SMT. MOLYKUTTY MATHEW : MEMBER
Complainant filed this complaint U/S 12 of Consumer Protection Act 1986 for an order directing the OP No. 1 to pay Rs. 30000/- as treatment expense and compensation to the complainant for the deficiency of service and unfair trade practice.
The case of the complainant in brief
The complainant is a medi policy holder under RSBY scheme policy No. URN 32021000513004768 valid till 31/03/2019. As per the advice of the doctor the complainant admitted with OP1 for fibroid uterus on 24/06/2018 and after operation discharged on 29/06/2018. The policy completely of a cashless scheme and reimbursement to the hospitals is based on the electronic transaction data received from hospital on daily basis through RSBY software. Claim information in TMS is a prerequisite for payment to hospital. OP No.1 failed to intimate the admission to OP No.2 even though the medi policy card was handed over to OP No.1 hospital at the time of admission. OP No.1 collected Rs 30000 from the complainant and discharge allowed only on payment received from the complainant. The complainant caused much mental agony and financial loss for the act of OP No.1. In fact RSBY medi policy is a cashless facility available to the complainant. The claim made for reimbursement disallowed by OP No.2 stating no provision for reimbursement. OP No.1 failed to intimate the admission to OP No.2 to facilitate cash less facility. The discharge bill was forced to pay by complainant. So the OP No.1 is liable to return Rs. 30000 as received by the complainant. The act of OP No.1 amounts to deficiency of service and unfair trade practice. Hence the complaint.
After filing the complaint notice was issued to both opposite parties. OP No.2 appeared before the commission and filed his written version OP No.1 not appeared before the commission and not filed his version and set ex-parte in this case. OP No.2 contended that OP No.2 is an unnecessary party to the complaint and there is no deficiency of service claimed against this OP. Moreover OP No.2 is not liable to pay any amount to complainant. Hence the complaint may be dismissed. On the basis of the rival contentions by the pleadings the following issues were framed for consideration.
- Whether there is any deficiency of service on the part of opposite parties
- Whether the complainant is entitled for any relief
- Relief and cost
The evidence on merits of the oral testimony of Pw1 and Ext. A1 to A7 were marked. No oral evidence and documents from the side of opposite parties.
For the sake of conveniences the issue No.1 to 3 taken together for consideration.
The complainant adduced evidence before the commission by submitting her chief affidavit in lien of her chief examination to the tune of the pleadings in the complaint and denying the contention in the version. She was cross examined as Pw1 by OP No.2. The documents Ext A1 to A7 (Series) marked on her part to substantiate her case. According to the complainant in Ext. A1 she is one of the medi policy holder under RSBY Scheme. The policy completely covers the cashless scheme and reimbursement to the hospital is based on the electronic transaction data received from hospital on daily basis through RSBY software. In Ext. A2 the reply sent by OP2 to District collector, Kannur states that the hospital have not informed the insurance company or blocked the procedure in RSBY software. In RSBY there is no option of reimbursement to beneficiaries as per tender clause 12 and it is completely a cashless Scheme and reimbursement to the hospital is based on the electronic transaction data received from hospital on a daily basis through RSBY software. So OP No.2 is not liable to reimbursement. In Ext. A3 is the discharge card and Ext. A4 is the investigation report. In Ext.A5 denotes the prescription by Dr. Ajith and Ext. A6 is the OP record. As per Ext. A7(Series) the complainant remitted an amount of Rs. 30,259 before OP No.1. In Ext. A7(Series) dated 29/06/2018 one entry noted “concession” (poor) deducted amount of Rs. 2108. So the financial capacity of the complainant is very low and she resides in a poor family. It is a cashless facility available according to RSBY medi policy the OP No.1 failed to intimate the admission to insurance company to facilitate cashless facility. So the complainant forced to pay the discharge bill to OP1. So we hold that there is deficiency of service on the part of OP1. Moreover the evidence the complainant (Pw1) deposed that OP No.1. OP No.2 വിനെ കൃത്യമായി അറിയിക്കാത്തതിനാലാണ് നിങ്ങൾക്ക് ഇൻഷുറൻസ് പോളിസി ലഭിക്കാതിരുന്നത് എന്ന് പറഞ്ഞാൽ ശരിയാണ്. OP No.2 വിൻറെ ഭാഗത്തു നിന്ന് യാതൊരു വീഴ്ചയും ഉണ്ടായിട്ടില്ല എന്ന് പറഞ്ഞാൽ ans. ശരിയാണ്. OP No.2 വിൻറെ കയ്യിൽ നിന്ന് നിങ്ങൾക്ക് നഷ്ടപരിഹാരം ആവിശ്യപെട്ടിട്ടില്ല . So it is clear that Pw1 claimes the relief sought against OP No.1only.
On perusal of the pleading evidence and documents we the commission hold that OP No.1 is directly bound to redressal the grievance caused to the complainant. So the complainant is entitled to get the re-imbursement of Rs. 30000/-(Medical bills) from the OP No.1 along with Rs. 5000 as compensation and litigation cost to the complainant.
In the result the complaint is allowed in part directing the OP No.1 to reimburse an amount of Rs. 30000 to the complainant along with Rs.5000/- as compensation and cost of the litigation to the complainant within 30 days of receipt of this order. Failing which the complainant shall be at library to execute the order as per the provisions of Consumer Protection Act 2019.
Exhibits for complainant
Ext. A1 - Policy Smart Card
Ext. A2 - Letter Issued by OP.2
Ext. A3 - Discharge Card
Ext. A4 - Investigation Report
Ext. A5 - Prescription by Dr. Ajith
Ext. A6 - OP Card dated 27/07/2018
Ext. A7(series) - Medical Bills
Examination of Witness
Pw1 - Complainant (Bushara K)
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
/Forward by order/
Senior Superintendent
