BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 31^st of October 2011

PRESENT

       SMT. ASHA SHETTY       :   Hon’ble PRESIDENT

                       SMT.LAVANYA M. RAI   :   Hon’ble MEMBER                 

COMPLAINT NO.293/2010

(Admitted on 30.10.2010)

Mangalore Nursing Home,

Upper Bendoor, Mangalore 1,

Represented by its Manager,

Mr.Venkatramana Bhat, Adult,

So Late Shamabhat.                        …….. COMPLAINANT

(Advocate for the Complainant: Sri. S.M.Bhat)

          VERSUS

1. T.T.K. Health Care Services Pvt. Ltd., (Claim Dept.)

    No.2HB Complex,

    100 feet B.T.M. Ring Road,

    Behind confident group building,

    Bangalore 560 068,

    Represented by General Manager,

    Medical Services.

(Advocate for Opposite Party No.1: Sri.G.Vasudeva Gowda)

2.  Rani L.Shenoy, Adult,

     C/o John G.L. Shenoy,

     Bajpe, Mangalore.                           ……. OPPOSITE PARTIES

 (Opposite Party No.2: Exparte)

                                                            *** ** ** ** ** ***

ORDER DELIVERED BY HON’BLE PRESIDENT SMT. ASHA SHETTY:

1.       This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency of service against the Opposite Parties claiming certain reliefs. 

The brief facts of the case are as under:

The Complainant submitted that, Opposite Party No.1 is a Private Limited Company having its Head Office at Bangalore had approached the Complainant in the year 2004 to create a network service provider, after mutual discussion entered into an agreement dated 18.10.2004 to extend the facility of Insurance claims to the beneficiaries. 

It is stated that, Opposite Party No.2 had admitted to the Complainant’s Nursing Home for delivery on 09.03.2008.  After delivery, the newly born baby was availed the facility of mediclaim insurance of the Opposite Party No.1.  It is stated that, on 11.03.2008 the Opposite Party No.1 had assured the said facility by approving the pre-authorization letter.  On the basis of the said assurance the said baby was discharged from the Complainant’s Nursing Home on 06.04.2008 without settling the hospital bills.  Subsequently, the bills were sent to Opposite Party No.1 for settlement.  The said bills were accepted but till date Opposite Party No.1 not paid the bill amount.  It is stated that, as per the Memorandum of Understanding executed between the Complainant and Opposite Party, the Opposite Party had agreed that they will pay all the eligible bills within 30 days but till this date the bill submitted by the Complainant is not settled, hence the Complainant got issued a Lawyer’s notice on 03.04.2010 despite of that not settled the claim  amounts to deficiency in service and filed the above complaint under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Party to pay a sum of Rs.49,914=26 towards the actual dues and compensation and Rs.10,000/- for mental agony and Rs.300/- towards the cost of Lawyer’s notice and also claimed cost of the proceedings.

2.       Version notice served to the Opposite Parties by RPAD. Opposite Party No.2 despite of serving notice neither appeared nor contested the case till this date.  Hence, we have proceeded exparte as against the Opposite Party No.2.  The acknowledgement placed before the FORA marked as court document No.1.

Opposite Party No.1 appeared through their counsel filed version denied the deficiency of service and stated that the Opposite Party No.1 has approached the Complainant and agreed to extend the facility of Insurance claims to the beneficiaries.  It is stated that, the Complainant has not fulfilled the conditions of the agreement as shown in the Memorandum of Understanding.   Complainant has not followed the said condition.  It is also stated that the Opposite Party No.1 is functioning under the National Insurance Company Limited but the Complainant does not made the said Company as Opposite Party in this case.  Apart from the above, it is again took a contention that all the disputes claims arising out of the Agreement shall be filed in Bangalore Jurisdiction only and hence the Complainant shall have to file the complaint in Bangalore only and the complaint is barred by limitation and prayed for dismissal of the complaint.

3.       In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the Complainant proves that the Opposite Parties committed deficiency in service?

