State Consumer Disputes Redressal Commission
Konaki Satyanarayanamma W/O Subbaiah vs 1. Gollu Surya Rao S/O Pydithalli on 3 October, 2012
BEFORE
A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
F.A.No.351
OF 2011 AGAINST C.C.NO.123 OF 2010 DISTRICT FORUM VIZIANAGARAM
Between:
M/s Visakha
Hospital & Diagnostics Ltd.
(Care Hospital), rep. by its Managing Director
cum Chairman, A.S.Raja Complex, Waltair
Main road, Ram Nagar, Visakhapatnam
Appellant/opposite
partyno.1
A N D
Gollu Surya Rao S/o Pydithalli
aged 55 years, Occ: Agriculture Labour
R/o 5-4-, Alamanda Village
Jami Mandal Vijayangaram Dist.
Respondent/complainant
The District Co-ordinator
Rajeev Aarogyasri Program
Dist. Govt. Head Quarters
Hospital Campus (Head Quarters Hospital)
Vijayanagaram
M/s The CEO, Rajeev Aarogyasri Health
Care Trust Dr.B.R.Amebdkar Open University
Road, Dr.YSR Bhavan Hyderabad
(R2 & 3 are proforma Parties)
Respondents/opposite
parties No.2 & 3
Counsel for
the Appellant M/s A.Srinath
Counsel for
the Respondent Served (R1)
G.P.for
State (R2&3)
QUORUM: SRI R.LAKSHMINARASIMHA RAO, HONBLE MEMBER
AND SRI THOTA ASHOK KUMAR, HONBLE MEMBER WEDNESDAY THE THIRD DAY OF OCTOBER TWO THOUSAND TWELVE Oral Order (As per Sri R.Lakshminarasimha Rao, Honble Member) ***
1. The first opposite party is the appellant. The complainant filed the complaint claiming reimbursement of medical expenses of `1,84,857/- with interest and `50,000/- towards damages and costs.
2. The complainant was admitted to the first opposite party-hospital on 13.09.2009 with the complaint of chest pain and for the treatment of CAD- Mild LV dysfunction and he was discharged on 23.09.2009 and the complainant paid the bill for an amount of `1,84,857/-. The complainant contended that the opposite parties no.2 and 3 issued Arogyasri card to him and the first opposite party-hospital at the time of his admission informed him that he need not pay any amount and at the time of discharge the first opposite party collected the amount from him and the opposite parties are liable to repay the amount to him.
3. The claim is resisted on behalf of the first opposite party on the premise that the complainants son informed the first opposite party that his father is not covered under Arogyasri and he issued letter undertaking to pay the expenses of his father and after three days he approached Arogyamitra with a request to see that his fathers case is covered by Arogyasri and as the card produced by him did not match, he paid the treatment charges of his father at the time of discharge of the complainant. The second opposite party has also stated that the card furnished by the complainant was mismatched and the complainant is not entitled to for any benefits under Arogyasri . There was no deficiency in service on the part of the first opposite party-hospital.
4. The second opposite party resisted the claim on the premise that the Arogyamitra, viz. the first opposite party hospital verified the ration card of the complainant and found that the card number belongs to Sri Verma Venkata Appa Rao. According to norms of the Arogyasri scheme the patient has to produce his white ration card within 48 hours in emergency cases, from the date of his admission and on his failure to do so, he is not entitled for benefits under the scheme as per the terms of the MOU.
5. It is contended that Arogyamitra had not informed the complainant is entitled to benefits under the scheme and the first opposite party informed him that the card details and particulars of the family members did not match and the treatment was completed on 13.09.2009 and as such he is not entitled for any benefits. It is contended that the complaint is barred by time and there was no deficiency in service on the part of the opposite party no.2 and 3. Hence, prayed for dismissal of the complaint.
6. In support of his claim, the complainant has filed his affidavit and the documents, ExA1 to A5 and on behalf of the opposite parties, the Medical Superintendent of the opposite party no.1, the District Co-Coordinator of the opposite party no.2 have filed their respective affidavits and the documents Exs.B1 to B14.
7. The District Forum allowed the complaint on the premise that the complainant is a member of Rajiv Arogya Community Health Insurance Scheme and he holds a white ration card and he is entitled for return of the amount paid by him at the time of discharge from the first opposite party-hospital. The District Forum directed the first opposite party-hospital to repay the amount of `1,84,857/- and pay an amount of `40,000/- towards compensation and `5,000/- towards costs. The second opposite party and the third opposite party were directed to accept the claim processed by the first opposite party-hospital.
