladies, who attained more than 39 years of age and the I.V.F. treatment was not done as per reference letter of the office of the O.P. No.1. Accordingly the payment of medical bill was made to the complainant. The O.P. No.1 in her letter dated 24.06.2017 admitted that the date given by the Reference No.16, has been wrongly mentioned in the letter and the actual date is 08.10.2015. In the above referral letter, on 08.10.2015, the age of the complainant has been mentioned 42 years. If the doctor who referred, was not having knowledge of the above rules, then she had not required to refer. The complainant was unnecessarily required to spend her hard earn money due to the OPs and when the time come for payment of the bills, then referring to the government rules, the payment of bills of the complainant was not made, which is an act of deficiency in service. The OPs have not provided the copy of rule to the complainant, which is an act of professional misconduct. Hence the complainant filed the instant consumer complaint before the District Forum and prayed for granting reliefs, as mentioned in the relief clause of the complaint.
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3. The OPs filed their joint written statement and averred that the premium amount is deposited in Employees State Insurance Corporation, in every month and the same is not deposited in the O.P. No.2. The complainant did not come to O.P. No.1 for treatment and the O.P. No.1 did not refer the complainant to a higher centre for treatment of infertility and fatty liver. The validity period was of one month. The complainant was required to take treatment and again to be examined by OPs. The complainant did not come to O.P. No.1 after one month and she was not referred for I.V.F. (Invitro Fertilization). The complainant without obtaining permission and without reference letter of the O.P. No.1, took treatment from the doctor, as per her choice, therefore, no amount is payable to the complainant. Actually, the age of the complainant is 43 years and the CGHS Rule which is framed by the Government of India, Medical Department, is effective. According to that rule, there is no provision to refer the lady for IVF, who attained more than 39 years of age , therefore, the bill was returned to the complainant. The reply of the legal notice of the complainant was given on 24.06.2017 in which guidelines of the Government for payment of medical bill and in respect of all facts, has been given. The reply of the notice sent by the complainant has been given on 24.06.2017. The complainant did not take treatment from time to time as per Government Rule and did not submit bill for payment to the OPs. The actual fact is that the as against the provisions of Government Medical Reimbursement Rule CGHS, without reference letter of the O.P. No.1, the complainant took treatment from the unauthorized institution and above treatment was not successful, but she demanded compensation for the same, which is not payable as per rule. At page No.104 Chapter 6 of CGHS Rules, // 5 // 2016, in sub para (c) it is clearly mentioned that treatment of IVF be taken from Government Hospital. If treatment for IVF is taken in the private hospital, then from time to time permission would have been taken, whereas the OPs had not given any permission to the complainant. After referring the complainant to higher centre Medical College Hospital, Raipur, reimbursement of medical bill of Rs.21,749/- was made as per Government rules. The complainant without obtaining reference letter from the O.P. No.1, took treatment from the unauthorized hospital, as per her choice, therefore, no amount is payable to her. For the purpose of providing better health facilities, for the employees of the organized and unorganized sector, the State Employees Insurance Services, was constituted, which is an institution of C.G. Government Department of Labour. It make arrangement for the medical reimbursement and treatment according to CGHS Rule and as per its provisions, the employer is deducting the premium amount, which is transmitted to Employees State Insurance Corporation. According as per rules of Government and State Government, the medical reimbursement is given to the employees according to legal provisions. Actually according to Page No.103 Chapter 6 of C.G.H.S. Rules, 2016, there is no permission to the ladies, who attained more than 39 years of age for I.V.F., therefore, the complainant was not referred for treatment of I.V.F. The complainant took treatment in Ayush Test Tube Baby Centre, Raipur which is not notified by the Labour Department and Ayush Test Tube Centre is not authorised by the C.G. Government, Department of Labour for reimbursement of medical expenses of the insured employees. The complainant was referred to a higher centre for treatment of infertility, obesity and fatty liver and not for the IVF. The actual // 6 // age of the complainant was mentioned. As for special treatment, the complainant was required to be referred, therefore, she was referred to Medical College Hospital, Raipur. The validity period of referring complainant was one month and thereafter she did not come for renewal, therefore, it cannot be said that the complainant was referred for IVF. Payment of Rs.21,749/- was made to the complainant according to the departmental CGHS rules. The complainant was referred to Medical College Hospital, Raipur for treatment of Infertility, Obesity and Fatty Liver on 08.10.2015 and its validity was of one month . If the doctor of referral Hospital Medical College Hospital, Raipur referred the complainant for IVF, then it is not according to the CGHS Rules. It can be done on the request of the complainant, therefore, for medical reimbursement, the Employees State Insurance Services, is not liable. The OPs took action as per the legal provisions and also gave reply of the advocate notice sent by the complainant. The complainant made the O.P. No.1 party in her individual capacity, which is not according to the legal provisions, therefore, the complaint of the complainant is liable to be dismissed.
