The Manager ,FHPL V/S Sharanabasappa S/o Earanna - Consumer Court Case

Karnataka

Raichur

CC/08/58

Sharanabasappa S/o Earanna - Complainant(s)

Versus

The Manager ,FHPL - Opp.Party(s)

T.M.Swamy

06 Nov 2009

ORDER

DIST. CONSUMER DISPUTES REDRESSAL FORUM
DIST. CONSUMER DISPUTES REDRESSAL FORUM,DC Office Compound, Sath Kacheri
consumer case(CC) No. CC/08/58

Sharanabasappa S/o Earanna						...........Appellant(s)
Vs.
The Manager ,FHPL The Manager, Yeshaswini Co-Op for Health Trust Dr. Sridhar Reddy						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

JUDGEMENT By Sri. Pampapathi President:- This is a complaint filed by the complainant Sharanabasappa against the Opposite Nos. 1 to 3 U/sec. 12 of Consumer Protection Act for to direct opposite No- 1 & 2 to pay a medi claim amount of Rs. 17,630/- and to award compensation amount for mental agony with cost. 2. The brief facts of the complainant case are that, he is the member of Yeshashiwini Scheme bearing Card No. UHID No. RCR-4170341 since 2004-05 and it valid upto 31-05-08. On 15-05-07 in the period of Yeshashiwini policy on 15-05-07 he sustained grievous injuries to his left leg and thereby there was a fracture of tibia and injury to his left hand. It requires immediate medical treatment, accordingly he admitted in the hospital of opposite No-3 wherein he has to undergo operation for the fracture injuries. According to medical advised he undergone operation by admitting on 15-05-07 and discharged on 29-05-07 totally he spent an amount of Rs. 17,630/-. Opposite No-3 furnished detail treatment with necessary bills to opposite No- 1 & 2 for to make the payment of the hospital bills, but opposite No- 1 & 2 shown their negligence in settling his medi claim by giving one or the other untenable grounds, as such he filed this complaint against opposite No- 1 & 2 for the reliefs as prayed in his complaint. 3. The Opposite Parties 1 & 3 placed Ex-parte. Opposite No-2 appeared in this case filed his written version by contending that benefit under Yashashiwini scheme, the beneficiary shall take treatment in the network hospital, if emergent surgery is required, the hospital authority who obtained pre-authorization from the implementing agency, then the hospital has to operate the patient. If in any case of extreme emergency the hospital authorities shall submit their entire records with history of the patient before discharge of him from the hospital. In the instant case opposite No-3 has sent incomplete information of pre-authorization regarding the surgery performed by the complainant. The opposite No-3 gave information only on discharge of the patient, hence it is against the terms and conditions of the trust deed and thereby the complainant is not entitled for any medi claim, accordingly he prayed for to dismiss the complaint among other grounds. 4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that: 1. Whether the complainant proves that, he is the member of the Yashashiwini scheme of opposite No- 1 & 2 for availing medical benefit and on 15-05-07 he sustained fracture injuries to his left leg due to fall of him on the ground, thereafter he admitted in the hospital of opposite No-3 on 15-05-07 his leg was operated and took treatment as in-patient and discharged on 29-05-07, he submitted all the relevant records to opposite No- 1 & 2 through opposite No-3 but opposite No- 1 & 2 shown their negligence in settling his medi claim, in spite of repeated oral written requests and thereby opposite No- 1 & 2 found guilty under deficiency in their services.? 2. Whether complainant is entitled for the reliefs as prayed in his complaint.? 3. What order? 5. Our findings on the above points are as under:- (1) In the affirmative against opposite No- 1 & 2 and in negative as against opposite No-3. (2) As discussed in the body of this judgement and as stated in the final order. (3) In-view of the findings on Point Nos- 1 & 2, we proceed to pass the final order for the following : REASONS POINT NO.1 & 2:- 6. To prove the facts involved in these two points, affidavit-evidence of complainant was filed, he was noted as PW-1. The documents Ex.P-1 to Ex.P-13 are marked. Affidavit-evidence of Chief Executive Officer of opposite No-2 was filed, he was noted as RW-1. The documents Ex.R-1 to Ex.R-3 are marked. 7. In the instant case it is undisputed fact that, the complainant undergone surgical treatment in the network hospital of opposite No-3, in view of the emergency of the matter. Further it is undisputed fact that the complainant himself paid total medical bill of Rs. 15,630/- to opposite No-3. 