BEFORE THE DISTRICT FORUM:KURNOOL
Present: P.V.Nageswara Rao , M.A., LL.M., President(FAC)
And
Smt. C.Preethi, M.A.LL.B., Lady Member
And
Sri. M.Krishna Reddy, M.Sc.,M.Phil., Male Member
Thursday the 24th day of September, 2009
C.C. 55/09
Between:
K. Siva Shankara Reddy, S/o. Hanumantha Reddy,
R/o.H.No. 87-1039, Balaji Nagar Colony, B.Camp, Kurnool … Complainant
Versus
1. M/s. Heritage Health Services Private Limited, Represented by its Managing Director,
No.1007, 10th Floor, Babukhan Estae, Basheer Bagh, Hyderabad-500 029.
2. National Insurance Company Limited, Represented by its Branch Manager,
First Floor, 27-33-31, Gudavallavari Street, Vijayawada-520 001.
3. M/s. The Scientific Fertilizers Company (P) Limited, Represented by its Regional Manager,
D.No.2/48, M.G.W.Commercial Complex, P.B.No.147, Gollapudi, Vijayawada-512 225.
4. M/s. The Scientific Fertilizers Company (P) Limited, Represented by its Sales Manager,
18/47, Rasool Bagh, A.J.Market , Nehru Road, Kurnool-518 001. ….Opposite parties
This complaint is coming on this day for orders in the presence of Sri.M.Sivaji Rao, Advocate, for the complainant, and opposite party No. 1 is called absent set exparte and Sri.L.Hari Hara Natha Reddy, Advocate for opposite party No. 2 and Sri.M.Azmathulla, Advocate for opposite party 3 and 4 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri.M.Krishna Reddy, Male Member)
C.C.No. 55/09
1. This case of complainant is filed U/S 11 and 12 of C.P.Act, 1986 seeking a direction on the opposite parties for the payment of an amount of Rs.23,834/- which is spent towards medical expenses, Rs.15,000/- towards mental agony and cost of the complaint.
2. The case of the complainant is that he was working as sales supervisor in the office of opposite party No. 4 which is under the control of opposite party No. 3 . A hospitalization benefit master policy was extended to complainant by opposite party No.2 through opposite party No.1 and opposite party No. 4 which covers the medi claim of the employees of opposite party No. 4 for which the premium was collected by opposite party No. 4 from the complainant and was paid to OP.No. 2 through OP.No. 1 . He was given a card bearing No. EHHSI – 0400239019 and P.No.550401/48 /06/8500000881. The period of policy was from 18-01-2007 to 17-01-2008 . He was admitted in Kurnool Heart and Brain Centre , Kurnool on 29-11-2007 for the complaint of heart attack . He took treatment in the said hospital from 29-11-2007 to 04-12-2007 as in patient and spent Rs.23,834/- towards treatment , medicines and other charges . He intimated the about his treatment on 05-12-2007 and sent all original documents pertaining to his treatment on 22-12-2007 to opposite party NO. 1 through courier service for the
reimbursement of the amount spent. He also wrote a reminder on 21—06-2008 to opposite party No. 1 . Since he received no reply from opposite party No. 1 he got legal notice issued to the opposite parties and as opposite parties did not properly respond, he was constrained to file the complaint seeking appropriate reliefs.
3. In pursuance of the contentions , the complainant has filed the sworn affidavit as many as 13 documents marked as Ex.A1 to Ex.A13 to substantiate his case. The complainant also examined Dr. Chandra Sekhar who treated him as PW.1 through whom Ex.X1 was marked.
4. Pursuant to the receipt of the notice of this forum , the OP.No. 1 remained ex-parte, and OP.No. 2 , OP.No. 3 , OP.No. 4, made their appearance through their counsels and contested the case by filling written version denying their liability to the complainants claim and seeking dismissal of the complaint.
5. The defence set out by OP.No. 2 in brief is that the complainant had not filed necessary documents to prove the issual of hospitalization benefit policy to the master policy holder by OP.No. 2 , coverage of medi claim for the employees of OP.No. 4 , collection of premium from complainant , issual of card bearing NO. 550401/48/06/8500000881 to complainant and period of policy from 18-01-2007 to 17-01-2008 . He also stated that the complainant produced fake correspondence between him and OP.No. 1 for the purpose of case not filing any material papers. He alleged that complainant had not submitted the copies of ECG, case sheet, discharge summary and other essential documents intentionally . His case would be settled as soon as the above said documents are received in his office the claim is as per the terms and conditions of the policy . Hence the claim of the complainant is not maintainable and liable to be dismissed in total.