4. The complainant has filed documents. Annexure A-1 is letter dated 26.04.2017 sent by the complainant to O.P. No.1, Annexure A-2 are postal receipts, Annexure A-3 is registered notice dated 03.04.2017 sent by Shri Awadhesh Kumar Rai, Advocate to the OPs, Annexure A-4 is acknowledgment in respect of O.P. No.1, Annexure A-5 is reply dated 10.04.2017 sent by O.P. No.1 to Shri Awadhesh Kumar Rai, Advocate in response to his notice dated 03.04.2017, Annexure A-6 is letter dated 24.06.2017 sent by the O.P. No.1 to Shri Awadhesh Kumar Rai, Advocate, Annexure 7 are the receipt for bills deposited // 7 // by the complainant, Annexure A-8/1 is letter dated 17.02.2016 sent by the complainant to O.P. No.1, Annexure A- 8/2 is letter sent by the complainant to the O.P. No.1, Annexure A-8/3 is letter sent by the complainant to O.P. No.1, Annexure A-8/4 is Card issued by E.S.I.C., Annexure A-8/5 is Temporary Identity Certificate, Annexure A-8/6 is application for acceptance for medical treatment, Annexure A-8/7 is report of Employees State Insurance Corporation, Annexure A-8/8 is report of Employees State Insurance Corporation, Annexure A-8/9 is Employees details, Annexure A-8/10 is pay slip for the month of November, 2015 of the complainant, Annexure A-8/11 is Declaration made by the complainant, Annexure A-8/12 is details regarding bank account of the complainant, Annexure A-8/13 is Referral Form, Annexure A-8/14 is passbook of Union Bank of India, Annexure A-8/15 is prescription of Dr. B.R. Ambedkar Memorial Hospital, Raipur, Annexure A-8/16 are Receipt dated 21.1.2016 issued by Aayush, cash memo no.429 and 430 dated 22.01.2016 issued by Aman Medical and General Stores, Raipur, Annexure A-8/17 are receipt dated 12.02.2016 issued by Aayush and bill No.1695 dated 15.09.2016 issued by Dewangan Medicose, Annexure A-8/18 is Cash Memo No.438 dated 12.02.2016 issued by Aman Medical and General Store, Raipur , Annexcure A-8/19 is Prescription issued by Aayush on 22.01.2016, Annexure A-8/20 is prescription issued by Aayush on 12.02.2016., Annexure A-8/21 is Discharge Summary dated 06.01.2016 issued by Aayush, Annexure A-8/22 is Instructions, Annexure A-8/23 is test report, Annexure A-8/24 is Test Report issued by Rapid Care Diagnostic and Research Centre, Annexure A-8/25 is Test report dated 12.02.2016, Annexure A-8/26 is report, Annexure A-9 are the details of bills submitted to the O.P. No.1, Annexure A-10 are the application with details of // 8 // bills submitted to the O.P. No.1, Annexure A-11 is Card issued by E.S.I.C. Annexure A-12/1 is Brochure of Aayush, Annexure A-12/2 is Discharge Summary dated 06.01.2016 issued by Aayush, Annexure A-12/3 is Special Test Report, Annexure A-12/4 is Test Report of Rapid Care Diagnostic and Research Centre, Annexure A-13/1 is prescription dated 29.08.2007 issued by Dr. M.H. Sharada, Annexure A-13/2 is prescription dated 2.07.2007 issued by DR. M.H. Sharada, Annexure A-13/3 is prescription issued by Dr. Smt. Ratna Gulati, Annexure A-14/1 to A-14/11 are Referral Forms, Annexure A-14/12 is letter dated 05.03.2013 sent by Pradeep Kumar Khelwar to E.S.I.C. Raipur.