8. As per the case of opposite No-2, opposite No-3 hospital not obtained pre-authorization from opposite No-2 without ascertaining as to whether the said surgical treatment covers under scheme or not and pre-authorization was not obtained by furnishing necessary records. Further case of opposite No-2 is that, the pre-authorization of operation was sent after discharging the complainant from the hospital, hence it violates the terms and conditions of the trust deed Ex.R-1 to Ex.R-3. In support of the claim of complainant he filed hospital bills at Ex.P-5, Ex.P-6(1) to Ex.P-6(3) which totally works out to Rs. 15,630/- but not as claimed by the complainant to the extent of Rs. 7,630/-. Ex.P-7 Summary card need not require much appreciation as the treatment taken by the complainant is not seriously disputed by the opposite No-2. In the light of the above facts and circumstances of this case, Ex.R-1 to Ex.R-3 is the trust deed, there are no other records from the side of the opposites to establish the fact that opposite No-3 submitted pre-authorization after discharging the complainant from his hospital. Further nothing is out coming from the side of the opposite No-2 to hold that opposite No-3 submitted incomplete records namely without ID Card, Receipts issued by the society and non-MLC certificate. On the other hand Ex.P-9 is a material document which is a letter of opposite NO-3 to opposite No-2 dt. 09-12-07. In the said letter the hospital authorities specifically stated that necessary documents pertaining to the complainants treatment including F.A.R. & ID furnished on 23-05-07 itself. Ex.P-9 is a reminder letter of opposite No-3 to opposite No-2 for having sent the necessary records. Ex.P-10 is the endorsement issued by the opposite No-3 supports the facts stated in Ex.P-9. Apart from it Ex.P-1 Xerox copy of ID Card of Yashashiwini scheme covering the policy of complainant, Ex.P-2 is the certificate issued by Secretary Co-operative Society Nakundi. Ex.P-3 is the certificate issued by Assistant Registrar Co-operative Society Raichur and Ex.P-4 is the policy copy of Yashashiwini Scheme supports the fact that the complainant is the member of the said scheme with Card No. UHID No. RVR-4170341 regularly the treatment taken by the complainant in the hospital of opposite No-3 for the said injury as per the medical records Ex.P-5, Ex.P-6(1) to Ex.P-6(3), further it is clear that opposite No-1 & 2 not shown their interest in settling the claim of complainant, even though it is as per the terms and conditions mentioned in the trust deed at Ex.R-1, as such we are of clear view that opposite No-2 is intended not to settle the claim of complainant by putting forth one or the other grounds to avoid its liability, as such it is a clear case of deficiency in service by the opposite No- 1 & 2, accordingly we answered Point No-1 & 2 as against opposite No-1 there is no claim against opposite No-3, as such the complaint is dismissed against opposite No-3. 9. As we have already stated in reference to medical bills at Ex.P-5, Ex.P-6(1) to Ex.P-6(3) complainant spent an amount of Rs. 15,630/- towards his treatment, as such he is entitled to recover the said medical bill amount from opposite No- 1 & 2 jointly and severally, accordingly complainant is entitled to recover a total sum of Rs. 15,630/- from opposite No- 1 & 2 jointly and severally. 10. We have noticed the deficiency in service on the part of opposite No- 1 & 2, as such complainant is entitled to recover a lumpsum amount of Rs. 3,000/- from opposite No- 1 & 2 jointly and severally. 11. The complainant is entitled to recover a lumpsum amount of Rs. 2,000/- towards cost of this litigation from opposite No- 1 & 2 jointly and severally, accordingly complainant entitled to recover total sum of Rs. 20,630/- from opposite No- 1 & 2 jointly and severally. 12. The complainant is entitled to recover future interest at the rate of 9% p.a. on the total sum of Rs. 20,630/- from the date of this complaint till realization of the full amount, accordingly we answered Point Nos. 1 & 2. POINT NO.3:- 13. In view of our finding on Point Nos.1 & 2 we proceed to pass the following order: ORDER The complaint filed by the complainant is partly allowed with cost. The complainant is entitled to recover a total sum of Rs. 20,630/- from the opposites 1 & 2 jointly and severally. The complainant is also entitled to recover future interest at the rate of 9% p.a. on the total sum of Rs. 20,630/- from the date of the complaint till realization of the full amount. The complaint filed by the complainant against opposite No-3 is dismissed. Intimate the parties accordingly. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 06-11-09) Sd/- Sri. Pampapathi, President, District Forum-Raichur. Sd/- Sri. Gururaj, Member, District Forum-Raichur. Sd/- Smt.Pratibha Rani Hiremath, Member. District Forum-Raichur.

