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Judgement in Yashaswini Claim - Bangalore District Forum denied, State Comm. granted CC No. 1886/2007
Filed on 10.09.2007
Disposed on 16.01.2008
BEFORE THE III ADDITIONAL BANGALORE URBAN DISTRICT
CONSUMER DISPUTES REDRESSAL FORUM,
BANGALORE -560 052
DATED THIS THE 16TH DAY OF JANUARY 2008
CONSUMER COMPLAINT NO.1886/2007
PRESENT:
Sri N. Srivathsa Kedilaya, B. A. B. L.
President
Smt. Dr. Subhashini M.B.B.S.
Member
Sri H. M. Shivalingappa B.Sc., L.L.B.
Member
COMPLAINANT:
Smt. Leelamma N.
W/ o Puttaswamappa C.,
Aged about 60 years
Sulibele,
Hosakote Taluk
BANGALORE RURAL DIST.
(Rep. by Sri G. B. Srinatha, Adv, Bangalore)
V/S
OPPOSITE PARTIES:
1. The Chairman/ CEO,
Yashaswini Co-operative
Farmers Health Care Scheme,
Co-operation Department,
Government of Karnataka
6th Floor, 2nd Gate
M. S. Building,
Bangalore – 560 001
(Rep. by Sri Gurudev & Sri I.
Gachchinamath, Advocates Bangalore)
2. The CEO,
Wockhardt Hospitals Limited
154/9, Opp. IIM, (Bangalore),
Bilekana Halli, Bannerghatta Road
Bangalore
(Through Agent)
ORDER
1. This Complaint is u/s 12 of the Consumer Protection Act 1986. This complaint is filed on 10/09/2007. The Complaint in brief is as under: The Complainant is a housewife. The first Opposite Party, Yashaswini Co-op. Farmers Health Care Scheme is providing insurance coverage for members under the said scheme. The 2nd Opposite Party is the Hospital wherein the Complainant had undergone the Operation. The Complainant is a member of gÉõÉä UÁæ«ÄÃt ªÀÄvÀÄÛ gÉÊvÀ ¸ÉêÁ ¸ÀºÀPÁj ¨ÁåAPï ¤AiÀÄ«ÄvÀ, ¸ÀÆ°¨É¯É. (hereafter, Bank). Her Membership bears No.597. She is eligible to the benefits of the Scheme. The Complainant fell ill suddenly on 5-10-2006. She was examined by Dr. R. Anil Kumar. He advised her to undergo medical tests. He referred the Complainant to Trinity Hospital and Heart Foundation, Bangalore. The Complainant visited the Hospital on 16-10-2006 and 17-10-2006. She was directed to get admitted as inpatient for medical checkup. After medical checkup they gave an opinion. The report revealed blockage in the heart. A second opinion was necessitated in that regard and the Complainant visited the 2nd Opposite Party – Hospital, namely Wockhardt Hospital, on 26-10-2006. She was advised in that hospital to go for an open heart surgery immediately. The Complainant informed the same to the Bank on 29-10-2006. They have admitted as per their letter dated 29-10-2006, that the Complainant is a member of the Bank having registered her membership No. as 597 of 23-8-2003. Accordingly the Complainant got admitted to the 2nd Opposite Party Hospital as inpatient on 1-11-2006. The Complainant had informed that ………the 1st Opposite Party to reimburse, the Complainant had to pay the entire medical bills to the 2nd Opposite Party – Hospital as claimed by them. That has resulted in sufferance and loss to the Complainant. The Opposite Party remained deficient in rendering service to the Complainant by not allowing her to reap the fruits of that medical benefit scheme, though she is entitled. Hence this Complaint is necessitated to direct the Opposite Parties to Pay Rs. 1,81,373.26 towards medical bills, Rs.75,000/- by way of future medical expenses and Rs.25,000/- by way of general damages totaling Rs. 2,81,373.26 with interest at 12% p.a. Along with the Complaint the Complainant has made available, the Xerox copies of some documents marking them at Document No.1 to Document No. 27.
