By. Sri. Jose. V. Thannikode, President:
The complaint is filed under section 12 of the Consumer Protection Act to get the medical expenses, cost and compensation due to the deficiency of service from opposite parties.
2. The complainant and his family is a member of RSBY Scheme which has been launched by Ministry of Labour and Employment, Government of India to provide health insurance coverage for BPL families. The objectives of RSBY is to provide protection to BPL households from financial liabilities arising out of health shocks that involve hospitalization. On 19.10.2010 the complainant fall from a coconut tree and his leg broke in two place and he was admitted to Medical College Hospital Kozhikode and availed treatment. But he was denied the benefit under the RSBY Scheme by opposite party No.3 stating that, in his RSBY card his name is entered as Balavarshan instead of Balakrishnan. It is a mistake committed by the opposite party No.1, it is a deficiency of service from the side of opposite party No.1, thereby the complainant could not get the benefit of the said scheme. He has incurred about Rs.50,000/- as treatment expense for the said injury. In this connection his wife Usha Balakrishnan given a complaint to opposite party No.2 on 21.01.2011. Then the opposite party No.2 send the complaint to opposite party No.1 with all his medical bills. Since no reply from the opposite party No.1, the complainant given a complaint to Chief Minister's “JANASAMBARKA PARIPADI” on 17.10.2011 and on 13.11.2011. Thereby the opposite party No.1 replied to complainant that he is treated without registering under the scheme health insurance.
3. The hospital counter(opposite party No.3) not registered his claim stating that his name is not there in the health card. Thereafter the complainant admitted in Vythiri Taluk Hospital for further treatment from 31.03.2011 to 04.04.2011, after that the complainant went to Akshaya Center and corrected the mistake in his name in the Card. The complainant belongs to scheduled caste and prayed before the Forum to direct the opposite parties to pay Rs.50,000/- which is spend for his treatment and to pay Rs.10,000/- as compensation for the deficiency of service and to pay the cost of this proceedings.
4. Notices were served to opposite parties, and opposite parties entered appearance and filed versions.
5. In the version of opposite party No.1 it is stated that IT applications are being used in the scheme in a large scale. Every beneficiary family is issued a biometric enabled smart card containing their finger prints and photographs. All the hospitals empaneled under RSBY are IT enabled and connected to the server at the district level. The card holder submits his smart card in the RSBY counter of the hospital and the hospital inserts his/her smart card in the smart card terminal/reader and once the terminal identifies and authenticates the beneficiary by matching the authentication key and the fingerprints, the application would allow the transaction to proceed further. System will never deny treatment to a beneficiary whose name is mis spelt on account of wrong data entry. The petitioner has no cause of action against the 1st opposite party to file the petition. There was no service deficiency from the side of the 1st opposite party. This petition was filed without any valid reason against the 1st opposite party. Relief sought in the petition cannot be given by the 1st opposite party. Hence it is prayed that the petition may be dismissed with cost to the 1st opposite party.
6. In the version of opposite party No.2 it is stated that the 2nd opposite party is an officer of Kerala Government, Labour Department and is functioning as the Nodel Agency for the organizational arrangements of comprehensive Health Insurance Scheme introduced by Government for the facilitation of free medical assistance for the members of families below poverty lines and for others conditionally. The scheme provided for ensuring free medical assistance in both government owned and private hospitals by way of payment to those institutions from insurance company, premium in respect of the beneficiaries are paid by Government to the insurance company. Government has formed comprehensive Health Insurance Agency of Kerala (CHIAK) for the Governance of the scheme and for the co-ordination between the insured company and hospitals. When received a complaint from the petitioner the respondent had forwarded it to the Executive Director, CHIAK and the fact was informed to the petitioner as the CHIAK is responsible for providing remedial measures. The respondent is no way responsible for the cause alleged in the petition.
7. In the version of opposite party No.3 it is stated that the above case is not maintainable either in law or in facts the complaint is bad for non jointer of necessary parties and this opposite party is an unnecessary party in the above case. The complaint is not entitles to get any reliefs from this opposite party. It is further submits that there is no consumer relationship between the complainant and this opposite party.
8. The RSBY has been launched by Government to provide health insurance coverage for families below poverty line, and others also. The beneficiaries belongs to below poverty line, need to pay Rs. 30/- only as registration fee and central and State Govt., paying the premium to the insurer. CHIS is a State Government initiative which provides the technical plat-form, at concerned hospitals and other outlets for those who are eligible under the insurance coverage. The entire expenses are met by the Government of Kerala. The Kozhikode Medical College, being a Government institution and an out let for providing free treatment, have attached with a center of the above project, for providing necessary help for treatment under the scheme.
