By Sri. Gururaj Member:-<br /> This is a complaint filed U/s. 12 of Consumer Protection Act by the complainant- H.Sharanagouda against the three Respondents (1) The Manager Yashashwini Co-operative Formers Health Care Scheme No. 45,Millers Road, Vasanth Nagar, Bangalore (2) The Medical Officer, Navodaya Medical College Hospital & Research Center, PB NO. 26, Raichur. and <br /> (3) The Manager, Yashashwini Co-operative Farmers Health Care Trust, Co-operation Department, 2nd Gate, VI Floor, M.S. Building, Bangalore. The brief facts of the complaint are as under:<br /> <br /> The complainant is the agriculturist and advocate by profession R/o. Wadloor village Tq. & Dist. Raichur. The Government of Karnataka had provided free medical treatment to the persons who are the members of the Co-operative Society and who have paid premium fixed by the Government in order to take medical benefits through Yashashiwini Scheme which is also called as “Yashashwini Co-operative Farmers Health Care Scheme”. The father of the complainant is the member of Raichur agriculture producing marketing and processing Co-operative society, Raichur and paid the premium to the Yashashwini Scheme through the said society. As per the Government Rules (4) family members of the person one who has become member to the above scheme are entailed to take medical benefits under said scheme of their any disease and operations. That on 21-02-05 the complainant approached the Navodaya Medical Hospital Raichur for his illness. There the doctor diagnosed that the complainant was suffering from Appendicities and advised for operation. As per the advise of the doctor he had undergone for operation and there by spent an amount of Rs. 14,000/-. After some days, the complainant approached the Respondents for refund of the amount which he has spent for his operation as per the Yashashiwini Co-operative Health Care Scheme. But the Respondents have not refunded the amount and there after he has got issued a legal notice on 03-03-06 and 15-09-06 to the Respondent NO-1. The Respondent No-1 had given reply to the said notice and asked the complainant to produce the Main Hospital bills, operation note, bill break-up etc., accordingly he has sent the above said documents to the Respondent No-1 through RPAD. The Respondent No-1 received the same but not refunded the medical expenses as per the terms of the said scheme. The delay and non-settlement of his medical expenses by the Respondent amounts to deficiency in service. Hence he has sought for direction to the Respondent to pay Rs. 14,000/- towards medical expenses incurred by him together with cost of the complaint and interest at the rate of 18% p.a.<br /> <br /> 2. In response to service of notice Respondents No-1 appeared through advocate and filed written version contending that the complainant has not approached this forum with clean hands and as per the reported judgment of the Hon’ble High Court reported in 1965(1) My. LJ Page No- 370. <br /> <br /> Therefore in the present case the complainant without disclosing the real and true facts of the case has filed this false complaint and so it is liable to be dismissed. According to the rules of Yeshasvini Co-operative Farmers Health Care Trust, the beneficiary to the scheme has to approach the network hospital and inform the network hospital that he is the beneficiary under the Yeshasvini scheme by showing his Identity Card issued by the Yeshasvini Co-operative Farmers Health Care Trust, there after the said network hospital has to check the patient and the network hospital is also required to obtain pre-authorization to cover the patient under the Yashashwini scheme and to treat him. Once the pre-authorization is granted, the patient would be covered under the Yashashwini Scheme. As per the trust deed it is mandatory that network hospital has to obtain the pre-authorization letter. All the requests are attended very quickly and promptly. But in the present case neither the complainant nor the network hospital have obtained any pre-authorization. Unless and until the pre-authorization is forwarded by the network hospital, the patient cannot be covered under the Yashashwini Scheme. This fact is being mentioned in the pamphlets distributed by the Yashashwini Co-operative Farmers Health Care Trust and it