CC Filed on 26.04.2010
Disposed on 04.01.2011
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KOLAR.
Dated: 04th day of January 2011
PRESENT:
Sri. G.V.HEGDE, President.
Sri. T.NAGARAJA, Member.
Smt. K.G.SHANTALA, Member.
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Consumer Complaint No. 49/2010
Between:
Sri. K.N. Gopal Krishna, S/o. K.G. Narayanappa, Aged 50 years, Resident of KonappanahalliVillage, Ambajidurga Hobli, Chintamani Taluk, Chikkaballapura District. V/S 1. Konapalli Milk Producers’ Co-operative Society Limited, Konapalli, Chintamani Taluk, Chikkaballapura District, By its Secretary. 2. Yeshaswini Co-operative Farmers Health Care Trust, 3rd gate 6th Floor, M.S.Building, Ambedkar Veedhi, Bangalore – 560 001, By its Chief Executive Officer. (By Advocate Sri. B. Mari Reddy & others) 3. Family Health Plan Limited, 45, Millers Road, Bangalore – 560 042. By its Managing Director. | ….Complainant |
4. R.L.JalappaHospital & Research Centre, Tamaka, Kolar District, By its Superintendent. (By Advocate Sri. K.V. Shankarappa & others) | ….Opposite Parties |
ORDERS
This is a complaint filed under section 12 of the Consumer Protection Act, 1986 praying for a direction against the opposite parties to pay a sum of Rs.20,000/- to complainant towards reimbursement of medical expenses of Rs.8,444/- and for compensation, for mental agony and expenses for the deficiency in service by the OPs.
2. The material facts of complainant’s case as may be gathered from the pleadings and documents produced by complainant may be stated as follows:
That the complainant is a member of OP.1 society. He is an agriculturist and milk producer and supplies milk to OP.1. OP.2 is a Trust entrusted with the work of carrying out the Yeshaswini Scheme sponsored by State Government. OP.3 is a Third Party Administrator for OP.2 for processing the claims under Yeshaswini Scheme. OP.4 is a Network Hospital (NWH) recognized under Yeshaswini Scheme.
The complainant is a beneficiary under Yeshaswini Scheme and his I.D. No. is 0262460. He paid Rs.480/- for enrollment of himself and wife and his minor son for Yeshaswini Scheme for the year 2009-10. The amount was collected by OP.1 and he was issued receipt dated 30.05.2009 bearing receipt No. 48 and was also issued I.D. card bearing No. 0262460.
It is alleged that the wife of complainant was suffering from acute appendicitis and she was admitted to OP.4 hospital on 11.02.2010 for treatment. The Doctor after investigation advised to undergo immediately for Apendisectomy Surgery. Due to urgency of the treatment, the required operation was conducted. The wife of complainant was discharged on 18.02.2010.
Before discharge of the wife of complainant from OP.4 hospital, the complainant intending to avail the benefit of Yeshaswini Scheme submitted his Yeshaswini I.D. card and with other documents to OP.4. The concerned person in the office of OP.4 by opening the Yeshaswini website and updating the required particulars of complainant’s I.D. card in the said website told the complainant that the details regarding the I.D. card number of complainant have not been hosted on the website. Therefore complainant was asked to pay the Hospital expenses by OP.4-Hospital. Therefore the complainant was compelled to pay hospital charge of Rs.8,444/- for discharging his wife.
The complainant made a representation dated 01.03.2010 to OP.2 and other concerned persons stating the reason why he could not avail cashless treatment in OP.4 hospital to his wife. Therefore he requested to reimburse the hospital bill of Rs.8,444/-.
The request of complainant was not met with OPs. Therefore he filed the present complaint on 26.04.2010 alleging deficiency in service on the part of OPs.
3. In response to the notices issued, the Secretary of OP.1 appeared in person and the other OPs appeared through Counsel. OP.1 admitted in its version that complainant was a member of the society and he was enrolled as a beneficiary under Yeshaswini Scheme along with his wife and son and that the complainant had paid Rs.450/- on 30.05.2009 for the year 2009-10 and that the said amount was transferred to OP.2-Trust. It also admitted that the I.D. No. of complainant was 0262460 and this society had issued Yeshaswini I.D. card cum receipt as alleged by complainant.