9. Every beneficiary family is issued a smart card at the time of admitting to the scheme. At the time of treatment when the holder of the card submits his smart card in RSBY counter of the hospital and when the smart card is inserted in smart card reader of the terminal, at once the terminal identifies the beneficiary and then it would allow the transaction to proceed. But in the above case the name of the beneficiary is mentioned as 'Balavarshan' But in the hospital record he gave the name as Balakrishnan. Therefore the system could not identify him and the benefits could not be given to him. It is further submits that according to the complainant also he was aware of the fact that his name is entered in the smart card as 'Balavarshan' instead of Balakrishnan. It is to be noted that the complainant himself had corrected the mistake in the smart card in 04.04.2011 and availed the benefit under the scheme. If the complainant had rectified the mistake at an early time he would not have been denied with benefits under the scheme. This opposite party having no connection with the mistake, if any occurred in the smart card. It is further submitted that M/s. Medicare T.P.A. services (Pvt. Ltd.)C/o United India Insurance Company Ltd, Branch office Rawther Building, Pinangode Road, Kalpetta is the Wayanad District Office and, Third Party Agency of the above said scheme and Medicare T.P.A service (Pvt. Ltd.) 3rd floor Jomer Arcade opposite to Government Girls Higher Secondary School Ernakulam South 682016 is the state office.
10. The T.P.A is doing all the activities, including the preparation of smart card, processing the claims and its payment etc., further the claim amount disbursed through with the sanction of Insurance Company who had paid the claim amount to T.P.A.Therefore the above said M/s. Medicare T.P.A Service Private Ltd., and United India Insurance Company are the necessary parties to the proceedings. It is further submitted that it is categorically stated in the compliant that the reason for denial of benefit under the scheme is only because of the mistake in printing his name in the smart card as 'Balavarshan' instead of Balakrishnan. This opposite party is not at all responsible for any mistake in printing of smart card. During the period of treatment the complainant had neither taken any steps to rectify the mistake in the smart card nor sought any alternative remedy. It is further stated in the complaint that since his name is changed he could not register at the counter of the hospital. Therefore it is evident that the denial of benefit is not due to any defect of this opposite party. It is further submitted that no allegation is raised by the complainant against this opposite party. Hence this opposite party is arrayed in the case only with ill-motive and to put this opposite party in unnecessary difficulties and troubles for which the complainant is liable to pay compensatory costs to this opposite party. Hence it is prayed to dismiss the complaint with cost to this opposite party.
11. In the version of opposite party No.4 they stated, this opposite party denies entire allegations and averments contained in the complaint except those that are specifically and expressly admitted herein. This opposite party submits that this complaint is not maintainable as per Iaw,facts and circumstances of this case. This opposite party submits that this complaint is bad for non-joinder of necessary party to this proceedings ie,MEDICARE IPA SERVICES (I) PVT LTD,N0.6,Bishop Lefroy Road,Kolkotta,700020 licensed by Insurance Regulatory Authority(IRDA). This opposite party denies the allegation that the complainant is covered by the Insurance coverage. The complainant had not mentioned the policy details for verification. The RSBY scheme provides the coverage for meeting the expense of hospitalization for medical and surgical procedures to the enrolled BPL families up to Rs.30,000/- per family per year. The provider will identify the beneficiary on the basis of smart card issued to them as per RSBY Scheme. The card has a chip with details of name ,age, relationship with head of the family and photograph of the rest of the family members enrolled for the benefit under the scheme. The finger prints are captured and saved in the chip for all the enrolled beneficiaries in a family. As soon as a beneficiary walks in to the hospital for medical attention,he will have to produce the smart card issued to the RSBY counter. The card will then fed to card reader No. l.MHC card reader fed in the card reader No.2 as soon as this card is inserted to the reader it will ask for user id and password and MHC pin number. Upon inserting the same transaction software will open. Then the beneficiary card details can be read by clicking on the option which will be provided in the transaction software and also finger print verification can be done of the relevant finger as mentioned in the card. Once the finger print verification is successfully completed the registration, blocking and transaction process can be accomplished. Once the identity of the beneficiary is established by verifying the fingerprint of the patient through the smart card following procedure shall be followed for providing the health care facility under package rates:-
(a) It has be seen that the patient is admitted for covered procedure and package for such intervention is available.
b)Beneficiary has balance in his account
c)At the time of discharge final entry shall be made on the smart card after verification of patient's finger print to complete transaction.
