BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 31^st of July 2013

PRESENT

           SMT. ASHA SHETTY           :   HON’BLE PRESIDENT

           SMT.LAVANYA M. RAI       :   MEMBER

           SRI. ARUN KUMAR K.        :   MEMBER

COMPLAINT NO.66/2013

(Admitted on 8.3.2013)

Smt.Kanya P.Rai,

Wo Pradeep Kumar Rai,

Aged about 30 years,

Rat Pambaru House,

Kolthige Village, Perlampady,

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,

   Kolthige Sahakari Vyavasayika Bank N.,

   Kolthige,

   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. This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service against the Opposite Parties claiming certain reliefs. 

The brief facts of the case are as under:

The Complainant along with six family members by paying Rs.774/- to the 2^nd Opposite Party were became the members of the Yashaswini Co-operative Farmers Health Care Scheme as per receipt No.051 dated 7.5.2010 and the same was valid for one year.  As per the above scheme the 1^st Opposite Party has undertaken to reimburse the medical expenses to the members of the Yashaswini Co-operative Farmers Health Care Scheme.

It is stated that, the Complainant was admitted to Dhanvanthari Hospital Puttur on 27.2.2011  for Caesarian operation and discharged on 3.3.2011 and spent Rs.17,275/- for the operation. Thereafter the Complainant submitted the claim form along with required documents as per letter dated 12.4.2011, but the 1^st Opposite Party repudiated the claim as per their letter dated 13.4.2011 stating that the Complainant not taken medical treatment at network hospitals listed by them, hence denied the claim.  Subsequently, the Complainant has issued a registered legal notice dated 2.3.2012 to the Opposite Parties and called upon to comply the demand made therein but the Opposite Parties not honoured the claim. 

It is further stated that, the membership receipt issued by the Opposite Parties is vague and does not contain the following details i.e., the name of the network hospitals, how the pre-authorization is to be obtained, which are the diseases are covered, what are the pre-conditions and who has to obtain pre-authorization, what is the assured amount etc. etc.  It is further stated that, the Opposite Party No.1 is duty bound to pay the claim amount under the Yashashwini Co-operative farmars health care scheme. The repudiation made by the Opposite Party is arbitrary and stated that the quality, nature and manner of performance of the service is deficient.  Feeling aggrieved by the above, the above complaint is filed 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 Rs.17,275/- along with interest at 12% per annum from 3.3.2011 till payment and also claimed compensation and cost of the proceedings.

II.      1. Version notice served to the Opposite Parties No.1 and 2 by R.P.A.D. Opposite Party No.1 and 2 appeared through their counsel filed separate version.

Opposite Party No.1 i.e. Yashaswini Co-operative Farmers Health Care Scheme represented by its Chief Executive Officer filed version admitted the membership of the Complainant along with family members but it is contended that 1^st Opposite Party 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 member has to follow the procedures prescribed under the scheme.  To claim any amount under the scheme, the member has to be operated 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 also submitted that the receipt issued to the members is very clear, the 2^nd Opposite Party clearly stated the benefits available under the scheme and also terms and conditions of the scheme before the Complainants joining the scheme.  It is further stated that the Complainant had taken treatment in Dhanvanthari Hospital Puttur which is not listed in network hospitals.  The Complainant and Dhanvanthari Hospital colluded each other filed the above complaint and the Complainant intentionally not made the hospital authority as a party in this proceedings and the complaint is bad for non-joinder of necessary party.  Since the Complainant taken treatment in hospital other than the network hospitals, the Opposite Party no way liable to pay the amount claimed in the complaint and stated that there is no deficiency and prayed for dismissal of the complaint.

Opposite Party No.2 stated that, he is only acted as an agent on behalf of the principal (Opposite Party No.1) as per the direction of the Deputy Registrar of Co-operative society, D.K. District, Mangalore.  As per the scheme, this Opposite Party is nothing to do with the claim of the Complainant regarding reimbursement of the medical expenses.  It is stated that the Complainant has to make claim directly before the 1^st Opposite Party regarding the reimbursement of the medical expenses.  It is stated that, this Opposite Party is unnecessarily made as a party to the proceedings and denied the deficiency and sought for dismissal of the complaint.