2. If so, whether the Complainant is entitled for the reliefs claimed?

3. What order?

4.         In support of the complaint, Mr.Venkatramana Bhat - Complainant (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on him and got marked Ex C1 to C9 as listed in the annexure in detail. 
The Complainant as well as Opposite Party No.1 filed written notes of arguments. 

          We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answered the points are as follows:

                       Point No.(i) : Negative.

                       Point No.(ii) & (iii): As per the final order.   

REASONS

5.  POINTS NO. (i) to (iii):

In the instant case, the facts which are admitted is that, Opposite Party No.1 is a Private Limited Company incorporated under the Companies Act 1956.  The Complainant and the Opposite Party No.1 entered into a Memorandum of Understanding on 18.10.2004 as per Ex C1.  As per the Memorandum of Understanding between the Complainant and the Opposite Party No.1, Complainant i.e., Mangalore Nursing Home joined the said network of providers and undertaken to extend medical facilities and treatment to its members covered under the Healthcare Management Plan on the agreed terms and conditions.  It is also admitted that, the Opposite Party No.2 had admitted in Complainant’s Nursing Home for delivery on 09.03.2008 and after the delivery the newly born baby was availed the facility of Mediclaim Insurance of Opposite Party No.1. 

Now the point in dispute between the parties before this FORA is that, the Complainant contended that as per the Memorandum of Understanding between the Complainant and Opposite Party No.1, the Opposite Party No.1 extended the medical facility of Insurance claims to the beneficiaries i.e., Opposite Party No.2.  The Opposite Party No.2 admitted in Complainant’s Nursing Home for delivery and after delivery the newly born baby was availed the medical facility in their Nursing Home.  The Opposite Party No.1 assured the said facility on 11.03.2008 by approving the pre-authorization letter and the Complainant submitted all the medical bills to the Opposite Party No.1 for settlement.  But the said bills were accepted but till date the claim amount is not paid, hence came up with this complaint.

The Opposite Party No.1 on the other hand contended that the Complainant has not fulfilled the condition of the Agreement as shown in the Memorandum of Understanding. 

The Complainant filed oral evidence by way of affidavit and produced Ex C1 to C9.  Opposite Parties not filed counter affidavit.

 On perusal of the admitted facts as well as oral and documentary evidence available on record, we find that, the Complainant and Opposite Party No.1 entered into a Memorandum of Understanding as per Ex C1.  Under the said Memorandum of Understanding the Opposite Party No.1 agreed to provide healthcare related services to its beneficiaries and clients and for these purposes the Opposite Party has created a network of service providers.  The Complainant agreed to join the said network of service providers and consented to extend medical facilities and treatment to its members covered under the Healthcare Management Plan on the agreed terms and conditions.

 In the instant case, the Ex C6 i.e., the discharge summary issued by the Complainant i.e., Mangalore Nursing Home reveals that, the Opposite Party No.2 i.e., one Rani L Shenoy admitted to the Complainant’s Nursing Home and delivered a baby on 09.03.2008 and discharged on 06.04.2008.  It is seen that, on 11.03.2008 the Opposite Party No.1 sent a pre-authorization request form for a total sum of Rs.90,000/- as per Ex C4 but the Opposite Party No.1 on 11.03.2008 authorized a total sum of Rs.50,000/- in the above case and requested the Complainant to forward all the original bills and discharge summary and other relevant documents / reports.  However, we have perused the Memorandum of Understanding i.e., Ex C1, wherein, the Complainant supposed to submit the original final bill with discharge card, investigation report and other original documents.  But there is no time limit in the Memorandum of Understanding but in Article 5.5 of the said document it is stated that ‘any revision in the fee schedule will be submitted to TTK at least 15-30 days prior to the effective date’.  And also in Article 8.1 ‘TTK agrees to pay all the eligible bills within 30 days of the receipt of the bill at their head office in Bangalore’.  Except the above, no such conditions mentioned in the Memorandum of Understanding as far as the compliance of the original medical bills are concerned. 

