BEFORE THE DISTRICT FORUM:KURNOOL
Present: Sri.K.V.H. Prasad, B.A., LL.B President
And
Smt. C.Preethi, M.A.LL.B., Lady Member
Wednesday the 10th day of September, 2008
C.C.No. 156/07
Between:
E.Eranna, S/o. Urukundaiah,
1-3502, Adoni By Pass Road, Raghavendra Colony, Yemmiganur. … Complainant
Versus
- The Civil Assistant Surgeon, E.S.I Dispensary,
Yemmiganur.
- The Joint Director of Insurance Medical Services,
Sankarapuram, Kadapa. … Opposite parties
This complaint is coming on this day for orders in the presence of Sri.M.Sivaji Rao, Advocate, for the complainant, and Smt.D.S.Saileela, Advocate, for the opposite parties and upon perusing the material papers on record, the Forum made the following
ORDER
(As per Smt. C.Preethi , Lady Member)
C.C.N.156/07
1. This consumer complaint of the complainant is filed U/S 11 and 12 of C.P.Act, 1986, seeking a direction on opposite parties to pay Rs.20,000/- with 18% interest p.a , Rs.10,000/- towards compensation for mental agony , cost of the complaint and any other relief or relief’s which the complainant is entitled in the circumstances of the case.
2. The brief facts of the complainants case is that the complainant is working in the Yemmiganur Weavers Co-operative Production and Sales Society, Yemmiganur, since 1978 and has become a member of ESI since then and the employer and the complainant’s contributions were paid to the ESI. The opposite party No.1 is the person to whom medical claim was submitted and opposite party No.2 is the person who delayed to settle the complainants claim. As per the ESI, Adoni the employee i.e., the complainant and his family members are entitled to get medical and maternity benefits from opposite party No.1 , in case opposite party No.1 did not provide the said services the member and his family members can avail the services from outside doctors and the medical expenditure can be reimbursed from the opposite parties. On 26-11-2003 the complainants wife E. Sarojamma got labour pains and was shifted to opposite party No.1 hospital for delivery. On that day i.e, 26-11-2003 being a holiday on account of Ramjan , the opposite party No.1 closed the dispensary and the complainants wife was shifted to Government Hospital, Yemmiganur and the doctors their advised the complainant to go to the Private Nursing Home and the complainant admitted his wife in Shakthi Nursing Home and the doctors their conducted caesarian operation on 27-11-2003 and a baby girl was born. But unfortunately the baby girl took some fluid inside the womb which resulted in serious condition of the baby girl and on advise the baby was shifted to Bhavana Children Hospital, Adoni and latter on advise the baby was shifted to Rainbow Neonatal Centre , Kurnool for treatment and Rs.1,000/- was spent by the complainant was shifting the baby to kurnool and subsequently during treatment on 01-12-2003 the baby girl died. For the said treatment of his wife and the baby and the complainant spend Rs.20,000/- towards the medicines , hospital charges, conveyance etc., Therefore, the complainant is having a facility to reimburse the medical expenditure by submitted a claim to opposite party No.1 along with medical bills , thereafter, on 8-6-2004 opposite party No.1 forwarded the claim to opposite party No.2, in spite of said receipt of claim the opposite party did not settle the claim. On 14-08-2006 the complainant sent a letter to opposite party No.1 and 2 and the opposite parties 1 and 2 even after receipt of said letter did neither settled the claim nor replied . Hence, as there is deficiency on part of opposite parties in delaying the settlement of claim , the complainant has to approach the forum for relief’s.
3. In support of his case the complainant relied on the following documents viz., (1) Xerox copy of ESI identity card issued to complainant , (2) carbon copy of letter dated 8-6-2004 of opposite party No.1 to opposite party No.2 copy marked to complainant , (3) letter dated 20-6-2005 of complainant to opposite party No.2 and (4) attested Xerox copy of letter dated 21-4-2004 of Manager, ESI Hospital , Adoni to opposite party No.2, besides to the chief affidavit (sworn affidavit) of the complainant in reiteration of his complaint averments and the above documents are marked as Ex.A1 to A4 for its appreciation in this case and replies to the interrogatories exchanged.
4. In pursuance to the notice of this forum as to this case of the complainant the opposite parties 1 and 2 appeared thorough their counsel and contested the case by filling written version by opposite party No.1 and its adoption by opposite party No.2.
5. The written version of opposite parties denies the complaint as not maintainable either in law or on facts and submits that on 26-11-2003 the ESI dispensary was closed on the event of Ramjan festival and throughout the state the ESI dispensaries would work for half a day on public holidays. The ESI dispensary , Yemmiganur was also opened on 26-11-2003 from 9-00 A.M to 12 P.M . It further submits that the complainant’s wife was shifted to Private Shakthi Nursing Home on 27-11-2003 and a caesarian operation was conducted by the doctors and she gave birth to a girl child and the complainant seeking reimburse for the medical bills which is not entitled as the family members availed treatment at a Private Nursing Home. It lastly submits that ESI scheme does not came with the purview of the C.P.At 1986 as ESI Act being a special Act, the remedy available to the complainant is to approach a Civil court for reliefs and seeks dismissal of complaint.