is also displayed in the Identity Card and is very well known to the complainant. No such pre-authorization is obtained by the network hospital and complainant, hence at no point of time it has caused any deficiency in its service and on this ground alone the present complaint is liable to be dismissed. Viewed from any angle the complainant has utterly failed to make out a prima-facie case. <br /> <br /> It is further contended that it is only implementing agency i.e, it has come into existence only to the implement the scheme. The Yashashwini Co-operative Farmers Health care Scheme Trust collects the premium amount from the beneficiaries and monitoring the funds. Therefore Respondent No-3 Trust is only the responsible for any claims made by the complainant if any. The complainant has not made the said trust as the party to the proceedings. The Respondent No-1 is not the re-reimbursing authority. It works as a Third Party Administrator and is only a facilitator.<br /> <br /> It is further contended that the complainant has not made the network hospital and Yashashwini Co-operative Farmers Health care Scheme Trust Co-operation Department as a party to the proceedings. Hence the complaint of the complainant is liable to be dismissed on the ground of non-joinder of necessary party with exemplary cost.<br /> 3. At the stage of evidence by complainant, the complainant moved an application for amendment of his complaint and impleaded the Navodaya Hospital and Yashashwini Co-operative Farmers Health care Scheme Trust as Respondent No-2 and 3. After service of the notice Respondent NO-2 appeared through his counsel and Respondent No-3 remained absent and has been placed Ex-parte.. The Respondent No-2 has not filed any written version as there is no allegation and claim against him i.e, hospital. <br /> <br /> 4. During the course of enquiry the complainant Sharanagouda has filed his sworn affidavit by way of examination-in-chief reiterating the averments of his complaint and has got marked (8) documents as Ex.P-1 to Ex.P-8. In rebuttal the Respondent NO-1 has filed sworn affidavit of Mallikarjuna Dist. Co-coordinator F.H.P.L. Branch Raichur by way of examination-in-chief reiterating the contents of written version and has got marked (3) documents at Ex.R-1 to Ex.R-3. Respondent No-2 has not filed any evidence on his behalf as there was no claim against them and no documents are filed.<br /> <br /> 5. Heard the arguments of L.C. for complainant and Respondent No-2. The L.C. for Respondent No-1 has filed written argument and perused the same. The following points arise for our consideration and determination:<br /> 1. Whether the complainant proves deficiency in service by the Respondents in not settling his claim as alleged.?<br /> <br /> 2. Whether the complainant is entitled for the reliefs sought for.?<br /> <br /> 6. Our finding on the above points are as under:-<br /> 1. In the affirmative. <br /> 2. As per final order for the following <br /> <br /> REASONS<br /> <br /> POINT NO.1:-<br /> <br /> 7. The case of the complainant is that his father is the member of Raichur Agriculture producing marketing and processing co-operative society Raichur and paid the premium to the said society and in-turn the said society had paid the premium to the Yashashwini Scheme in-order to take free medical treatment as provided by the Government under the said scheme. As per the rules laid down by the Government, any four members of the family are entitled to take free medical treatment through network hospital of the Respondent NO- 1 & 3. It is also the case of the complainant that in the month of February 2005 i.e, on 21-02-05 he admitted in Respondent NO-2 hospital and has under gone for operation and spent Rs. 14,000/- and after some days the complainant approached the Respondent NO-1 for refund of the same under Yashashwini Scheme but the Respondents have not refund the same even after submission of required documents and even after issuing the legal notice in this regard. <br /> <br /> 8. The Respondent No-2 is the network hospital of Respondent NO-1 who is a formal party to the proceedings and there was no claim against the Respondent No-2. The Respondent No-3 has remained absent even inspite of service of the notice issued by the Forum and hence placed Ex-parte. The