Judgement against Yashaswini DK District Forum-2

[Raviprakash]

BEFORE THE DAKSHINA KANNADA DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM AT
MANGALORE

Dated this the 31st August 2009
COMPLAINT NO. 70/2009
(Admitted on 24.03.2009)
PRESENT: 1. Smt. Asha Shetty, B.A. L.L.B.,
President
2. Sri. K. Ramachandra, Member
BETWEEN:
Smt. Hemalatha,
W/o Ganesh K.
Aged about 34 years,
R/A. Kajegadde House,
Kanakamajalu Village,
Sullia Taluk,
Dakshina Kannada District. ……..COMPLAINANT

(Advocate for the Complainant: : Sri Chandrashekara N. G.)

VERSUS

1. The Medical Officer,
Adarsha Hospital,
A.P.M.C. Road, Puttur,
Dakshina Kannada District.

(Advocate for Opposite Party No. 1: Sri Sanjay D.)

2. The Manager,
Yeshaswini Co-operative Farmers Health Care Scheme,
No.45, Millers Road
Vasantha Nagar,
Bangalore – 560 052 ……OPPOSITE PARTIES

(Opposite Party No.2: Exparte).
**********
ORDER DELIVERED BY PRESIDENT SMT. ASHA SHETTY

1. The facts of the complaint in brief are as follows:
This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Parties claiming certain reliefs.

The complainant is the holder of Yashaswini Health Scheme Card bearing ID No. 0214308. It is submitted that on 31.5.2008 the Complainant was admitted to Adarsha Hospital Puttur i.e., 1st Opposite Party and underwent caesarian surgery on 1.6.2008 and was discharged on 8.6.2008. The documents in connection to the claim benefits produced before the 1st Opposite Party on 6.6.2008 but the Opposite Parties not made any attempt to make payment of beneficiary reliefs to the Complainant till this date. Thereafter the Complainant issued a notice dated 31.1.2009 but the Opposite Parties not complied the same which amounts to deficiency in service and hence the above complaint is filed by the Complainant before this Hon’ble Forum under Section 12 of the Consumer Protection Act, 1986 (herein after to as ‘the Act’) seeking direction from this Hon’ble Forum to the Opposite Parties to make payment of beneficiary reliefs amount sanctioned under the scheme with interest at 12% p.a. and Rs. 10,000/- claimed as compensation and cost of the proceedings.

2. Version notice served to the Opposite Parties by RPAD. Opposite Party No.1 appeared through their counsel filed version and admitted that the Complainant is the holder of Yashaswini Health Scheme Card and admitted to the hospital and discharged on 8.6.2008. The Complainant produced the documents of Yashaswini Scheme on 6.6.2008 and the same has been sent to the 2nd Opposite Party through fax but the pre-authorization acceptance was not received back by the 1st Opposite Party, who then enquired over the telephone. The 2nd Opposite Party informed that when the pre-authorization form was sent it was the transition period of pre-authorization system from fax to E-mail. Since the 2nd Opposite Party received the fax but did not inform the change of system or gave pre-authorization sanction. The 1st Opposite Party has sent E-mail on 11.8.2008 and the pre authorization sanction of Rs.6,000/- was done by the 2nd Opposite Party on 13.8.2008. The bill was prepared and as per the Yashaswini Scheme Rules the bills have to be approved and the patient should be identified by the co-ordinator appointed by the Government. The co-ordinator visited the 1st Opposite Party only on 29.8.2008, the 1st Opposite Party has sent the bills and identification signature to Bangalore on 1.9.2008. The 2nd Opposite Party has rejected the claim stating that the bill reached on 9.9.2008 not within 90 days of discharge. It is submitted that the 1st Opposite Party has done all the procedures and there is no delay or deficiency on the part of this Opposite Party and prayed for dismissal of the complaint.

Opposite Party No.2 despite of serving notice neither appeared nor contested the case till this date. Hence we have proceeded exparte as against the Opposite Party No.2. The acknowledgement placed before the FORUM marked as court document No.1.

3. In view of the above said facts, the points now that arise for our consideration in this case are as under:
(i) Whether the Complainant proves that the Opposite Parties committed deficiency in service?
(ii) If so, whether the Complainant is entitled for the reliefs claimed?
(iii) What order?

4. In support of the complaint, Smt. Hemalatha (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her. Ex C1 to C8 were marked for the Complainant as listed in the annexure. One Dr. Y. Subraya Bhat (RW1), Treating Doctor of the Opposite Party No.1 filed counter affidavit and answered the interrogatories served on him. Ex R1 to R8 were marked for the Opposite Party No.1 as listed in the annexure. The Complainant and Opposite Party No. 1 produced notes of arguments.

