SMT. RAVI SUSHA : PRESIDENT
Complainant filed this complaint under Sec.12 of the Consumer Protection Act 1986 seeking direction against the OP to paybRs.62276.22 being medical expenses besides Rs.36,000/- as compensation to the complainant .
The gist of the complainant’s case is that complainant was a member of state employees Insurance corporation at the time of filing of this complaint having Number IP.NO.5402395156. He was working at Sabari Wood Arts,UTC compound,Muzhippilangadi(employers code No.72000106640000902). On 26/12/2003, the complainant was admitted at E.S.I Thottada due to sugar and blood pressure complaint. Since he had not recovered from the decease, he had been admitted at Koyili Hospital Kannur from there AKG Hospital Kannur for better treatment. From there he had admitted at KMC hospital Mangalore and treated there. After discharge from KMC, as per the direction of ESI Medical Officer, Dharmadam, the complainant submitted application form, copies of hospital bill, description of medicine and test report to ESI Dharmadam for reimbursement of medical expense. But all the documents were returned with the reason that all of those documents were not attested by treating doctor. After curing the defects, the complainant again submitted and sent to Insurance Medical officer, Thycad,Thiruvananthapuram by speed post. But from there also it was returned to ESI Dharmadam after 6 months, the entire documents were given back to the complainant with another reason that the calculations in the bills are not correct. Hence filed this complaint as prayed for.
After receiving notice Ops 1&2 jointly filed version admitting the admission and treatment of the complainant at ESI Thottada, Koyili Hospital, AKG Hospital Kannur and KMC hospital Mangalore. It is pleaded by the Ops that the sanction of Insurance Medical Services Director, and State Medical Commissioner, ESI Corporation, are essential for allowing application of the complainant. For that the letters were sent to those officers. But State Medical Commission, rejected the sanctioning letter due to some reasons. It is further pleaded that the above letters were enclosed and submitted along with version for perusal of this commission. But any of the letters were not produced. It is pleaded by Ops that all the bills were returned to the complainant with a direction to re-submit with detailed impatient bill and split up details. But instead of doing that he filed this consumer complaint. Ops submitted that there is no deficiency or negligence on their part in giving service to the complainant and prays for the dismissal of the complaint.
While pending of this case the original complainant expired. So his wife and children were impleaded as additional complainants 2 to 4.
At the evidence stage addl. complainant filed chief-affidavit in lieu of evidence with documents. He was examined as PW1 and marked those documents as Exts.A1 to A62. She was made cross- examined by the OP’s counsel. After that there was no representation from the OP side and not adduced any oral or documentary evidence for supporting their contentions.
It is to be noted that mere submitting version without adducing any evidence from the side of Ops, for substantiating their contentions, we cannot accept the pleadings of them. From the pleadings alone we cannot assume that Ops have performed their duty to recover the medical expenses incurred to the complainant. Complainant produced each and every medical bills and treatment details along with lab test results. Through Exts.A1 to A62 complainants proved their case. On the testimony of PW1, also reveals that complainant’s case is a genuine one. Since there is no contradictory evidence from the side of Ops., we are inclined to believe the complainant’s submissions. Through complaint, chief affidavit and Exts.A1 to A62 documents complainant proved her case. The Ops in their version not denied the eligibility of the complainant to get reimbursement of his treatment expenses. So there is deficiency in service and negligence on the part of Ops 1&2 from getting the treatment expenses of the complainant from State Insurance Medical service. Hence the complainants are entitled to get relief.
In the result complaint is allowed in part. Opposite parties 1&2 are directed to pay Rs.62276.22 as treatment expenses and Rs.25,000/- as compensation and cost to the proceedings of this case to the complainants 2 to 4. Opposite parties 1&2 are jointly and severally liable to pay the award amount within one month from the date of receipt of this order. Failing which the amount of Rs.62276.22 will carry interest@7% per annum. The complainants are at liberty to realize the amount as per the provisions of Consumer Protection Act 2019.
Exts:-
A1- 28/12/13-OP ticket of Koyili hospital Kannur
A2-28/12/13-Discharge summary –AKG Hospital Kannur
A3- ambulance receipt
A4-6/1/14-final bill issued by KMC hospital Mangalore
A5-toA15 medical
A16-Cardiac scan report
A17-Discharge summary
A18-lab report
A19-Copy of discharge certificate issued by ESI hospital Kannur
A20- Lab report
A21-letter issued by complainant to 2nd OP
A22-Entitlement certificate
A23-copy of ID card
A24-to A33- lab report
A34 In patient bill
A35&36- cash bill
A37 to A47- medical bill
A48 to A55-Essentiality certificates
A56to A61-lab report
A62-Details of patient
PW1-Nitha.P.P-witness of complainant
sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew. Sajeesh K.P
eva /forwarded by Order/
SENIOR SUPERINTENDENT