2. (a) The version of the 1st Opposite Party is made available on 13.11.2007. In brief, it is as hereunder; The Complainant has approached this Forum suppressing the true facts in order to make wrongful gain if possible. Any person who wants to become a member of Yashaswini Scheme should have prior membership with a Rural Co-operative Society/ Bank at least for a minimum period of 6 months. The receipts produced by the Complainant regarding membership are concocted and they are also irreconcilable. The medical bills so made available by the Complainant along with the Complaint are not at all helpful to the Complainant, since she is not entitled for benefits under the said scheme. A member in order to get the benefits of that scheme, has to take treatment for the ailment from any of the Network Hospitals. Wockhardt Hospital, located at Bilekana Halli, Bannergatta Road, Bangalore is not a hospital which came within the network of Hospitals at the relevant point of time. For having opted treatment at a hospital which was not within the network hospitals description, the Complainant cannot claim the benefit of that scheme even if she was a member at the relevant point of time. However in the present case the Complainant was not at all a member of that scheme at the relevant point of time. When that is so, it has to be held that the Complainant has not approached this Forum with clean hands. Moreover, the Complainant has not chosen to make the particular Society through which she claimed membership a party to this proceeding. Under these circumstances the Complainant is not entitled for any relief much less the relief sought in the Complaint and the Complaint has to be dismissed with exemplary costs of this Opposite Party. Along with their version the 1st Opposite Party has made available Xerox copies of some documents marking them at Annexure R1 to Annexure R5.
(b) The 2nd Opposite Party has made available their version of the case in the form of an affidavit on 13-11-2007. In short, it is as hereunder. This complaint has no merits since it is based on false assumptions and presumptions. The 2nd Opposite Party – hospital is a reputed Hospital. It is true that the Complainant had approached the 2nd Opposite Party –Hospital and got admitted on 1-11-2006 and got treated for the heart cardiac problems and was discharged on 11-11-2006. The hospital charges in that regard were to the tune of Rs.1,76,536/- . The Complainant has settled the same. The complainant was admitted to the 2nd Opposite Party as a regular patient and not as a patient under Yashaswini Co-operative Farmers Health Care Scheme. The 2nd Opposite Party – Hospital, located at Bannerghatta is not a recognized network hospital under Yashaswini Co-operative Farmers Health Care Scheme. When that is so, the question of reimbursement of the medical expenses by this 2nd Opposite Party – hospital does not arise. Yashaswini Co-operative Farmers Health Care Scheme is a medical insurance scheme launched by the co-operation department of the Government of Karnataka in the year 2002-03. The interested Farmers are made members of that Scheme and they have to contribute a nominal amount every month which will cover treatment of major diseases. The scheme like any other scheme recognizes network hospitals in each city. However the difference is the hospitals interested to get recognition, have to submit the application in the prescribed format, fill in the self-assessment chart and send the same to the third party administrator (TPA) appointed by them. The TPA in the case of Yashaswini Scheme is Family Health Plan Limited (FHPL). After inspection and scrutiny jointly by Yashaswini and FHPL, they recognize the concerned hospital as network hospital. Wockhardt Hospital and Heart Institute at Cunningham Road, Bangalore was included in the said network hospitals for the 1st time in 2003. However the Wockhardt Hospital at Bannerghatta Road, Bangalore was not an empanelled hospital/ network hospital at that time and it was so recognized only with effect from 29.7.2006. The 1st Opposite Party Yashaswini Scheme by their letter, dated 2-12-2006, has excluded Wockhardt Hospital and Heart Institute, Cunningham Road, Bangalore from the list of Network Hospitals under that scheme. Wockhardt Hospital and Hospital and Heart Institute, Cunningham Road is a different and separate Hospital from Wockhardt Hospital, Bannerghatta Road, Bangalore. Even the Cunningham Road Hospital was not a member of Yashaswini Scheme during the relevant point of time by virtue of that letter of Yashaswini Scheme. Without checking the correct position, the Complainant got admitted into Wockhardt Hospital, Bannerghatta Road, Bangalore. Further to avail the benefit of Yashaswini Scheme, the patient has to be a member of that scheme and should have a valid membership at the time of treatment and if requested to provide that benefit, the hospital has to send that request for pre-authorization of treatment to that Family Health Plan Limited (TPA) for carrying out the procedure and the FHPL has to give authorization to the concerned recognized network hospital and not to other hospitals. In the circumstances, this complaint shall lie as against this Opposite Party and the Complaint has to be dismissed with the costs of this Opposite Party – Hospital. Along with the version, the 2nd Opposite Party has made available, Xerox copies of some documents.