Respondent NO-1 is the only contesting party. The Respondent No-1 in his written version contended that the complainant has not approached this Forum with clean hand as he has not disclosed real and true facts. It is further contended that according to the rules of Yeshasvini Co-operative Farmers Health Care Trust, the beneficiary has to approach the network hospital and inform the said hospital that he is the beneficiary under the Yeshasvini Scheme by showing his identity card thereafter the network hospital has to take pre-authorization letter from the concerned authority then treat the patient. But in this case neither the complainant nor the network hospital i.e, Respondent NO-2 has taken any pre-authorization letter hence they are not responsible for the claim of the complainant. It is also further contended that it is only implementing agency i.e, which is come into existence only to implement the scheme. The Yeshasvini Co-operative Farmers Health Care Trust i.e, Respondent No-3, alone is collecting the premium from the beneficiary and monitoring the funds hence it is only responsible for settle the claim of the complainant. <br /> <br /> 9. The complainant has produced following documents in support of his case: (1) Discharge Cash Bill Dt. 02-03-05 for having paid the hospital bill marked at Ex.P-1, (2) Discharge Summary issued by Dr. N.K. Bhatt doctor of Respondent NO-2 hospital which is marked at Ex.P-2. (3) Doctors treatment chart commencing from 21-02-05 marked at Ex.P-3, (4) Legal Notice dt. 15-09-06 issued by the counsel for complainant to the REspondent No-1 marked at Ex.P-4, (5) the letter written by REspondent No-1 in reply to the notice dt. 15-09-06 marked at Ex.P-5, (6) Two letters dt. 05-03-07 and 22-06-07 written by the counsel for complainant to the Respondent NO-1 which are marked at Ex.P-6 & 7 respectively. (7) The acknowledgement card for having receipt of letter dt. 22-06-07 by the Respondent No-1 is marked at Ex.P-7(1) and (8) the Receipt dt. 28-04-07 for having paid the membership renewal fees by the father of the complainant under the Yeshasvini scheme is marked at Ex.P-8. <br /> <br /> 10. The Respondent NO-1 in all produced (3) documents in support of his case namely:- (1) copy of Registered Deed of Trust of Yashashwini Co-operative Farmers Health Care Trust dt. 10-02-03 executed by the Hon’ble Governor of Karnataka represented by principal secretary, Department of Co-operation Government of Karnataka marked at Ex.R-1, (2) Sample Identity Card marked at Ex.R-2, (3) Pamphlet showing the details of Yashasvini scheme published by Government of Karnataka marked at Ex.R-3.<br /> <br /> 11. From the close perusal of the Ex.P-8 it is very clear that the father of the complainant Sri. Marigouda is the member of Raichur agriculture producing marketing and processing Co-operative society, Raichur. It is also clear that he has paid the Yeshasvini membership fees for himself and also for his other three family members. It is also discloses that the name of the complainant and his I.D. Card No. as 415322 at Sl.No. 3. From this document it is evident that the complainant is the member of Yeshasvini scheme and paid the premium as required under the provision of the said scheme. The Ex.P-1 to Ex.P-3 clearly go to shows that the complainant was admitted in the Respondent NO-2 hospital on 21-02-05 and undergone the operation for his “acute appendicitis”. The Respondent No-1 has not denied at any point of time that the Respondent No-2 is not the network hospital under the scheme then nothing wrong to say that the complainant is right in approaching the said hospital and took the treatment. So far this we can hold that the complainant has fulfilled the one of the condition of the Respondent NO-1 as per the Ex.R-1 Trust Deed as the beneficiary should approach the network hospital. <br /> <br /> 12 Now crucial question arise for our consideration as to whether the network hospital i.e, Respondent NO-2 has sent the pre-authorization form to the concerned authority in order to cover the beneficiary under the scheme as mainly contended by the Respondent No-1. For this question we hold that the Ex.P-5 the letter dt. 07-10-06 written by the Respondent NO-1 to the complainant counsel in reply to the notice dt. 15-09-06 i.e, Ex.P-4 is the