6. In substantiation of their case the opposite parties relied on the following documents viz., (1) attested Xerox copy of letter 1-6-2004 of complainant to opposite party No.2 , (2) attested Xerox copy of referral letter of EN Varalakshmi to Dr. Goud ,26-11-2003, (3) attested Xerox of showing the date of admission and date of discharge of baby of Saroja , (4) attested Xerox of circular dated 10-04-1995 , (5) attested Xerox of extract out-patient register of ESI Dispensary, Yemmiganur from the period 27-11-2003 to 30-11-2003 , (6) communication of Joint Director of Insurance dated 16-05-2003 ,(7) attested Xerox of Registrar of Attendance and fees for November, 2003 as to Dr. Aruna Kumari and P. Raghothama , (8) attested Xerox of patient register for the period 22-11-2003 to 26-11-2003 ,(9) Copy of G.O.Ms.No. 117 Health Medical and Family Welfare (Q2) Department dated 27-03-2000 along with annexure, (10). Amendment to G.O.Ms.No. 42 of Labour Enrollment Training Factories (IMS) Department dated 25-10-2002 ,(11) attested copy of G.O.Ms.No. 42 dated 25-10-2002 , (12) attested copy of Pg.No.59 of ESI medical manual besides to the sworn affidavit of opposite party No.2 in reiteration of his complaint averments and the above documents are marked as Ex.B1 to B12 for its appreciation in this case and replies to the interrogatories exchanged.
- Hence, the point for consideration is to what relief the complainant is entitled alleging deficiency of service on part of opposite parties.?
8. It is the case of the complainant that he is an employee of the Yemmiganur Weavers Co-operative Production and Sales Society , Yemmiganur since 1978 and the complainant became a member of ESI, the employer of the complainant deducted contributions from the complainant’s salary and remitted the same with the opposite parties along with his share of contribution an identity card was issued by opposite parties to the complainant vide Ex.A1. The Ex.A1 is the identity card issued by ESI Corporation, Adoni to the complainant E.Eranna on 16-1-2003. On 26-11-2003 the complainants wife had labour pains and approached opposite party No.1 hospital for delivery, as 26-11-2003 being a holiday on account of Ramzan, the opposite party No.1 hospital was closed and the complainant had to shift his wife to a Government Hospital, and later on advise shifted to a Private Shakthi Nursing Home and caesarian was conducted on her on 27-11-2003 and a baby girl was born with some complication and the baby girl was shifted to Rainbow Neonatal Centre, Kurnool for treatment and subsequently the baby girl died on 1-12-2003.
9. The complainant for the incurred expenses for treatment of his wife and baby submitted medical bills through opposite party No.1 to opposite party No.2 vice Ex.A2 . The Ex.A2 is the letter of opposite party No.1 dated 8-5-2004 addressed to opposite party No.2 , it envisages the submitting of an application of Sri. E.Eranna along with medical bills, Advance Stamp Receipt, check list for reimbursement of medical bills worth Rs.15,835/-. The opposite
party No.2 though received the said letter did neither responded nor settled the claim. There after, on 20-6-2005 the complainant had addressed a letter to opposite party No.2 requesting opposite party No.2 to inform him about his written application for reimbursement in connection to his wife’s operation and his baby’s treatment.
10. While such is so with the complainant, the opposite party in their written version averments submits that the complainant’s wife has taken treatment in a private hospital, hence the medical bills cannot be reimbursed and the ESI Act is a special Act and it does not come within the purview of C.P.Act. As no cogent material is filed on record in substantiation that ESI Act a special Act, , the said plea of opposite party is rejected.
11. With regard to the main contention of the opposite parties that the complainants family is not entitle for reimbursement of medical bills as they availed treatment at a private hospital. Firstly the complainant along with his wife approached opposite party No.1 dispensary as no body were available for admitting the complainants wife and as she was suffering from severe labour pains, the complainant has to shift her to private hospital in emergency as she requires urgent medical treatment.
12. The counsel for opposite parties strongly contended that if the ESI dispensaries are unable to provide treatment to the patients, the patients had to approach a Government Hospital and not to a private hospital , but as per Ex.B10 G.O.MS.No.117 dated 15-11-2003, all cases should be first referred to local Government Hospitals and if facilities are not available at Government Hospital the patients may be referred to tie up Hospitals. But in this case when the complainant approached opposite party No.1dispensary for admitting his wife, it was closed and as no one was available to refer the complainants wife, therefore complainant shifted her to a private hospital as it is an emergency case .
13. As per Ex.B10, the opposite party No.1 dispensary should refer the patients to other hospitals, but in this case as opposite party No.1 dispensary is closed and no body was available to give a referral letter, the complainant had to approach a private hospital directly of his own choice.