3. Since a consumer dispute arose, the parties were called upon to substantiate their respective case by way of evidence in the form of affidavits and documents. Accordingly affidavit of the Complainant is made available on 3-12-2007. The Complainant has also made available as many 27 documents (Originals) along with a list of documents dated 3-12-2007 by way of evidence marking them at Documents No.s 1 to 27. For the 1st Opposite Party, their CEO namely Sriranga Rama Naik, S/o Rama Narayana Gaonkar has sworn to an affidavit which is made available on 13-12-2007 along with 5 documents marking them at Annexures R1 to R5. They are the very same documents so produced by the 1st Opposite Party along with their version. For the 2nd Opposite Party – Hospital, one Ganesh Hegde, as manager, administration of Wockhardt Hospitals Ltd. has sworn to an affidavit which is made available in evidence on 13-12-2007 along with that affidavit some documents are also made available marking them at Ex.1, Ex.1A, Ex.2 and Ex.3. At the end, the Forum heard on merits.
4. In the circumstances, the points for our consideration and decision are;
a) Whether the Complainant was entitled for the medical benefit under the Yashaswini Co-operative Farmers Health Care Scheme?
b) Whether the Opposite Parties were deficient in rendering services to the Complainant by not extending that medical benefit to her?
c) Whether the Complainant is entitled for any relief in her favour in this proceeding?
d) What Order?
5. Our findings to these pints are as hereunder:
i) No
ii) No
iii) No
iv) As shown in the operative portion of the Order here below.
6. We shall lend support to our findings on the following:
R E A S O N S
POINT NO.1: (a) The grievance of the Complainant is that the Opposite Parties ought to have extended the benefits of Yashaswini Scheme to her in respect of the Medical expenditure that she had to incur and the failure of the Opposite Parties to extend that benefit though she is a beneficiary, has made her to file this Complaint alleging deficiency of Service and seeking appropriate orders. To substantiate the same, the Complainant has to establish primarily that she is so entitled to avail the said benefit under that scheme.
(b) Now let us look into the evidence on record, touching the above aspect of the matter. The 1st Opposite Party has made available a copy of Deed o Trust dated 10-11-2003. It is styled as Yashaswini Co-operative Farmers Health Care Trust. As revealed in that deed, a scheme is floated by the Trust known as Yashaswini Co-operative Farmers Health Care Scheme (hereafter scheme). The Author of that Trust is the Hon’ble Governor of Karnataka. As revealed therein, that scheme is managed by the Department of Co-operation to the Government of Karnataka. That scheme is meant for the benefit of Farmers in the State. As per the Appendix 1 of that scheme, the beneficiary should be a member of the society which comes within the province of that scheme for the last six months prior to getting entitlement for the benefit of that scheme and the beneficiary must have contributed his/her share to that scheme as provided therein. There is no dispute as to the fact that gÉõÉä UÁæ«ÄÃt ªÀÄvÀÄÛ gÉÊvÀ ¸ÉêÁ ¸ÀºÀPÁj ¨ÁåAPï ¤AiÀÄ«ÄvÀ, ¸ÀÆ°¨É¯É – 562 169 comes within the province of that scheme.
