State Consumer Disputes Redressal Commission
Swarn Singh vs The Senior Divisional Medical Officer, ... on 10 March, 2016
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.856 of 2013
Date of Institution: 12.08.2013.
Date of Decision : 10.03.2016.
Swaran Singh S/o Kalyan Singh, House no.19, Gali no.1,
Dharampura, Samrala Road, Ludhiana.
.....Appellant/complainant
Versus
1. The Senior Divisional Medical Officer, Northern Railway,
Ludhiana.
2. The Chief Medical Director, Northern Railway, Baroda House,
New Delhi.
3. The Chief Medical Superintendent, Northern Railway, Ferozepur
Cantt. Punjab.
4. The Divisional Railway Manager (P), Northern Railway, Divisional
Office, Ferozepur Cantt. Punjab.
.....Respondents/opposite parties
First appeal against order dated
21.06.2013 passed by the District
Consumer Disputes Redressal
Forum, Ludhiana.
Quorum:-
Shri J. S. Klar, Presiding Judicial Member.
Shri H.S. Guram, Member.
Present:-
For the appellant : Sh. Munish Goel, Advocate
For the respondents : Sh. Karamjit Verma, Advocate
................................................... J. S. KLAR, PRESIDING JUDICIAL MEMBER:-
This appeal has been directed by appellant of this appeal (the complainant in the complaint) against order dated 21.06.2013 of the District Consumer Disputes Redressal Forum, Ludhiana (in short the "District Forum"), vide which, the complaint of the complainant First Appeal No.856 of 2013 2 was dismissed. The instant appeal has been preferred against the respondents of this appeal herein (the opposite parties in the complaint).
2. The complainant has filed the complaint under Section 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that he is retired OS-I (Office Supdt.) of OPs under pensioner identity card number 001762 dated 31.08.2003. OP no.2 issued card no.019942 dated 14.10.2003 under liberalized health scheme to complainant and her wife was shown as dependent member therein for availing medical treatment alongwith complainant without any expenditure under the above scheme. Joginder Kaur wife of complainant was rushed to CMC in casualty on 22.03.2009 due to history of pain in right lumbar region, fever & vomiting for 6 days. She was admitted thereat keeping in view of her worse condition and was diagnosed to have right pyelonphritis + right adrenal adenoma + right sacral ala asteocondroma + diabetes mellitus type-II. It was further averred that insurance claim was submitted to OPs for Rs.56,477/- as expenses incurred on treatment of his wife for the period 02.03.2009 to 01.04.2009 at CMC Hospital Ludhiana. The OPs repudiated the insurance claim, vide letter dated 10.07.2009 on the ground that "Normally medical reimbursement claim is being sanctioned only when a railway employee or retired employee has to avail treatment in a private hospital/recognized hospital & Civil Hospital under such emergency, that there was no scope for coming to Railway Hospital e.g. road side traffic accident, First Appeal No.856 of 2013 3 heart attack etc." The treatment availed of was not emergency treatment and hence the terms and conditions were not complied with. There was no treatment in Railway Hospital Ludhiana and due to that reason, she was rushed to CMC Hospital Ludhiana. The emergency is not established in this case; as per Railway Board no.2005/H/6-4/80 dated 31.01.2007. The complainant termed the repudiation of the insurance claim as arbitrary and illegal and prayed that OPs be directed to pay the treatment expenses of Rs.56,477/- incurred on his wife alongwith interest @18% per annum from the date of lodging claim till realization, besides Rs.5500/- as costs of litigation.
3. Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant. It was averred in preliminary objections that the matter requires elaborate evidence and full trial and cannot be adjudicated in summary manner by Consumer Forum. Any deficiency in service on the part of OPs was vehemently denied. It was further averred that as per CMS/FZR letter No.13-Med/Reimb/CMS/FZR dated 10.07.2009, as mentioned in discharge summary, the patient had pain in Right lumber area for 5-6 days, no ICU admission was done. As per Railway Board Policy No.2005/H/6-4/Policy-II, dated 31.01.2007, the emergency in this case was not established, hence claim was not admissible and was rightly rejected by OP No.3. On merits, the complaint was alleged to be malafide by OPs. On merits, OPs averred that a bill for Rs.57,477/- was submitted to Railway Hospital, Ludhiana by the First Appeal No.856 of 2013 4 complainant, which was forwarded to the OPs. It was rejected as 'no emergency case was established'. The complainant filed an appeal dated 25.05.2010 which was devoid of any merit and was rightly dismissed. The letter dated 10.07.2009 by the OPs for rejection of claim was justified. The OPs further averred that since no emergency in the case of treatment of wife of complainant was established, hence claim is not admissible. The complainant filed the complaint before District Forum, which was withdrawn on 14.08.2012 by suffering statement that he would file fresh complaint by setting the technical defect right. The OPs prayed for the dismissal of the complaint by controverting the averments of the complainant.
4. The complainant tendered in evidence affidavit Ex.CA-1 alongwith documents Ex.C-1 to Ex.C-10 and closed the evidence. As against it, OPs tendered in evidence affidavit Ex.RW1 alongwith documents Ex.D-1 to Ex.D-2 and closed the evidence. On conclusion of evidence and arguments, the District Forum dismissed the complaint of the complainant, as referred to above. Dissatisfied with the order of the District Forum dated 21.06.2013, the complainant now appellant preferred this appeal against the same.
5. We have heard the learned counsel for the parties and also examined the record of the case. The affidavit of complainant is Ex.CA-1 on the record stating that his claim has been wrongly repudiated by the OPs. Ex.C-1 is the copy of RELHS card of complainant. Ex.C-2 is the copy of Pensioner's identity card. Ex.C-3 is the copy of discharge summary issued by Department of Urology First Appeal No.856 of 2013 5 of CMC Hospital Ludhiana. Ex.C-4 is the copy of letter dated 10.05.2010 from Dr.George Mathew, Assistant Professor, Department of Urology to The Chief Medical Superintendent, Divisional Hospital, Northern Railway, Ferozepur Cantt. to the effect that the wife of the complainant was admitted on 22.03.2009under Urology and diagnosed to have right Pyelonephritis + right adrenal adenoma + right sacral ala osteocondroma + diabetes mellitus type II and she was managed conservatively and discharged on 01.04.2009. Ex.C-5 is copy of record submitted to Northern Railway. Ex.C-6 is copy of Medical reimbursement claim of wife of complainant. Ex.C-7 is copy of appeal preferred before The Chief Medical Director, Baroda House (N.R.) New Delhi by complainant. Ex.C-8 is copy of rejection of appeal of the complainant. Ex.C-9 is copy of record of casualty admission on 23.03.2009 of wife of complainant at CMC Hospital Ludhiana. Ex.C-10 is copy of Pay Patient C7187862 of Joginder Kaur wife of complainant. OPs relied upon affidavit of Dr.S.P.Sharma, Senior D.M.O (ADG) Ferozepur, Northern railway, in support of averments of the OPs, as pleaded in the written reply. Ex.D-1 is the copy of reimbursement of medical expenses procedure of disposal. Ex.D-2 is the copy of letter dated 15.02.2011 from Dr.V.K.Sinah to The Chief Medical Superintendent, NR, Ferozepur regarding the diagnosis of the aliment of the wife of the complainant.
