HIMACHAL PRADESH STATE CONSUMER DISPUTES REDRESSAL COMMISSION, SHIMLA
Inder Singh Mehta, President
Employees State Insurance and Anr. – Appellants
versus
Priya Ranjan Kumar and Anr. – Respondents
First Appeal No.196 of 2023 and
First Appeal No.292 of 2023
Decided on 29.11.2024

Headnote:

ESI Act, 1948 – Sections 53, 57 and 61 – ESI Regulations, 1950 – Rule 96-B – Workmens Compensation Act, 1923 – Reimbursement of medical benefits – Kidney transplant – Reimbursement as per CGHS rates – No deficiency in service – Complainant has approached Fortis Hospital on his own without consulting ESIC/ESIS – Section 57 of ESI Act & Rule 96-B of ESI Regulations clearly provide that insured person is entitled to medical benefits as per rates prescribed by State Government or Corporation or Central Government Health – OP/ESI has calculated & remitted the amount of medical benefits to the tune of Rs.2,79,042/- on the basis of CGHS rates, which were admissible at the relevant point of time – No deficiency in service can be attributed to OP/ESI – Forum had jurisdiction to try & decide the complaint regarding dispute between insured person & Corporation – Appeal of appellant is allowed & impugned order passed by Forum is set aside – Appeal filed by complainant seeking interest @ 9% p.a. on awarded amount is dismissed as medical benefits to the tune of Rs.2,79,042/- as per CGHS Rules have already been remitted to complainant before filing of complaint.

Held: Perusal of the Annexure R-1 further indicates that Committee has observed that complainant has not approached the Fortis Hospital through ESIC/ESIS channels. Relevant portion of Annexure R-1 is reproduced as under:-

“In view of the position given above it is observed that the IP has not approached the Fortis through the ESIC/ ESIS channels. Subsequently also he is not consulting the ESIC/ ESIS medical institutions. In view of the fact that at the relevant time no tie-up arrangement was available and it was a lifesaving procedure taking a lenient view and to avoid any legal complications, the committee allows the reimbursement of Rs.2,79,042 (Two Lakh Seventy Nine Thousand Forty Two Rupees Only) However, the IP hereafter, may be advised to take the treatment through the ESIC/ ESIS network failing which no reimbursement of the procedures/medicines will be allowed in future.”

Thus, it is crystal clear that complainant has approached the Fortis Hospital on his own without consulting the ESIC/ESIS, therefore, the reimbursement of Rs.2,79,042/- was allowed to the complainant as per the CGHS rates.

Thus, Section 57 of the ESI Act and Rule 96-B of the ESI Regulations clearly provide that insured person is entitled to the medical benefits as per the rates prescribed by the State Government or the Corporation or for the Central Government Health (CGHS). The opposite party/ESI has calculated and remitted the amount of medical benefits to the tune of Rs.2,79,042/- on the basis of CGHS rates, which were admissible at the relevant point of time. In these circumstances, no deficiency in service can be attributed to the opposite party/ESI.

As far as plea of the opposite party/ESI that District Forum had no jurisdiction to try and decide the complaint regarding dispute between the insured person and the Corporation is concerned, the same is of no help to the case of the opposite party/ESI, as the Hon’ble Supreme Court of India in case titled Kishori Lal V. E.S.I. Corporation II (2007) CPJ 25 (SC) has held in para 21 of its judgment that medical services rendered in the ESI hospital/dispensary by the respondent corporation falls within the ambit of Section 2(1) (o) of the Consumer Protection Act.

Relevant portion of the aforesaid judgment is reproduced as under: –

“21.......We are of the view that the appellant is a consumer within the ambit of Section 2 (1)(d) of the Consumer Protection Act, 1986 and the medical services rendered in the ESI hospital/dispensary by the respondent corporation falls within the ambit of Section 2(1) (o) of the Consumer Protection Act and, therefore, the consumer forum has jurisdiction to adjudicate upon the case of the appellant. We further hold that the jurisdiction of the consumer forum is not ousted by virtue of sub-section (1) or (2) or (3) of the Section 75 of the Employees’ State Insurance Act, 1948.”

In view of the above stated facts and circumstances of the case, the appeal of the appellant/ESI is allowed and the impugned order passed by learned District Commission below is set aside.

Consequently, the appeal filed by the complainant/ appellant seeking interest at the rate of 9% per annum on the awarded amount is hereby dismissed, as the medical benefits to the tune of Rs.2,79,042/- as per CGHS rates have already been remitted to the complainant before filing of the complaint. (Paras 18, 19, 22, 23 to 26)

Result: Appeal allowed.