JUDGEMENT By Sri. Pampapathi President:- This is a complaint filed by the complainant Sharanabasappa against the Opposite Nos. 1 to 3 U/sec. 12 of Consumer Protection Act for to direct opposite No- 1 & 2 to pay a medi claim amount of Rs. 17,630/- and to award compensation amount for mental agony with cost. 2. The brief facts of the complainant case are that, he is the member of Yeshashiwini Scheme bearing Card No. UHID No. RCR-4170341 since 2004-05 and it valid upto 31-05-08. On 15-05-07 in the period of Yeshashiwini policy on 15-05-07 he sustained grievous injuries to his left leg and thereby there was a fracture of tibia and injury to his left hand. It requires immediate medical treatment, accordingly he admitted in the hospital of opposite No-3 wherein he has to undergo operation for the fracture injuries. According to medical advised he undergone operation by admitting on 15-05-07 and discharged on 29-05-07 totally he spent an amount of Rs. 17,630/-. Opposite No-3 furnished detail treatment with necessary bills to opposite No- 1 & 2 for to make the payment of the hospital bills, but opposite No- 1 & 2 shown their negligence in settling his medi claim by giving one or the other untenable grounds, as such he filed this complaint against opposite No- 1 & 2 for the reliefs as prayed in his complaint. 3. The Opposite Parties 1 & 3 placed Ex-parte. Opposite No-2 appeared in this case filed his written version by contending that benefit under Yashashiwini scheme, the beneficiary shall take treatment in the network hospital, if emergent surgery is required, the hospital authority who obtained pre-authorization from the implementing agency, then the hospital has to operate the patient. If in any case of extreme emergency the hospital authorities shall submit their entire records with history of the patient before discharge of him from the hospital. In the instant case opposite No-3 has sent incomplete information of pre-authorization regarding the surgery performed by the complainant. The opposite No-3 gave information only on discharge of the patient, hence it is against the terms and conditions of the trust deed and thereby the complainant is not entitled for any medi claim, accordingly he prayed for to dismiss the complaint among other grounds. 4. In-view of the pleadings of the parties. Now the points that arise for our consideration and determination are that: 1. Whether the complainant proves that, he is the member of the Yashashiwini scheme of opposite No- 1 & 2 for availing medical benefit and on 15-05-07 he sustained fracture injuries to his left leg due to fall of him on the ground, thereafter he admitted in the hospital of opposite No-3 on 15-05-07 his leg was operated and took treatment as in-patient and discharged on 29-05-07, he submitted all the relevant records to opposite No- 1 & 2 through opposite No-3 but opposite No- 1 & 2 shown their negligence in settling his medi claim, in spite of repeated oral written requests and thereby opposite No- 1 & 2 found guilty under deficiency in their services.? 2. Whether complainant is entitled for the reliefs as prayed in his complaint.? 3. What order? 5. Our findings on the above points are as under:- (1) In the affirmative against opposite No- 1 & 2 and in negative as against opposite No-3. (2) As discussed in the body of this judgement and as stated in the final order. (3) In-view of the findings on Point Nos- 1 & 2, we proceed to pass the final order for the following : REASONS POINT NO.1 & 2:- 6. To prove the facts involved in these two points, affidavit-evidence of complainant was filed, he was noted as PW-1. The documents Ex.P-1 to Ex.P-13 are marked. Affidavit-evidence of Chief Executive Officer of opposite No-2 was filed, he was noted as RW-1. The documents Ex.R-1 to Ex.R-3 are marked. 7. In the instant case it is undisputed fact that, the complainant undergone surgical treatment in the network hospital of opposite No-3, in view of the emergency of the matter. Further it is undisputed fact that the complainant himself paid total medical bill of Rs. 15,630/- to opposite No-3. 