Date of filing:-06/07/2015.
Date of Order:-26/07/2017.
DISTRICT CONSUMER DISPUTE REDRESSAL FORUM(COURT)
B A R G A R H
Consumer Complaint No.43 of 2015.
Sri Nilesh Kumar Desai, aged about 53(fifty three) years S/o Late Kishor Chandra Desai R/o. College Road,Ward No.12(twelve), Po/P.s/Dist –Bargarh.
..... ..... ..... Complainant.
-: V e r s u s :-
The Insurance Medical Officer, E.S.I Dispensary, At/Po:-Bardol Dist- Bargarh, ODISHA.
The Regional Director, Employees State Insurance Corporation, Panchadeep Bhawan, Unit-IX, Janpath, Bhubaneswar.
Director, Directorate of Employee’s State Insurance Scheme, Odisha, Plot No. A/122, Near Kalani Mandap, Unit-111, Nayapali, Bhubaneswar-751012
..... ..... ..... Opposite Parties
Counsel for the Parties.
For the Complainant:- Sri P.K. Mahapatra, Advocate with other Advocates.
For the Opposite Party No.1(one):- Sri S.K. Naik, Advocate with other Advocates.
For the Opposite Party No.2(two):- Himself.
For the Opposite Party No.3(three):- Ex-parte.
-: P R E S E N T :-
Sri Krishna Prasad Mishra ..... ..... ..... ..... ..... P r e s i d e n t.
Sri Pradeep Kumar Dash ..... ..... ..... ..... ..... M e m b e r.
Ajanta Subhadarsinee ..... ..... ..... ..... ..... M e m b e r(w).
Dt.26/07/2017 -: J U D G E M E N T :-
Presented by Sri K.P. Mishra, President:-
Brief Facts of the case :-
In pursuance of the provision of the Consumer Protection Act-1986 U/s 12 the Complainant has preffered to file the complaint pertaining to the unfair trade practice and deficiencies of service against the Opposite Parties as mentioned here under.
The Complainant has entered in to an insurance policy with the Opposite Parties company namely Employees State Insurance Corporation in short (ESIC) by paying a considerable amount of premium amount, being a member of the said corporation, was issued with a policy bond vide No. 4401623345, which covers the reimbursement of the expenses relating to any treatment of his entire family members including his dependent mother. And The Opposite Parties are liable for such reimbursement if any, being the authorized officers of the same.
The case of the Complainant is that during the subsistence of the said policy the mother of the Complainant fell ill due to the severe pain in her left side breast, for which he took his mother to Yoshoda Super Speciality Hospital, Hydrabad for her treatment, and there after various laboratory tests at Vijaya Diagnostic Centre were conducted, it was detected that she was suffering from breast cancer, as such he came back to Bargarh and decided to take his mother to Krishna Institute of Medical Sciences Ltd. in short KIMS Ltd, Secunderabad and accordingly on being reffered by the Opposite Party No.1(one) vide letter No.203 Dt.12.04.2015 took his mother to the said Hospital on Dt.13.04.2015 and got her admitted there.
The doctors of the said Hospital after examining her, advised the Complainant for immediate operation, so he got his mother operated there, on his own expenses and due to the prevailing situation there in between the Andhra and Telengana dispute issue he could not contact with the Opposite Parties, which costs an amount of Rs.1,04,169/-(Rupees one lakh four thousand one hundred sixty nine)only in total, so after discharge of his mother the Complainant submitted all the bill, vouchers before the Opposite Party No.1(one) as he being the doctor of the said corporation of the Opposite Party, but he did not receive those documents, so he sent all those documents to the Opposite Parties No.2(two) & No. 3(three) through the registered post on Dt.27.05.2015, but they did not turn up for which he had to undergo a lot of mental agony which amounts to unfair trade practice and deficiencies of rendering proper service on the part of the Opposite Parties. Later on the Complainant got information from the Opposite Party No.1(one) regarding an inquery letter sent by the Opposite Party No.3(three) seeking details of the said information from the Opposite Party No.1(one), which in turn was intimated to the Complainant vide Memo No.398 Dt.27.09.2015 and in response to that the Complainant complied with all the documents again to the Opposite Party No.1(one) by Regd. Post on Dt.05.10.2015. But again to no effect and in the mean time the recurring expenses in medication were being carried out by the Complainant, which emburden him financially further, due to the non reactive attitude of the Opposite Parties, which amounts to the unfair trade practice and deficiencies in rendering his legitimate claim on their part, for which has filed this case claiming the expenses amount of Rs. 1,04,169/-(Rupees one lakh four thousand one hundred sixty nine) only and an amount of Rs.50,000/-(Rupees fifty thousand)only against compensation due the aforesaid action of the Opposite Parties, along with an amount of Rs.10,000/-(Rupees ten thousand)only as litigation expenses with an interest @ 18% (eighteen percent). And to substantiate his such case has relied upon some relevant documents mentioned below.
The xerox copy of consultation fees of the doctor at Yasoda Hospital. (one sheet).
Xerox copy of expenses of test conducted at Vijaya Diagnostic Pvt. Ltd., with prescription. (three sheets).
Xerox copy of the Hospital Bills of KIMS Ltd. (twelve sheets).
Xerox copy of test conducted after operation. (one sheet).