5. The OPs have filed documents. Annexure NA-1 is copy of C.G.H.S. book, Annexure NA-2 is sanction order dated 01.09.2016, Annexure NA-3 is office order dated 24.11.2016, Annexure NA-4 I office order dated 23.06.2016, Annexure NA-5 is office order dated 29.02.2016, Annexure NA-6 is order dated 30.04.2015 issued by Under Secretary, Government of C.G., Health and Family Welfare Department.
6. Learned District Forum, after having considered the material placed before it by the parties, has dismissed the complaint of the complainant by the impugned order.
7. Shri Awadhesh Rai, learned counsel appearing for the appellant (complainant) has argued that complainant is working in the post of Computer Operator in Krishna Public School, Nehru Nagar, Bhilai, District Durg (C.G.). The employer of the complainant, Krishna Public School, Bhilai, has deducted a sum of Rs.226/- per month from the salary of the complainant and the same // 9 // was transmitted to the O.P. No.2 - Director Employees State Insurance Corporation. The E.S.I. Employee Code was allotted to the complainant. The complainant is issueless/childless. For fulfillment of desire of the child, the complainant obtained permission from the O.P. No.1 on 08.10.2015 and took treatment in another hospital. The complainant submitted bills amounting to Rs.1,89,246/- to the OPs for her treatment, vide bills dated 13.01.2016, 20.01.2016, 25.04.2016 and 25.02.2017, which were returned by the OPs by saying that the age of the Insurance Card I.P. (complainant) is 43 years. Therefore, the case was returned. The complainant several times written letters to the OPs and requested for payment of the above amount, but the OPs did not give reply to the above letters. On 03.04.2017, the complainant sent registered notice to the OPs to the effect that the OPs have not taken back the permission given on 08.10.2015 to the complainant in writing. The complainant took treatment from time to time as per Government rules and submitted bills for the same to the OPs and the OPs are legally bound to pay the same because the OPs accepted the premium amount and did not return the amount. In the notice, the complainant requested the OPs to pay a sum of Rs.1,89,246/- along with interest @ 24% p.a. and Rs.3,000/- towards notice expenses. The above notice was received by the OPs. The O.P. No.1 informed the advocate of the complainant that on being submission of the receipt, after examination of the documents, intimation will be given and the complainant was paid a sum of Rs.6,032/-, Rs.3,572/-, Rs.12,144/- by the office of the O.P. No.1 from 21.01.2016 to 12.05.2016 on the basis of bills, as per government rules. The O.P. No.1 has no authority to pay the remaining amount to the complainant. Vide letter No. Establishment/2017/443, dated 24.06.2017, the O.P. No.1 informed that // 10 // Employees State Insurance Corporation is not maintaining the particulars mentioned in para 1. In para 2, the O.P.No.1 admitted that the employer is deducting premium amount and the same is transmitted to the Employees State Insurance Corporation. The O.P. No.1 has denied the permission given to the complainant and again returned the bill. In her letter, the O.P. No.1 also mentioned that treatment cannot be provided to the lady, who attained more than 39 years of age and the I.V.F. treatment was not done as per reference letter of the office of the O.P. No.1. Accordingly the payment of medical bill was made to the complainant. The O.P. No.1 in her letter dated 24.06.2017 admitted that the date given by the Reference No.16., has been wrongly mentioned in the letter and the actual date is 08.10.2015. In the above referral letter, on 08.10.2015, the age of the complainant has been mentioned 42 years. If the doctor who referred, was not having knowledge of the above rules, then she had not required to refer. The complainant was unnecessarily required to spend her hard earn money due to the OPs and when the time come for payment of the bills, then referring to the government rules, the payment of bills of the complainant was not made, which is an act of deficiency in service. The impugned order passed by the District Forum is erroneous and is liable to be set aside. The appeal of the appellant (complainant) be allowed. The complainant is entitled to get reliefs, as mentioned in the relief clause of the complaint.
