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Yeshasvini Co-Operative Farmers Health Care Scheme v/s L. Adisesha & Others


Company & Directors' Information:- INDIA FARMERS PRIVATE LIMITED [Active] CIN = U01110MH1950PTC008084

Company & Directors' Information:- FARMERS LIMITED [Dissolved] CIN = U99999MH1928PTC001404

    Revision Petition No. 2222 of 2008 in Appeal Nos. 2086, 2087 of 2007

    Decided On, 28 May 2008

    At, National Consumer Disputes Redressal Commission NCDRC

    By, THE HONOURABLE MR. JUSTICE R.C. JAIN
    By, PRESIDING MEMBER & THE HONOURABLE DR. P.D. SHENOY
    By, MEMBER

    For the Petitioner: Nitesh Rana, Advocate. For the Respondents: None.



Judgment Text

Dr. P.D. Shenoy, Member:

1. Aggrieved by the order dated 5.3.2008 passed by the State Consumer Disputes Redressal Commission, Karnataka (herein after referred to as the State Commission), Bangalore in appeal Nos. 2086 and 2087 of 2007 directing the Deputy Manager as well the Chief Executive of Yeshasvini Co-operative Farmers Health Care Scheme (herein-after referred to as the Scheme), Bangalore to pay a sum of Rs. 1,11,055 to the complainant with interest @ 8% p.a. from the date of filing of the complaint before the District Forum till its realization, the Chief Executive Officer of the Scheme has filed this revision petition before us.

Facts of the case in nutshell are that the complainant L. Adisesha and his family members were insured for their health care under the Scheme by paying the requisite insurance premium to the Primary Agriculture Co-operative Credit Bank Limited, Mudigundam Village. As the father of the complainant was suffering from blood pressure he got himself admitted for operation in BGS Apollo Hospital for surgery and was discharged from the hospital on 19.11.2005 and subsequently died at his house on 26.11.2005. At the time of discharge complainant delivered membership identity card No. CJR 1677099 but the hospital authorities refused to accept the same and collected the full bill amount without giving any concession. Accordingly, the complainant filed the complaint seeking reimbursement of Rs. 1,12,555. This was contested by the authorities of the scheme as they had not received pre-authorization from the hospital hence, they were not aware of the case. Further, the treatment extended to the patient was mainly for the medical management and intensive care support and as the pre-authorization, is a must to avail cashless benefit under the scheme; they had no liability to pay.

2. The Administrative Officer of the Apollo Hospital, Mysore had contended that father of the complainant was shifted from JSS hospital to their hospital in an unconscious condition, they had deposited Rs. 3,000 as an advance amount and the treatment meted out was mainly medical management and intensive care support.

3. After going through the records of the scheme and hearing the parties Counsel the District Forum directed the authorities of the Scheme to pay Rs. 1,11,055 to the complainant with interest @ 8% p.a. from the date of complaint till payment of entire amount.

4. The Forum also directed the OP No. 2 to pay a compensation of Rs. 1,000 to the complainant and OP No. 5 was directed to pay to complainant compensation of Rs. 1,000 for mental agony. In addition OP Nos. 2 to 5 were directed to pay the complainant Rs. 500 towards cost.

5. Dissatisfied by the order of the District Forum, the Chief Executive Officer as well as the Deputy Manager of the Scheme filed two different appeals before the State Commission. The State commission modified the order of the District Forum as narrated above. Hence this revision petition.

6. The undisputed facts are that Shri L. Adisesha and his family members were covered by the Scheme, as Adisesha, the complainant had paid the insurance premium, the father of the complainant is a beneficiary of the Scheme and eligible for reimbursement of hospital expenditure in connection with the surgical procedure, and that when the patient was admitted to the Apollo Hospital, Mysore he was in an unconscious state and emergency surgical procedure was required. It is also seen from this record that the membership card was produced by the complainant at the time of discharge. As pre-authorization letter was not produced by the complainant, the hospital authorities collected the treatment charges in full, from the complainant.

Findings:

(1) In this case, it is useful to look into the genesis of the scheme. The extract of the Para ‘A’ of the Deed of Trust reads as follows:

A. Whereas the Government having realized that the existing arrangements for medical and surgical care for the Co-operative farmers are inadequate, more particularly in cases where surgical treatment is required in super specialty hospitals and Nursing Homes for serious and complicated ailments, and with a view to establish as health care scheme for serious diseases requiring surgical treatment, has formulated a health care scheme under the name of the 'Yeshasvini Co-operative Farmers Health Care Scheme'.

(2) It is necessary to find out whether the complainant’s father underwent medical treatment or surgical treatment. From the case sheets produced by the hospital authorities, it is clear that the patient Lakshminarayana suffered acute intra-ventricular he morrhage and for that reason the concerned doctor of O.P. No. 5 proposed operation described as external ventricular drainage and on 29.10.2005 the operating surgeon obtained 'High Risk Consent' from the son of deceased Lakshminarayana on the prescribed form on the ground that it involves intra-ventricular bleed in Type-II DM HTN and on 30.10.2005 the concerned doctor obtained another signature of son of Lakshminarayana on another consent form to carry out the operation procedure described as external ventricular drainage.

In the consent form it is clearly mentioned thus:

'I have read (or have read to me) the above surgery/procedure consent, I know what it means and I consent to the procedures'.

In the operation notes dated 30.10.2005 it is mentioned thus:

PRE OP DIAGNOSIS: Massive Pan Ventricular bleed C gross obstructive hydrocephalus.

Name of procedure: Rt. Frontal external ventricular drainage.

Surgeons: Dr. Ramesh/Dr. Das.

The analysis of the case sheet referred to above leads no manner of doubt that the patient had undergone the surgical procedure at the hands of two Surgeons Dr. Ramesh and Dr. Das.

(3) Clause 9 of the scheme which is reproduced in Kannada in the District Forum’s order when translated reads as follows:

'When the beneficiaries of the Scheme are admitted in hospital for surgical procedure, hospital authorities shall not collect fees for surgical procedure, doctors fee, bed charges, cost of medicine, tests etc. from the date of admission, till the date of discharge of treatment charges would be borne by the Yashasvini Trust.'

(4) Now, let us analyze the last issue of pre-authorization. As the patient was admitted in an unconscious state to the Apollo Hospital, M

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ysore there was no time to secure pre-authorization. However, the complainant had produced the membership card. The complainants have also paid the treatment charges. Hence, we do not want that this technical lacunae to come in the way of beneficiary getting benefits under such a laudable scheme introduced by the Government of Karnataka. (5) Accordingly, we do not see any material irregularity or legal infirmity in the orders passed by the lower Fora, necessitating intervention at our level. Therefore, this revision petition is dismissed. There shall be no order as to costs. The petitioner shall pay the awarded amount within four weeks to the complainant. Dasti. Revision Petition dismissed.
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