Tamil Nadu

StateCommission

A/71/2021

The Manager, United India Insurance Company Ltd., Chennai-600 006 - Complainant(s)

Versus

. G. Murugesan, S/o. Govindan, Krishnagiri Taluk & District-635 001. And 3 Others - Opp.Party(s)

/S. T. SHANMUGAM

25 Jan 2023

ORDER

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present:   Hon’ble THIRU JUSTICE R. SUBBIAH  :     PRESIDENT

                 THIRU R  VENKATESAPERUMAL           :      MEMBER

 

F.A. No. 71 of 2021

(Against the order passed in C.C. No.53 of 2016 dated 18.07.2019 on the file of the D.C.D.R.F., Dharmapuri @ Krishnagiri.

 

Wednesday, the 25^th day of January 2023

 

 

The Manager

United India Insurance Co.Ltd.,

5^th Floor, PLA Rathna Tower

No.212, Anna Salai

Chennai – 600 006.                                            .. Appellant/

    3^rd Opposite Party

 

- Vs –

 

1.  G. Murugesan

     S/o. Govindan

     No.2/164, Nethaji Nagar

     Kanagamutlu Post

     Krishnagiri Taluk & District

     Pin -635 001                                                ..  1^st Respondent/

                                                                                Complainant

 

2.  The General Manager

     Tamilnadu State Transport 

Corporation (Salem) Ltd.,

     Bharathipuram, Dharmapuri Dvn.,

     Dharmapuri – 636 701

 

3.  Star Health @ Allied Insurance Co.Ltd.,

     Old No.64A, New No.2A

     Ganga Nagar Road

     (Opp.to BSNL Office),

     Kodambakkam

     Chennai – 600 024.

 

4.  The Managing Director

     Sparsh Hospital

     No.29/P2, Narayana Health City

     Bommasandra Industrial Area

     Hosur Road, Bangalore

     Karnataka State-560 099.                         .. Respondents 2 to 4/   

    1^st,2^nd & 4^th Opposite Parties

   

 

  Counsel for Appellant / 3^rd Opposite party :  M/s.T. Shanmugam

        1^st Respondent/Complainant               :  Party-in-person                                                                     

  Counsel for the 3^rd Respondent/

2^nd opposite party      :  M/s.M.B.Gopalan Asso.       

 Respondents 2 & 4/ Opposite parties 1&4   :  Notice served

                                                       

 

This appeal came before us for final hearing today, on 25.01.2023 and on hearing the arguments of the counsel for the appellant, counsel for the 3^rd respondent and the 1^st respondent in person, and on perusing the material records, this Commission made the following :-

 

O R D E R

R.SUBBIAH J., PRESIDENT [Open Court]

 

        1.     This appeal has been filed under Section 15 of the Consumer Protection Act, 1986 as against the order passed in         C.C.No.53 of 2016 dated 18.07.2019, by the District Consumer Disputes Redressal Forum, Dharmapuri @ Krishnagiri, allowing the complaint filed by the 1^st respondent herein, in part. 

 

           2.  The Appellant herein is the 3^rd Opposite Party and the 1^st Respondent is the Complainant.  Respondents 2 to 4 are the 1^st , 2^nd and 4^th opposite parties.  For the sake of convenience, the parties shall be referred as per their ranking before the District Forum.

 

