Back
2009(1) CPR 118 (NC)
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION,
NEW DELHI
Ashok Bhan, President and B.K. Taimni, Member
CGHS Services through Additional
Director (East) —Petitioner
versus
Amar Singh —Respondent
Revision Petition No. 2006 of 2008
Decided on 18.12.2008
Counsel for the Parties:
For the Petitioner:Mr. K.C. Dubey, Advocate.
For the Respondent No. 1:Mr. Rajeshwar Kumar, Gupta, Advocate.
For Dharamshila Cancer Hospital:Mr. N.K. Jha, Advocate.
IMPORTANT POINT
A CGHS card holder is entitled to get treatment from a Government Hospital or from the empanelled Hospital. If he gets a treatment from a hospital not covered under CGHS panel without being referred to the said hospital, then the Government is not obliged to reimburse the CGHS card holder the amount of the bill raised by the hospital.
Headnote:Consumer Protection Act, 1986—Section 12 and 17—Deficiency in service—Claim for reimbursement of medical bill covered under CGHS scheme for operation/surgery got carried in private hospital—Bill for Rs. 4,74,259 settled by petitioner for Rs. 1,63,885 as per rules and balance bill amount was declined on plea that surgery was got carried out in private hospital without prior permission and reference—District Forum allowed complaint directing petitioner to pay balance amount Rs. 3,10,374 with interest—State Commission upheld order in appeal—Revision—Respondent had gone to hospital without taking permission from petitioner in terms of office memorandum—If complainant got treatment from a hospital not covered under CGHS Panel without being referred to said hospital, Government was not obliged to reimburse the expenses—Impugned order was liable to be set aside.
Result: Revision allowed.
Ashok Bhan, President—CGHS Services-petitioner (hereinafter referred to as ‘petitioner’ for short) through its Director (East) has filed this present Revision Petition.
Shortly stated, the facts of the case are:
2. That the respondent-complainant (hereinafter referred to as ‘respondent’ for short), a former Government servant and his wife are members of CGHS scheme. Card No. P033875 was issued to them on 10.11.2000. The wife of the respondent was admitted in Dharmshilla Cancer Hospital and Research Centre, Vasundra, Delhi (hereinafter referred to as ‘the hospital’ for short) for urgent surgery. The surgery was carried out on the person of the wife of the respondent on 12.07.2005. She was discharged on 02.08.2005. The respondent paid a sum of Rs. 4,74,259 for the treatment of his wife. Being CGHS card holder, the respondent applied to the petitioner for reimbursement. The petitioner paid a sum of Rs. 1,63,885 out of the total expenses of Rs. 4,74,259. Terming the short payment as deficiency in service, the respondent filed a claim before the District Consumer Disputes Redressal Forum (East), Saint Enclave, Delhi (hereinafter referred to as ‘the District Forum’ for short) seeking a direction to the petitioner to pay the balance amount of Rs. 3,10,374 cost and compensation. The petitioner justified the reimbursement of Rs.1,63,885 out of the total expenses of Rs. 4,74,259 inter alia on following defences:
(i) No prior permission was taken by the respondent. Hence, violation of office memorandum No.SA.11017/1/95-CGHS(P) dated 20.9.1995.
(ii) Dharmshila Hospital was not authorized to provide treatment of this nature to the wife of the respondent i.e. surgical treatment.
(iii) Bills were settled as per the rules of CGHS.
(iv) That the appellant calculated the amount of Rs.1,63,885 as per CGHS Rules and denied any deficiency in service on its part and prayed for dismissal of the complaint.
3. The District Forum did not accept the plea raised by the petitioner and allowed the complaint filed by the respondent and, accordingly, directed the petitioner to pay a sum of Rs 3,10,374 towards reimbursement of medical expenses with interest @ 8% per annum from 01.12.2005 till the date of realization. Rs. 3000/- was granted by way of litigation expenses. The petitioner being aggrieved filed the Appeal before the State Consumer Disputes Redressal Commission, Delhi (hereinafter referred to as ‘the State Commission’ for short). The State Commission dismissed the appeal thereby upholding the Order of the District Forum.
4. It is an admitted case before us that without taking permission and/or reference, the respondent went to the hospital for surgery of his wife. It is also not disputed that the hospital raised a bill of Rs. 4,74,259 for the treatment provided to the wife of the respondent. The respondent paid the sum of Rs. 4,74,259. The petitioner processed the bill and calculated the amount as per Government guidelines and policy applicable to the CGHS members and paid Rs.1,63,885. The case of the respondent was that the hospital was covered under the CGHS scheme whereas the case of the petitioner was that the said hospital was not covered under the CGHS scheme and the respondent was not entitled to reimbursement of the amount spent by him in the said hospital until and unless reference has been made to the said hospital. Since, the respondent had gone to the hospital without taking permission, the petitioner processed the bill and calculated the amount as per Government guidelines and policy applicable to the CGHS members and paid Rs. l,63,885.
5. To find out as to whether the hospital was covered under the CGHS scheme, we directed the petitioner on 7.5.2008 to write to the hospital as to why the hospital charged in excess of the CGHS rates from the complainant and if it has charged in excess of CGHS rates, then the excess amount be refunded to the respondent. The Commission also directed that the hospital be made as party-respondent
