BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 29^TH June 2013

PRESENT

        SMT. ASHA SHETTY         :   PRESIDENT

                        SMT.LAVANYA M. RAI       :   MEMBER

                        SRI. ARUN KUMAR K.        :   MEMBER

COMMON ORDER IN

C.C.NOs. 35 & 38/2013

C.C.Nos. 35/2013

(Admitted on 2.2.2013)

Smt.Sujatha D.S. Bhat,

Wo Shivarama Bhat,

Aged about 45 years,

 Rat. Darbe House, Irde Post,

Puttur Tq., D.K.                           …… COMPLAINANT

(Advocate for the Complainant: Sri.Sanjay.D.)
     VERSUS

1. Chief Executive Officer,

    Yashaswini Co-Op. Farmers

    Health Care Scheme,

    6^th Floor,  M.S. Building,

    Co. Op. Secretariat,

    Dr. Ambedkar Street,

    Bangalore – 1.  

2. Manager,

   Irde-Bettampady Vyavasaya

   Seva Sahakari Bank, Bettampady,

   Puttur Tq. D. K.                       ……. OPPOSITE PARTIES

(Advocate for Opposite Party No.1 & 2 :Sri Thimmayya .P)

CC.No. 38/2013

(Admitted on 2.2.2013)

Shivarama Bhat,

So Shankaranarayana Bhat,

Aged about 55 years,

Rat. Darbe House, Irde Post,

Puttur Tq., D.K.                     …… COMPLAINANT

(Advocate for the Complainant: Sri.Sanjay D)

     VERSUS

1. Chief Executive Officer,

    Yashaswini Co-Op. Farmers

    Health Care Scheme,

    6^th Floor, M.S. Building,

    Co. Op. Secretariat,

    Ambedkar Veedi,

    Bangalore – 01.

2. Manager,

   Irde-Bettampady Vyavasaya

   Seva Sahakari Bank,

   Bettampady,

   Puttur Tq. D. K.                             ……. OPPOSITE PARTIES

(Advocate for Opposite Party No.1 & 2: Sri Thimmayya P.)

*        *        *        *

ORDER DELIVERED BY HON’BLE PRESIDENT

SMT. ASHA SHETTY:

I.       1. Both the Complainants filed the above complaints under Section 12 of the Consumer Protection Act alleging deficiency in service against the common Opposite Parties claiming similar reliefs.  In order to save the time as well as for the sake of convenience we have taken up all the cases together and passed common order as under:

The brief facts of the case are as under:

The Complainants in CC.No.35 and 38/2013  are the members of Yashaswini Co-operative farmers health care scheme and during the validity of the membership they have taken medical treatment in Dhanvanthari hospital situated in D.K. District and spent certain sum of money for the medical treatments as mentioned in their respective complaints.

 However, we have taken up in detail as under:-

The Complainant in C.C.No.35 and 38/2013 stated that the Complainants were admitted in Dhanvanthari Hospital Puttur on 26.4.2011 for Right and left shoulder Deformity due to fracture caused in due to fall from motor cycle at Bailadi Bridge at Irade – Bettampadi and was operated on 26.4.2011 and 27.4.2011 and spent Rs.26,460/- by the Complainant in CC.No.35/2013 and Rs.2,745/- in CC.No.38/2013 and contended that the Opposite Parties failed to reimburse the medical expenses till this date and also contended that the membership receipt issued by the 1^st Opposite Party is vague and does not contain the terms and conditions.  The service rendered by the Opposite Parties amounts to deficiency in service.  Feeling aggrieved by the above both the Complainants filed the above complaints before this Forum under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Parties to pay the entire medical expenses spent by them respectively mentioned in their complaints and also sought for compensation and cost of the proceedings.

