IMPORTANT POINT
Ignorance of terms and conditions of insurance policy cannot enure to benefit of beneficiary.

Mrs. Vineeta Rai, Member—Revision Petition Nos.1172/2007 and 1173/07 have been filed by the same Petitioner i.e. The Authority under Yeshashwini Wima Yojana [Arogya Wima Yojana(Insurance)] being aggrieved by the single order of the State Consumer Disputes Redressal Commission, Karnataka (hereinafter referred to as the ‘State Commission’) dismissing their Appeal Nos.1378/05 and 1379/05. In both cases, Respondents and certain facts pertaining to their medical treatment are different, but since the Petitioner is the same and the grounds on which the claims were rejected are also similar, these revision petitions are being disposed of by a single order taking into account the facts in Revision Petition No.1172 of 2007.

2. The facts according to the Respondent in the above case, are that she was a beneficiary of the Yashashwini Arogya Wima Yojana (Insurance) Scheme which provide health insurance cover to farmers like her. She was diagnosed with suffering from thyrodectomys specimen disease and a doctor at Bijapur whom she consulted, informed her that since it was a complicated medical condition which would require major surgery for which no specialist was available in Bijapur, she should get the operation done by a specialist at Solapur. Respondent, thereafter, went to Solapur and underwent a surgery. She thereafter applied for reimbursement of expenditure incurred by her to the Petitioner along with necessary documents but the Petitioner refused the reimbursement on the grounds that medical treatment could have only undertaken from hospitals authorized by the Petitioner under the Scheme, which was not so in the instant case. Since the objective of the Scheme was to provide medical treatment and reimbursement, Respondent contended that the Petitioner wrongly rejected her genuine claim for reimbursement and filed a complaint before the District Forum on grounds of deficiency in service seeking reimbursement of Rs.15,000/- towards her medical treatment and Rs.20,000/- as compensation for harassment and mental torture.

3. Petitioner challenged the above contentions. According to the Petitioner, taking in view the inadequate existing arrangements for medical care and treatment of farmers, the Government of Karnataka floated a Scheme to ensure that all beneficiaries under the Scheme could avail medical treatment including surgical treatment from a network of hospitals and nursing homes including super-specialty hospitals, the procedure etc. for which was incorporated in the Scheme. The hospitals designated under the Scheme were selected and notified and special rates arranged with them to ensure cashless transactions for treatment to beneficiaries under the Scheme. In the instant case, the Respondent did not follow the procedure in availng medical treatment from any of the network hospitals authorized under the Scheme and, therefore, her claim was rightly rejected.

4. The District Forum after hearing the parties and considering the evidence on record dismissed the complaint. The operative part of the order of the District Forum reads as follows:

“As per Rules and Regulations of Yashashwini Vima Yojana claim of the complainant is repudiated. The members must take treatment with the doctors and hospitals mentioned by the (Y.V.Y) or on the advice of said doctors with other consultants or hospitals. As such the claim of complainant is rightfully rejected by the respondent. This procedure has not been followed by the complainant. Complainant miserably fails to prove that Dr.Jalil Muzawar’s Hospital is included in Yashashwini Vima Yojana Scheme. Secondly, complainant fails to prove that there is deficiency of service by the respondent side.”

5. Aggrieved by this order, Respondent filed an appeal before the State Commission which accepted the appeal by making the following observations:

“The complainants are the poor farmers. They will not be knowing the conditions of the policy as they are from rural areas. Therefore, we ar