proper answer. From the close perusal of the said Ex.P-5 it appears that the Respondent NO-1 has received the pre-authorization letter from the Respondent No-2 network hospital and same has been sent back for want of relevant documents like I.D. Card of the beneficiary and Receipt for having paid the contribution under Yeshasvini Scheme. But there is no document from the Respondent NO-1 to show that they have returned the same to the Respondent No-2 network hospital. The said Ex.P-5 further discloses that the Respondent NO-1 has called the complainant to produce the documents such as Main Hospital Bill, Operation Note, Bill Break-up and Discharge Summary with detail. In-reply to that letter the complainant has sent all the required documents as sought for by the Respondent No-1 through his counsel letter dt. 05-03-07 and 22-06-07 which are marked at Ex.P-6 & Ex.P-7. The acknowledgement card produced by the complainant at Ex.P-7(1) shows that the letter along with documents were served upon the Respondent No-1. If suppose the Respondent No-1 is only the implementing agency working as third party and they are not reimbursing authority as contended in their written version, evidence and written argument, then what was the necessity to call upon the complainant to produce all these documents through Ex.P-5 as supra. It is worth while to note that there is no single word in the said Ex.P-5 to show that they are the only Implementing/authority and they are not reimbursing Authority and that the Respondent NO-3 is only responsible for settling the claim of the complainant. Therefore the defence raised by the Respondent NO-1 holds no good. <br /> 13. As stated above the Respondent NO-3 has remained absent and set ex-parte. This act would go to shows that the Respondent NO-3 admits the facts, allegation, and claim of the complainant. Under the above circumstances the Respondent NO- 1 & 3 have intentionally avoided the claim of the complainant by not making reimbursement of medical bills even in-spite of fulfillment of all the requirements as sought by them and there by they have caused deficiency in service. The Respondent No-2 is network hospital is a formal party to the proceedings and there was no claim against the Respondent No-2 by the complainant. Therefore for above said reasons and discussions we hold that the complainant has proved the negligence and deficiency in service by the Respondent No-1 & 3. Hence Point NO-1 is answered in the affirmative. <br /> <br /> POINT NO.2:-<br /> 14. The complainant has claimed Rs. 14,000/- towards medical expenses incurred by him while taking treatment in Respondent No-2 hospital against the Respondents with cost of the proceedings. The complainant has produced Discharge Cash Bill at Ex.P-1 for an amount of Rs. 8,000/- issued by Respondent NO-2 network hospital. Except this cash bill no other document are produced before this Forum to substantiate his claim as Rs. 14,000/-. Under these circumstances we feel it is just and proper to award Rs. 8,000/- in-respect of his medical claim so far as the cost of the proceedings and interest claimed at the rate of 18% p.a. is concerned, we feel Rs. 2,500/- is proper hence we award Rs. 2,500/- towards interest and cost. Therefore awarded Rs. 10,500/- against the Respondent NO- 1 & 3. In this view of the matter we pass the following order:<br /> <br /> <br /> <br /> ORDER<br /> <br /> The complaint of the complainants is allowed in part <br /> The Respondent No- 1 & 3 are jointly and severally shall pay Rs. 8,000/- towards hospital charges (medical bills) and Rs. 2,500/- towards interest and cost of the proceedings.<br /> The claim against the Respondent NO-2 is dismissed.<br /> The Respondent No- 1 & 3 shall comply this order within a period of six weeks from the date of receipt of copy of this order.<br /> Office to furnish certified copy of this order to both the parties forth with free of cost.<br /> (Dictated to the Stenographer, typed, corrected and then pronounced in the open Forum on 29-11-08)<br /> <br /> Sd/-<br /> Sri. N.H. Savalagi<br /> President<br /> Dist.Consumer Forum-Raichur.<br /> <br /> Sd/-<br /> Sri. Gururaj <br /> Member.<br /> Dist.Consumer Forum-Raichur.<br /> <br /> Sd/- <br /> Smt.Pratibha Rani Hiremath<br /> Member.<br /> Dist.Consumer Forum-Raichur.