::BEFORE THE DISTRICT CONSUMER DISPUTES  REDRESSAL COMMISSION AT BIDAR::

                                                                   C.C. No.37/2021.

                                                                                                                                  Date of filing: 06.04.2021.

                                                              Date of disposal: 29.04.2023.

P R E S E N Ts:-    

                                (1) Shri. Mabu Saheb H.Chabbi,                                                                                                               B.Com.,LL.B.,(Spl.),

                                                                         President.,  

                                (2) Kum. Kavita,

                                                               M.A.,LL.B.,(Spl.),  

                                                                         Member.

                                   (3) Shri.Thriyambakeshwara,

                                                                                   B.A.,LL.B.,(Spl.), 

                                                                                           Member.

COMPLAINANT/S                     Veeranna S/o Annarao,

                                                      Age:65 years, Occ: Retired Driver in
                                                      NEKSRTC, R/o H.No.11-1-68,
                                                      Mangalpet, Bidar.                                                                                                   

                                                    (By Smt.Kirti V.B., Advocate.)                         

                 V/s

OPPONENT/S       

1. The North East Karnataka Road Transport
         Corporation, through its managing Director,
          Sarige Sadan, ManinRoad, Kalaburagi. 

2.      The North East Karnataka Road Transport
         Corporation, through its Division Controller, 
          Raichur Division, Raichur.                                               

3.       The North East Karnataka Road Transport
          Corporation, through its Division Controller, 
          Bidar Division, Bidar,
          Near Haralayya Circle Bidar.                                                             

                                                         (OP.No.2&3 By.Smt.Soniya Patil., Advocate, 
                                                      and OP No.1 Ex-parte.)

                                                                                                    ::  J U D G M E N T  ::

By. Shri.Thriyambakeshwara,. Member.

The complaint has been filed by complainant under section 35 of the Consumer Protection Act, 2019, against the opponents for the deficiency of service by not settling the medical reimbursement claim of complainant.  Hence, passed the following judgement.

Brief facts of the complaint.

The brief facts of the complaint in nut-shell are summarized as follows: -

1.         That, the Complainant was the Driver with Driver No.611 working under the Office of the Opponent No.3 at Bidar Bus Depot-1, who is now retired from the service.  The wife of the Complainant namely Basamma undergone Heart Operation at "INDO US SUPERSPECIALITY HOSPITAL HYDERABAD" for which the Complainant spent amount of Rs.2,08,318/-(Rupees Two Lakh Eight Thousand three hundred Eighteen only). The Complainant stayed in said hospital about fifteen days (15 days) and sustained lot of loss. Thereafter the Complainant gave representation to the Office of the Opponents No.3 for claiming the Medical reimbursement Claim on 13-05-2017. But, the OP.No.3 till today not paid single rupee to the Complainant.  Therefore, the Complainant decided to fight against the OPs legally. Then he sent legal Notice on 02-01-2021 to the Opponents through his Advocate, which was replied on 21-01-2021 by Ops by rejecting claim on the ground that, the Hospital in which the Complainant had treatment to his wife, is not recognized hospital under the network Office of the N.E.K.R.T.C. Therefore the cause of action arose to the Complainant on 21-01-2021 to file the Complaint against the Opponents.  The Complainant is the resident of Bidar and Hyderabad is a near city to Bidar by road distance of hardly 120-130 Kilometers, hence he had taken her wife to save her life and at that time he not taken his wife to recognized Hospital of N.E.K.S.R.T.C. The intention of the Opponents to avoid the medical reimbursement on technical ground and accordingly claim was rejected. The Ops not issued single acknowledgement that, the Complainant had taken treatment to other than the recognized hospital of the NEKRTC, by saying one or the other reason avoid to reimburse the claim.  The Complainant had hand loans from his friends and relatives for non paying of medical expenditure of the Complainant’s wife by Ops and thereby suffered lot of physical and mental loss and thereby deficiency of service and negligence on the opponents. Hence without any other go filed this complaint.

Written version of OP No.2 and 3.

