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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
J.M. Malik, Presiding Member and Dr. S.M. Kantikar, Member
YESHASWINI CO-OP. FARMERS HEALTH CARE SCHEME - Appellant
Versus
KURIAKOSE AND ORS., CHOMANNA NAIK G AND ORS., C. PADMANABHA SHETTY AND ORS., CHANDRANARH RAI AND ORS., GANESH PRASAD AND ANR., NARASIMHA BHAT AND ORS., SATHYANARAYANA BHAT AND ORS., JOSEPH MONTERO AND ORS., RAVINARAYANA BHAT AND ANR., K. CHANDRASEKHARA BHAT AND ANR., UDAY BHAT AND ANR. - Respondents
Revision Petition Nos. 1786 to 1789, 2114, 3283 to 3288 of 2012 against Order dated 3.2.2012, 23.4.2012, 25.5.2012, 5.7.2012 in Appeal Nos. 690 to 693, 723, 4738, 1470 to 1475 of 2011, 2012, 2010, of Karnataka State Consumer Disputes Redressal Commission, Bangalore
Decided on : 14-05-2013
Mr. Anand Sanjay M. Nuli, Advocate, for the Appellant; Mr. C.B. Gururaj, Advocate, for the Respondent
Patients must seek treatment in network hospitals as per the terms and conditions of the medical insurance scheme to be eligible for reimbursement.
Headnote:
Medical Insurance Scheme - Reimbursement of Medical Expenses - Yeshaswini Co-op. Farmers Health Care Scheme - [Appendix-1(d) of the Scheme, condition No. 14] - The court discussed the interpretation of the medical benefits under the scheme, the requirement to approach approved hospitals for treatment, and the obligation of the patient to select approved hospitals for reimbursement purposes. The court emphasized the importance of adhering to the terms and conditions of the scheme and upheld the requirement for patients to seek treatment in network hospitals for reimbursement.
Fact of the Case:
The complainants, members of Yeshaswini Co-op. Farmers Health Care Scheme, sought reimbursement for medical expenses incurred at a non-network hospital. The District Forum partly allowed the complaints, directing reimbursement and compensation. The petitioner appealed to the State Commission, which also dismissed the appeals.
Finding of the Court:
The court analyzed the terms and conditions of the scheme, emphasizing the requirement to seek treatment in network hospitals for reimbursement. It rejected the argument that the complainants were entitled to reimbursement despite not seeking treatment at approved hospitals.
Issues: Interpretation of medical benefits under the scheme, obligation to seek treatment in network hospitals for reimbursement, adherence to terms and conditions of the scheme.
Ratio Decidendi: The court held that patients must adhere to the terms and conditions of the scheme, including seeking treatment in network hospitals for reimbursement. Ignorance of the approved hospitals by the patient is not a justification for seeking reimbursement from non-network hospitals.
Final Decision: The court accepted all 11 revision petitions, set aside the State Commission's order, and dismissed the complaints.
ORDER
J.M. Malik, Presiding Member - This order shall decide the above mentioned 11 revision petitions. The facts and law points involved in all these cases are same and consequently, they are being disposed of by this common order. We are taking the facts from RP No. 1786/2012. In this case, the complainants became Members of Yeshaswini Co-op. Farmers Health Care Scheme. As per the Medical Insurance Scheme, the petitioner/OP was to reimburse the medical expenses of its Members. This is an indisputable fact that Manager, Health Family Plan Ltd., received the premium from each of the complainants and he also issued the policies. The petitioner/OP refused to pay the medical bills of the complainants on the ground that they did not undergo treatment in the network hospitals. There is no dispute that all the complainants took treatment in Dhanvanthari Hospital, Puttur. The petitioner refused to reimburse the said bills.
2. The complainants filed the complaints before the District Forum which were partly allowed by it. C.E.O., Yeshaswini Co-op. Farmers Health Care Scheme, petitioner/OP 1 and Manager, Family Health Limited Plan, Respondent No. 2/OP2 were directed to reimburse the medical expenses of the complainants and were further directed to pay Rs. 5,000 each as compensation and Rs. 1,000 as costs of litigation expenses, within a period of 30 days. Aggrieved by that order, the petitioner/OP filed appeals before the State Commission. The State Commission also dismissed the appeals.
3. We have heard the Counsel for the parties. It is interesting to note that both the Counsel have filed two divergent judgments of the same Bench. The first judgment is with reference to the authority in Yeshashwini Bima Yojna v. Shahinbanu and Yeshashwini Bima Yojna v. Mumtaz Begum, RP Nos. 1172 and 1173 of 2007. In these cases, it was held that:
"A reading of the Appendix-1(d) of the Scheme makes it very clear that medical benefits shall mean inpatient hospitals including the related surgeries as notified by the Trust which can be availed by the members subject to the maximum eligibility at any of the network hospitals under the Scheme. Further, the procedure for availing medical benefit is also clearly stated in the same Trust Deed that a beneficiary under the Scheme who wants to avail of medical benefits has to first approach the Society for approval which after satisfying itself will authorize the beneficiary to approach any of the network hospitals approved by the Society and it is for the network hospital to forward a request for pre-authorisation as provided for under the Scheme. In the instant case, it is clear that the respondent did not adhere to the terms and conditions of the Scheme, i.e. she neither approached the Society to get approval for availing the medical benefits nor did she approach any of the hospitals authorized under the Scheme for her medical treatment. Further, it is not disputed that the network of authorized hospitals under the Scheme included super specialty hospitals wherein the respondent could have easily got the best medical treatment, however, complicated her medical condition was, ignorance of the terms and conditions by which the respondent was bound, cannot be a justification for her not adhering to these and yet insisting on claiming, the benefits of medical treatment under the Scheme. The State Commission erred in not appreciating this important fact while reaching its conclusion. We, therefore, have no option but to set aside the order of the State Commission and restore the order of the District Forum. The revision petitions are dismissed with no order as to costs".
4. The second judgment is also by the same Bench in the cases, C.E.O., Yeshaswini Co-operative Farmers Health Care Scheme v. Hemanth Kumar and C.E.O., Yeshaswini Co-operative Farmers Health Care Scheme v. Smt. Susheela Rai K.S., RP Nos. 3873 and 3875 of 2012, wherein it was held that:
"Finding recorded by the Fora below that the appellant had not notifi
