Complaint filed on: 26-04-2013

Remanded on: 08-12-2016

                                                      Disposed on: 15-07-2017

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM

OLD DC OFFICE COMPOUND, TUMAKURU-572 101

CC.No.60/2013

DATED THIS THE 15^th DAY OF JULY 2017

PRESENT

SMT.PRATHIBHA. R.K. BAL, LLM, PRESIDENT

SMT.GIRIJA, B.A., LADY MEMBER

Complainant: -

                                        Sri.Kalaiah Alias Kale Gowda,

                                                S/o. Thimmaiah, Sr. Citizen and

Beneficiary, Under Yashaswini Raita

Arogya Rakshana Yojane,

R/o. Kaggere Village, Kunigal Taluk,

Tumakuru district  

(By Advocate Sri.H.M.Nagabhushan)

                                            V/s            

Opposite parties:-    

1.   The Deputy Registrar of Co-operative Societies and office in-charge of Yashaswini Raita Arogya Rakshana Yojane, Tumakuru district, Deputy Commissioner office complex, Tumakuru-01

2.   The Co-operative Development officer and office in-charge of Yashaswini Raita Arogya Rakshana Yojane, Kunigal Taluk, TAPCMS buildings, Kunigal Town, Tumakuru District

3.   The Secretary,

Milk Producers Co-operative Society Ltd, Kaggere, Kunigal taluk, Tumakuru district

4.   Yashaswini Trust,

No.70, 2^nd Floor, KMC building, near Basavanagudi post office, KR Road, Basavanagudi, Bengaluru.

5.   Bharathi Hospital, Enriching lives, No.4, Nagarabhavi main road, Prashanthanagar, Bengaluru-79       

(OP No.1 and 2-Reptd. by District Government pleader)

(OP No.3- Reptd. by advocate Sri.N.C.Gangadhara Shastry)

(OP No.4- Reptd. by advocate Sri.Santhosh Kumar.M.B)

(OP No.5- Reptd. by advocate Sri.B.Rudrachar)

REMANDED ORDER

SMT.PRATHIBHA. R.K. PRESIDENT

This complaint is filed by the complainant against the OP Nos.1 to 3, under Section 12 of the Consumer Protection Act. The complainant prays to direct the OP No.1 to 3 to pay the medical expenses of Rs.25,000=00 and Rs.5,000=00 incurred towards conveyance expenses with interest at the rate of 12% p.a. from the date of discharge from the hospital till realization along with costs and such other reliefs as deemed fit in the interest of justice and equity.

2. The brief facts of the complaint is as under:-

The complainant being Beneficiary as member of Yashaswini Raita Arogya Rakshana Yojane by paying renewal premium through the 3^rd OP under proper receipt No.30963 dated 26-7-2011 for the year 2012, the OPs are liable to reimburse the amount spent by the complainant towards surgery and that the complainant has undergone treatment/surgery as in patient in Bharathy Hospital, Nagarabhavi Main road, Bengaluru in between 8-10-2012 to o6-11-2012 by spending over Rs.25,000=00 and that his claim was not processed during the course of undergoing treatment as the complainant has lost his ID card and then the complainant claimed the same from the OPs for reimbursement, but in vain, as the official of the OPs told the complainant that, they cannot pay the medical bills, now as it was to be paid to the said hospital before discharge an thereby refused to reimburse, which amounts to deficiency in service and hence, the complainant got issued a legal notice dated 8-3-2013, but the OPs have not responded to the same inspite of service of notice. Hence, the complainant has filed this complaint against the OPs.

3. After service of the notice, the OP No.1 and 2 have appeared through the District Government Pleader and the OP No.3 to 5 have appeared through the advocate. The OP No.1 and 2 have filed common version and the OP No.3 to 5 have filed their separate version.

4. In the objection, the OP Nos.1 and 2 have contended that, the complaint filed by the complainant is not maintainable as it is bad for mis-joinder and non-joiner of necessary parties and that there was no deficiency in service on the part of these OPs and that OP No.1 was not aware of the transactions of the complainant with the OP No.3 and also about the treatment stated to have availed by the complainant or the expenses incurred by him towards medical treatment and that the complainant has failed to comply the terms and conditions laid down by Yashaswini Trust pertaining to Yashaswini Scheme and that the 1^st OP is only a facilitator of the scheme and the district level and that the complainant never approached the 1^st OP for redressal and of his grievance and that the notice got issued by the complainant though received was not replied as it was un-concerned and that the OP no.2 is not aware about the illness of the complainant or the treatment obtained by him by spending the amount and that the 2^nd OP is not even service provider under the Yashaswini Scheme, but only a facilitator to get the village mass enrolled willfully and voluntarily to Yashaswini Scheme and that the complainant though enrolled to the Yashaswini Scheme, the OP No.2 is not authorized to receive the premium, whatsoever by issuing the receipt and that these OPs are no way concerned about the strain or stress alleged by the complainant and that there was no talks held between the complainant and OP no.2 regarding the reimbursement and that the allegation made contrary to the law and facts, which are all false and that the complaint filed by the complainant is mis-conceived and that these OPs are not necessary parties and hence, among other grounds, it was requested to dismiss the complaint, in the interest of justice and equity.

