Karnataka

StateCommission

A/196/2015

Yeshasvini Co-operative Farmers - Complainant(s)

Versus

Sandhyamani, - Opp.Party(s)

Santhosh Kumar M B

12 Oct 2023

ORDER

Date of Filing :18.02.2015

Date of Disposal :12.10.2023

 

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

 

DATED:12.10.2023

 

PRESENT

 

HON’BLE Mr JUSTICE HULUVADI G RAMESH : PRESIDENT

 

Mr K B SANGANNANAVAR: JUDICIAL MEMBER

 

Mrs DIVYASHREE M:LADY MEMBER

 

APPEAL No 196/2015

 

 

M/s Yeshasvini Co-operative Farmers

Health Care Trust

6^th Floor, M S Building Co-Op Secretariat

Dr B R Ambedkar Veedhi

Bengaluru-560 001

Rep. by its Chief Executive Officer
(By Mr Santhosh Kumar M B, Advocate)                               Appellant    

 

-Versus-

 

1.  Smt Sandhyamani

     D/o Sri Sanjeeva Poojari

     Aged about 23 years

     R/at Mallibettu House

     Kadeshwalya Village

     Bantwal Tq.,

     Dakshina Kannada

    (By Mr Krishnamoorthy D, Advocate)

2.  The Manager

     Athena Hospital

     Falnir Road

     Mangaluru-01

 

3. The Manager

    Medi Assist India TPA Pvt. Ltd.,

    Sri Krishna Arcade

    47/1, 9^th Cross

    1^st Main Road,

    Sarakki Industrial Layout

    3^rd Phase, J P Nagar

    Bengaluru – 560 078

 

 

4. The Secretary

    M/s Kadeshwalya Milk Producers

    Mahila Co-Operative Society

    Bantwal Taluk

    Dakshina Kannada District                                             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 28.11.2014 passed in Consumer Complaint No.152/2014 by District Consumer Disputes Redressal Forum, Mangaluru, Dakshina Kannada District(for short, the District Forum).

 

2.       Heard the arguments of the Learned Counsel for Appellant & Respondent No.1.   Inspite of service of Notice on Respondent Nos.2 to 4, none appeared and hence their argument has been taken as heard.

 

3.       The District Forum after enquiring into the matter, deemed it fit to allow the Complaint in part and directed the OP1 to pay Rs.44,485/- to the Complainant along with interest @ 8%p.afrom the Date of Complaint till the date of payment.

 

4.       Aggrieved by this Order, OP1 is in Appeal inter-alia contending amongst other grounds that, the payment made by the Complainant is not a premium amount for any Insurance Policy or any Medi-claim Policy, instead, it is his voluntary contribution to the Trust’s Corpus Fund, which includes beneficiary’s contribution and other contributions/donations received by the Trust and the Government of Karnataka is funding the scheme for the benefits of the Members of the Trust.   Further,pleaded that TPA looking on the line of treatment, has sanctioned the maximum limit of amount for surgery, which benefit was provided to the Complainant, now his claiming for the difference amount, for the treatment which is not covered under the Scheme is illegal and thus seeking 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, the Complainant is a Member of OP1 and on 15.10.2013 she took treatment for pus discharge & loss of  hearing, in Athena Hospital/OP4 and was discharged on 19.10.2013 after spending  Rs.49,500/-.  OP2 sanctioned Rs.5,000/-to OP4 but, OPs 1 & 2 not reimbursed the remaining medical expenses incurred by the Complainant. The main allegation of the Complainant is that she is entitled for reimbursement of the amount spent by her towards treatment. As per the procedure, OP4 sent request for pre-authorisation to OP2 and accordingly, OP2 sanctioned Rs.5,000/-, out of Rs.49,500/- spent towards treatment.  Hence, Complainant seeking reimbursement of medical expenses incurred by her.

 

7.       The contention of Appellant/OP1 that Yashaswini Co-operative Farmers Health Care Scheme is not an InsuranceScheme, it is a Trust formed by the Government of Karnataka in the year 2003 to help theCo-operative Farmers.  In order to avail benefits of the Yashaswini Co-operative Farmers Health Care Scheme, members have to follow the procedure prescribed under the Scheme.  To claim any amount under the Scheme, the Member has to take treatment in any of the Network Hospitals earmarked by the Trustand if the Member availed treated elsewhere, OP1 is not liable to pay any amount to the Member,since it is breach of the Terms of the procedure prescribed under the Scheme.   Some of the Hospitals have not obtained pre-authorisation from the implementing agency and some of the Members had chosen to enjoy the Special Ward benefits which are not coming under the Scheme.  Co-operative Society/Bank and Medi Assist India Pvt. Ltd., are neither Necessary nor Proper Party to the case.

 

8.       The observation of the District Forum in para IV of its Impugned Orderthat there is no details of names of the listed Network Hospitals or list of operation and the amount fixed on 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 Farmers.  OPs cannot expect from the members/beneficiaries that they violated the terms and conditions or any alleged procedure and thereby denying the benefits.   

 

          The District Forum further recorded in the Impugned Order that, in order to safeguard consumer interest, six consumer rights were initially envisaged, the right to choice is one among them.  Hence, when the Health Care Scheme is introduced by the Trust or otherwise should borne in mind that it should be inconsonance with the articles mentioned in the Indian Constitution. The 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 do not operate harshly against the Insured/Members and in favour of the Insurer/Trust. A Prospectus of Insurance products/ Healthcare Scheme are required to be clearly state the scope of benefits, the extent of insurance cover and in explicit manner explain the warranties, exceptions and conditions of the insurance health cover/scheme and the product shall be clearly spelt out with regard to their scope of insurer or its agent or other intermediary shall provide all material information in respect of the proposed cover to the Insured/Members herein.

 

9.       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 specimen of an Identity Card issued under the Scheme.     

 

10.     On perusal of the documents produced along with Memo by the learned Counsel for Appellant, it is seen that as per Gazette Notification No.CO 423 CLS 2012, Bangalore dated 27.09.2013, wherein, in Part-2, the list of Net Work Hospital District-wise has been mentioned and the same has been renewed as on 31.08.2013, wherein at Sl. No.232 Athena Hospital, Dakshina Kannada-575 001has been listed as one of the Net Work Hospital.

 

11.  Thus Athena Hospital, Dakshina Kannada has been listed as one of the Net Work Hospital by Govt. of Karnataka and the Complainant took treatment for pus discharge from Ear & loss of  hearing in said hospital and spent  Rs.49,500/-.  Though OP2 sanctioned Rs.5,000/- to OP4, but, OPs 1 & 2 not reimbursing the remaining 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 claimof reimbursement of expenses with minor deviations are to be considered, that too, when the 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.

 

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

 

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

 

14.     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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