14. The Ex.B11 is the G.O.MS.No.42 dated 25-10-2002 of Labour Employment Training and Factories ( IMS-1) Department at page No.4 para 12, wherein it was stated that patients who are admitted directly in an emergency without referral, for such cases the procedure and conditions and nature of diseases as mentioned in G.O.MS.No.117 dated 27-3-2000 are applicable for reimbursement. Such bills are to be forwarded to the Director of Insurance Medical Services, Andhra Pradesh, Hyderabad through proper channel for reimbursement and for settlement.
15. The Ex.B9 is the G.O.Ms.No.117 dated 27-3-2000 where in it was decided to constitute a Special Scrutiny Committee at the Directorate Level for settlement of the medical reimbursement bills and credit bills of various hospitals for proper check .
16. The complainant forwarded his application for reimbursement of medical bills for treatment of his wife delivery and baby’s treatment for Rs.15,835/-, through opposite party No.1 i.e proper channel to opposite party No.2, who is the Joint Director of Insurance Medical Services and opposite party No.2 in turn had to send the said complainants application to the Director of Insurance Medical Services, Andhra Pradesh, Hyderabad and who in turn has to place it before the Special Scrutiny Committee for settlement of reimbursement bills. The written version of opposite party No.2 no where submitted as to what is position of complainants application or whether the opposite party N.2 has forwarded the said complainants application to the said Director or not. The written version of opposite parties is silent that
there is no averments regarding the application submitted by the complainant for medical reimbursement.
17. Therefore, to conclude from the above, the complainant forwarded his application through proper channel i.e, opposite party No.1 as contemplated in G.O.Ms.No.42 dated 25-10-2002 to opposite party No.2, the opposite party No.2 though received the said application and several representations of the complainant did not respond nor any information was given as to what happened to complainants application, there appears clear deficiency of service on part of opposite party No.2 in not performing his statutory in duty settling the medical reimbursement bills of the complainant and for the above lapsive conduct the opposite party No.2 had to pay to the complainant Rs.10,000/- as compensation for suffered mental agony and as the opposite party No.2 driven the complainant to the forum for redressal the opposite party No.2 also has to pay costs of Rs.5,000/- besides to the medical reimbursement bill for Rs.15,835/- .
18. With regard to opposite party No.1, the opposite party No.1 has forwarded the application of the complainant and has done his part of duty and no cause of action is made out against opposite party No.1 and there is no liability on opposite party No.1 in settling the complainants claim for medical reimbursement. Hence, case against opposite party No.1 is dismissed.
19. In the result, case against opposite party No.1 is dismissed and allowed against opposite party No.2 directing opposite party No.2 to pay to the complainant the medical reimbursement bill of Rs.15,835/- and Rs.10,000/- as compensation for suffered mental agony and costs of Rs.5,000/- within one month from the date of receipt of this order. In default the opposite party No.2 shall pay the above award with 12% interest from the date of default till realization.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 10th day of September, 2008.
Sd/- Sd/-
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :Nil For the opposite parties :Nil
List of exhibits marked for the complainant:-
Ex.A1. Xerox copy of ESI identity card issued to complainant.
Ex.A2. Carbon copy of letter dated 8-6-2004 of opposite party No.1 to opposite party No.2 . Copy marked to complaint.
Ex.A3. Letter dated 20-6-2005 addressed by the complainant to opposite party No.2.
Ex.A4. Attested Xerox letter dated 21-4-2004 of Manager, ESI
Hospital, Adoni to opposite party No.2
List of exhibits marked for the opposite parties:
Ex.B1. Attested Xerox of letter dated 1-6-2004 of complainant to opposite party No.2.
Ex.B2. Attested Xerox of referral letter of EN Varalakshmi to Dr.Goud
dated 26-11-2003.
Ex.B3. Attested Xerox of showing the date of admission and dated discharge of the baby of saroja.
Ex.B4. Attested Xerox of circular dated 10-4-1995.
Ex.B5. Attested Xerox of extract out-patient register of ESI dispensary, Yemmiganur for the period 27-11-2003 to 30-11-2003.
Ex.B6. Communication of Joint Director of Insurance dated 16-5-2003.
Ex.B7. Attested Xerox of registrar of attendance and fees for November, 2003 as to DR. Aruna Kumari and P. Raghothamma.
Ex.B8. Attested Xerox of patient register for the period 22-11-2003 to 26-11-2003.
Ex.B9. Copy of G.O.Ms.No.117 Health Medical and Family Welfare ( (Q2) Department dated 27-3-2000 along with annexure.
Ex.B10. Amendment to G.O.Ms.No.42 of Labour Employment Training and Factories (IMS) dated 25-10-2002.
Ex.B11. Attested copy of G.O.Ms.No.42 dated 25-10-2002.
Ex.B12. Attested copy of Pg.No.59 of ESI medial manual.
Sd/- Sd/-
MEMBER PRESIDENT
// 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
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