III.     1. In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the Complainant proves that the Opposite Parties committed deficiency in service?

2. If so, whether the Complainant is 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): Affirmative.

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

REASONS

IV.  1.  POINTS No. (i) to (iii):

          In support of the complaint, Smt. Kanya P.Rai (CW1) filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her and got marked Ex C1 to C8. One Sri.R.M.Nataraj (RW1), Chief Executive Officer of the Opposite Party No.1 filed counter affidavit and answered the interrogatories served on him and got marked Ex R1 to R5 for the Opposite Parties.  

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 Complainant along with six family members became the members of the Yashaswini Co-operative Farmers Health Care Scheme by paying Rs.774/- towards the premium amount to the 2^nd Opposite Party on behalf of Opposite Party No.1 as per receipt No.051 dated 7.5.2010 and the same was valid for one year (as per Ex C1). 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, the Complainant contended that, she admitted to Dhanvanthari Hospital Puttur on 27.2.2011 with a history of Caesarian operation and discharged on 3.3.2011 spent Rs.17,275/- for the operation as per Ex C3 (i.e. copy of the medical bills 11 in No.s).  But the Opposite Party No.1 repudiated the claim stating that the Complainant not taken treatment in network hospital which is arbitrary.  It is further contended that Opposite Party No.1 not issued any details which containing the name of the network hospitals or any other information with regard to pre-authorization procedure, diseases covered and other terms and conditions. The membership receipt issued by the Opposite Parties is vague and does not give any vital details.  Feeling aggrieved by the above, this complaint came to be filed before this FORA.

The Opposite Party No.1 i.e. trust formed by the Government of Karnataka 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.  But in the instant case, the Complainant has taken treatment in Dhanvanthari Hospital the same is not listed in network hospital and further stated that the Complainant colluding with the Dhanvanthari Hospital filed the above complaint and hence the claim is not entertainable and denied the deficiency.

We have heard the counsels for the parties and perused the oral as well as documentary evidence available on record, wherein, the Ex C1 is the membership receipt issued by the 2^nd Opposite Party on behalf of the 1^st Opposite Party shows that the Complainant along with six members became the members of the Yashaswini Scheme introduced by the Government of Karnataka and they are the beneficiaries under the scheme. Ex C2 is the discharge summary issued by the Dhanvanthari hospital shows that, on 27.2.2011 the complainant admitted with a history of Caesarian operation and discharged on 3.3.2011 under the scheme. Ex.C3 is the copy of the medical bills issued by the Dhanvanthari hospital (11 in numbers) shows that the Complainant has spent Rs.17,275/-.  Ex C4 and C5 are the office copy of the claim and repudiation letter sent by the 1^st Opposite Party with postal acknowledgement. Ex. C6 dated 2.3.2012 office copy of the regd. Lawyer’s notice sent by the Complainant to the Opposite Party.  Ex.C7 and C8 are the Reply of the 1^st Opposite party.  Apart from the above, we have perused the Ex.R1 i.e. name of the Dakshina kannada district network hospitals name list produced before this FORA reveals certain names of the hospitals shown i.e., 20 in numbers. Ex R2 is the copy of the brochure, Ex. C3 is the true copy of the notice issued to Dhanvanthari Hospital and Ex.R4 and R5 are the correspondences between the 1^st Opposite Party and insurance regulatory and development authority one Mr.Randip Singh, Joint Director, IRDA and J.Meena Kumari, Joint Director, IRDA.  However, it is noted that the name of the Dhanvanthari Hospital Puttur is not found in Ex. R1.  But at the same time the Opposite Party No.1 or Opposite Party No.2 not produced any material evidence before this FORA to show that the above said list of the network hospital names was brought to the knowledge of the beneficiaries/members or within the knowledge of the beneficiaries/members of the Yashaswini Health Care Scheme herein the Complainants. There is no credible/convincing evidence available on record.