2.         That, subsequent to service of notices on OPs by this commission, OP No.2  & 3 filed power and later filed W.V. on permission by order dated 25.05.2022, by taking complainant’s objection as nil. The OP No.2&3 by filing separate W.V contended in their W.V. by raising common defense stating that, at the out-set, the complaint filed by the complainant is prima facie not maintainable either in law or on the facts of the case and the same is liable to be dismissed in-limine. The Ops 2&3  admit that, the averments made in complaint, the complainant was the Driver working under the Office of the Opponent No.3 at Bidar bus Depot-1, now the complainant retired from the service and his number bearing Driver No.611, all are true and correct.  And, the averments made in para 2 of the complaint that, the wife of the complainant namely Basamma undergone Heart Operation at "INDO US SUPERSPECIALITY HOSPITAL HYDERABAD", for this the complainant spent amount of Rs.2,08,318/-(Rupees Two Lakh Eight Thousand three hundred Eighteen Only).  The complainant stayed in hospital about fifteen days(15days) for this the complainant sustained lot of loss, are all not within the personal knowledge of these respondents and the petitioner is put to strict proof of the same with documentary evidence. The averments made in para 3 of the complainant that, thereafter the complainant gave application to the Office of the respondent No. 3 by claiming the Medical claim amount on 13-05-2017, but the office of the respondent No. 3 till today not paid single amount to the complainant all are true and the complainant is not eligible to get the benefit of the same and the complainant's wife was not taken any treatment in recognized hospital under the Office of the N.E.K.R.T.C and the N.E.K.S.R.T.C recognized some Hospital situated at outside the Karnataka State, Viz: Miraj and Sholapur of Maharastra and Hyderabad of Telangana State for the reimbursement to the employee/officers of the Corporation and to their dependents for the treatment/surgery of severe disease. The complainant's wife was taken the treatment at "INDO US SUPERSPECIALITY HOSPITAL HYDERABAD" which not comes under the recognized hospital of the Corporation and the complainant is not eligible to get the benefit of reimbursement. OP herein produced the recognized Hospitals list for kind perusal of this Hon'ble Forum. The averments made in para 4 of the complainant that, the complainant decided to fight against the opponent legally, then he approached to the counsel with relevant document and sent legal notice on 02-01-2021 to the opponents, the Opponent No.3 replied on 21-01-2021 that, and replied that, the Hospital in which the complainant's wife taken treatment is not recognized hospital under the Office of the N.E.K.R.T.C, therefore the claim of the complainant was rejected. Hence the complainant is not eligible to get the reimbursement. There is no cause of action to file this complaint and the cause shown in the complaint is created by the complainant itself to file this complaint.  It is submitted that, further the complainant is employee of the Corporation and not coming under the definition of "Consumer" as per Sec.7 of Consumer 6 on Protection Act. As such, this authority is not having jurisdiction to try this case and same may liable for rejection.

3.         Further, it is submitted that, there is no any contract/agreement entered between the complainant and the question of deficiency of service does not arise. The averments made in the para 5, 6 and 7 of the complaint are all baseless and concocted one and which are not specifically traversed herein, are hereby denied as false. The case filed is misconceived and frivolous one, the complainant has no right to maintain the case, and it is liable to be dismissed in limine.

Evidence of complainant.

4.         The complainant has been examined himself by filing his evidence affidavit on 04.07.2022 and got marked 36 documents as per Ex.P.1 to Ex.P.36 on behalf of complainant which are as follows,

1. Ex.P.1-Mediclaim Form submitted to OP No.3 on13.05.2017.
2. Ex.P.2-Medical reference letter issued by OP panel doctor.
3. Ex.P.3to6-03 Laboratory reportS dt:14.04.2017.
4. Ex.P.7&8 -02 ECG  Graphics films
5. Ex.P.9-  Echo Cardio graphic Report
6. Ex.P.10- Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:15.04.2017.
7. Ex.P.11- Echo Cardio graphic film.
8. Ex.P.12-Coronary Angiogram report of Indo-US Superspeciality Hospital Hyderabad dt:17.04.2017.
9. Ex.P.13-PTCA report of Indo-US Superspeciality Hospital Hyderabad dt:17.04.2017.
10. Ex.P.14-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:17.04.2017.
11. Ex.P.15&16- Echo Cardio graphic film.
12. Ex.P.17-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:19.04.2017.
13. Ex.P.18-Medicine bill.
14. Ex.P.19-Doctor prescription of Indo-US Superspeciality Hospital Hyderabad.
15. Ex.P.20-Medicine bill.
16. Ex.P.21- Hospital final bill dt:19.04.2017.(3pages)
17. Ex.P.22-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:13.04.2017
18. Ex.P.23- Echo Cardio graphic film.
19. Ex.P.24-Bill cum receipt dt:27.04.2017.
20. Ex.P.25- Echo Cardio graphic film.
21. Ex.P.26-Discharge summary.(2 pages)
22. Ex.P.27-OPD Card dt:27.10.2017.
23. Ex.P.28-O/c legal notice dt:02.01.2021.(03 copies)
24. Ex.P.29 to 31-Postal receipts.
25. Ex.P.32 to 34-Postal acknowledgements.
26. Ex.P.35-Reply notice of OP No.3 dt:21.01.2021.
27. Ex.P.36-Aadhar card of complainant.