6. The point of controversy in this case between the parties is whether the treatment taken by the wife of the complainant in First Appeal No.856 of 2013 6 CMC hospital Ludhiana for the above referred aliment falls within the definition of emergency, as set out in the reimbursement policy from private hospital or not? This is the core point of controversy between the parties in this case. Sh.Munish Goel, counsel for the appellant submitted that no emergency was established in this case in the railway hospital, as such wife of complainant had no option, but to seek the treatment by getting herself admitted in the CMC Hospital Ludhiana. The contention of OPs is that the patient was having pain in right lumber area for 5-6 days, no ICU admission was done and as per Railway Board Policy No.2005/H/6-4/Policy-II, dated 31.01.2007, the emergency was not established, hence claim was not admissible and was rightly rejected by the competent authority. We have to determine this point whether emergency was established in the matter of treatment of complainant's wife or not? The wife of complainant remained admitted in CMC Hospital Ludhiana from 02.03.2009 to 01.04.2009 for treatment of above referred aliment and she was diagnosed as right pyelonphritis with hydro- uretronephrosis with right adrenal adenoma with osteochondroma right sacral ala NCCT KUB showed bulky right kidney with mild hydrouretronephrosis. The OPs had not accepted this claim on the ground that emergency was not established in the case of treatment of wife of complainant. The District Forum recorded observations that vide Ex.D-1, the grounds for sanctioning the reimbursement claim are as "to provide proper medical treatment, the Indian Railway Health Care Delivery System has 121 number of Railway Hospital and 586 number of Railway Health Units established all over India. First Appeal No.856 of 2013 7 In addition to this, all Govt.Hospitals and more than 115 private hospitals all over the country have been recognized to provide necessary medical treatment to Railway beneficiaries." The Railway beneficiary has to report the matter to Railway Medical Officer for treatment of any dependent or himself.
7. The word of emergency situation means as under:-
"Emergency" shall mean any condition or symptom resulting from any cause arises suddenly and if not treated at the early convenience be detrimental to the health of the patient or will jeopardize the life of the patient. Some examples are:- Road accident, other type of accidents, acute heart attack etc. under such conditions, when the Railway beneficiaries feels that there is no scope of reporting to the higher authorized Railway Medical Officer and avails treatment in the nearest and suitable private hospital, the reimbursement claims are to be processed for sanction after the condition of the emergency is confirmed by the authorized Railway Medical Officer ex-post facto. In order to establish the emergency condition, following parameters are to be examined on record:-
(a) Admission details:-
i) Date and time of admission.
ii) Admitted through OPD service/emergency service. First Appeal No.856 of 2013 8
iii) Admitted to an ICU bed or general bed or cabin bed.
(b) Clinical findings at the time of admission. Following findings should be made available and critically evaluated:-
i) Pulse rate.
ii) D.P.
iii) Level of consciousness.
iv) Any conclusive feature.
v) Urine Output
vi) Any other feature of shock.
vii) Body temperature
vii) Extant of external wound
ix) Extant of active bleeding.
x) Extant of chest pain or pain in other parts of the body.
c) Types of medical treatment given immediately after admission.
i) List of emergency medicines used immediately after admission.
ii) Type of surgical procedure done immediately after admission."
The District Forum observed that the case of complainant has not fallen in emergency and hence it was rightly rejected. Emergency means any condition or symptoms resulting from any cause arising First Appeal No.856 of 2013 9 suddenly and if not treated at the early convenience, it could be detrimental to the health of patient and will jeopardize the life of patient. Here in this case, we find from the report of CMC Hospital Ludhiana on the record that wife of complainant was suffering from fever & vomiting for 6 days when she was rushed to hospital and she was diagnosed with the above referred disease. Even continuous fever and vomiting for six day could have been detrimental to the health of patient. She remained admitted for so many days at CMC Hospital Ludhiana for her treatment. The District Forum has wrongly observed that her case is not covered under the emergency established clause. We are of this view that keeping in view of her condition and her continuous suffering from fever and vomiting for six days and she was also having continuous pain in right lumber region, she was rightly taken to CMC Hospital and her condition was a case of emergency. The District Forum wrongly held it not to be covered under the Railway plan for reimbursement of claim to the retired employees or their dependents. We reverse the findings of District Forum on this point in this appeal.
8. As a result of our above discussion, we accept the appeal of the appellant and by setting aside the order of District Forum Ludhiana dated 21.06.2013, we accept the complaint of the complainant by directing OPs to pay the amount of 56,477/- as medical reimbursement to the complainant for the above treatment of his wife. The OPs are further directed to pay Rs.15,000/- as First Appeal No.856 of 2013 10 composite amount of compensation for mental harassment and litigation expenses.
9. Arguments in this appeal were heard on 09.03.2016 and the order was reserved. Now, the order be communicated to the parties.
10. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR) PRESIDING JUDICIAL MEMBER (H.S.GURAM) MEMBER March 10, 2016.
(MM)