However, we have noted that, in Ex C1 i.e. receipts issued by the Opposite Party in all the cases not mentioned/found the detailed terms and conditions of the scheme/policy and also with regard to the obtaining of pre-authorization before taking treatment  or any other procedure supposed to be adopted by the members or the hospitals. Further there is no details of name of the listed network hospitals or list of operation and the amount fixed on the operation etc etc.  At the same time there is no credible/convincing evidence available on record to prove that the terms and conditions within the knowledge of the complainant. Further, the Opposite Party No.1 or any other Opposite Parties not produced any material/cogent evidence before this FORA to show that the above said list of network hospitals/list of the operation and the amount fixed thereon or any other procedure to be adopted by the members or the hospitals were brought to the knowledge of the beneficiaries/members or within the knowledge of the beneficiaries/members of the Yashaswini Health care scheme herein the Complainant.  In the repetition, we would like to point out that, it is to be borne in mind that the Government of Karnataka has introduced the above said scheme in the year 2003 to provide medical assistance to the poor co-operative farmers and their family members.  And most of the beneficiaries are uneducated and villagers.  The Ex.C1 in the above case issued by the Opposite Parties those are the vital document in proof of the membership does not contain any detailed terms and conditions/exclusion clauses, more specifically the list of the name of the recognized/network hospitals or the list of the surgery and the amount fixed thereon and the role of the hospital authority or the Complainants/members before taking the treatment in the hospital. In the absence of the same Opposite parties cannot expect from the members that they violated the terms and conditions or any alleged procedure and denying the benefits.

Further it is seen on record that the above said receipts do not disclose how preauthorization is to be obtained and what diseases are covered and other terms and conditions/information. In order to appreciate the above reasoning’s, some relevant portion is reproduced/quoted herebelow:-

 The above statement do not show the name of the network hospitals or name of the surgery or any diseases covered and the amount fixed thereon.  In normal course, it is impossible and not practically possible for the members/beneficiaries to go in search of the network hospitals when they fall sick. In the absence of any disclosure/information of the name of the network hospitals/name of the surgeries/disease covered/amount fixed thereon and other terms and conditions in detail, the beneficiaries/members herein the Complainant cannot take advantage/benefit of the scheme/policy introduced by the Government of Karnataka. That the terms and conditions must be in the knowledge of the beneficiary/members of the Yashasvini Health Care Scheme herein the Complainant in order to avail the benefit. But in all the cases we noticed that, the Opposite Parties failed to disclose the name of the network hospitals/name of the surgeries/disease covered/amount fixed and other precondition to avail benefits either in the receipt or in any other enclosures.  The receipt issued by the Opposite Parties are proved to be vague do not contain the detailed terms and conditions of the Yashaswini Health Care Scheme.  In the absence of incorporation of terms and conditions and name of the hospitals/ name of the surgeries/disease covered/amount fixed/exclusion either in the I.D. card or in the beneficiary receipts or in the brochure as stated supra the Opposite Parties cannot avoid their liability in a case of like this nature.

It is a settled law that, in case the Opposite Parties suppresses any material information, concealment of any exclusion clauses it adversely affect the beneficiaries/members/consumers herein the Complainant.  The Regulation 3 of the Insurance Regulatory and Development Authority (Protection of Policy Holder’s Interests) Regulations, 2002, framed by Insurance Regulatory and Development authority (IRDA) in exercise of powers under Section 114 (A) of the Insurance Act,  1938, read with Sections 14 and 26 of the Insurance Regulatory and Development Authority Act 1999 – the exclusion clauses - if not explained they are not binding on the insured – those exclusion clauses are required to be ignored while considering the claim of the insured. (Reported in S.C. & National Commission Consumer Law Cases 2005-2008).

In a case NATIONAL INSURANCE CO. LTD. Vs D.P.JAIN reported in III (2007) CPJ (34) the Hon’ble National Commission held that, when statues provides manner in which particular thing must be done, the same must be done in that manner only.  IRDA (Protection of Policy Holders Interest) Regulation bound to be followed.