Evidence of OPs.

5.         One Sri Ravikumar S/o Mahadevappa, Labour Officer K.K.R.T.C filed his evidence affidavit on behalf OP.No.2 as RW-1 on 13-12-2022 One Sri Rajshekar S/o Suresh, Labour Officer KSRTC Bidar, filed his evidence affidavit on behalf OP 3 as RW-2 and both in all got marked 4 documents as per Ex.R.1 to Ex.R.4 on behalf of OPs.

1. Ex.R.1 –Copy of Board Resolution.
2. Ex.R.2- Copy of list of recognized Hospital at Hyderabad.
3. Ex.R.3-Copy of legal notice dt:21.01.2021.
4. Ex.R.4-Retierment details of complainant issued by OP No.3.

Points/Issues.

6.         The OP submitted his written argument and heard the arguments advanced by the complainant, based on the pleadings and documents produced by the complainant and OP, the points that arose for consideration before this Commission are as below. 

1. Whether the complainant proves that, he is consumer to OP and further proves the deficiency of service from the OP?  
2. Whether the complainant proves that, he is entitled for any compensation from the OP? What orders? 

7.         Our answers to the points raised above are as follows: -

1. In the affirmative.
2. In the affirmative and as per the final order.

Points No.1 and 2.

8.         In order to decide the complaint issues, this commission discussed points/issues No.1 and 2 altogether for discussion as each points are inter related to each other- as follows.

9.         On perusal of the contents of W.V. it is not in dispute that, the complainants wife had under gone for heart disease as per reference made by Ops panel Doctor Dr.Somshekhar S.Bhalke, as per Ex.P.2 by referring the complainant wife to Dr.Sharat Chandra Indo-US-Specialty Hospital Hyderabad, and as per discharge summery Ex.P.26 the date of discharge is on 19.04.2017 after having under gone for heart surgery and treatment.  Later the complainant submitted his claim as per Ex.P.1 dated 13.05.2017.  The Ops despite having notice of submission of claim, OP no.3 did not reply in either way till receipt of Ex.P.28 legal notice addressed to all Ops, and they replied to the claim of complainant legal notice as per Ex.P.35 =Ex.R.3 reply notice dated 21.01.2021.  Therefore, though the claim was submitted by complainant to OP No.3 as on 13.05.2017, but nothing was intimated till 21.01.2021 as per Ex.P.35=Ex.R.3 by rejecting the claim of complainant.  Therefore, this commission though noticed that, no ground of bar of limitation ground raised in their W.V. by Ops, but still it is duty of court to look in to that aspect and accordingly in view of rejection of claim by Ops as on 21.01.2021, the cause of action for filing this complaint arose only on 21.01.2021 and not earlier to that day.  Hence, this commission is of considered opinion that, the complaint filed by the complainant is well within limitation as provided under Sec.69 of C.P.Act 2019. 

10.       The complainant and OPs in order to prove his case, complainant lead his evidence as P.W.1 by reiterating the facts of complaint and got marked in all 36 documents and in similar manner the Ops No.2 & 3 also lead their respective evidence as R.W.1 and 2 and in all marked Ex.R.1 to Ex.R.4.  The exhibits of complainant in all 36 and out of which Ex.P.1 is the medi-claim representation dt: 13.05.2017 to OP No.3 and Ex.P.2 is medical reference letter issued by OPs panel doctor, Ex.P.3 to 6 are the laboratory investigation reports in respect of complainant’s wife, Ex.P.7 to 9 and Ex.P.11 to 13 and Ex.P.15, 16, 23&25 are the echo cardio graphic sheets and its report, Ex.P.10,14,17,22&24 are the hospital receipts, Ex.P.18&20 are  Medicine bills, Ex.P.19 prescription, Ex.P.21 is Final bill of hospital, Ex.P.26 discharge summery, Ex.P.27 OPD Card, Ex.P.28 to 34 are O/C of legal notice, postal receiptsa and acknowledgements, Ex.P.35 reply notice of OP dt:21.01.2021, Ex.P.36 aadhar card of complainant.  On perusal of the above documents, it is crystal clear that, the wife of the complainant was admitted for treatment of heart disease and operated at Indo US-Super-Specialty Hospital Hyderabad, and he spent above Rs.2,08,318/- for totally 15 days treatment and complainant represented claim as per Ex.P.1, before OP No.3 which came to be rejected by OP No.3 by relying on the resolution passed by its department on the ground that, said hospital do not come under the network hospital recognized by its department as per Ex.R.2, based on resolution passed by the department as per Ex.R.1.