6. The OP.No. 2 did not file any document in support of his case.
7. OP.No.3 denying the allegations of the complainant avered that he was not the master policy holder of the hospitalization benefit policy and did not issue any policy to the complainant . He submitted that complainant worked in his office from 18-08-2004 to 30-06-2007 . During his period of work he obtained an individual mediclaim policy No. 550401/48 /06/8500000881 out of sympathy on the employee , this opposite party paid 50% of premium to the insurance company. He also submitted that he was not aware of the alleged treatment under gone by the complainant as complainant was removed from service on 30-06-2007 , much prior to the period of alleged treatment . He also avered that complainant had represented his case to insurance company directly , hence he is fully aware of settlement authority . Further he submitted that there is deficiency from his side and the complainant unnecessarily filed the complaint against him, hence it is prayed for the dismissal.
8. In support of his case OP.No. 3 filed sworn affidavit and documents marked as Ex.B1 to B4.
9. Hence, the point for consideration is whether the complainant has made out any deficiency on the part of opposite parties sustaining its liability to the complainants claim.
10. The contention of the complainant is that when he was working as sales supervisor of OP.No. 3 in OP.No.4 , he paid premium to OP.No. 2 through OP.No. 1 for a medicalim policy which was covered under master hospitalization benefit policy of OP.No. 3 , Ex.A7 was the card valid up to 17-01-2008 issued to the complainant by OP.No. 1 to present to service provide for receiving services. As an emergency complainant was admitted in Kurnool Heart and Brain Centre, Kurnool for the complaint of ches pain , . The complainant also contented that Ex.A1 to A6 would establish the duration of treatment in the hospital , investigations done , treatment given , and the total expenditure of Rs.23,834/- incurred for different purposes in the hospital. As the card was issued by (Heritage Health Services Private Limited ) OP.No. 1 the claim was made with him by complainant and Ex.A8 to Ex.A13 are the proof correspondence between the complainant and OP.No. 1 with regard the cliam.
11. The contention of OP.No. 2 is that intentionally the complainant did not produce any evidence in support of his health policy , treatment taken in the hospital and expenditure incurred by him . OP.No. 2 also contended that if the complainant would have cooperated in submitting the required documents he would have already settled the claim with in the limits of the terms and conditions of the policy.
12. The contention of OP.No. 3 was that the Ex.B3 was an individual policy issued to complainant by OP.No. 2 . Out of sympathy on his employee he paid 50% premium to the policy . Ex.B1 was letter of resignation by the complainant and Ex.B2 was the acceptance of resignation of complainant w.e.f 30-06-2007 by opposite party No. 3 . He submitted that as per Ex.A1 the complainant under went treatment in the hospital from 29-11-2007 to 04-12-2007 much later to the date of resignation of complainant. OP.No.3 also contended that during the period of treatment the complainant was no more his employee and Ex.B3 issued to insured individually by OP.NO.2 .
13. The totality of the circumstances is clear that the action of OP.No.2 in dealing the issue clearly establishes deficiency of service on him. In view of what is stated above the forum holds that the complainant has established all the facts, entitling him to receive compensation under different heads as claimed by him.
14. For the reasons set out above the OP.No.2 is directed to pay Rs.23,834/- towards compensation for medical expenses, Rs.1500/- towards mental agony and Rs.1,000/- towards cost of the case. The case against OP.No. 1 , OP.No. 3 and OP.No. 4 is dismissed. The above awarded amounts are to be paid with in 45 days from the date of receipt of this order.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 10th day of September, 2009.
LADY MEMBER PRESIDENT FAC) MALE MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :l For the opposite parties :Nil
PW.1 Deposition of PW.1
(Dr. P.Chandra Sekhar) dated 24-06-09.
List of exhibits marked for the complainant:-
Ex.A-1 | Discharge Summary . |
ExA-2 | Essentiality Certificate . |
ExA-3 | Emergency Certificate issued by Dr.P. Chandra Sekhar. |
ExA-4 | Investigations bills. |
ExA-5 | Kurnool Heart and Brain Centre cash receipt. |
ExA-6 | Cash receipt dated 04-12-2007. |
ExA-7 | Health Card. |
ExA-8 | Courier receipt dated 05012-2007 |
ExA-9 | Original R.P. receipt dated 21-12-2007. |
ExA-10 | Courier receipt dated 22-12-2007. |
ExA-11 | Postal receipts and acknowledgements. |
ExA-12 Ex.A13 Ex.X1. | Letter from OP.No.1 to complainant dated 25-11-2008. Postal receipt dated 28-11-2008. Case sheet |
List of exhibits marked for the opposite parties:
EX.B1 | Resignation letter of the complainant dated 07-05-2007. |
ExB-2 | Acceptance if resignation of the complainant dated 25-06-2007. |
ExB-3 | Policy copy issued by OP.No.2 |
ExB-4 | Authorization letter dated 31-03-2009. |
LADY MEMBER PRESIDENT (FAC) MALE MEMBER
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties
Copy was made ready on :
Copy was dispatched on :
BEFORE THE DISTRICT FORUM:KURNOOL
Present: P.V.Nageswara Rao , M.A., LL.M., President(FAC)
And
Smt. C.Preethi, M.A.LL.B., Lady Member
And
Sri. M.Krishna Reddy, M.Sc.,M.Phil., Male Member
Thursday the 24th day of September, 2009
C.C. 55/09
Between:
K. Siva Shankara Reddy, S/o. Hanumantha Reddy,
R/o.H.No. 87-1039, Balaji Nagar Colony, B.Camp, Kurnool … Complainant
Versus
1. M/s. Heritage Health Services Private Limited, Represented by its Managing Director,
No.1007, 10th Floor, Babukhan Estae, Basheer Bagh, Hyderabad-500 029.