“Consumer Protection Act, 1986 – Section 21(b) – Insurance Regulatory and Development Authority (Protection of Policy Holder’s Interests Regulations, 2002 – Regulations 3 and 11(4) Insurance – Mobile phone –Stolen – Repudiation of claim – Ground, absence of ‘actual or threatened force’ – Complaint allowed by District Forum – Compensation awarded – Appeal dismissed – Hence revision – Prospectus required to state scope of benefits, extent of insurance cover and in explicit manner explain warranties, exceptions and conditions of Insurance cover – If exclusion clauses not explained, regulations not binding on insured – Said clauses required to be ignored while considering claim of insured –Exclusion clauses should be read, as they are – When statute provides manner in which particular thing must be done, same must be done in that manner only – OP bound to follow regulations – Procedure prescribed under Regulation 3, required to be followed – If said procedure not followed, Regulatory Authority free to take action under Regulation 11(4) against OP – In present case, intermediary (HCL) issued insurance cover as an agent of OP – OP bound to reimburse complainant. [Pg.37-38 (Paras 13, 16, 17,18, 20, 21), Pg. 39-41 (Paras 26, 27 and 36]

In another case, Sukanta Das versus National Insurance Co. Ltd., reported in II (2009) CPJ 294 the Hon’ble State Commission West Bengal held that, the exclusion clauses not incorporated in policy, not part of the policy cannot be included later.

“Consumer Protection Act, 1986 – Section 15 – Insurance – Mediclaim Policy – Exclusion Clause – Not incorporated in policy – Not part of policy at time of taking of policy or its renewal – Insurance Company cannot impose/include Exclusion Clause in later date, directing the reimbursement not entitled in case of Heart Ailment – Incorporation of Exclusion Clause highly unethical, illegal – insurance Company directed to honour terms and conditions of contract without Exclusion of Heart Ailment.”

The Hon’ble National Commission has held that imposition of restriction in exclusion clause was a unilateral action and the Complainant was not told about such clause and hence not binding (Reported in 2011 Vol-I CPJ 25 NC)

From the catena of Land Mark Judgments rendered by the Hon’ble National Commission, the exclusion clauses if not explained or if not incorporated in the policy then they are not binding on the insured herein the beneficiaries, those exclusion clauses are required to be ignored while considering the claim of the insured.  The above judgments are self-explanatory. 

However, the learned counsel appearing for the Opposite Party No.1 in the above  case vehemently argued that, the 1^st Opposite Party is not doing insurance business, it is a trust formed by the Government of Karnataka to help the co-operative farmers produced exhibits mentioned in the annexure. However, we are not convinced with the submissions and documents made on behalf of the 1^st Opposite Party because the correspondences between the IRDA and the 1^st Opposite Party are not binding on this authority because the same are unsupported and without any basis. More particularly ops failed incorporate the terms and conditions in detail and not explained or not brought within the knowledge of the members. Opposite Parties randomly collected money under the semblance of healthcare scheme without fallowing certain mandate procedure as discussed hereinabove amounts to unfair trade practice.

However, our attention was drawn towards the citation relied by the counsel appearing for the Complainant as well as the Opposite Party.  On perusal of the citations relied by the counsels, we find that, the order dated 30.10.2012 passed in Revision Petition No.3869/2012, 3873/2012, 3875/2012, 3872/2012, 3876/2012, 3877/2012 and order passed in Revision Petition No.2001/2007 by the Hon’ble National Commission decided on merits on the same subject in dispute i.e. the treatment taken in non-network hospital.  Further we observed that, even in some of the Revision Petitions the respondents taken treatments in Dhanvanthari Hospitals, i.e. non network hospitals was in dispute.   Against the said order the 1^st Opposite Party i.e. C.E.O. Yashaswini Co-operative Health Care Trust challenged the order in SLA(Civil)26928/2012 before the Hon’ble Supreme Court, wherein the Hon’ble Supreme Court upheld the order passed by the Hon’ble National Commission as well as Lower Courts on 3.12.2012 by passing the order on merits.