11.       On perusal of the Ex.P.2, the complainant initially said to have brought his wife for treatment at OP panel doctor by name Dr.Somshekhar S.Bhalke, Bidar, for emergency treatment who in turn referred the said wife of complainant for higher treatment to Doctor Sharat chandra Indo US-Hospital Hyderabad.  Therefore, the complainant took his wife to Indo  US-Super-specialty Hospital, for treatment and also Surgery for the heart related disease.  The Ex.P.21 speaking final bill to the tune of Rs.2,03,887/-, and other medicine bills etc, which totally comes to Rs.2,08,318/- which is the claim preferred by complainant before OP No.3.  From the above reference letter Ex.P.2, it is clear that, the complainant not taken her wife for higher treatment at Indo US-Super-Specialty Hospital on his own motion, but only on impression that, it is within the network of hospital recognized by Ops corporation, as the very OP panel doctor referred through letter as per Ex.P.2, to the above hospital.  Therefore, when such being the facts, the contention of Ops holding that, the said Hospital is not coming under the network hospital of recognized Hospital list as per Ex.R.2, which is based on Ex.R.1 does not hold good under law.  It is the OP panel doctor who referred the complainant to take his wife to above hospital and the acts of said OP panel doctor made the complainant to believe that, the said hospital is coming under the listed recognized hospital as per Ops list.  Otherwise, there was no occasion for complainant to take his wife to such hospitals.  Therefore, this commission finds no fault with act of complainant who acted as per the Ops panel doctor.  The Ops ought to have informed their panel doctors to refer the patients for higher treatment only as per network hospital recognized list by its department.  So, failure on the part of Ops to bring to the notice of either to complainant or his panel doctor regarding their network of hospital recognized by it as per Ex.R.2, makes the Ops liable for all such expenses incurred by complainant for the treatment of his wife.  Mere passing of resolution as per Ex.R.1 and preparing list of recognized hospitals as per Ex.P.2without due intimation to its employees or its panel doctors and raising such conditions at the time of processing the claim is unwarranted and illegal on the part of Ops corporation.  On perusal of the Ex.P.2, this commission is of the opinion that, the complainant not acted contrary to any provisions of Ops medi claim reimbursement rules as their own panel doctor referred patient to said Indo US-multi-Specialty Hospital. 

12.       Apart from the above, the Ops raised another major contention regarding maintainability of complainant on the ground that, the dispute raised by complainant is out of the purview of definition of consumer under C.P.Act as the dispute is between employee and employer.  On keen consideration of said objection this commission not in agreement with the contention raised by Ops as the nature of dispute raised before Ops by its employee/complainant is not related with any of his service or retirement benefit disputes, so as to keep outside the per view of C.P.Act.  The claim/dispute is in respect of medical bill reimbursement on the basis that, he is employee and the said benefits also covers not only to himself but also to his family which is evident from on plain perusal of Ex.R.1 as stipulated under condition No.15.3 to 15.8.  When the proceedings of Ex.R.1 are clear to the extent of providing benefits not only to its employee but also extended to his dependents, therefore, the Ops cannot reject the claim of complainant against to their benefits extended as per Ex.R.1, under the stated major disease to be treated at higher center out the Karnataka State.  The question of whether the complainant being employee can claim medical reimbursement of his or his family is answered by Hon’ble National Commission which is relied upon by the complainant in R.P.No.3868/2008, in case of MTNL Vs S.R.Singh through LRs. Decided on 07.07.2021.  Apart from the above decision this commission gains judgment of Hon’ble Karnataka State Consumer Commission reported in Vol II (2008) CPJ 285 in the case of Andhra Bank Vs B. Ramakrishna Reddy, by holding that, the claim of benefits cannot be denied by the employer only on the stated ground of employee is not consumer to employer.  Therefore, we are of the considered opinion that, the OP No.3 had rejected the claim of complainant against to the proceedings of Ex.R.1 that, too the complainant had the treatment in such non listed recognized hospital only on the reference made by Ops own panel Doctor as per Ex.P.2, which amply proves that, the said listing of recognized hospital for treatment to its employees is not only not intimated to its employees including complainant but also it is not within the knowledge of his own panel doctor Dr.Somshekhar S.Bhalke, who referred the complainant wife to said Indo US-multi-specialty Hospital Hyderabad.  Under the said circumstances for the mistake committed by either by himself/OP No.3 or through his panel doctor, the complainant cannot be supposed to put under loss for the expenses incurred in the said Hospital for the need full emergent genuine treatment had to his wife. 