  But Ex C9 i.e., the letter issued by the Opposite Party No.1 indicates that the Opposite Party No.1 has informed the Complainant that their Memorandum of Understanding between the hospital i.e., Complainant and the Opposite Party No.1 has been already expired and they stopped cashless facility.  It is seen that, the above agreement was made on 18^th October 2004 and the said agreement valid for an initial period of three years and can be extended on mutual consent.   There is no document to show that it has been mutually agreed and renewed the same.

In our view, evidence on record shows that, in the matter of presentation of pre-authorization request form complainant has not acted with reasonable care.  Because it is seen from the Memorandum of Understanding on record that it has been expired.  When that being so, Complainant could have acted diligently before discharging the patient.  Without holding valid Memorandum of Understanding in hand Complainant carelessly discharged the patient in this case. However, it is the bounden duty of the Complainant to see whether their Memorandum of Understanding is in force at the time of submitting pre-authorization form.

However, we observed that, Memorandum of Understanding was not in force, under such circumstances Complainant has got no right to seek reimbursement from the Opposite Party No.1.  If at all any dues they must approach insurer of the Opposite Party  No.2.   The Complainant before discharging the Opposite Party No.2 should have verified their Memorandum of Understanding entered between the Complainant and the Opposite Party No.1.  Since the Memorandum of Understanding is expired the Complainant cannot claim directly from the Opposite Party No.1 but they can claim from the Opposite Party No.2 and her Insurer.  No doubt in Ex C9 the Opposite Party No.1 specifically stated that Memorandum of Understanding between the hospital and TTK health care services has expired and also stopped cashless facility from 1^st November 2008. In the last para of the said letter all the pending payments, however, will be settled.  But we understand that the reference made in respect of the pending bills mean legally entitled pending bills it may not refer to the above subject bills.   

  In view of the above discussion, we hold that there is no deficiency on the part of the Opposite Party No.1, hence complaint deserves to be dismissed.  No order as to costs.

6.       In the result, we pass the following:  

ORDER

The complaint is dismissed.  No order as to costs.

The copy of this order as per the statutory requirements be forwarded to the parties free of charge or sent to the parties under postal certificate and thereafter the file shall be consigned to the record room.

(Page No.1 to 9 dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 31^st day of October 2011.)

       PRESIDENT                                                    MEMBER                                

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Mr.Venkataramana Bhat – Complainant.

Documents produced on behalf of the Complainant:

Ex C1 – 18.10.2004: Memorandum of understanding between Complainant and Opposite Party No.1.

Ex C2 – Acknowledging the admission of member ship (Empanelment NO.HOS-BLR-1284)

Ex C3 –27.9.2007: Letter from the Opposite Party No.1.

Ex C4 – 11.3.2008: Pre-authorization request form duly signed by Complainant, patient and Doctor.

Ex C5 – 24.3.2008: Reply from Opposite Party NO.1.

Ex C6 – Letter from the Complainant to O.P No.1 along with Bills.

Ex C7 – 3.4.2010: Copy of legal notice.

Ex C8 – 7.4.2010: Postal acknowledgement with receipt.

Ex C9 – 31.10.2008: Letter from O.P.No.1 to the Complainant.

Complainant’s unmarked documents:

Doc.No.1 04.07.2008: Claim settlement advice of insured Mr.Joseph Martis.

Doc.No.2  04.10.2008: Claim settlement advice of insured Mr.Radhakrishna Rao.K.

Doc.No.3   7.10.2008: Claim Settlement advice of Insured Mr.Vishwanath S.Prabhu.

Doc.No.4     16.10.2008: Claim settlement advice of insured Mr.Mohan B.M.

Doc.No.5     21.10.2008: Claim Settlement advice of insured Mrs.Suma Madhava.

Doc.No.6       29.10.2008: Claim Settlement advice of insured MR.Diwakar Poojary.

COURT DOCUMENT:

Doc No.1: Postal Acknowledgement.

Witnesses examined on behalf of the Opposite Parties:

                         -Nil-

Documents produced on behalf of the Opposite Parties:

                       - Nil -

Dated:31.10.2011                                                PRESIDENT