5. In the version, the 3^rd OP has admitted the enrollment of the complainant as member to Yashaswini Scheme by paying the premium under the receipt as averred in the complaint, but it is contended inter-alia that the said amount was forwarded to the concerned authority by the 3^rd OP and a sum of Rs.24,910=00 allotted to the family of the complainant among 128 persons, was remitted to DCC bank and that since there was no deficiency in service on the part of this OP among other grounds, it was requested to dismiss the complaint with costs, so far as against the 3^rd OP.

6. In the version, the 4^th OP has categorically denied all the allegations made in the complaint are false and baseless. The 4^th OP has no knowledge of the treatment taken by the complainant at Bharathy hospital, Bengaluru. The complainant himself admitted that, he had lost the identity card and has not informed his membership to the Yashaswini scheme to the hospital nor to the OP. The complainant has not come before this forum with clean hands. No information regarding his treatment was provided during his stay in the hospital or even before admitting to the hospital. As per the terms and conditions of the scheme, any beneficiary who has to avail benefits of the scheme has to approach the hospital with his identity card and inform the hospital authority regarding his membership to the Yashaswini Scheme, the hospital submits for the pre-authorization informing the TPA of the Trust about the line of treatment provided to the beneficiary. If such beneficiary has availed any special wards in his treatment, the difference amount has to be paid to the hospital and hospital informs regarding the same to the beneficiary. In the present case, the complainant has not at all informed the hospital regarding his membership to the scheme. It is evident from his own statement in the complaint, where the complainant himself accepts that, he had no identity card at the time of admission. Hence, question of pre-authorization by the hospital does not arise at all and as the complainant had obtained treatment as paying patient in special ward, the scheme is not applicable to the complainant. The entire allegation of deficiency of service is on the OP No.1 and 2 in the complaint. There is a delay of more than two years in impleading the 4^th OP. The delay is caused by the complainant himself no explanation is providing for the delay caused. No allegation of deficiency of service is made on the 4^th OP. The terms and conditions in the brochure clearly mentioned that, the original identity card and receipt has to be provided to the hospital to claim the scheme benefits. Every member provides the steps to be taken in case of lost identity card. The treatment provide to the complainant is not an emergent surgery. Hence, it is evident that, the complainant has deliberately not informed about his membership to the hospital and also to the trust, now cannot claim damages for his own wrong. There is no cause of action and the 4^th OP has not committed any deficiency in service nor followed any unfair trade practice. Hence, the complaint is liable to be dismissed with cost.

7. In the version, the 5^th OP submitted that, the complaint filed against the 5^th OP is not maintainable. The 5^th OP admitted that, the complainant Kalaiah @ Kalegowda was admitted in the 5^th OP hospital for treatment on 27-10-2012 to 30-10-2012 and the complainant took treatment as an inpatient. As on the date of admission, the complainant has not furnished any document to claim the benefit under the scheme of Yashaswini Raitha Arogya Rakshana Yojane in the hospital. The complainant has not produced any kind of document to claim benefit under the Yashaswini scheme, therefore the 5^th OP directed the complainant to pay the hospital charges. Under this circumstances, the 5^th OP is not liable to reimburse or to compensation as claimed in the complaint. Hence, the 5^th OP has prayed to dismiss the complaint with cost.    

8. In the course of enquiry into the complaint, the complainant and the OPs have filed their affidavit evidence reproducing what they have narrated in their respective complaint and version.    The complainant has produced documents which were marked as Ex-C1 to C15 and the OP No.1 and 2 have produced documents which were marked as Ex-R1 and R2 and the 4^th OP has produced documents which were marked as Ex.R1 to R4.

9. Based on the above materials, the following points will arise for our consideration.

1.Whether there is deficiency in service on the part of the OPs?

2.What Order?

