Mohali: ESIC fined for not reimbursing full mediclaim amount to beneficiary - Hindustan Times
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Mohali: ESIC fined for not reimbursing full mediclaim amount to beneficiary

By, Mohali
Feb 29, 2024 06:03 AM IST

Terming ESIC guilty of deficiency in service, the commission ordered the corporation to refund the balance amount of ₹10,056 with 8% interest, along with ₹10,000 as compensation

The District Consumer Disputes Redressal Commission, Fathegarh Sahib, has penalised the Employees’ State Insurance Corporation (ESIC) for not reimbursing the complete mediclaim amount to a beneficiary who had sustained an eye injury at work in February 2017.

After waiting for nearly eight months, petitioner Rama Shankar filed a consumer complaint in December 2017, following which ESIC paid <span class='webrupee'>₹</span>44,736 as per CGHS rules, which he accepted under protest. (Getty Images/iStockphoto)
After waiting for nearly eight months, petitioner Rama Shankar filed a consumer complaint in December 2017, following which ESIC paid 44,736 as per CGHS rules, which he accepted under protest. (Getty Images/iStockphoto)

Terming ESIC guilty of deficiency in service, the commission ordered the corporation to refund the balance amount of 10,056 with 8% interest, along with 10,000 as compensation.

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The order came on the complaint of Rama Shankar, who works for M/s Boparai Metal Pvt Ltd in Phase 7, Industrial Area, Mohali.

His counsel Jasbir Singh submitted that as a member of the ESI Scheme, Shankar had been paying ESI contributions since January 1, 2016, including the employer’s share regularly. On February 12, 2017, Shankar sustained a right eye injury while working at the factory. On the reference of ESI Hospital, he was taken to a private hospital in Mohali and paid 54,792 for treatment from his own pocket.

After ESIC refused to accept the medical bill, he submitted a medical reimbursement bill through a legal notice in April 2017 to the ESIC Regional Office, Chandigarh. But despite a legal obligation to clear his reimbursement bill within 21 days, there was no response.

After waiting for nearly eight months, Shankar filed a consumer complaint in December 2017, following which ESIC paid 44,736 as per CGHS rules, which he accepted under protest.

Allowing his complaint, the consumer commission observed that ESIC was liable to reimburse the entire medical expenses where there was no facility either in an ESI-run hospital or in a tie-up hospital, and treatment had to be taken from another hospital having the required facility.

The complainant himself did not go to the non-empanelled hospital, but was referred by the ESI Hospital. Therefore, it is obligatory on ESIC’s part to reimburse the whole claim because they did not have the required parameters/facilities in their hospital, the commission said.

Hence, the commission directed ESIC to reimburse the balance amount of 10,056, along with interest at 8% per annum from the date of filing of this complaint till actual realisation, within 30 days. The senior state medical commissioner was also directed to pay 10,000 as compensation.

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