8. Feeling aggrieved by the order of the District Forum, the first opposite party-hospital has filed appeal contending that the District Forum had not considered the evidence on record and that the ration card produced by the complainant is that of another person , Sri Varma Venkat Appa Rao and that as per Article 2.5 of MOU entered into between Star Health and Allied Insurance Company Ltd and the opposite parties, the applicability of the scheme has to be decided by the opposite parties no.2 and 3. It is contended that the complainant was required to pay the hospitalization charges in the event of deferring the processing of his claim and the complainant has to proceed against the authorities which process and decide him claim. It is contended that as per the guidelines of Rajeev Arogyasree Scheme the insurance company has to pay the amount if any, to the complainant and the insurance company is not made party to the complaint.
9. The learned Government Pleader has filed written arguments.
10. The point for consideration is whether the order of the District Forum suffers from misappreciation of fact or law?
11. The State Government had introduced a social welfare insurance scheme Rajiv Arogyasri Scheme for providing health insurance coverage to the persons of BPL families belonging to five districts of Hyderabad, Adilabad, Kurnool, Vijayanagaram and Vishakapatnam against specified surgical/therapeutic procedures for which purpose the Arogysri Health Care Trust created a network of service providers. An Agreement/MOU was entered into between the Star Health and Allied Insurance Company Ltd and the opposite parties which was in force for a period of one year from 17.07.2010 to 16.07.2010. Articles 2.5 to 2.10 of the MOU read as under:
2.5 Conversion of cash patients into Aarogyasri:
Provider agrees to take a declaration from patient at the time of admission itself on the applicability or otherwise of Aarogyasri in his/her case. In emergency/trauma cases, patients may be allowed 48 hours after admission to claim Aarogyasri benefit.
2.6. Online Updation of Bed Occupancy:
Provider agrees to upload the bed occupancy under each specialty for which hospital is empanelled as and when required.
2.7 The first point of contact for all the patients (out patients and in patients) coming under the Scheme will be the Aarogyamithra positioned at Network Hospital.
2.8. The Provider agrees to follow ALL the guidelines in rendering the services to Aarogyasri patient annexed hereto as part & parcel of this MOU. The Provider also agrees to follow and adhere to the guidelines issued by the Trust/Insurer from time to time.
2.9. The Provider agrees to follow & adhere to the ON-LINE workflow of the Aarogyasri community Insurance Scheme in providing services to Aarogyasri patients.
2.10. Eligibility Criteria:
The provider agrees to follow the guidelines on eligibility criteria for admission of patients under Rajiv Aarogyasri Community Health Scheme as mentioned here under and the Following guidelines are re-emphasized by the Trust to be followed by Network hospitals in cases where clarifications are sought.
Sl.No. ANOMALY IN CARDS NATURE OF TREATMENT REQUIREMENT FOR BENEFIT 1 No Rajiv Aarogyasri Health Card
-
BPL Card
2.
No name but photo available in
-
Patient self declaration is
12. The complainant claims to be a beneficiary within the meaning of Article 2.10 of the MOU and he relies upon the entries in white ration card which the first opposite party denied to be that of the complainant. The learned counsel for the first opposite party has contended that the complainants son had issued undertaking at the time of admission of his father to the hospital and entries in the white ration card did not match to the entries in the format as also the first opposite party is a facilitator and the complainant cannot claim any amount from it.
13. The learned government pleader has contended that the complainant is not entitled and the period of insurance coverage is already expired and that the opposite parties no.2 and 3 are only facilitators and as such the complainant cannot proceed against them. It is contended that the MOU does not provide for reimbursement of amount incurred for treatment even in a net-work hospital.
14. The opposite parties are mediators or facilitators and their role in terms of the MOU is limited to process the claim. There has been a dispute as to the entitlement of the complainant to claim the benefit under the scheme and the opposite parties being facilitators between the beneficiary and the insurance company and they cannot be fastened with any liability in terms of the MOU.
15. In Manager, Andhra Bank Vs Smt S.Shantha Kumari and others in FA NO.1314 of 2004,
2. The Branch manager, Andhra Bank, Vikarabad Branch Vs. Smt G.Sulochana and others in F.A.No.1099 of 2005 this Commission considering the ratio laid down in various decisions of the National Commission , held that the role of facilitator cannot be stretched to the extent of its liability to pay the amount under the insurance policy.
16. For the foregoing reasons and in view of the settled proposition of law that the facilitator could not be fastened with liability as regards the payment of sum assured under the Rajiv Arogysri scheme, the order of the District Forum for recovery of the amount by the first opposite party and direction to the opposite parties no.2 and 3 to process unsustainable claim is liable to be set aside.
17. In the result, the appeal is allowed. The order of the District Forum is set aside. Consequently, the complaint is dismissed. The parties shall bear their own costs.
Sd/-
MEMBER Sd/-
MEMBER Dt.03.10.2012 KMK*