II.      1. Version notice served to the Opposite Parties by R.P.A.D. in all the complaints. The chief executive officer Yashaswini cooperative farmers health care scheme Bangalore filed similar version in all the complaints wherein stated that Yashaswini cooperative farmer health care scheme is not a insurance, it is a trust formed by the Government of the Karnataka to help the Co-operative farmers in the year 2003.  It is also stated that, in order to avail the benefits of the Yashaswini Co-operative Farmers Health Care Scheme, the members have to follow the procedures prescribed under the scheme.  To claim any amount under the scheme, the member has to be operated/taken treatment in any of the network hospitals earmarked by the trust, if the member treated elsewhere this Opposite Party is not liable to pay any amount to the member for breach of the terms of the procedure prescribed under the scheme.  It is further stated that as per the condition No.14, the members who sustain injuries in road accident not entitled any claim from the Yashaswini health care scheme and denied the deficiency and prayed for dismissal of the complaints.

III.     1. In support of the above complaints, all the respective Complainants are examined as CW-1 and answered the interrogatories served on them and produced documents got marked under the ‘Ex.C’ series detailed in the annexure here below. Opposite Parties also examined and filed their counter affidavits and answered the interrogatories served on them and produced documents got marked under the ‘Ex R’ series detailed in the annexure herebelow.

In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the Complainants prove that the Opposite Parties committed deficiency in service?
2. If so, whether the Complainants are entitled for the reliefs claimed?
3. What order?

             We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:       

                                                  Point No.(i): Negative.

                       Point No.(ii) to (iii): As per the final order.  

REASONS

5.  Points No. (i) to (iii):

In the instant case, the facts which are not in dispute is that, the Yashaswini Scheme is a benevolent Insurance Healthcare Scheme introduced by the Government of Karnataka to provide medical assistance to poor Co-operative farmers and their family members in the year 2003.  It is also admitted fact that, the Complainants were the members of Yashaswini Co-operative Farmers Health Care Scheme. Further it is admitted fact that, the 1^st Opposite Party i.e., a trust formed by the Government of Karnataka undertaken to reimburse the medical expenses of the Yashaswini Healthcare Scheme members. 

Now the points are in dispute between the parties before this FORA is that, in both the complaints the complainants taken treatment in Dhanvanthari Hospital, Puttur for left shoulder joint fracture due to fall from motor cycle and spent Rs.26,460/- and Rs.2,745/- respectively. But the Opposite parties not reimbursed the medical expenses under the scheme. 

The Opposite Party No.1 interalia contended that, to avail benefit under Yashaswini Scheme, the beneficiary has to follow the procedures prescribed under the scheme.  In order to claim any amount under the scheme, the members have to undergo operation in any of the network hospital earmarked by the trust.  The receipt issued by the Opposite Party clearly discloses that the member has to take treatment only at network hospital. It is further contended that, as per the terms and conditions of the Yashaswini Health Care scheme the injuries sustained in road accident not entitled to any claim under the scheme and contended  that they are not liable to reimburse the claim and denied the deficiency.

In order to prove the case of the Complainants, the Complainants are filed oral evidence by way of affidavit supported by documents i.e. Ex C1 to C8.  Opposite Parties also filed evidence by way of affidavit and produced Ex R1 to R5.

We have heard the counsels for the parties and perused and examined the admitted as well as oral and documentary evidence available on record, wherein, in both the case the Ex C1 membership receipt and identity card issued by the 1^st Opposite Party shows that the Complainants were the member of the Yashaswini Scheme introduced by the Government of Karnataka. The Ex.C2 is the Office copy of the claim sent to the 1^st Opposite party and Ex.C3 is the postal acknowledgement.  Ex. C4 is the discharge summary and Ex. C5 is the Copy of the bills pertaining to the treatment taken by the complainants in Dhanvanthari Hospital and on 26.4.2011 the Complainant was admitted with the history of Road Traffic Accident, taken treatment and discharged on 27.4.2011.  Ex C6 is the registered lawyer’s notice issued by the Complainant dated 5.7.2011 calling upon the Opposite Parties to reimburse the medical expenses spent by him.  Ex C7 and C8 are the replies given by the Opposite Parties to the above lawyer’s notice.  However, the Ex.R1 the hospital list issued by the Opposite Party No.1 produced before this FORA, wherein, certain names of the hospitals shown i.e., 20 in numbers. However, it is admitted by the complainants in their complaints as well as evidence on affidavit that the injuries sustained due to fall from motor cycle at Byladi Bridge, Irde, Bettampadi.  When the complainants admitted that the injuries sustained was due to the Motor Cycle accident then definitely the complainants are not entitled any claim under the Yashaswini Health Care Scheme.