2. National Insurance Company Limited, Represented by its Branch Manager,
First Floor, 27-33-31, Gudavallavari Street, Vijayawada-520 001.
3. M/s. The Scientific Fertilizers Company (P) Limited, Represented by its Regional Manager,
D.No.2/48, M.G.W.Commercial Complex, P.B.No.147, Gollapudi, Vijayawada-512 225.
4. M/s. The Scientific Fertilizers Company (P) Limited, Represented by its Sales Manager,
18/47, Rasool Bagh, A.J.Market , Nehru Road, Kurnool-518 001. ….Opposite parties
This complaint is coming on this day for orders in the presence of Sri.M.Sivaji Rao, Advocate, for the complainant, and opposite party No. 1 is called absent set exparte and Sri.L.Hari Hara Natha Reddy, Advocate for opposite party No. 2 and Sri.M.Azmathulla, Advocate for opposite party 3 and 4 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri.M.Krishna Reddy, Male Member)
C.C.No. 55/09
1. This case of complainant is filed U/S 11 and 12 of C.P.Act, 1986 seeking a direction on the opposite parties for the payment of an amount of Rs.23,834/- which is spent towards medical expenses, Rs.15,000/- towards mental agony and cost of the complaint.
2. The case of the complainant is that he was working as sales supervisor in the office of opposite party No. 4 which is under the control of opposite party No. 3 . A hospitalization benefit master policy was extended to complainant by opposite party No.2 through opposite party No.1 and opposite party No. 4 which covers the medi claim of the employees of opposite party No. 4 for which the premium was collected by opposite party No. 4 from the complainant and was paid to OP.No. 2 through OP.No. 1 . He was given a card bearing No. EHHSI – 0400239019 and P.No.550401/48 /06/8500000881. The period of policy was from 18-01-2007 to 17-01-2008 . He was admitted in Kurnool Heart and Brain Centre , Kurnool on 29-11-2007 for the complaint of heart attack . He took treatment in the said hospital from 29-11-2007 to 04-12-2007 as in patient and spent Rs.23,834/- towards treatment , medicines and other charges . He intimated the about his treatment on 05-12-2007 and sent all original documents pertaining to his treatment on 22-12-2007 to opposite party NO. 1 through courier service for the
reimbursement of the amount spent. He also wrote a reminder on 21—06-2008 to opposite party No. 1 . Since he received no reply from opposite party No. 1 he got legal notice issued to the opposite parties and as opposite parties did not properly respond, he was constrained to file the complaint seeking appropriate reliefs.
3. In pursuance of the contentions , the complainant has filed the sworn affidavit as many as 13 documents marked as Ex.A1 to Ex.A13 to substantiate his case. The complainant also examined Dr. Chandra Sekhar who treated him as PW.1 through whom Ex.X1 was marked.
4. Pursuant to the receipt of the notice of this forum , the OP.No. 1 remained ex-parte, and OP.No. 2 , OP.No. 3 , OP.No. 4, made their appearance through their counsels and contested the case by filling written version denying their liability to the complainants claim and seeking dismissal of the complaint.
5. The defence set out by OP.No. 2 in brief is that the complainant had not filed necessary documents to prove the issual of hospitalization benefit policy to the master policy holder by OP.No. 2 , coverage of medi claim for the employees of OP.No. 4 , collection of premium from complainant , issual of card bearing NO. 550401/48/06/8500000881 to complainant and period of policy from 18-01-2007 to 17-01-2008 . He also stated that the complainant produced fake correspondence between him and OP.No. 1 for the purpose of case not filing any material papers. He alleged that complainant had not submitted the copies of ECG, case sheet, discharge summary and other essential documents intentionally . His case would be settled as soon as the above said documents are received in his office the claim is as per the terms and conditions of the policy . Hence the claim of the complainant is not maintainable and liable to be dismissed in total.
