At, National Consumer Disputes Redressal Commission NCDRC
By, THE HONOURABLE MR. JUSTICE K.S. CHAUDHARI
By, PRESIDING MEMBER
For the Petitioner: K. Singhal, Advocate. For the Respondents: R1, Exparte, B.S. Sharma, S. Radha Pyari, Advocates, R3, Deleted.
This revision petition has been filed by the petitioner against order dated 7.1.2008 passed by State Commission in Appeal No. 2494/2007- M/s. Yeshasvini Co-operative Farmers Vs. D. Ramappa & Ors.; by which appeal was dismissed.
Brief facts of the case are that complainant/respondent No. 1 being a farmer by profession subscribed himself for healthcare scheme sponsored by O.P. No. 1/ Respondent No. 3 managed by O.P. No. 3/ Petitioner. At the time of joining of the said scheme he was assured by OP.1 that they will bear all the medical expenses in the event of any accident, casualties or illness suffered by the complainant. On 18.3.2006 while complainant was working at his field, accidentally the borewell motor fell on his hands and face, thereby he sustained the severe injuries. Immediately he was taken to Hosmat Hospital, OP.2/ respondent No. 2 for treatment. At the time of getting himself admitted as a patient he informed OP.2 that he is a subscriber to OP.1 and OP.3 health scheme. Unfortunately, OP.2 did not accept his submission, on the other hand forced to deposit the amount for treatment. As the complainant was badly in need of the treatment he deposited Rs. 50,000/- and underwent the treatment at OP.2 hospital. OP.2 doctors conducted the operation for the fracture injuries by open reduction and internal fixation of right ulna on 20.03.2006 and he was discharged on 22.03.2006. In all he incurred the medical expenses of Rs. 60,000/-, soon after the discharge he contacted the OP.1 to reimburse the expenses. Neither OP.1 nor OP.3 responded to his demand. The repeated requests and demands made by the complainant to all the OP’s have gone in vain. Alleging deficiency on the part of opposite party, complainant filed complaint before District Forum. OP. 1 & 3 resisted complainant and submitted that OP.2 should have obtained pre authorization form which is mandatory. It was further submitted that OP.1 is rendering the service to its members, actually financial matter is controlled by OP.3 the trust. Due to the fault committed by OP.2, complainant is put to little inconvenience. If OP.2 had obtained the pre-authorisation, OP.1 and 3 would have definitely come to the aid of the complainant. So, there is no deficiency in service of any kind on the part of OP.1 and 3 and prayed for dismissal of the complainant. OP.2 resisted complaint and submitted that at no point of time, complainant informed them that he is entitled for the benefit under the scheme floated by OP.1 and 3 and that he is a member of the said scheme. As such OP.2 directed the complainant to deposit certain amount to undergo the said treatment. OP discharged its obligation by conducting the successful operation and collected the necessary hospital charges. There is no deficiency in service on the part of OP.2 and prayed for dismissal of complaint. Learned District Forum after hearing all the parties allowed complaint against OP. 1 & 3 and directed them to reimburse Rs. 60,000/- to the complainant and further directed to pay litigation cost of Rs. 3,000/- and dismissed complaint against OP-2. Appeal filed by opposite parties was dismissed by Learned State Commission vide impugned order against which this revision petition has been filed.
None appeared for respondent No. 1 even after service of notice and he was proceeded exparte. Respondent No. 3 was deleted.
Heard Learned Counsel for the parties and perused record.
Learned Counsel for petitioner submitted that inspite of not seeking authorization by complainant from petitioner, Learned District Forum committed error in allowing complaint and Learned State Commission, further, committed error in dismissing appeal, hence, revision petition be allowed and impugned order be set aside. Learned Counsel for respondent No. 2 submitted that no liability has been fastened on him.
Perusal of Deed of Trust of petitioner reveals that a beneficiary desirous of availing medical benefits shall first approach Society for seeking an approval and on satisfaction of Society, beneficiary is entitled to avail medical benefits and Society shall approve request and forward it to the implementing agency and then beneficiary will approach Network Hospitals with the approval. Admittedly, complainant has nowhere stated in the complaint that he approached OP-1 & 3 for seeking approval for availing medical benefits and has specifically pleaded in the complaint that on sustaining injury, complainant was immediately taken to hospital of OP-2 where he was treated. When complainant has not followed procedure for seeking approval for treatment in the approved hospital, complainant was not entitled for reimbursement of expenses incurred by him in treatment. Learned District Forum rightly dismissed complaint against OP-2 but committed error in allowing complaint against OP-1 & 3.
This Commission in similar matter in RP No. 1172 of 2007 - Authority under Yeshashwini Wima Yojna Vs. Shahinbanu, while allowing revision petition and dismissing complaint, rightly observed as under:-
'…..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………….. The State Commission erred in not appreciating this important fact while reaching its conclus
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ion.' In the light of aforesaid discussion and judgment in Shahinbanu’s case, revision petition is to be allowed and impugned order and order of District Forum are liable to set aside. Consequently, revision petition filed by petitioner is allowed and order dated 7.1.2008 passed by Learned State Commission in Appeal No. 2494/2007- M/s. Yeshasvini Co-operative Farmers Vs. D. Ramappa & Ors.; and order of District Forum dated 28.11.2007 passed in Complaint No. 1384/2007- D. Ramappa Vs. M/s. Yeshasvini Co-operative Farmers Healthcare Scheme & Ors.; is set aside and complaint stands dismissed. Parties to bear their costs.