8. As per the case of opposite No-2, opposite No-3 hospital not obtained pre-authorization from opposite No-2 without ascertaining as to whether the said surgical treatment covers under scheme or not and pre-authorization was not obtained by furnishing necessary records. Further case of opposite No-2 is that, the pre-authorization of operation was sent after discharging the complainant from the hospital, hence it violates the terms and conditions of the trust deed Ex.R-1 to Ex.R-3. In support of the claim of complainant he filed hospital bills at Ex.P-5, Ex.P-6(1) to Ex.P-6(3) which totally works out to Rs. 15,630/- but not as claimed by the complainant to the extent of Rs. 7,630/-. Ex.P-7 Summary card need not require much appreciation as the treatment taken by the complainant is not seriously disputed by the opposite No-2. In the light of the above facts and circumstances of this case, Ex.R-1 to Ex.R-3 is the trust deed, there are no other records from the side of the opposites to establish the fact that opposite No-3 submitted pre-authorization after discharging the complainant from his hospital. Further nothing is out coming from the side of the opposite No-2 to hold that opposite No-3 submitted incomplete records namely without ID Card, Receipts issued by the society and non-MLC certificate. On the other hand Ex.P-9 is a material document which is a letter of opposite NO-3 to opposite No-2 dt. 09-12-07. In the said letter the hospital authorities specifically stated that necessary documents pertaining to the complainants treatment including F.A.R. & ID furnished on 23-05-07 itself. Ex.P-9 is a reminder letter of opposite No-3 to opposite No-2 for having sent the necessary records. Ex.P-10 is the endorsement issued by the opposite No-3 supports the facts stated in Ex.P-9. Apart from it Ex.P-1 Xerox copy of ID Card of Yashashiwini scheme covering the policy of complainant, Ex.P-2 is the certificate issued by Secretary Co-operative Society Nakundi. Ex.P-3 is the certificate issued by Assistant Registrar Co-operative Society Raichur and Ex.P-4 is the policy copy of Yashashiwini Scheme supports the fact that the complainant is the member of the said scheme with Card No. UHID No. RVR-4170341 regularly the treatment taken by the complainant in the hospital of opposite No-3 for the said injury as per the medical records Ex.P-5, Ex.P-6(1) to Ex.P-6(3), further it is clear that opposite No-1 & 2 not shown their interest in settling the claim of complainant, even though it is as per the terms and conditions mentioned in the trust deed at Ex.R-1, as such we are of clear view that opposite No-2 is intended not to settle the claim of complainant by putting forth one or the other grounds to avoid its liability, as such it is a clear case of deficiency in service by the opposite No- 1 & 2, accordingly we answered Point No-1 & 2 as against opposite No-1 there is no claim against opposite No-3, as such the complaint is dismissed against opposite No-3. 9. As we have already stated in reference to medical bills at Ex.P-5, Ex.P-6(1) to Ex.P-6(3) complainant spent an amount of Rs. 15,630/- towards his treatment, as such he is entitled to recover the said medical bill amount from opposite No- 1 & 2 jointly and severally, accordingly complainant is entitled to recover a total sum of Rs. 15,630/- from opposite No- 1 & 2 jointly and severally. 10. We have noticed the deficiency in service on the part of opposite No- 1 & 2, as such complainant is entitled to recover a lumpsum amount of Rs. 3,000/- from opposite No- 1 & 2 jointly and severally. 11. The complainant is entitled to recover a lumpsum amount of Rs. 2,000/- towards cost of this litigation from opposite No- 1 & 2 jointly and severally, accordingly complainant entitled to recover total sum of Rs. 20,630/- from opposite No- 1 & 2 jointly and severally. 12. The complainant is entitled to recover future interest at the rate of 9% p.a. on the total sum of Rs. 20,630/- from the date of this complaint till realization of the full amount, accordingly we answered Point Nos. 1 & 2. POINT NO.3:- 13. In view of our finding on Point Nos.1 & 2 we proceed to pass the following order: ORDER The complaint filed by the complainant is partly allowed with cost. The complainant is entitled to recover a total sum of Rs. 20,630/- from the opposites 1 & 2 jointly and severally. The complainant is also entitled to recover future interest at the rate of 9% p.a. on the total sum of Rs. 20,630/- from the date of the complaint till realization of the full amount. The complaint filed by the complainant against opposite No-3 is dismissed. Intimate the parties accordingly. (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 06-11-09) Sd/- Sri. Pampapathi, President, District Forum-Raichur. Sd/- Sri. Gururaj, Member, District Forum-Raichur. Sd/- Smt.Pratibha Rani Hiremath, Member. District Forum-Raichur.