13.       In view of the detailed discussion as afore stated by this commission,  we are of the considered opinion that, the complainant has proved his case against OPs  and the point No.1 and 2 answered in the affirmative accordingly  in favor of complainant and proceed to pass the following order.

::ORDER::

        The complaint u/s 35 of CP Act 2019, filed by the complainant against OPs is hereby allowed in part along with cost and compensation.

       The Ops NO.1 to 3 are hereby directed to pay medical reimbursement  to the complainant for Rs.2,08,318/- (Rupees two lakhs eight thousand three hundred eighteen only) with interest at the rate of 6% from the date of Ex.P.1 (claim submission to OP No.3) dated 13.05.2017 till the date of realisation. 

The OP is hereby directed to pay compensation amount of Rs.10,000/- and litigation charges as Rs.5,000/- to the complainant.  The above orders shall be complied by Ops within 45 days from the date of this order.                                    

                Intimate the parties accordingly.                         

 (Typed to our dictation then corrected, signed by us and then pronounced in the open Commission on this 29^th day of April-2023).

Documents produced by the complainant.

1. Ex.P.1-Mediclaim Form submitted to OP No.3 on13.05.2017.
2. Ex.P.2-Medical reference letter issued by OP panel doctor.
3. Ex.P.3to6-03 Laboratory reportS dt:14.04.2017.
4. Ex.P.7&8 -02 ECG  Graphics films
5. Ex.P.9-  Echo Cardio graphic Report
6. Ex.P.10- Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:15.04.2017.
7. Ex.P.11- Echo Cardio graphic film.
8. Ex.P.12-Coronary Angiogram report of Indo-US Superspeciality Hospital Hyderabad dt:17.04.2017.
9. Ex.P.13-PTCA report of Indo-US Superspeciality Hospital Hyderabad dt:17.04.2017.
10. Ex.P.14-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:17.04.2017.
11. Ex.P.15&16- Echo Cardio graphic film.
12. Ex.P.17-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:19.04.2017.
13. Ex.P.18-Medicine bill.
14. Ex.P.19-Doctor prescription of Indo-US Superspeciality Hospital Hyderabad.
15. Ex.P.20-Medicine bill.
16. Ex.P.21- Hospital final bill dt:19.04.2017.(3pages)
17. Ex.P.22-Receipt issued by the Indo-US Superspeciality Hospital Hyderabad along with bill dt:13.04.2017.
18. Ex.P.23- Echo Cardio graphic film.
19. Ex.P.24-Bill cum receipt dt:27.04.2017.
20. Ex.P.25- Echo Cardio graphic film.
21. Ex.P.26-Discharge summary.(2 pages)
22. Ex.P.27-OPD Card dt:27.10.2017.
23. Ex.P.28-O/c legal notice dt:02.01.2021.(03 copies)
24. Ex.P.29 to 31-Postal receipts.
25. Ex.P.32 to 34-Postal acknowledgements.
26. Ex.P.35-Reply notice of OP No.3 dt:21.01.2021.
27. Ex.P.36-Aadhar card of complainant.

Document produced by the Opponent.

1. Ex.R.1 –Copy of Board Resolution.
2. Ex.R.2- Copy of list of recognized Hospital at Hyderabad.
3. Ex.R.3-Copy of legal notice dt:21.01.2021.
4. Ex.R.4-Retierment details of complainant issued by OP No.3.

Witness examined.

Complainant.

P.W.1- Veeranna S/o Annarao,   (complainant)

Opponent.

R.W.-1 Sri Ravikumar S/o Mahadevappa, Labour Officer KKRTC.

R.W.-2  Sri Rajshekar S/o Suresh, Labour Officer KSRTC.        

SDC