DIRECTOR OF MEDICAL INSURANCE SERVICES Vs. MANI NAIR

JUDGEMENT

(1.) This Insurance Appeal is filed under Sec. 82(2) of the Employees State Insurance Act, 1948 (for short, 'the Act') by the Director of Medical Insurance Services, challenging the judgment dtd. 12/6/2014 in Insurance Case No.137 of 2012 of the Employees Insurance Court, Alappuzha ('EI Court' for short) allowing the application under Sec. 75 of the Act filed by 1st respondent employee for full reimbursement of the medical bills for the treatment of his employment injury. The parties are referred to as per their status in the Insurance Case.

(2.) The applicant was a general worker in Cochin Shipyard. He was insured under the provisions of the Act and the Scheme framed thereunder. On 24/6/2007, at about 1.30 p.m, while the applicant was removing waste from the working skid of the work place, he slipped and hit his chest on the working skid and fell unconscious. As the injury sustained was very serious, he was immediately rushed to the nearest private hospital viz., Medical Trust Hospital, Ernakulam, in the employer's vehicle. The accident happened on Sunday afternoon. The applicant was treated in ICU for seven days. After discharge from the hospital, the applicant claimed an amount of Rs.48,227.35 towards reimbursement of medical bill with essentiality certificate before the 1st opposite party, the Director of Medical Insurance Services. However, the 1st opposite party allowed only Rs.6,079.00. Though the applicant submitted repeated representations, the balance amount claimed by him was not reimbursed. Accordingly, he filed I.C No.13 of 2011 before the EI Court to reimburse the balance amount with interest. The applicant was relegated to the 1st opposite party, the Director of Medical Insurance Services to consider his claim for reimbursement of the entire amount. The 1st opposite party rejected the claim of the applicant stating that he is not entitled to get any further amount other than Rs.6,079.00. Accordingly, the applicant preferred I.C. No.137/2012 under Sec. 75 of the Act to realise the amount of Rs.42,148.35 with 12% interest per annum from July, 2007 till realisation.

(3.) Before the EI Court, the opposite parties contended that, as per Sec. 57 of the Act, the applicant is entitled to receive medical benefit only of such kind and on such scale as may be provided by the State Government or by the Employees State Insurance Corporation (for short, 'the ESI Corporation'). It was further contended that, since the applicant approached the private hospital on his own will and satisfaction without any prior reference or sanction during the treatment period, he can be granted only the benefits as per the rates fixed in Ext. D1 G.O (MS) No.92/95 LBR dtd. 21/9/1995. The 2nd opposite party, the ESI Corporation filed written statement contending that the expenses incurred for treatment at private hospitals are on higher side and medical expenses are restricted at government rates. It was further contended that their role is limited to reimburse the medical expenses passed by the 1st opposite party.