The District Consumer Disputes Redressal Commission, Fathegarh Sahib, has recently delivered a significant verdict against the Employees’ State Insurance Corporation (ESIC), highlighting a case of deficiency in service. The commission found ESIC guilty of not reimbursing the complete mediclaim amount to a beneficiary who had suffered an eye injury at work. Consequently, ESIC has been ordered to refund the balance amount of ₹10,056 with 8% interest, coupled with ₹10,000 as compensation.
The case revolves around Rama Shankar, an employee of M/s Boparai Metal Pvt Ltd in Phase 7, Industrial Area, Mohali. Shankar, a member of the ESI Scheme, had diligently contributed to ESIC since January 1, 2016, including the employer’s share. However, in February 2017, he encountered a right eye injury while on duty at the factory. Subsequently, he incurred medical expenses amounting to ₹54,792 at a private hospital in Mohali.
Despite Shankar’s entitlement to reimbursement, ESIC initially refused to accept the medical bill. Even after submitting a legal notice in April 2017, as per the mandated 21-day clearance period, Shankar received no response from ESIC. Faced with prolonged delays and unmet obligations, he resorted to filing a consumer complaint in December 2017.
Upon scrutiny, the commission noted ESIC’s failure to fulfill its obligations adequately. It emphasized ESIC’s liability to reimburse the entire medical expenses in cases where no facility is available either in an ESI-run hospital or in a tie-up hospital. In Shankar’s case, he was referred to a non-empanelled hospital by the ESI Hospital due to the unavailability of requisite facilities. Therefore, ESIC was mandated to reimburse the complete claim amount.
The commission’s directive underscores the importance of ensuring prompt and comprehensive healthcare reimbursement to beneficiaries. ESIC’s failure to meet its obligations not only constitutes a breach of trust but also deprives beneficiaries of their rightful entitlements. The ruling serves as a reminder to service providers to uphold their commitments diligently, especially in matters as critical as healthcare.
In light of the commission’s verdict, ESIC has been instructed to refund the balance amount of ₹10,056, along with 8% interest per annum from the date of filing the complaint. Additionally, the senior state medical commissioner has been directed to pay ₹10,000 as compensation to Shankar. This ruling stands as a testament to the judiciary’s commitment to safeguarding consumer rights and holding service providers accountable for their actions.
As stakeholders in the realm of healthcare and insurance, it is imperative for institutions like ESIC to prioritize the welfare of beneficiaries and ensure seamless access to healthcare services. The verdict serves as a wake-up call for all service providers to reevaluate their processes and strive towards delivering efficient and transparent services to those in need.