8. Shri Manish Sinha, learned counsel appearing for the respondents (OPs) has argued that the the complainant did not come to O.P. No.1 after one month and she was not referred for I.V.F. (Invitro Fertilization). The complainant // 11 // without obtaining permission and without reference letter of the O.P. No.1, took treatment from the doctor, as per her choice, therefore, no amount is payable to the complainant. Actually, the age of the complainant is 43 years and the CGHS Rule which is framed by the Government of India, Medical Department, is effective. According to that rule, there is no provision to refer the lady for IVF, who attained more than 39 years of age , therefore, the bill was returned to the complainant. According to the C.G.H.S. Rules without referring by the competent authority, if the complainant took treatment from the unauthorized institution or hospital, then she is not entitled for reimbursement of the treatment expenses. If treatment for IVF is taken in the private hospital, then from time to time, permission would have been taken, but the complainant had not taken any permission from the O.P. No.1 for the same and she was not referred by the O.P. No.1. For special treatment, the complainant was required to be referred, therefore, she was referred to Medical College Hospital, Raipur. The payment of Rs.21,749/- was made to the complainant according to the C.G.H.S. Rule. The complainant is not entitled for remaining amount because she took treatment without obtaining permission from the O.P. No.1. Therefore, the impugned order passed by the District Forum, is just and proper and does not call for any interference by this Commission. The appeal filed by the appellant (complainant) is liable to be dismissed.
9. We have heard learned counsels appearing for both the parties and have also perused the record of the District Forum as well as impugned order.
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10. According to the appellant (complainant), she is issueless /childless, therefore, for fulfilling her desire, she obtained permission from O.P. No.1 on 08.10.2015 and took treatment in another hospital. The complainant incurred expenditure of Rs.1,89,246 in her treatment, but the O.P. No.1 paid only a sum of Rs.12,144/- to the complainant and remaining amount was not paid by the O.P. No.1 to the complainant. The OPs have specifically pleaded the age of the complainant is more than 39 years, therefore, she is not entitled to refer for IVF. The complainant took treatment without issuance of reference letter by the O.P. No.1, therefore, the complainant is not entitled to get remaining amount from the O.P. No.1. The complainant sent notice to the O.P. No.1 and the O.P. No.1 gave reply of the same. In the reply, the O.P. No.1 has specifically mentioned the bill is not acceptable as per the C.G.H.S. Rule, because the age of the complainant is more than 39 year. According to the directions issued by Employees State Insurance Corporation and Government, the complainant was referred to a Gynaecologist and not referred for IVF treatment. The complainant herself took treatment from the hospitals, which were not recognized by the E.S.I.C. and State Government.
11. The complainant has filed document Annexure A-7/14 which is referral form (Permission Letter) dated 08.10.2015 issued by Insurance Medical Officer, E.S.I. Services, Nandini Road, Bhilai in which it is mentioned :- "Referral No. 16
Insurance No./Staff Card No./Pension Card No. 5915180478 Name of Patient : Asha Khelwar Age / Sex : 42 / F Address / Contact No. : Qtr. No.1/B, No.25, Zone -01, Khursipar, Bhilai Identification Marks if any IP/Beneficiary / Staff : IP // 13 // Relationship with IP/Staff : Self F/M/S/D/Other Entitled for Specialty /Super Sp. it Yes Diagnosis / Clinical opinion/ case summary H/O Gynaecological Problem 11 yrs.
Married life 13 years. No issue yet.
Relevant treatment given/
Procedure Taken off for infertility for 11 years
Investigation done in referring
dispensary ...................
Treatment /Procedure/Investigation
For which patient is being referred
/Name of Department to which
patient is referred. ................"