12. The services have to be provided to the beneficiary based on smart card and finger print authorization. The reimbursement to providers will be based on the electronic data received from providers. The issue of smart card including the project involving Smart Card envisages the need for the necessary Hardware and soft ware installation. This opposite party submits that this scheme was newly introduced through out India at a stretch and due to some software problem some mistakes happened in the name portion of the smart card. The persons will be identified through the finger print The name of the beneficiary was mistakenly noted due to the software mistake it is beyond the control of this opposite party and not due to any willful default. There is no deficiency of the service on the part of this opposite party. The hospital authorities could have admitted the claim and contact this opposite party for verification in case the datas were not tallied instead of denying the benefit. Even the complainant also not approached this opposite party when the hospital authority denied the benefit. This opposite party denies the allegations made in the complaint. The complainant is put to strict proof of allegations made in the complaint. This opposite party submits that the complainant is not entitled to get sum of Rs.50,000/- towards treatment expense and Rs.10,000/- towards compensation, as prayed for. Hence prayed for the dismissal of the complaint.
13. Complainant filed proof affidavit and stated as stated in the complaint and further stated that in his family’s RSBY Smart card his name, photo, fingerprint is added and the card is given to the RSBY counter of opposite party No.3. Then the RSBY counter rejected his request stating that there is a spelling mistake in his name without verifying the photos and fingerprint and further stated that when his family enrolled into the RSBY with opposite party No.1 they have given all the details and all the requested documents in which complainant's name is written as Balakrishnan to the opposite party No.1 and paid Rs.30/- as the required fees. But the opposite party No.1 entered the complainant's name as Balavarshan instead of Balakrishnan and complainant is examined as PW1 and Exts.A1 to A8 is marked. Ext.A1 is the photocopy of complainant's Ration Card, wherein the complainant's name can be seen as Balakrishnan. Ext.A2(1) is the Election Identity Card of complainant, wherein also his name is seen as Balakrishnan. Ext.A2(2) is the copy of Identity card of complainant's mother Kalyani. Ext.A2(3) is the copy of Identity card of complainant's daughter Akshara Balakrishnan. Ext.A2(4) is the copy of Identity card of complainant's wife Usha. Ext.A3(1) is the Reference card, Medical College Hospital, Kozhikode dated 19.10.2010 to 31.10.2010. Ext.A3(2) is the Reference card, Medical College Hospital, Kozhikode dated 29.10.2011 to 01.11.2011. Ext.A4 series is the Bills issued to complainant worth Rs.17,650/-. Ext.A5 is the Discharge Card of Taluk Head quarters Hospital, Vythiri dated 31.03.2011 to 04.04.2011. Ext.A6(1) is the Medical Bill from Neelikandy Medicals worth Rs.303/-. Ext.A6(2) is the Medical Bill from Neelikandy Medicals worth Rs.97/-. Ext.A6(3) is the Receipt from Leo Hospital, Kalpetta worth Rs.100/-. Ext.A6(4) is the Receipt from Leo Hospital, Kalpetta worth Rs.100/-. Ext.A7 is the copy of Smart Card in the name of complainant's mother bearing No.02052452320023508. Ext.A8 is the copy of Smart Card in the name of complainant's mother bearing No.32030401413000428.
14. The opposite party No.1 and opposite party No.4 filed proof affidavit and stated as stated in the version and opposite party No.1 examined as OPW1 and opposite party No.4 is examined as OPW2 and Ext.B1 is marked. Ext.B1 is the Order in GO(P) No.95/2008/LBR implementation of the scheme of CHIS(RSBY)
15. In the deposition PW1 stated that " the complainant and his family went to Manivayal club for RSBY Scheme registration and given the copy of Identity card and copy of ration card. Thereafter I taken steps to clear the mistakes in my name, after correcting the mistakes the rejected benefits is received by me and further deposed that I understood the mistake in the name of me in the card only when the opposite party No.3 rejected the claim".
16. In the deposition of OPW1 he deposed that "all the members of RSBY scheme are entitled for the treatment expenses. we collected Rs.30/- from the complainant as required Registration Fees and when we enrolled the complainant in to scheme I have verified the Ration Card of the complainant. We are entertaining any complaint regarding the complaints in the entries for treatment benefit if it is noticed, we are entering into the card,name, age, gender, relationship, photograph and fingerprints. The benefit will not rejected on account of the mis-spelt in the name, if there is any mis-spelt in the name after verifying the other details benefits will be given". In the present case, we have understood that the Balavarshan and Balakrishnan is one and the same person. The complainant's name in the card can only be seen when it is inserted to the system.
17. After analyzing all the above facts, Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the part of opposite parties?
