Andhra Pradesh

Kurnool

CC/55/2009

K. Siva Shankara Reddy, S/o. Hanumantha Reddy, - Complainant(s)

Versus

M/s. Heritage Health Services Private Limited, Represented by its Managing Director, - Opp.Party(s)

Sri.M.Sivaji Rao

24 Sep 2009

ORDER

Heading1
Heading2
 
Complaint Case No. CC/55/2009
 
1. K. Siva Shankara Reddy, S/o. Hanumantha Reddy,
R/o.H.No. 87-1039, Balaji Nagar Colony, B.Camp, Kurnool
Kurnool
Andhra Pradesh
...........Complainant(s)
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.
Hyderabad
Andhra Pradesh
2. National Insurance Company Limited, Represented by its Branch Manager
First Floor, 27-33-31, Gudavallavari Street, Vijayawada-520 001.
Krishna
Andhra Pradesh
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
Vijayawada
Andhra Pradesh
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.
Kurnool
Andhra Pradesh
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MRS. Smt.C.Preethi, M.A., L.L.B., PRESIDING MEMBER
 HON'BLE MR. Sri.M.Kirshna Reddy, M.Sc, M.Phil., MEMBER
 
For the Complainant:
For the Opp. Party:
ORDER

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          :

 

 
 
[HON'BLE MRS. Smt.C.Preethi, M.A., L.L.B.,]
PRESIDING MEMBER
 
[HON'BLE MR. Sri.M.Kirshna Reddy, M.Sc, M.Phil.,]
MEMBER

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