Mandatory instructions for Referral Hospital if applicable Referral hospital is instructed to perform only the procedure / treatment for which the patient has been referred to.
In case of additional procedure / treatment / investigation is essentially required in order to treat the patient for which he / she has been referred to, the permission for the same is essentially require from the referring hospital either through e-mail, fax or telephonically (to be confirmed in writing (at the earliest) The referred hospital is requested to raise the bill as per the agreement on the standard proforma along with supporting documents within 6 days of discharge of the patient giving account number and RTGS number etc."
12. The OPs have filed copy of Central Government Health Scheme Rules, which is marked as Annexure NA-1, in which it is mentioned thus :-
"Reimbursement for In-Vitro Fertilisation (IVF) Treatment :-
Reimbursement shall be allowed for expense of IVF treatment subject to a maximum of Rs.65,000 per cycle of actual cost, whichever is lower, for a maximum of 3 fresh cycles. The reimbursement shall be subject to specified conditions including :-
(a) The couple has no living issue and it is a case of infertility.
// 14 //
(b) There is a clear evidence of failure of conventional treatment.
(c) The women is between 21 and 39 years, married and living with her husband.
(d) The treatment is advised by Head of Deptt. Of Gynaecology & Obstetrics of a Govt. Medical Institution based on which the permission shall be allowed by the HOD.
(e) The treatment shall be carried out in a Govt. Hospital. For treatment in a private hospital, approval shall be given on case to case basis."
13. The complainant has filed documents. Annexure A-8/19 is prescription dated 22.01.2016 issued by Aayush, Fertile Hope, ICSI Test Tube Baby Centre , Annexure A-8/23 is Special Test Report dated 21.01.2016 issued by Rapid Care Diagnostic & Research Centre. The OPs have filed photocopy of the order dated 29.02.2016 (Annexure NA-5) issued by State Medical Commissioner, Employees State Insurance Corporation, Raipur, in which it is mentioned that Sanjeevani U.S.A. C.B.C.C. Cancer Hospital, Pachpedi Naka, Raipur, Shree Narayana Hospital, Devendra Nagar, Raipur, Mittal Hospital, Awanti Bai Chowk, Pandri, Raipur (C.G.), Ganga Diagnostic and Research Centre, Dhamtari Road, Raipur (C.G.), Ramkrishna Care Hospital, Dawda Colony, Pachpedi Naka, Raipur (C.G.), Suyash Hospital, Gudhiyari Road, Kota, Raipur (C.G.), Apollo BSR Hospital, Nehru Nagar, Bhilai, Durg (C.G.), Mark Hospital, Mission Hospital Road, Bilaspur, KIMS Superspecialty Hospital, Agrasen Chowk, Bilaspur , are recognized by the Employees State Insurance Corporation and State Government for the period from 01.03.2016 to 28.02.2018. Annexure NA-6 is also an order dated 30.04.2015 issued by Under Secretary, // 15 // Chhattisgarh Government, Department of Health and Family Welfare Department, in which the list of the hospitals recognized by the State Government / Employees State Insurance Corporation, are mentioned. In the above list, the name of the hospitals, where the complainant took treatment are not mentioned and they are not recognized by the State Government or E.S.I.C. Therefore, the complainant is not entitled to get treatment without referring or without obtaining permission from the competent authority. Hence, the complainant is not entitled to get the amount of Rs.1,89,246/- from the OPs, which was incurred by her in her treatment. The O.P. No.1 had rightly sanctioned a sum of Rs.12,144/- towards medical expenses, which was incurred by the complainant in her treatment in the recognized hospital of the State Government/ E.S.I.C.
14. Therefore, the impugned order dated 26.02.2018, passed by learned District Forum, is just and proper and does not suffer from any irregularity or illegality, hence does not call for any interference.
15. Hence, the appeal filed by the appellant (complainant) being devoid of any merits, deserves to be and is hereby dismissed. No order as to cost of this appeal.
(Justice R.S. Sharma) (D.K. Poddar) (Smt. Ruchi Goel)
President Member Member
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