2. Whether the complainant is entitled for compensation and cost?
3. Who is liable?
4. Relief and Cost.
18. Point No.1:- On perusal of the deposition of OPW1 itself, we can come to the conclusion that there is a deficiency of service from the side of opposite party No.1 because OPW1 stated that "when we have enrolled the complainant in to the scheme we have verified his ration card, in the ration card complainant's name is clearly written as Balakrishnan but the opposite party No.1 entered it as Balavarshan and further stated that, we are entertaining any complaint regarding the complaints in the entries for treatment benefit if it is noticed we are entering into the card,name, age, gender, relationship, photograph and fingerprints. The benefit will not rejected on account of the mis-spelt in the name, if there is any mis-spelt in the name after verifying the other details benefits will be given". In the present case, we have understood that the Balavarshan and Balakrishnan is one and the same person. The complainant's name in the card can only be seen when it is inserted to the system. This clearly shows that opposite party No.1 mistakenly entered the complainant's name as Balavarshan instead of Balakrishnan. The complainant cannot be blamed for the mistakes in the name because it cannot read without inserting in to a system. The deposition of OPW1 and version of Opposite party No.1 and 3 it is evidenced that there is a gross deficiency of service from the side of opposite party No.3. Since the claimant can be identified by photo and fingerprint easily after inserting the card in to the system. The opposite party No.1 in his version stated that if the RSBY counter of the hospital insert the card in the reader and once the terminal identifies and authenticates the beneficiary by matching the authentication key and the fingerprints, the application would allow the transaction to proceed further. System will never deny treatment to a beneficiary, whose name is mis-spelt on account of wrong data entry.
19. In the version of opposite party No.3 in para 3 it is clearly stated that Every beneficiary family is issued a smart card at the time of admitting to the scheme. At the time of treatment when the holder of the card submits his smart card in RSBY counter of the hospital and when the smart card is inserted in smart card reader of the terminal, at once the terminal identifies the beneficiary and then it would allow the transaction to proceed. But in the above case the name of the beneficiary is mentioned as 'Balavarshan' But in the hospital record he gave the name as Balakrishnan. Therefore the system couldnot identify him and the benefits could not be given to him. If we read it coupled with the version of opposite party No.1 and deposition of OPW1, it is a clear case of deficiency of service from the side of opposite party No.1 & 3. The Point No.1 is found accordingly.
20. Point No.2:- Since the complainant admitted in his deposition that after correcting the mistakes in the name in the smart card he received the benefit of treatment under the scheme. But due to the deficiency of service of Opposite party No.1 and 3 the complainant caused great difficulty, mental agony and loss of money and time. Hence the complainant is entitled for compensation and costs. The point No.2 is found accordingly.
21. Point No.3:- Since the Point No.1 is found against opposite party No.1 & 3 only the opposite party No.1 & 3 is liable to compensate the same.
22. Point No.4:- Since the Point No.1 & 3 is found against opposite party No.1 and 3. Opposite party No.1 is liable to pay Rs.5,000/- as compensation and Rs.5,000/- as cost of the proceedings to the complainant and opposite party No.3 is liable to pay Rs.5,000/- as compensation and Rs.5,000/- as cost of the proceedings to the complainant.
In the result, the complaint is partly allowed and opposite party No.1 and opposite party No.3 is directed to pay Rs.5,000/- (Rupees Five Thousand) only each as compensation and Rs.5,000/- (Rupees Five Thousand) Only each as cost with 12% interest from 31.01.2012 to the complainant within 30 days from the date of receipt of this Order. Thereafter the complainant is entitled for interest @ 15% per annum for whole amount.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 29th day of November 2014.
Date of Filing: 30.01.2012.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:
PW1. Balakrishanan. Complainant.
Witness for the Opposite Parties:
OPW1. Anas. P. M. CHIAK Assistant District Co-Ordinator.
OPW2. Naveen Palliyal. Manager, United India Insurance Co Ltd,
Kalpetta.
Exhibits for the complainant:
A1. True Copy of Ration Card.
A2(1). True Copy of Identity Card of Complainant.
A2(2). True Copy of Identity Card Complainant's Mother.
A2(3). True Copy of Identity Card Complainant's Daughter.
A2(4). True Copy of Identity Card Complainant's Wife.
A3(1). Reference Card.
A3(2). Reference Card.
A4(Series). Medical Bills (41 Nos).
A5. Discharge/Referral Card.
A6(Series). Medical Bills (4 Nos).
A7. Copy of Smart Card of complainant's mother bearing No.02052452320023508.
A8. Copy of Smart Card of complainant's mother bearing No.32030401413000428.
Exhibits for the opposite Parties.
B1. Copy of Government Order.
Sd/-
PRESIDENT, CDRF, WAYANAD.