We have considered the notes/ oral arguments submitted by the learned counsels and also considered the materials that was placed before the Hon’ble Forum and answer the points as follows:
Point No. (i): Affirmitive.
Point No. (ii) & (iii): As per the final order.
Reasons
5. Point No. (i) to (iii):
It is admitted fact that the Complainant is the holder of Yashaswini Health Card Scheme bearing ID No. 0214308. Under the said Yashaswini Health Card Scheme the Complainant is entitled for the medical benefits. It is also not disputed that the Complainant got admitted to Adarsha Hospital Puttur i.e., 1st Opposite Party on 31.5.2008, undergone LSCS (caesarian surgery) on 1.6.2008 and discharged on 8.6.2008.
Now the point in dispute is that the documents in connection to claim benefits from Yashaswini Scheme produced before the 1st Opposite Party on 6.6.2008 by the Complainant. As per pre-authorization request made by the 1st Opposite Party, the pre-authorization sanction of Rs.6,000/- was done by the 2nd Opposite Party on 13.8.2008. The medical bills, identification and the approvals were done and sent to the 2nd Opposite Party but the 2nd Opposite Party failed to pay the amount till this date. Thereafter the Complainant issued a notice to comply the same. In spite of repeated requests the Opposite Parties failed to reimburse the medical expenses.
The 1st Opposite Party admitted that the Complainant was admitted to the hospital and discharged on 8.6.2008. The Complainant has produced the documents of Yashaswini Scheme on 6.6.2008, immediately the 1st Opposite Party sent the pre-authorization form through fax. But the pre-authorization acceptance was not received back by the 1st Opposite Party. Thereafter 1st Opposite Party repeatedly enquired and sent E-mail on 11.8.2008. The pre-authorization sanction of Rs.6,000/- was done by the 2nd Opposite Party on 13.8.2008. It is submitted that as per the Yashaswini Scheme rules the bills have to be approved and identified by the co-ordinator appointed by the Government. The co-ordinator visited the 1st Opposite Party on 29.8.2008. On 1.9.2008 the 1st Opposite Party sent the bills and identification signature but the 2nd Opposite party rejected the claim on 26.9.2008 stating that bill not reached within 90 days. There is no lapse on the part of the 1st Opposite Party.
Now the point for consideration is that, admittedly the Complainant submitted the Yashaswini Scheme document particulars on 6.6.2008 to the 1st Opposite Party. Thereafter the pre-authorization form was sent to the 2nd Opposite Party and the pre-authorization sanction of Rs.6,000/- was done by the 2nd Opposite Party on 13.8.2008. It is not disputed that as per Yashaswini Scheme Rules the bills will have to be approved and the patient should be identified by the co-ordinator appointed by the Government. In the given case, the co-ordinator appointed by the Government visited the 1st Opposite Party on 29.8.2008. There is no dispute that the bills were sent on 1.9.2008 hence there is no delay or lapses on the part of the 1st Opposite Party as well as the Complainant. We find that the co-ordinator appointed by the Government visited the 1st Opposite Party only on 29.8.2008 when such is the case without any further delay the 1st Opposite Party sent the bills and other particulars to honour the claim of the Complainant but the 2nd Opposite Party rejected the claim stating that the claim was not presented within 90 days is not acceptable. Admittedly the pre-authorization was sanctioned on 13.8.2008 by the 2nd Opposite Party and as per Ex R2 the 1st Opposite Party sent the pre-authorization form through fax on 6.6.2008. The 2nd Opposite Party ought to have sanctioned the pre-authorization as soon as the receipt of the pre-authorization fax from the 1st Opposite Party on 6.6.2008. Since the 2nd Opposite Party received the pre-authorization fax within 90 days and pre-authorization was sanctioned on 13.8.2008, the co-ordinator appointed by the Government visited the hospital only on 29.8.2008 as per Ex R5, now the Opposite Party No.2 is not reasonable to reject the claim of the Complainant. There is no lapse on the part of the Complainant as well as Opposite Party No.1 is proved before us by oral as well as documentary evidence.
Apart from the above, it can be seen that the 2nd Opposite Party did not appear before this FORUM nor contradicted the oral evidence as well as documentary evidence placed on record from the Complainant and the 1st Opposite Party. The entire evidences of the Complainant as well as the 1st Opposite Party is not contradicted nor rebutted by the 2nd Opposite Party hence it requires no further proof. Non-appearance of the 2nd Opposite Party itself shows their negligence.
By looking into the entire materials placed on record, we are of the considered opinion that in spite of sending pre-authorization on 13.8.2008 for Rs.6,000/- as per Ex R4 now it cannot be contended that the claim of the Complainant was not submitted within 90 days. The repudiation of the bill amount i.e., Rs. 6,000/- by the 2nd Opposite Party is arbitrary and not justifiable. Therefore, we hold that the service rendered by the Opposite Party No.2 is deficient. We direct the 2nd Opposite Party to pay Rs.6,000/- to the Complainant immediately. And further Rs.3,000/- is awarded as compensation for the inconvenience and harassment caused by the 2nd Opposite Party. And further Rs.1000/- is awarded as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.
As far as the 1st Opposite Party is concerned, there is no deficiency or any lapse on their service. Hence the complaint against Opposite Party No.1 is hereby dismissed.
6. Accordingly we pass the following:

ORDER
The complaint is allowed. Opposite Party No.2 is hereby directed to pay Rs.6,000/- (Rupees Six thousand only) to the Complainant immediately. And Rs.3,000/- (Rupees Three thousand only) as compensation and Rs.1,000/- (Rupees One thousand only) as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.


Complaint against Opposite Party No.1 is hereby dismissed.

Copy of this order as per statutory requirement, be forwarded to the parties free of cost and file shall be consigned to record room.

(Dictated to the Stenographer typed by her, revised and pronounced in the open court on this the 31st day of August 2009)


PRESIDENT MEMBER
(SMT. ASHA SHETTY) (SRI. K. RAMACHANDRA)

[Raviprakash]

Yeshaswini's Appeal in this case was dismissed for non-prosecution. Yeshaswini's advocate or Yeshaswini's representatives never turned up in the court even when called on six counts. Karnataka State Consumers Redressal Commission dismisses its appeal and orders for payment of claim amount to the Consumer. Open and see the attached order sheet.

[Raviprakash]

Yashaswini has sent a cheque for Rs.10,000/- to Mrs. Hemalatha. Mr. N.G. Chandrashekar advocate for the complainant states that the case is closed as satisfied.
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