E-Paper
ESIC gets the stick for repudiating employee’s medical reimbursement claim
Told to release Dhanas woman’s medical claim of ₹2.16 lakh.
The District Consumer Disputes Redressal Forum has directed the regional director of Employees’ State Insurance Corporation (ESIC), Chandigarh, and in-charge, ESI Dispensary, to release a Dhanas woman’s medical claim of ₹2.16 lakh.
Sonia, a resident of small flats, HBS, Dhanas, had complained that she worked in New Delhi, and being a member of the ESI scheme, deposited 1.75% from her salary, along with employers contribution at 4.75%.
She stated that her father, Dev Narayan Singh, who was dependent on her, sustained injuries in a road accident on February 4, 2015.
For this, he got treatment at Government Medical College and Hospital, Sector 32, Chandigarh, and Mayo Healthcare Super Specialty Hospital, Sector 69, Mohali, from February 4 to May 14, 2015, costing ₹3.5 lakh.
In July 2015, she submitted the medical bills for reimbursement to the regional director, ESIC, but it was returned with the advice to submit it with the dispensary concerned.
Therefore, the bill was submitted to the senior medical officer (SMO), who was in-charge, of ESI Dispensary, Sector 23. But, it was not processed.
Therefore, alleging deficiency in service and unfair trade practice, Sonia moved the consumer forum, praying for reimbursement of the medical bill, along with interest at 18%, ₹50,000 on account of mental agony and ₹25,000 as litigation cost.
The ESIC regional director responded that the corporation had nothing to do with the complaint, as the claim was to be reimbursed by the ESI dispensary. However, the claim was not submitted to the dispensary on time.
The SMO responded that reimbursement allowed was verified at ₹2.16 lakh. But, it had become time barred, following which the matter was taken up with the director (medical), Headquarters Office, ESIC, New Delhi. But, the official did not condone the delay. Therefore, the claim could not be processed.
After hearing the arguments, the forum directed the SMO to process the claim to the extent of ₹2.16 lakh, along with interest at 9% per annum with effect from October 26, 2016.
Apart from this, the respondents were directed to pay the complainant ₹20,000 as compensation for mental agony and harassment and ₹10,000 as cost of litigation.
ESI is a self-financing social security and health insurance scheme for Indian workers. The fund is managed by the ESIC according to rules and regulations stipulated in the ESI Act, 1948.
