Sudheer vs ESI CORPORATION LTD

THE unsuccessful complainant is the appellant.

THE case of the complainants in brief is that himself and his family members were covered by ESI Scheme vide Ex. A1 ESI card. While so, his mother Smt. CH. Radha suddenly fell ill. She had severe vomiting and pain in stomach. She was admitted in ESI Hospital at Sanathnagar on 1. 5. 2006. She was given treatment for four days by administering glucose, etc. They diagnosed that she was suffering from ''uretei Collie (L) Renal Caluli'' and referred her to Urology Department of Osmania Hospital, Hyderabad by discharging her on 4. 5. 2006 vide Ex. A2. When he took her to Osmania General Hospital they refused to admit her. As he has no other alternative, he admitted her in a private hospital by name Pramila Hospital at Basheerbagh, Hyderabad. The doctors at the hospital opined that it was an emergency case, and had to perform an operation. They conducted the operation on 5. 5. 2006 and discharged her on 8. 5. 2006. Altogether he paid Rs. 50,000 evidenced under Exs. A3. When he claimed the said amount from the ESI under Ex. A4 they informed under Ex. A5 that the disease was not covered under G. O. Ms. No. 117 for reimbursement (vide letter Ex. A5 ). Since the Osmania General Hospital did not admit his mother, he was forced to spend the amount in a private hospital for which he was entitled to be reimbursed. Therefore, he claimed Rs. 50,000 with interest @ 24% p. a. , together with compensation of Rs. 30,000 and costs of Rs. 3,000.

The respondent ESI Corporation Ltd. resisted the case. While admitting that complainant''s mother Smt. CH. Radha was admitted in their hospital. as she was suffering from ''uretei Collie (L) Renal Caluli'' referred her to Osmania Hospital as they were not having the department of Urology. It was in conformity with the instructions contained in G. O. Ms. No. 117 dated 27. 3. 2000. Only in case of refusal or denial of treatment for any reason by a Government hospital, the patient can be referred to any of the hospitals recognized by the Government as per tie-up arrangement. Prameela Hospital where the complainant''s mother was admitted, is not one of the hospitals recognized by the Government as a referral hospital. There is no proof that Osmania General Hospital refused to admit the patient or render medical assistance. On the application filed by the complainant, a special scrutiny committee was constituted and it has rejected the claim. He did not suffer any mental agony nor any loss, and therefore prayed for dismissal of the complaint.

THE complainant in proof of his case filed his affidavit evidence and Exs. A1 to A5. Refuting his evidence the affidavit of the Director of the hospital was filed and got Exs. B1 to B3 marked. The Dist. Forum after considering the evidence placed on record opined that the complainant is not entitled to the amount spent towards treatment in private hospital as it was not a recognized hospital. Besides that the disease from which she was ailing is also not covered under the scheme.

AGGRIEVED by the said decision, the complainant preferred this appeal contending that the Dist. Forum did not appreciate the facts in correct perspective. It ought to have observed that the complainant approached the Osmania General Hospital and when they refused to admit her she was taken to a private hospital due to emergency and got her treated with heavy expenditure. since has been making contributions regularly. Even on humanitarian grounds the Dist. Forum ought to have allowed the complaint. It is an undisputed fact that the complainant is the son of Smt. Ch. Radha the patient who is covered by ESI facility. It is also not in dispute that when she was suffering from ''uretei Collie (L) Renal Caluli'' , she was referred to Osmania General Hospital vide Ex. A2 in view of the fact that the said treatment is not available with the respondent hospital. Though the appellant alleges that she was not admitted by Osmania Hospital when she was taken, no proof whatsoever was filed evidencing the said fact. The fact remains that she underwent treatment at Prameela Hospital, and incurred an expenditure of Rs. 50,000 evidenced under bills Ex. A3. When the complainant made the claim it was refused on two grounds, (1) the disease from which the patient was suffering is not covered under G. O. Ms. No. 117 dated 27. 3. 2000 and (2) the hospital wherein the complainant had taken treatment is not recognized by the Government. Assuming without admitting that the disease from which the patient was ailing is covered by ESI, since the hospital wherein the treatment was taken was not recognized by the Government, he was not entitled to the amount. The G. O. reads that if the facilities are not available with the ESI the patient could be referred to recognized Government hospitals and only in case where such treatment is not available in the Government hospital then the treatment could be taken from Government recognized hospitals. Since the case on hand, does not qualify any of these parameters, the claim was refused.

THE complainant contended that in view of emergency, he got operated in a private hospital, and therefore he was entitled to be reimbursed. Assuming without admitting that it was an emergency admission, even then the following diseases are only recommended for reimbursement (1) Acute Myocardial Infraction (Heart Attack) (2) Accidents involving head/spine and crush injuries (3) Patient in Coma (4) Acute Paralytic Stroke (5) Acute Poisoning.

vide Ex. B1 G. O. Ms. No. 117, Health Medical and Family Welfare Department dated 27. 3. 2000. The disease suffered by the patient is not one covered by the above clauses. Therefore, the complainant was not justified in getting his mother treated in an unrecognized private hospital, and claim reimbursement charges. We do not see any misappreciation of fact or law in this regard. There are no merits in the appeal.

IN the result, the appeal is dismissed, however, in the circumstances of the case no costs. Appeal dismissed.