10.  Our answer to the above points are as under:-

Point No.1:           In the negative  

Point No.2:           As per final order below

REASONS

11. Earlier this forum on merits had passed an order on 29-08-2013 allowing the complaint in part with costs of Rs.2,000=00. The OPs 1 and 2 jointly and severally shall pay a sum of Rs.25,000=00 to the complainant either directly or through OP No.3 within a period of 45 days from the date of communication of this order, failing which, the payable amount under this order shall carry future interest at the rate of 9% p.a. from the date of complaint till realization.  

          12. Being aggrieved by the order of this forum, the OPs have preferred an appeal before the Hon’ble State Commission, Bengaluru bearing Appeal No.1532/2013. The Hon’ble State Commission, Bengaluru passed an order on 14-7-2016 allowed the above appeal, impugned order dated 29-8-2013 passed by the District Consumer Dispute Redressal Forum, Tumakuru in complaint no.60/2013 is set aside and the matter is remanded to the District Forum to provide an opportunity to the complainant to implead necessary parties viz., Trust and hospital where he took the treatment.

          13. Thereafter, the complainant has impleaded the OP No.4 and 5 in the complaint and the OP No.4 and 5 have filed their version, affidavit and documents.  The complainant has filed his affidavit evidence. We have heard the arguments of both parties and we have gone through the oral and documentary evidence of both sides in between lines.

          14. It is an admitted fact that, the complainant was a member of the Yashaswini Raita Arogya Rakshana Yojane through the 3^rd OP in the year 2012 as per the Ex-C3. It is also an admitted fact that, the complainant had undergone surgery in the 5^th OP hospital on 27-10-2012 as per the Ex-C8.

          15. The main contention of the complainant is that, at the time of admission to the hospital, the complainant had lost his identity card. Thereafter, the complainant had given self declaration form to the 5^th OP hospital to claim the bill amount from the Yashaswini Trust/Ex-C5.

          16. The complainant counsel submitted that, due to loss of the complainant’s identity card, the membership number was not uploaded in the computer software. Hence the complainant has contacted the Yashaswini Trust through telephone. The Yashaswini trust had advised the complainant over telephone and assured that, the amount paid by the complainant will be reimbursed after discharge from the hospital. Hence, the complainant had paid the hospital bill amount to the 5^th OP hospital, but Yashaswini Trust had not reimbursed the hospital bill amount to the complainant.      

          17. The contention of the 4^th OP is that, the complainant has not informed about the loss of his identity card to the Yashaswini Trust. The 4^th OP came to know only when the case was remanded from the Hon’ble State Commission, Bengaluru in Appeal no.1532/2013 dated 14-7-2016. Thereafter, this forum has issued notice to the 4^th OP and then they came to know about the complainant had lost his identity card.

18. The 4^th OP submitted that, as per the terms and conditions in the brochure provided to the complainant at the time of enrollment of the scheme it is clearly mentioned that, the original identity card and receipt has to be provided to the hospital to claim the scheme benefits. To substantiate his contention, the 4^th OP has produced brochure/Ex-R1 issued by the 4^th OP to its member.    

19. On perusal of the document produced by the 4^th OP i.e. brochure/Ex-R1 issued by the 4^th OP to its members and terms and conditions of the brochure, it reads as under”

“ ºÉaÑ£À «ªÀgÀUÀ¼ÀÄ:

• UÀÄgÀÄw£À PÁqÀÄð PÀ¼ÉzÀÄ ºÉÆÃzÀ°è CxÀªÁ E¤ßvÀgÀ AiÀiÁªÀÅzÉà ¸ÀªÀĸÉåUÀ½zÀÝ°è, C£ÀĵÁ×£À KeɤìUÉ ºÁUÀÆ lÖ¹ÖUÉ vÀPÀët ªÀgÀ¢ ªÀiÁqÀvÀPÀÌzÀÄÝ”

As per the brochure/Ex-R1 produced by the 4^th OP, it is clearly shows that, the loss of identity card should be informed to the Yashaswini Trust.

20. The 4^th OP further contended that, it is mandatory to produce the identity card and receipt at the time of admission to the hospital and informed the hospital about the membership of Yashaswini Scheme for obtaining preauthorization from the Yashaswini Trust for the surgery.

21. As per the version of the 5^th OP submitted that, the complainant has not produced any kind of documents to claim the benefits under the Yashaswini Raita Arogya Rakshana Yojane. Hence, the 5^th OP is directed the complainant to pay the hospital charges which he has taken the treatment in the hospital.

