Karnataka

StateCommission

A/1904/2017

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

Versus

Thirumaleshwar Bhat - 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 1904/2017

 

 

M/s Yeshasvini Co-operative Farmers

Health Care Trust

No.70, 2^nd Floor, K M C 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 Thirumaleshwar Bhat

     S/o Sri Ramachandra Bhat

     Aged about 45 years

     R/at Kallarthane House

     Kombaru Village & Post

     Puttur Taluk, D.K

     (By Mr Krishnamoorthy D, Advocate)

 

2.  M/s Kenjala Milk Producers Co-Op Society

     Konbaru,

     Puttur Taluk, Dakshina Kannada

     Rep. by its Secretary

 

3. M/s A J Hospital and Research Center

    Kuntikana

    Mangaluru

    Rep. by its Medical Officer                                               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 09.08.2017 passed in Consumer Complaint No.21/2012 by District Consumer Disputes Redressal Forum (hereinafter referred to as District Forum).

 

 

2.       Heard the arguments of learned Counsels for Appellant and Respondent No.1. Inspite of service of Notice on Respondent No.2, none appearedand hence his arguments has been taken as heard.

 

 

3.       It is pertinent to make mention of the fact that OP had challenged the Order of the District Forum before this Commission in Appeal No.1436/2012 and on 17.04.2014, the same was allowed by remanding the matter to the District Forum to decide the case afresh by providing an opportunity to the Complainant to implead the concerned treating Hospital as party to the proceedings.  Accordingly, A J Hospital and Research Center, Kuntikana, Mangaluru is impleaded as party to the proceedingsand OP3 entered appearance and filed its Version and Affidavit Evidence. The District Forum after enquiring into the matter, deemed it fit to allow the Complaint in part against OPs 1 & 3 and held that they are jointly and severally liable pay a sum of Rs.1,02,510/- to the Complainant along with interest @ 8% p.a from the date of Complaint till the date of realisation.

 

          Further held, OPs 1 to 3 are jointly and severally held liable to pay a sum of Rs.10,000/- as Compensation and Rs.3,000/- towards cost of the litigation.

 

4.       Aggrieved by this Order, OP1 is in Appeal inter-alia contending amongst other grounds that, the Appellant had issued instruction and directions to the listed Net Work Hospitals to provide medical benefits to the beneficiaries of the Appellant.  If any beneficiary is in need of Surgical treatment, the beneficiary has to approach the listed Hospital, with their Identity Card issued by the Appellant Trust at the time of enrolment and each & every listed Hospital shall have a separate Counter clearly mentioning to assist the Yeshasvini Scheme beneficiaries.  Upon receipt Surgery, the Hospital has to send a pre-authorisation requisite to the Third Party Administrator, appointed by the Trust to obtain a pre-authorisation and sanction for the Surgery.  The TPA looking at the line of treatment and would sanction the amount pre-agreed by the Trust to obtain a pre-authorisation and sanction for the surgery.  The TPA looking at the line of treatment would sanction the amount pre-agreed by the Trust and Hospital for surgery.   On obtaining the pre-authorisation, the Hospital has to provide Cashless treatment facility at the Hospital.   The pre-agreed rates are for the treatment obtained in General Ward and the beneficiaries are entitled only for general ward tariffs.  If at all the beneficiary opts for higher wards, the difference amount has to be borne by the beneficiary himself.  This fact has been made known to the beneficiary and also clearly mentioned in the Terms & Conditions of the Scheme.  In case, the beneficiary opts for higher wards, the Hospitals  are instructed to inform the beneficiariesto the effect that the difference in amount are to be paid by the concerned and also to obtain a consent for the same.  Further pleaded that, O3 has not at all submitted the Bills to the Appellant for processing the claim of the Complainant and as such the entire treatment was kept out of the reach of the Appellant and as the terms and conditions of the scheme doesn’t provide for reimbursement of the treatment amount to the beneficiary, the claim of the beneficiary was rejected who has submitted his claim after obtaining treatment. 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.

 

à6.      It is not in dispute that, the Wife of the Complainant is a Member of OP1’s Scheme withMembership No.16972 dated 30.05.2010 by paying Membership Fee of Rs.833/-.  On 09.04.2011, she admitted to the Bonanathya Hospital, Puttur for severe abdominal pain alongwithectopic pregnancy and after the In-patient treatment, she was discharged on 12.04.2011 for further advanced medical management.  Subsequently, she was shifted to AJ Hospital & Research Centre, Mangaluru where, even after spending Rs.1,61,387/- she could not recover from her ailments and breathed her last on 18.04.2011.  Due to the un-timely death of his Wife, coupled along with the need to follow various rituals, besides upset in the family environment, the Complainant could not send the Claim papers in time.

 

7.       The contention of the Appellant is that, he had issued instructions & directions to the listed Hospital to provide medical benefits to the beneficiaries of the Appellant. If any beneficiary is in need of surgical treatment, the beneficiary has to approach the listed Hospital, with their Identity Card issued by the Appellant Trust at the time of admission and each and every listed Hospital shall have a separate Counter clearly indicating itsexistence to assist the Yeshasvini Scheme beneficiaries.  Upon receipt of the Identity Card and in case the treating Doctor suggests for any surgery, the Hospital has to send a pre-authorisation requisite to the third party Administrator appointed by the Trust to obtain a pre-authorisation and sanction for the proposed Surgery.   The TPA looking at the line of treatment would sanction the amount pre-agreed by the Trust and Hospital for the surgery.   On obtaining the pre-authorisation, the Hospital has to provide cashless facility at the Hospital.  The pre-agreed rates are for the treatment obtained at General Ward and the beneficiaries are entitled only for General Ward Tariffs.  If at all the beneficiary opts fortreatment staying in higher Ward, the difference of Tariff charges has to be borne by the beneficiary himself.   This fact is made known to the beneficiary and also it is clearly mentioned in the Terms & Conditions of the Scheme.

 

8.       The observation of the District Forum in Paras 19 & 20 of its Impugned Order to the effect that, Ex-R1 is the Dakshina Kannada District Network Hospital List under Yeshasvini Co-op Farmers Health Care Scheme, wherein, at Sl. No.1 name of the OP3’s Hospitalis appearing.  Ex-C5 is the Treatment Summary issued by OP3, wherein, in the column pertaining to ward/bed, the related entry is not reflected. Hence, the question of the Complainant’s wife had taken facility of special ward as she treated as ICU patient has not been proved. In the circumstances, we are of the view that collecting Bill amount before handing over the body of the deceased patient namely Jayashree, the wife of the Complainant instead of submitting those bills to OP No.1 by OP No.3 for collecting the charges, which was not done and as such in our considered view, the Complainant succeeded in establishing deficiency in service on the part of the OPs 1 to 3.

 

9,9.      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 copy of the sample 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 name of Net Work Hospital District-wise has been mentioned and same has been renewed as on 31.08.2013, wherein at Sl No.230 the name of the Net Work Hospital appears.

 

11.     Thus A J Hospital & Research Centre, Mangalore, Dakshina Kannada listed as one of the Net Work Hospital by Govt. of Karnataka and OPs 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 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 Impugned Order 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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