(c) According to the Complainant, she is a member of that Bank right from 1983. But in the Complaint the Complainant has recited that she is a member of the Bank and her membership is registered at No.597 dated 23-8-2003 and that the said membership is confirmed by the letter bearing No. Y/K/W/H/B/73A/2006 – 07 dated 29-10-2006 issued by that Bank. The Complainant has made available that letter along with her Affidavit evidence and that letter is marked by the Complainant as document No.13. We have gone through the said letter in detail. It is the one addressed by the above bank to the 2nd Opposite Party – Hospital herein. It is dated 29-10-2006. Strangely in that letter, it is recited that the applicant N. Leelamma is a member of that Bank as number, Membership No.597 dated 23-8-1983. In the Complaint and in the Affidavit, evidence of the Complainant, that date has been mentioned as 23-8-2003. How this discrepancy could occur? Who has to explain it? Has it been explained?
(d) The Complainant has placed reliance on Document No.1 produced by her to probabilize that she is a member of that Bank. Document No. 1 is her membership identity card issued by the Bank. Though it mentions the Membership No. as 597, absolutely there is no recital as such regarding from which date, she had so become member of that Bank. Moreover, there is no recital in that card as to on which date, that card was so given by the said Bank. In the context, the Complainant has also placed reliance upon document numbers 2 and 3 made available by her along with her affidavit. Document No.2 is the counterfoil signed by that Bank. It is dated 3.3.2006. It refers to the Share Pan number of the Complainant and it also recites that a sum of Rs. 65/- was so collected from the Complainant. Document No.3 is also a counter foil signed by the Said Bank. It is also dated 3.3.2006. It reveals that a sum of Rs.120/- has been collected from the Complainant by that Bank under the name and style “Yeshaswini”. It is the very contention of the 1st Opposite Party that these documents 1 to 3 are not genuine and that they are manufactured with an intention to get the benefit of that Scheme if possible. Significantly , documents No.s 2 and 3 both are dated 3.3.2006. If really the Complainant had become a Member of that Bank either in the year 1983 or in the year 2003, certainly there could have been documentary proof in that regard maintained by that Bank and the Complainant could have chosen to make available the documentary evidence to substantiate her contention that she is a Member of that Bank from such and such time. However, the Complainant has not chosen to proceed in that line and rest contended with the documents 1 to 3 referred to above and also the Document No.13 referred to above.
(e) Admittedly, the Complainant had undergone her heart surgery in the month of November 2006 at the 2nd Opposite Party Hospital. The documents made available in evidence revealed that she was admitted to that hospital o 1.11.2006 and was operated on 2-11-2006 and was discharged on 11.11.2006. As stated supra, to claim the benefit of that Scheme, the Beneficiary should necessarily be a Member of that Bank at least for a period of six months prior to her membership under that Scheme. Therefore in the circumstances, we find force in the contention of the 1st Opposite Party that the Complainant failed to establish her eligibility to claim that benefit. It cannot be said as if there could not have been any documentary proof to opine that the Complainant became the Member of that Bank for the first time on such and such a date. No doubt, the Complainant has produced another Card said to have been issued by the Authorized Signatory of that Scheme for the year 2006-07. The genuineness of that Card is not admitted by the 1st Opposite Party. That Card is so made available along with the document no.1 Identity Card. The Complainant and the affidavit evidence of the Complainant is very much silent as to when exactly that Card was so issued to her and who exactly had issued that Card to her. It is not the case of the Complainant that at the time of seeking admission to the 2nd Opposite Party – Hospital, she had shown that Card to that Hospital Authority and that having satisfied with the same, the Hospital Authority had admitted her to that hospital on 1-11-2006. On the other hand, her contention is that she had been to the 2nd Opposite Party – Hospital on 26-10-2006 itself and that after getting the necessary Report, the concerned Doctor advised her to undergo open-heart surgery immediately and directed her to get admitted into that hospital as inpatient. Significantly, she was not admitted to that hospital even according to her on 26-10-2006 and on the other hand, she was so admitted as revealed in the evidence, only on 1-11-2006. If the open heart surgery was so imminent, why she had not chosen to get admitted into that hospital on 26-10-2006 itself, especially when the concerned Doctor had advised her to get admitted as an inpatient wince the surgery to be conducted was imminent? On the other hand, the contention of the Complainant is that she informed the opinion of that Doctor to that Bank and accordingly that Bank gave that letter dated 29-10-2006 (Document No.13, referred to above) to her. The question is, has she produced that letter to that hospital or to any other Authority to claim the benefit of that Scheme? There is no evidence on record in that regard. Above all, that Document No.13 is in the original form. It is not addressed to the Complainant. As already stated, it is addressed by that Bank to the 2nd Opposite Party – Hospital Authority. If at all that letter had come into existence, as on that date under normal circumstances, certainly that could have been produced before the 2nd Opposite Party Hospital Authority and in that event, the production of that original by way of evidence by the Complainant in this case herself would not have arisen at all. Moreover, it is not the case of the Complainant that the said document was returned to her by the said hospital Authority. If really it was so produced before the hospital Authority, certainly there could have been at least an endorsement in that letter by that hospital authority. Further, if really that letter was returned by that hospital to the Complainant, certainly in that event also, there could have been an endorsement to that effect in the said letter. Significantly, no such endorsements are found in the said letter.