22. On perusal of the brochure/Ex-R1 produced by the 4^th OP, it reads as under.

“20.AiÉÆÃd£ÉAiÀÄr aQvÉì ¥ÀqÉAiÀÄ®Ä ¥sÀ¯Á£ÀĨsÀ«UÀ¼ÀÄ ¸ÀzÀ¸ÀågÀ G¥ÀAiÉÆÃUÀPÁÌV ¤ÃqÀ¯ÁzÀ ªÀÄÆ® UÀÄgÀÄw£À PÁqïð ªÀÄvÀÄÛ ªÀÄÆ® ºÀt ¥ÁªÀw gÀ¹Ã¢AiÀÄ£ÀÄß DAVÃPÀgÀ¹zÀ D¸ÀàvÉæUÀ¼À°è vÀ¥ÀàzÉ ºÁdgÀÄ¥Àr¸ÀvÀPÀÌzÀÄÝ.

21. D¸ÀàvÉæ ªÉÊzÁå¢üPÁjUÀ¼ÀÄ CAvÀºÀ ¥sÀ¯Á£ÀĨsÀ«UÀ¼À DgÉÆÃUÀå vÀ¥Á¸ÀuÉ ªÀiÁr ±À¸ÀÛç aQvÉì CªÀ±ÀåªÉAzÀÄ PÀAqÀħAzÀ°è ªÀÄvÀÄÛ ¸ÀzÀj ±À¸ÀÛç aQvÉìAiÀÄÄ AiÉÆÃd£ÉAiÀÄ°è M¼ÀUÉÆArzÀÝ°è, ¥ÀÆtð zÁR¯ÁwUÀ¼ÀÄ ºÁUÀÆ aQvÁì «ªÀgÀUÀ¼ÉÆA¢UÉ EAlgï£Émï ªÀÄÄSÁAvÀgÀ C£ÀĵÁ×£À KeɤìUÉ ±À¸ÀÛç aQvÉìUÉ ¥ÀƪÁð£ÀĪÀÄw PÉÆÃj ¥Àæ¸ÁÛªÀ£É PÀ¼ÀÄ»¸ÀĪÀgÀÄ.

22. C£ÀĵÁ×£À KeɤìAiÀÄÄ aQvÁì ¥ÀƪÁ£ÀĪÀÄw PÉÆÃjPÀUÉAiÀÄ£ÀÄß ¥Àj²Ã°¹ AiÉÆÃd£ÉAiÀÄ ¤AiÀĪÀÄUÀ¼À£ÀéAiÀÄ DºÀðvÉ EzÀÝ°è ±À¸ÀÛç aQvÁÛ ¥ÀƪÁð£ÀĪÀÄw ¤ÃqÀĪÀgÀÄ. D£ÀAvÀgÀ D¸ÀàvÉæAiÀĪÀgÀÄ ±À¸ÀÛç aQvÉìAiÀÄ£ÀÄß ¤ªÀð»¸ÀĪÀgÀÄ”.

23. Hence, the above said material evidence produced by 4^th OP, it is clearly show that, before taking the treatment from the hospital, as per the terms and condition of the scheme, the complainant has to produce the identity card to the hospital and obtain the preauthorization for the surgery. But as per the 5^th OP contention, the complainant has not produced any documents to claim the amount from Yashaswini Trust. Hence, it is clearly shows that, the complainant has not informed about loss of his identity card to the Yashaswini Trust neither he had claimed the amount to the Yashaswini trust through hospital  Hence, we hold that, the complainant had violated the terms and conditions of the scheme.

24. Taking the oral and documentary evidence of complainant and compare the same with the material evidence of OPs, it is made clear that, the OPs have acted as per the terms and conditions of the scheme and there is no negligence or deficiency of service on the part of the OPs in rejecting the claim of complainant as the complainant did not inform the loss of his identity card and not made the claim amount through 5^th OP as per the terms and conditions of scheme of the OPs.  We are of the opinions that, the oral and documentary evidence of OPs are more believable trustworthy and acted upon than the material evidence of complainant. On making careful scrutiny of the case of complainant on the background of oral and documentary evidence of both parties, we are of the considered opinion that, the complainant has utterly failed to prove this point by placing clear cogent and consistent material evidence. Accordingly we answer this point in a negative. In the result, for the foregoing reasons, we proceed to pass the following order.

ORDER

The complaint is dismissed.

          Supply free copy of this order to both parties. 

(Dictated to the Stenographer, transcribed and typed by him, corrected and then pronounced by me in the Open Forum on this, the 15^th day of July 2017)

LADY MEMBER                                  PRESIDENT