Karnataka

StateCommission

A/664/2021

Yeshasvini Cooperative Farmers Health Care Trust, - Complainant(s)

Versus

Lokesh Rai - Opp.Party(s)

Santhosh Kumar MB

11 Oct 2023

ORDER

Date of Filing :06.09.2021

Date of Disposal :11.10.2023

 

BEFORE THE KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU (PRINCIPAL BENCH)

 

DATED:11.10.2023

 

PRESENT

 

HON’BLE Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

Mr K B SANGANNANAVAR: JUDICIAL MEMBER

 

Mrs DIVYASHREE M:LADY MEMBER

 

APPEAL No 664/2021

 

Yeshasvini Co-operative Farmers

Health Care Trust

No.70, 2^nd Floor, KMC Building

Opp : to Basvanagudi Post Office

KR Road, Basavanagudi

Bengaluru-560 004

Rep. by its Chief Executive Officer

(By Mr Santhosh Kumar M B, Advocate)                                Appellant

         

 

-Versus-

 

1.  Sri Lokesh Rai

     S/o Sri Babu Rai

     Aged about 40 years

     R/at Kukkunjodu House

     Kedambady Village

     Puttur Taluk

     Dakshina Kannada District

2.  Kedambady Keyyuru Primary

     Agricultural Co-operative Society

     Kedambady, Puttur

     Represented by its Secretary

     (By Mr.I Gopalakrishna, Advocate)

 

3. M/s Yenepoya Speciality Hospital

    K S Road, Kodiyalabail

    Mangaluru-03

    Represented by its Director                                           Respondents                                 

 

 

 

:ORDER:

 

Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

1.       This is an Appeal filed under Section 15 of Consumer Protection Act 1986, by the Complainant, aggrieved by the Order dated 20.05.2021 passed in Consumer Complaint No.80/2019 by District Consumer Disputes Redressal Commission, Mangaluru, Dakshina Kannada District(for short, the District Commission).

 

 

2.       Heard the arguments of learned Counsel for Appellant and Respondent No.2. Inspite of service of Notice on Respondent Nos.1  & 3, none appeared and hence their arguments has been taken as heard.

 

3.       The District Commission after enquiring into the matter, deemed it fit to allow the Complaint against OP1 and Dismissed the Complaint against OP Nos. 2 & 3.

 

 OP 1 was directed to pay a sum of Rs.2,77,632/- with interest @ 6% p.a from the date of filing of the Complaint till realisation and also to pay a sum of Rs.20,000/- as Compensation and Litigation cost.

 

4.       Aggrieved by this Order, OP1 is in Appeal, contending P3 Hospital had also intimated the Complainant with regard to the requirement of pre-authorisation and inspite of this, the Complainant had given consent for the Surgery and also consented to bear the entire cost of the Surgery, which fact is not at all considered by the District Commission.  The joint Replacement Expert Committee on the line of treatment, had opined that Surgery is not required to be underwent by the Complainant, upon which, the OP3 should not have subjected the Complainant for the Surgery, inspite of which, on the instance of the Complainant the Surgery was performed by OP3 Hospital, consequently, the Complainant has foregone his rights of Claims from the OP1.  Further, Appellant contended that the Yeshasvini is a Government subsidiary, has listed the Hospitals to provide treatment at a pre-agreed rate to its beneficiaries, wherein, even the rates charged are too high as compared to the agreed rates with the Yeshasvini Scheme.   As the Complainant had consented for to bear the expenses he was provided treatment by OP 3 at the rates agreed to between the Complainant and the Hospital. Thus, Appellant seeks to set aside the Impugned Order by allowing the Appeal.

 

5.       Perused the impugned order, Grounds of Appeal and documents on record.

 

6.       It is not in dispute that Complainant is a member of OPs1 & 2 as per Receipt No.1454, which is valid for one year and he had paid Rs.1,285/- to OP2 towards the Medical Insurance of OP1, based on which, OP1 will reimburse the medical expenses to the members.  OP3 is one of the Network Hospital and the Complainant was admitted to the OP3 Hospital on 16.05.018 for Vascular Necrosis Bilateral Hip Operation and he was discharged on 23.05.2018 and had spent a sum of Rs.2,77,632/- for the Operation.

 

7.       The District Commission in Para 30 of its Impugned Order had observed that there is no details of the listed Network Hospitals or list of operation and the amount fixed for the Operation, etc., at the same time, there is no credible/convincing evidence available on record to prove that the Terms & Conditions of the Scheme are within the knowledge of the Complainant and most of the beneficiaries are un-educated  villagers/Co-operative Farmersand this being the ground reality, OPs cannot form an unilateral opinion that the members/beneficiaries  violated the Terms & Conditions or any violation of the alleged procedure and thereby preferring to deny the benefits to the members.   

 

          The District Commission further recorded in the Impugned Order that, in order to safeguard consumer interest, six consumer rights were initially envisaged and the right to choice is one among them.  Hence, when the Health Care Scheme is introduced by the Trust or otherwise, it should be borne in mind that, it should be in consonance with the Articles mentioned in the Indian Constitution. The subject Scheme is a benevolent scheme started by the Government of Karnataka to provide medical assistance to the poor farmers and to protect the interest of the members of the Yashaswini Scheme holders/Members and not to make profit out of it.  The Opposite Party should see that the Terms of the Insurance Scheme does not operate harshly against the Insured/members and in favour of the insurer/trust.  A Prospectus of Insurance product/Healthcare Scheme are required to be clearly state the scope of benefits, the extent of insurance cover and in an explicit manner explain the warranties, exceptions and conditions of the Insurance Health cover/Scheme and the product shall clearly spell out with regard to the scope of Insurer or its agent or other intermediaryand shall provide all material information in respect of the proposed cover to the Insured/Members in general and the Complainant herein, in particular, in so far as the present Complaint is concerned.

 

8.       During the course of arguments, the learned Counsel for Appellant in this Appeal, filed Memo along with copy of Gazette Notification dated 27.09.2013, Terms &Conditions of the Scheme and a copy of the sample Identity Card issued under the Scheme.         

 

9.       On perusal of the Terms & Conditions of Scheme, copy of sample Identity Card and copy of Gazette Notification dated 27.09.2013 produced along with Memo by learned Counsel for the Appellant, it is seen that as per Gazette Notification No.CO 423 CLS 2012, Bangalore dated 27.09.2013, wherein in Part-2, in the list of names of Net Work Hospital District-wise,it has been mentioned and the same has been renewed as on 31.08.2013, wherein, at Sl No.247 OP’s Hospital appears under the Net Work Hospital.

 

10.     Thus M/s Yenepoya Speciality Hospital, Mangalore, listed as one of the Net Work Hospital by Govt. of Karnataka and OPs having not reimbursed the medical expenses incurred by the Complainant, amounts to deficiency in service.  The very purpose & object of a Welfare Scheme implemented by a Government gets defeated, if a narrow and conservative approach is taken by the implementing/enforcing authorities, while the claim of reimbursement of expenses is with minor deviations are to be considered, that too, when the alleged additional treatment availed is a related suffering of the main ailment.  Therefore, the expenses incurred and claimed by the Complainant needs to be reimbursed in full.

 

11.     In view of the foregoing observation, this Commission is of the considered opinion that the Impugned Order is just and proper and there are no strong reasons to interfere with the same. Accordingly, the Appeal stands Dismissed with no order as to costs.

 

12.     The Statutory Deposit in this Appeal is directed to be transferred to the District Commission for further needful.

 

13.     Send a copy of this Order to the District Commission, as well as to the parties concerned, immediately.

 

 

Lady Member                  Judicial Member                       President

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