Mr. Bheem Bhat, a member of Peramogru Milk Producers Co-Op Society, a poor farmer, had an enlarged prostate. He had difficulty in passing urine. The Co-Operative Department had compelled all the members to buy Yashaswini Health Insurance promising that their operative needs will be taken care by them subject to certain terms and conditions. The terms and conditions remained elusive not followable as it had difficult practical problems. Somehow he got operation done at a center which he thought was quite sufficient for him. There was no problem so far as the treatment was concerned. Unfortunately for Yashaswini, the centre chosen by him was not a panel hospital. Yashaswini had not made any attempt or effort to make Dhanvanthari Hospital a panel hospital. This is where the deficiency lied. When Bheem Bhat approached Yashaswini with claim bills, it could not break its own rules. It had to say that as per the Yashaswini Protocol, a non-empanelled hospital bill will not be reimbursed. Little did Yashaswini think that this stance which it was going to take was against the existing rule of law and also that it could be counterproductive to stick to this principle in the long run and that would only attract flack from one and all.

Bheem Bhat promptly approached Dakshina Kannada District Consumer Forum through Advocate Mr. Sanjay D., who by this time had become an expert in such health insurance claim repudiation matters. The DF headed by Mrs. Asha Shetty promptly delivered the verdict after thorough examination that Yashaswini shall pay the full claim amount along with suitable interest and court expense of Rs.1,000/- within 30 days of the judgment.

Please go through the attached judgment copy for details


Bheem Bhat Judgment DK Dist Forum.zip

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