4. OP.2 and 3 contended in their common version that there was no request by OP.4 for pre-authorization for conducting the operation and that there is no scope for reimbursement for medical expenses after discharge of the patient from hospital and that the benefit under the Scheme can be extended as per the guidelines only during the inpatient period of the patient. They explained the guidelines prescribed for extending cashless treatment under Yeshaswini Scheme by obtaining pre-authorization by the NWH. They admitted the receipt of representation dated 01.03.2010 sent by complainant. It contended that on this representation they could not have acted upon for reimbursing the medical expenses as such claim is not entertainable under the guidelines issued for running Yeshaswini Scheme.
5. OP.4 in its version admitted that the wife of complainant was treated in the hospital for appendicitis and she was inpatient in between 11.02.2010 to 18.02.2010. Further it stated that the patient was suffering abdomen pain and fever and it was diagnosed to have acute appendicitis, accordingly the patient underwent Appendiscectomy operation and she was discharged on 18.02.2010 with follow up advise. OP.4 has contended that complainant came to the office of OP.4 a day earlier to the discharge of the patient and enquired whether the name of the said patient was appearing in Yeshaswini Scheme, but it was an oral enquiry without submitting any documents pertaining to the said Scheme. Further that even on the date of discharge he has not produced any documents as such the said patient was treated as general patient and the hospital charge of Rs.8,444/- was collected for settlement of bill. OP.4 admitted that complainant has made a request in writing on 03.03.2010 for refund of Rs.8,444/- on the ground that he was a member of Yeshaswini Scheme and stated that only on that day he had produced the copies of required Yeshaswini Scheme documents. Further that OP.4 forwarded the request to OP.2 for taking further action. Therefore OP.4 contended that there was no negligence on its part.
6. The parties filed affidavits and documents. We heard the parties.
7. The following points arise for our consideration:
Point No.1: Whether the complainant proves that there was
deficiency in service on the part of OPs?
Point No.2: If so, to which reliefs the complainant is entitled to?
Point No.3: To what order
8. After considering the records and the submissions of parties our findings on the above points are as follows:
Point No.1: One important fact in dispute is whether the complainant produced his I.D. card on 17.02.2010 before OP.4 for claiming the benefit under Yeshaswini Scheme. According to complainant he submitted his I.D. card of Yeshaswini Scheme subsequent to the operation on 17.02.2010 and thereafter when there was an attempt by the hospital authority to open the website with reference to this I.D. card, the details of beneficiaries have not been found on the web and therefore the hospital authority compelled him to pay the bill amount. On the other hand OP.4 contended that on 17.02.2010 the complainant came and enquired in the office whether the name of said patient was appearing in the Yeshaswini Scheme and that the said request was only an oral request but the complainant had not furnished any documents pertaining to him relating to this Scheme. Further it stated that only on 03.03.2010 the complainant produced the documents relating to Yeshaswini Scheme with a request to reimburse the bill amount of Rs.8,444/-.
The complainant gave a representation dated 01.03.2010 to OP.2 claiming reimbursement of hospital expense in which he stated after operation he produced his I.D. card No. 0262460 to the hospital authority but the details of beneficiaries with reference to this I.D. card were not traced in the website. It can be seen that on 30.05.2009 itself the complainant paid Rs.450/- being the contribution amount towards Yeshaswini Scheme for himself and his wife and son apart from paying Rs.30/- towards contribution to OP.1 society as required. OP.1 claimed that soon thereafter it had forwarded the application to OP.2 for further action. Therefore we can safely believe that the complainant obtained his I.D. card cum receipt on 30.05.2009 itself from OP.1-society. The version of OP.4 shows that complainant approached the office of OP.4 to enquire whether his name was hosted in the concerned website or not. The complainant is a literate person. When he came to make such enquiry he must be having the I.D. card or atleast the I.D. No. in a separate slip. The version of OP.4 leads to draw an inference that it had no opportunity to open the website as complainant did not produce the I.D. card. Such contention of OP.4 appears to be not acceptable. The complainant had sufficient opportunity to collect his I.D. card subsequent to the operation on 11.02.2010. In the ordinary course of business and considering the human conduct we can believe that the complainant had brought with him the I.D. card or the I.D. card No. in a separate slip. In any such event the office of OP.4 must have made an attempt to verify whether the particulars of complainant are hosted in the website or not. Therefore the say of OP.4 that complainant had never produced any particulars of his I.D. card appears to be not true. Therefore on this disputed question of fact, considering the evidence as a whole, we believe that the complainant had produced his I.D. No. and when the hospital authorities made an attempt to verify the particulars with reference to this I.D. No. it did not display any particulars.