Xerox copy dressing charges after operation. (one sheet).
Xerox copy of Medicine Expenses after operation. (six sheets).
Xerox copy of Insurance Policy No. 440162334. (two sheets).
Copy of representation.(three sheets).
Postal Receipts. (two sheets).
Perused the complaint and documents in it’s support and on hearing the advocate for the Complainant we found it to be a genuine case hence admitted and sent notice to the Opposite Parties and on being noticed the Opposite Parties No. 1(one) and No. 2(two) appeared and filed their version but the Opposite Party No.3(three) did not appear till Dt.02.08.2016 hence he was set ex-party and the case was heard.
On perusal of the version filed by the Opposite Party No.2(two) it is seen that it has admitted to have insured the Complainant but has denied to have received the copy of the documents filed by the Complainant and has contended that it is the duty of the Opposite Party No.1(one) to deal with the matter and as he is under the administrative control of the Directorate of Employees State Insurance Scheme, Odisha, is required to receive and reimburse the claim of the Complainant as per the existing procedure and rules, and at the same time in it’s version in the para 6(six) it has mentioned that the matter relating to the reimbursement of medicine bill are being dealt with by the Opposite Party No.3(three), as Opposite Party No.1(one) is under the said Opposite Party No.3(three), he is to reimburse the same, and at same time in para no.3(three) it has denied the claim as not maintainable in the Forum as it should have been agitated under the provision of Employees State Insurance Act U/S 75(1) (e), in the insurance court, and has prayed to dismiss the case against it.
Further it reveals from the version of the Opposite Party No.1(one) that the case of the Complainant was not within his knowledge, but later on admitted the case of the Complainant after getting the documents submitted by him, it has also been admitted the expenses made by the Complainant but has denied for his claim with a ground that as the said Hospital is tied up with the scheme so the Complainant should not have made cash payment and as the amount as claimed is huge (in para no.8(eight)) is not within his jurisdiction to reimburse. And has claimed for dismissal of the complaint.
On perusal of the complaint, version of both the Opposite Parties and the documents filed by the Opposite Parties, Complainant and on hearing the counsel and the authorized officer of the Opposite Party No.2(two) two vital points have come to our notice for adjudicating the case (i) whether there is any unfair trade practice and deficiencies of service have been committed on the part of the Opposite Parties ? (ii) whether the Complainant is entitle for the reimbursement of the expenses made in course of the treatment of his mother and for the compensation amount as claimed by him ?
Firstly while dealing with the point as to whether the unfair trade practice and deficiencies in service has been committed by the Opposite Parties, in this regard delving deep in to the materials available in the records it is clearly reveals that it has never been denied by any of the Opposite Parties at any point of time regarding the Complainant being a consumer or not and he being a member of their corporation or the amount paid by him for such membership or the amount being spent by him in the treatment of his mother, rather in the averments made by them in their version admitting all the case of the Complainant and has admitted the amount spent in due course of such treatment, but have not taken any steps to make the claim amount of the Complainant with out any reason, which itself amounts to unfair trade practice and deficiencies of service on their part. So our view is assertive and goes in favor of the Complainant.
And with regard to the question of the maintainability of the case while agitating the question of the Section 75(1)(e) of the Employees Insurance Act, when it has already been admitted by the Opposite Parties that the Complainant is a consumer there is no bar for him to file the case under the Consumer Protection Act 1986 in view of the Section 3 of the Act clearly envisages that the provision of this Act shall be in addition to and not in derogation of the provision of any other law for the time being in force. So in our view the case in hand is maintainable in the Forum.
Further while dealing with the question as to whether the Complainant is entitled to the insured reimbursement amount, in this context as we have already expressed our view that the Opposite Parties have committed unfair trade practice and have been proved to be deficient in rendering due service to the Complainant and in addition to that when the Opposite Parties have admitted the expenditure made by the Complainant in the treatment of his mother it can be safely concluded that the Complainant is entitled to the reimbursement of the expenses made by him for the aforesaid purpose and also it is already established that the Opposite Parties have committed unfair trade practice coupled with their deficiencies in rendering due service to the Complainant causing him losser of money and mental peace which entitles him for compensation, as such in our view he is entitle for compensation for which all the opposite parties are jointly and severally liable. Hence answered accordingly. Hence order follows.
-: O R D E R :-
Hence the Opposite Parties are jointly and severally directed to pay the expenditure made by the Complainant for the treatment of his mother amounting to Rs.1,04,169/-(Rupees one lakh four thousand one hundred sixty nine) only towards the reimbursement amount and Rs. 5,000/-(Rupees five thousand )only towards the mental agony sustained by the complainant, and both the amount would carry an interest @ of 9%(nine percent) per annum from the date of filing of the case till date of Order, and the Opposite Parties are directed to pay both amount with said interest within 30 (thirty) days from the date of receipt of the order in default of which interest @ of 16% (sixteen percent) per annum would accrue on the total amount till the actual realization of the same.
According the case is disposed off allowing the complaint against the Opposite Parties.
Typed to my dictation
and corrected by me.
(Sri Krishna Prasad Mishra)
P r e s i d e n t.
I agree, I agree,
(Ajanta Subhadarsinee) (Sri Pradeep Kumar Dash)
M e m b e r. M e m b e r.