In so far the order passed in Revision Petitions No.1786 to 1789/2012, 2014, 3283 to 3288/2012 are concerned, we are of the opinion that, the order passed by the Hon’ble National Commission in the Revision Petitions i.e. No. No.3869/2012, 3873/2012, 3875/2012, 3872/2012, 3876/2012, 3877/2012 mentioned above are affirmed by the Hon’ble Supreme Court in SLA No.26928/2012 still holds final and the observations/discussions made in the above citations are self explanatory.

Further, we are of the considered opinion 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. Therefore, it is repeatedly observed that when statute provides manner in which particular thing must be done, same must be done in that manner only.  When the Government of Karnataka introduced Yashaswini Health Care Scheme for the benefit of the poor farmers, it is the bounden duty of the Opposite Parties who may be a trust or through the agent to explain/disclose the name of the network hospitals/name of the surgeries/disease covered/amount fixed thereon and other terms and conditions to the beneficiaries to get the benefits.  It is to be stated that, the above said 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 product/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 benefits. Further it is made very clear under the regulation that insurer or its agent or other intermediary shall provide all material information in respect of the proposed cover to the insured/members herein the Complainant. 

From the above, it is amply clear that, the Regulatory Authorities taken much care to protect the interest of the consumers.  Under such circumstances, the scheme introduced by the Karnataka Government through the trust or agent or companies shall protect the interest of the poor beneficiary/consumer herein the Complainant.  In our view, the unexplained or unnoticed information regarding name of the network hospitals and prerequisite conditions would not be binding to the insured/members of the scheme herein the Complainant. The reason being, the regulations are mandatory in nature so as to protect the consumer’s interest.

 We further state that, when a statute or regulations provides for a manner in which a particular thing must be done, then that thing must be done in that manner only.  The Rule of Law laid down in Taylor vs. Taylor 1876 1 Ch.D 426 has been founded on sound principle and well recognized and followed by courts in India for several decades.  The principle laid down is that, “if a statute has conferred a power to do an act and has laid down the method in which that power has to be exercised, it necessarily prohibits the doing of the act in any other manner than that which has been prescribed”. The principle behind the rule is that if these were not so, the statutory provision might as well would have not been enacted.  [III (2007) CPJ 34 (NC)]. 

Similarly, in the present case, though the Government introduced the benevolent scheme as stated supra, it cannot overlook the Regulation laid down under the Insurance Regulatory and Development Authority (Protection of Policy Holder’s Interest), Regulations, 2002, framed by Insurance Regulatory and Development Authority in exercise of powers under Section 114(A) of the Insurance Act, 1938 read with Sections 14 and 26 of the Insurance Regularly and Development Authorities Act, 1999.  Therefore, the Opposite Party No.1 cannot contend that it is not a insurance. Under the above circumstance, it is the duty of the Opposite Parties to disclose the hospital names network hospitals/name of the surgeries/disease covered/amount fixed thereon and other terms and conditions notified by the Government under the scheme while issuing the Identity Card or beneficiary receipt.  But in the present case, the Opposite Parties failed to discharge their duty to disclose the hospital names network hospitals/name of the surgeries/disease covered/amount fixed thereon and other terms and conditions to bring within the knowledge of the Complainant to get the benefits while issuing the Identity Card or related documents or subsequently which amounts to deficiency in service as well as unfair trade practice. The Opposite Parties should keep in mind that the beneficiaries under the scheme are the poor farmers and they cannot avoid the benefits by taking unilateral action as the beneficiaries/members were not told about such clauses and information’s and hence the same are not binding.  The Opposite Party No.1 is liable to reimburse the entire medical expenses in all the cases.

In view of the above discussion, we are of the considered opinion that, though the Opposite Parties received the membership fee under the Yashaswini Scheme from the poor member/Complainant herein and admitted that the Complainant as well as their family members under the Yashaswini Scheme and the said scheme was valid to avail the medical benefits for one year and the Complainant had taken medical treatment during the existence of the policy but the Opposite Party No.1 not reimbursed the medical expenses till this date is not justifiable which amounts to deficiency in service as well as unfair trade practice as stated supra. 