The documents produced by OP No.2 and 3 show that from the year 2009-10 new applications were received through co-operative societies including the existing members of the Yeshaswini Scheme. The new application forms required affixation of photos of the head of the family and other family members. It appears the co-operative societies were required to forward the application to OP.2 and thereafter OP.2 was required to update the particulars of these applications along with photos of head of the family and other members in the concerned website. If the particulars are once hosted in the website all NWH could open the website with reference to I.D. No. and could easily ascertain whether the person claiming benefit under the Yeshaswini Scheme is a member or not and whether free medical treatment is to be extended or not. This is clear from the circular dated 04.03.2009 issued by OP.2 to OP.4 hospital. The relevant part of it is as follows:
----- Please note that to identify the beneficiaries using this system you should know the ID no. of Yeshasvini beneficiary. Therefore request the beneficiaries to inform their ID no. or to display their ID card for identification purpose. Hence kindly identify all the patients using web based application without fail and for further clarifications please contact us.
Please do not entertain such beneficiaries whose details have not been hosted on the web and advise them to approach the Yeshasvini Trust or Implementing Agency.”
The above guidelines also make it clear the beneficiary need not necessarily produce the I.D. card itself but it is sufficient for him to inform his I.D. No. Further it instructs not to entertain such beneficiaries whose details have not been hosted on the web and also to advice them to approach the Yeshaswini Trust or Implementing Agency. As already noted OP.2 is required to update and host the particulars in the website after receipt of the applications from various co-operative societies. In the present case, it is not known whether the particulars regarding complainant and his family members were hosted in the web at the appropriate time. The version of OP No. 2 & 3 is silent on this point. In view of the allegation made by complainant that inspite of search with reference to his I.D. No., no particulars were displayed in the web, it was necessary for OP No. 2 & 3 to ascertain whether these particulars were hosted or not. In the absence of that material fact in the pleadings or evidence of OP No.2 and 3 one can believe that it was not hosted at the appropriate time. It was required to make a specific mention in the pleading by OP No.2 and 3 whether the application filed by complainant for the year 2009-10 was received by them and whether the website was updated or not relating to this beneficiary. These material facts are not stated in the pleadings of OP No.2 and 3. In view of the guidelines stated in the letter dated 04.03.2009 addressed to OP.4 by OP.2, we think OP.4 did not make up its mind to obtain self declaration form and other particulars from complainant or OP.4 may not be aware of the procedure when to obtain the self declaration form. In such state-of-affairs of pleadings by OP No.2 to 4, we hold that complainant has placed sufficient materials and circumstance to shift the burden of proof on OP No.2 to 4, to establish that they followed every step at appropriate time. In the present state of pleadings and evidence, we hold that OP No.2 and 3 failed to place the proper rebuttal evidence to establish negligence or inadvertence on the part of complainant. Therefore atleast as against OP No. 2 and 3 we hold that the complainant has made out a case of deficiency in service. Hence point No.1 is held accordingly.
Point No.2: OP.2-Trust is aided by Government fund. It also collects contribution from beneficiaries. In the present case, complainant was a beneficiary and he was entitled to the benefit of hospital bill to the extent of Rs.8,444/-. It may be true that as per the guidelines issued under Yeshaswini Scheme obtaining pre-authorization by hospital before admission or atleast before discharge in the case of emergency case, may be mandatory and there is no procedure for reimbursement of the claim for medical expenses after discharge of the patient. If because of the inadvertence or negligence the particulars of a beneficiary is not hosted in the web, OP.2 cannot escape its liability for reimbursement on the ground that pre-authorization was not obtained by hospital. Therefore we hold OP No.2 and 3 are liable for reimbursement of Rs.8,444/- to complainant. Hence Point No.2 is held accordingly.
Point No.3: Hence we pass the following:
O R D E R
The complaint is allowed with costs of Rs.1,000/- as against OP No.2 and 3. The OP No.2 and 3 shall pay Rs.8,444/- with interest at the rate of 12% p.a. from 18.02.2010 till the date of payment of the said amount. The complaint against OP No.1 and 4 is dismissed. They shall bear their own costs.
Dictated to the Stenographer, corrected and pronounced in open Forum this the 04th day of January 2011.
MEMBER MEMBER PRESIDENT