(f) Further, Appendix-1 of the said Scheme as revealed in the said Trust Deed, reveals the aspects of eligibility and payment procedure. As per the same, any person desirous of availing the medical benefits under that Scheme, should have been a Member of that Society or Bank as the case may be for at least 6 months prior to his/her admission as a person eligible for the medical benefits under that Scheme and that the said person should not have exceeded 75 years of age. As stated supra, absolutely there is no satisfactory evidence on record to hold that the Complainant was a Member of that Bank at least for six months prior to her admission as a person eligible for the medical benefits under that Scheme. Now as far as the payment procedure is concerned, as revealed in that Appendix-1, the person desirous of becoming a Beneficiary under that Scheme, shall have to pay his or her contribution amount (Rs.60/- p.a.) to the Society or the Bank as the case may be of which that person is a Member at the time of seeking admission and such other amounts that may be prescribed by that Trust from time to time and that amount would be treated as the amount of Beneficiary Contribution. It is further recited in that Appendix – 1 that the Beneficiary is required to fill up the necessary Format in triplicate providing the details required therein and submit the same to the Bank or the Society of which that person is a member and after scrutiny of the same, that person shall be informed by the Trust that his/her name is enrolled in that Scheme. Further it is also recited therein that the Bank or the Society shall forward a list of all the Beneficiaries and the list so forwarded shall be duly authenticated by an Office Bearer not less than the rank of a Secretary to the Registrar of Co-operative Societies and that list so forwarded to the Registrar of Co-operative Societies shall be accompanied by 2 copies of the Application Form along with the photograph and the Registrar of Co-operative Societies shall forward the list after scrutiny along with one copy of the Application Form to the Trust which shall then forward the same to the Implementing Agency. It is also recited therein that prior to forwarding the list to the Implementing Agency, the Trust/Registrar of Cooperative Societies shall ensure that the Beneficiary contribution or any other donations/ contributions are deposited in the concerned Bank account and shall provide conclusive proof to the Implementing Agency regarding the ……..(not visible)…
(g) Now coming to the procedure for availing the medical benefits is concerned that very same Appendix-1 to that Scheme reveals that a Beneficiary desirous of availing the medical benefits, shall firs approach the Society or the Bank as the case may be for seeking approval and the Bank/ Society shall upon satisfying that the Beneficiary is entitled to avail the medical benefits, shall approve the request and forward it to the implementing Agency and the Beneficiary shall then approach any of the network hospitals with the approval given by the Society and the Network Hospital shall forward a request for preauthorization by Fax to the Implementing Agency giving details of the ailment and the proposed course of treatment and the surgical procedure stated therein is required and thereafter, the Implementing Agency shall satisfy itself that there is adequate fund available in the Float Fund Account to pay the Network Hospital indicating therein that only the amount in excess of the ceiling amount only shall be collected by the Network Hospital from the Beneficiary. When that is so, where is the evidence that the Complainant has complied with those requirements? Significantly, the Complainant has not chosen to make that Bank and also that Implementing Agency as parities to this Proceeding. As revealed in the evidence, the Implementing Agency is, Family Health Plan Limited (FHPL). According to us, in a situation like this, their participation was warranted. However in spite of raising that point in their Version, the Complainant has not chosen to proceed in that line by getting the needful done.