We further observed that, whenever a trust or company or any agent who introduces health care scheme/policy under the insurance, they must borne in mind that those schemes/policy introduced under the insurance are very clear that means the terms and conditions to avail benefit should be within the knowledge of the Complainant like how the general insurance companies/private companies introduced the policy/scheme to the general public. As we know the insurance companies are managing large number of general public under the beneficiary scheme like health policy etc etc. but those companies are taken pain to introduce the terms and conditions at the time of introducing the policy.  Likewise the Opposite Party trust should have taken pain to introduce the terms and conditions along with their membership receipt by mentioning all terms and conditions.  We have observed that the trust formed by the government not bothered to explain the terms and conditions in detail and the intention behind the scheme introduced by the Karnataka Government to the poor members/villagers/beneficiaries are not taken care.

In view of the above discussion, we are of the considered opinion that, though the Opposite Parties received the membership fee under the Yashaswini Scheme from the poor members/Complainant herein and admitted that the Complainant is one of the member under the Yashaswini Scheme and the said scheme was valid to avail the medical benefits for one year and the Complainant taken treatment during the existence of the policy but the Opposite Party No.1 not reimbursed the medical expenses till this date is not justifiable and amounts to deficiency as well as unfair trade practice as stated supra.

As far as medical expenses are concerned, the Complainant produced the medical bills for Rs.17,275/- (Rupees Seventeen thousand two hundred seventy five only). However, we observed that the Complainant is a innocent consumer paid Rs.17,275/- (Rupees Seventeen thousand two hundred seventy five only)as demanded by the Dhanvanthri Hospital for which the Complainant is not accountable and the Opposite Party No.1 liable to reimburse the medical expenses paid by the Complainant to the hospital.  In view of the above discussion, we hereby directed the Opposite Party No.1 to pay Rs.17,275/- (Rupees Seventeen thousand two hundred seventy five only) to the complainant towards the medical expenses along with interest at 9% per annum from the date of complaint till the date of payment. Further we awarded Rs.2,000/- as cost of the litigation expenses. Payment shall be made within 30 days from the date of this order.

There is no contractual obligation on the part of the Opposite Party No.2 to reimburse the medical expenses under the above scheme, hence complaint against Opposite Party No.2 is hereby dismissed.

In the present case, interest considered by this Forum itself is compensation and therefore, no separate amount for compensation is awarded.

In the result, we pass the following:-         

ORDER

The complaint is partly allowed.  Opposite Party No.1 i.e. Yashaswini Co-operative Farmers Health Care Scheme represented by its Chief Executive Officer shall pay Rs.17,275/- (Rupees Seventeen thousand two hundred seventy five only) to the complainant along with interest at 9% per annum from the date of complaint till the date of payment and also pay Rs.2,000/- (Rupees two thousand only) towards the cost of litigation expenses. Payment shall be made within 30 days from the date of this order.

Complaint against Opposite Party No.2 is hereby dismissed.

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

(Page No.1 to 21 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 31^st day of July 2013.)

      PRESIDENT                 MEMBER                MEMBER          

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Smt.Kanya P.Rai – Complainant.

Documents produced on behalf of the Complainant:

Ex C1 – 7.5.2010: Copy of the membership receipt.

Ex C2 – 3.3.2011: Copy of the Discharge Summary.

Ex C3 – 3.3.2011: Copy of the bills (11)

Ex C4 – 12.4.2011: O/c of the claim sent to the 1^st O.P.

Ex C5 – 13.4.2011:Postal Acknowledgement by 1^st O.P.

Ex C6 – 11.3.2011: O/c of regd. Lawyer’s notice.

Ex C7 – 30.3.2011: Reply of the 1^st O.P.

Ex C8 – 21.3.2011: Reply of the 2^nd O.P.

Witnesses examined on behalf of the Opposite Parties:

RW1 –Sri.R.M.Nataraj (RW-1), Chief Executive Officer of Opposite Party No.1

Documents produced on behalf of the Opposite Parties:     

Ex R1 – True copy of the List of the network Hospital.

Ex R2 – True copy of the brochure.

Ex C3 – 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:31.7.2013                                        PRESIDENT