However, the complainants contended that the Opposite party has not issued the proper receipts to the complainants. The above said contentions taken by the Complainant is not convincing because it is the obligation on the part of the complainants to obtain a receipt after making the payment.  If at all the Opposite parties not issued the proper receipt then the matter is left open to the complainants at the earliest point of time and not at the time of availing benefit under the scheme.  In other words at the time of claiming medical reimbursement, the Complainant cannot contend that the Opposite Party No.1 is not issued a proper receipt.  As we know, the injuries sustained in Motor Vehicle accident the claimant/injured can very well file a claim under the Motor Vehicles Act and not under the C. P. Act that to say under the health care scheme introduced by the Opposite Party No.1.  Therefore, we are of the considered opinion that in both the cases the complainants admitted the hospital with history of road traffic accident, since the road traffic accident not covered under the Yashaswini Health Care Scheme, the complainants are not entitled for any claim/benefits.  In view of the above said reasons, the complaints deserves to be dismissed. No order as to costs.

In the result, we pass the following:                          

ORDER

The complaints are dismissed. No orders as to costs.

The copy of this order as per the statutory requirements be forwarded to the parties free of charge and therefore the file be consigned to record.

(Page No.1 to 8 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 29^th  day of June 2013.)

PRESIDENT          MEMBER          MEMBER

ANNEXURE

Witnesses examined on behalf of the Complainants:

CW1 – Smt.Sujatha D.S. Bhat – Complainant in C.C.No.35/2013.

CW1 – Sri.Shivarama Bhat – Complainant in C.C.NO.38/2013.

Documents produced on behalf of the Complainant in CC.No.35/2013:

Ex C1 – 26.4.2010: Copies of the receipt.

Ex C2 – 5.5.2011: O/c of the claim sent to the 1^st O.P.

Ex C3 – 12.5.2011: Postal Acknowledgement.

Ex C4 – 2.5.2011: Copy of the discharge summary.

Ex C5 – 2.5.2011: Copy of the bills (6).

Ex C6 – 5.7.2011: O/c. of the regd. Lawyer’s notice.

Ex C7 & C8 – 18.7.2011 & 2.8.2011: Reply of the 1^st  and 2^nd O.P.

Documents produced on behalf of the Complainant in CC.No.38/2013::

Ex C1 – 26.4.2010: Copy of the receipt.

Ex C2 – 5.5.2011: O/c of the claim sent to the 1^st O.P.

Ex C3 – 12.5.2011: Postal Acknowledgement.

Ex C4 – 27.4.2011: Copy of the discharge summary.

Ex C5 – 27.4.2011: Copy of the bills (4).

Ex C6 – 5.7.2011: O/c. of the regd. Lawyer’s notice.

Ex C7 & C8 – 18.7.2011 & 3.8.2011: Reply of the 1^st  and 2^nd O.P.

Witnesses examined on behalf of the Opposite Parties in CC.No.35 & 38/2013:

RW1 –Sri.R.M.Nataraj, Chief Executive Officer of O P No.1.

RW2 – Sri.Ramesh Rai.P. Chef Executive Officer of O.P. No.2.

Documents produced on behalf of the Opposite Parties in CC.No.35 & 38/2013::    

Ex R1 – Copy of the list of the network hospitals.

Ex R2 – True copy of the broucher.

Ex R3 – True copy of the notice issued to Dhanvanthari Hospital.

Ex R4 - True copy of the letter written by the O.P.No.1 to IRDA.

Ex R5 – True copy of the Endorsement issued by IRDA.

Dated:29.6.2013                                        PRESIDENT