(h) No doubt, the 2nd Opposite Party has tried to impress upon this Forum that the 2nd Opposite Party-Hospital did not come within the purview of the Network Hospitals under that Scheme for the reason that the Opposite Party-Hospital has nothing to do with Wockhardt Hospital, Cunningham Road, Bangalore which was one of the hospitals under the Network Hospitals. The evidence on record has revealed that as on 1-11-2006, the Wockhardt Hospital, Cunningham Road, Bangalore was in the list of Network Hospitals though subsequently as revealed in Ex.3 dated 2-12-2006, that that hospital is excluded from the list of Network Hospitals. Ex.3 is a copy of the letter dated 2-12-2006 addressed by the Manager of that Implementing Agency namely, Family Health Plan Limited to the Wockhardt Hospital, Cunningham Road, Bangalore. The 2nd Opposite Party placing reliance upon the copies of the Trade License Certificate and Business License which are produced by them contended that the 2nd Opposite Party-Hospital is altogether a different Hospital from that of Wockhardt Hospital, Cunningham Road, Bangalore. The Trade License Certificate referred to therein is the one issued by Bruhath Bangalore Mahanagara Palike to one Feroz Ali to run a medical store at No.14, Cunningham Road, Shivajinagar. How it is relevant to the above contention of the 2nd Opposite Party, is not made clear. The other license is the one issued by Bruhath Bangalore Mahanagara Palike to M/s Wockhardt Hospital, Bilekanahalli to run a canteen and a hospital in premises No.154/9, Bannerghatta Road, Bangalore. Admittedly, that hospital at Bilekanahalli came to be opened recently and that the Wockhardt Hospitals had only one hospital premises at the time when its name was included in the list of Network Hospitals at Cunningham Road, Bangalore. Now, Wockhardt Hospital has their branches at different places in the city of Bangalore. Significantly, the 2nd Opposite Party has remained silent as to who exactly is running those hospitals. If really those hospitals are being managed by independent Managements, certainly the 2nd Opposite Party would have made available necessary documentary proof in that regard and would not have rest contended only by producing those two licenses. On the other hand, what has been revealed is, Wockhardt Hospital located in Cunningham Road and at other places are being managed by one and the same Management headed by Dr. Vivek Jawali. What was brought under the Network Hospitals was, Wockhardt Hospital. It may be situated at Place-A or at Place-B. That does not matter much. When the Management is one and the same, it cannot be concluded that they are independent by themselves and nothing to do with each other. What best can be inferred in a situation like this is, the 2nd Opposite Party-Hospital is a leg of Wockhardt Hospital, Cunningham Road, Bangalore. Wherefore, we do not fine force in the above contention of the 2nd Opposite Party. Even then, for the reasons stated supra, we have to hold that the Complainant has not become successful in establishing that she is entitled to that medical benefit provided under the benevolent Scheme. In the result, this point is answered against the Complainant in this Proceeding.
7. Point No. 2. In the light of our finding on Point No.1, supra, the allegation of deficiency of service by the Opposite Parties falls to the ground. Accordingly, this point is answered.
8. Point No. 3. In the light of our findings on Point No.s 1 and 2 supra, the Complainant is not entitled for any relief much less the reliefs sought in this Complaint. Accordingly, this point is answered.
9. Point No. 4 In the result, we proceed to pass the following:
O R D E R
The Complaint stands dismissed. However in the peculiar circumstances of the case, the Opposite Parties shall bear themselves the costs incurred by them in this Proceeding.
This Order is pronounced on this the 16th day of January 2008.
H. M. Shivalingappa
Member Dr. Subhashini
Member N. Srivathsa Kedilaya President
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