6. The OP.No. 2 did not file any document in support of his case.
7. OP.No.3 denying the allegations of the complainant avered that he was not the master policy holder of the hospitalization benefit policy and did not issue any policy to the complainant . He submitted that complainant worked in his office from 18-08-2004 to 30-06-2007 . During his period of work he obtained an individual mediclaim policy No. 550401/48 /06/8500000881 out of sympathy on the employee , this opposite party paid 50% of premium to the insurance company. He also submitted that he was not aware of the alleged treatment under gone by the complainant as complainant was removed from service on 30-06-2007 , much prior to the period of alleged treatment . He also avered that complainant had represented his case to insurance company directly , hence he is fully aware of settlement authority . Further he submitted that there is deficiency from his side and the complainant unnecessarily filed the complaint against him, hence it is prayed for the dismissal.
8. In support of his case OP.No. 3 filed sworn affidavit and documents marked as Ex.B1 to B4.
9. Hence, the point for consideration is whether the complainant has made out any deficiency on the part of opposite parties sustaining its liability to the complainants claim.
10. The contention of the complainant is that when he was working as sales supervisor of OP.No. 3 in OP.No.4 , he paid premium to OP.No. 2 through OP.No. 1 for a medicalim policy which was covered under master hospitalization benefit policy of OP.No. 3 , Ex.A7 was the card valid up to 17-01-2008 issued to the complainant by OP.No. 1 to present to service provide for receiving services. As an emergency complainant was admitted in Kurnool Heart and Brain Centre, Kurnool for the complaint of ches pain , . The complainant also contented that Ex.A1 to A6 would establish the duration of treatment in the hospital , investigations done , treatment given , and the total expenditure of Rs.23,834/- incurred for different purposes in the hospital. As the card was issued by (Heritage Health Services Private Limited ) OP.No. 1 the claim was made with him by complainant and Ex.A8 to Ex.A13 are the proof correspondence between the complainant and OP.No. 1 with regard the cliam.
11. The contention of OP.No. 2 is that intentionally the complainant did not produce any evidence in support of his health policy , treatment taken in the hospital and expenditure incurred by him . OP.No. 2 also contended that if the complainant would have cooperated in submitting the required documents he would have already settled the claim with in the limits of the terms and conditions of the policy.
12. The contention of OP.No. 3 was that the Ex.B3 was an individual policy issued to complainant by OP.No. 2 . Out of sympathy on his employee he paid 50% premium to the policy . Ex.B1 was letter of resignation by the complainant and Ex.B2 was the acceptance of resignation of complainant w.e.f 30-06-2007 by opposite party No. 3 . He submitted that as per Ex.A1 the complainant under went treatment in the hospital from 29-11-2007 to 04-12-2007 much later to the date of resignation of complainant. OP.No.3 also contended that during the period of treatment the complainant was no more his employee and Ex.B3 issued to insured individually by OP.NO.2 .
13. The totality of the circumstances is clear that the action of OP.No.2 in dealing the issue clearly establishes deficiency of service on him. In view of what is stated above the forum holds that the complainant has established all the facts, entitling him to receive compensation under different heads as claimed by him.
14. For the reasons set out above the OP.No.2 is directed to pay Rs.23,834/- towards compensation for medical expenses, Rs.1500/- towards mental agony and Rs.1,000/- towards cost of the case. The case against OP.No. 1 , OP.No. 3 and OP.No. 4 is dismissed. The above awarded amounts are to be paid with in 45 days from the date of receipt of this order.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 10th day of September, 2009.
LADY MEMBER PRESIDENT FAC) MALE MEMBER
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :l For the opposite parties :Nil
PW.1 Deposition of PW.1
(Dr. P.Chandra Sekhar) dated 24-06-09.
List of exhibits marked for the complainant:-
Ex.A-1 | Discharge Summary . |
ExA-2 | Essentiality Certificate . |
ExA-3 | Emergency Certificate issued by Dr.P. Chandra Sekhar. |
ExA-4 | Investigations bills. |
ExA-5 | Kurnool Heart and Brain Centre cash receipt. |
ExA-6 | Cash receipt dated 04-12-2007. |
ExA-7 | Health Card. |
ExA-8 | Courier receipt dated 05012-2007 |
ExA-9 | Original R.P. receipt dated 21-12-2007. |
ExA-10 | Courier receipt dated 22-12-2007. |
ExA-11 | Postal receipts and acknowledgements. |
ExA-12 Ex.A13 Ex.X1. | Letter from OP.No.1 to complainant dated 25-11-2008. Postal receipt dated 28-11-2008. Case sheet |
List of exhibits marked for the opposite parties:
EX.B1 | Resignation letter of the complainant dated 07-05-2007. |
ExB-2 | Acceptance if resignation of the complainant dated 25-06-2007. |
ExB-3 | Policy copy issued by OP.No.2 |
ExB-4 | Authorization letter dated 31-03-2009. |
LADY MEMBER PRESIDENT (FAC) MALE MEMBER
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties
Copy was made ready on :
Copy was dispatched on :