           3.  The factual background culminating in this appeal is as follows: 

        The Complainant is employed as a Technical staff in the office of the 1^st opposite party, namely, Tamil Nadu State Transport Corporation (Salem) Ltd.  On 29.09.2012, he met with an accident due to sudden crossing of a stray dog, while he was proceeding in  his two wheeler.  In the said accident, the complainant sustained fracture of left leg, left ribs, injury to the spleen, bruises on head and other injuries all over the body.  Immediately, he was taken to the 4^th opposite party hospital, Bangalore by his wife in ambulance.  At the time of admitting the complainant in the hospital, he was in an unconscious stage.  The complainant was paying a monthly contribution of Rs.25/- from his salary towards Group Insurance Scheme from the year 2008 to 2012 (NHIS) and so the complainant was holding the ID Card issued by the 2^nd opposite party namely, Star Health & Allied Insurance Co. Ltd.  As evident from the ID card, the said card has been issued by the 2^nd opposite party, under the new medical insurance scheme floated by Government of Tamil Nadu in collaboration with them.   It is also stated that the ID card issued by the 2^nd opposite party is valid upto 2012.  In G.O.Ms. No.243 dated 29.06.2012, the Finance department, Government of Tamil Nadu had made it clear that during the interim period of preparation and distribution of new identity cards, the Insurance Company/ 3^rd Party Administrator shall authorise acceptance of the existing identity cards, already issued under the Scheme for the period 2008-2012, for the time being i.e., till 30.09.2012.  The date of accident being 29.09.2012, was within the interim period as specified in the said G.O.  The said scheme is on cashless basis and no payment for approved cost need be made by an employee or their eligible family members to the approved hospitals.  The 4^th opposite party, namely, Sparsh Hospital, Bangalore is one of the listed hospitals or approved hospitals.  The 4^th opposite party/ Sparsh Hospital is part of Narayana Healthcity, located in Hosur Road, Bommasandra, Bangalore-9.  Thus, the complainant was taken to the 4^th opposite party/Sparsh Hospital, which is one of the approved hospitals, and was admitted on 30.09.2012 and he was taking treatment as in-patient till 26.10.2012.  During the period of treatment, the 4^th opposite party informed the complainant that he should remit the amounts due to the hospital on the date of discharge and claim reimbursement, since the Sparsh Hospital did not receive any official communication regarding the applicability of the scheme during the transition period.  The complainant had spent a total sum of Rs.7,56,917.44 towards hospital bills and medical bills.  Thereafter, the complainant sent a written representation to the District Collector, Krishnagiri. In reply to the said representation, the District Collector, vide his letter in Na.Ka.No.9764/2015/Q2 dated 11.09.2015 informed that the District Level Committee had decided to send a recommendation for payment of Rs.2,00,000/- to the complainant.   The said letter was addressed to the 3^rd opposite party, marking a copy to the complainant and to the Commissioner- Treasury, Chennai-15.  The 3^rd opposite party sent a reply letter on 08.10.2015 repudiating their liability on the ground that the 4^th opposite party Hospital was not covered under their Network Hospitals during the period of treatment of the complainant and that the 1^st opposite party alone is liable to meet the claim of the complainant, since the 4^th opposite party hospital was empanelled only with effect from 08.12.2012 but the complainant had taken treatment on 30.09.2012.   The reply sent by the 3^rd opposite party is not sustainable, when the 1^st opposite party had deducted a sum of Rs.150/- pm from the salary of the complainant under Group Insurance Scheme.  Moreover, when the Government of Tamil Nadu had issued G.O.Ms. No.243 dated 29.06.2012 clearly stating that the existing identity card, already issued under the Scheme for the period 2008-2012, is valid upto 30.09.2012, the 3^rd opposite party cannot deny their liability to meet the claim of the complainant.  Apart from that, the 3^rd opposite party in their letter dated 05.03.2015 addressed to the 1^st opposite party had clearly stated that the complainant had taken treatment from 30.09.2012 to 26.10.2012 in Sparsh Hospital, Bangalore, which is a Network hospital.  On that ground also, the 3^rd opposite party cannot repudiate their liability to meet the claim of the complainant.  However, the complainant had added the Star Health and Allied Insurance Company as the 2^nd opposite party, with abundant caution, since the 2^nd opposite party is the insurer under the Group Insurance Scheme for the employees of the 1^st opposite party, who were holding Insurance ID card.  Therefore, he made a complaint as against the opposite parties, alleging deficiency of service, seeking the following directions to the opposite parties:-

1. To pay the said sum of Rs.7,56,917.44 with subsequent interest thereon,  @ 12% pa from 27.10.2012 till the date of realization;
2. To pay a compensation of Rs.3,00,000/- to the complainant, towards mental agony and for deficiency of service on the part of the opposite parties; and
3. To pay a sum of Rs.30,000/- towards cost.

 

 

        4. The 2^nd opposite party/ Star Health and Allied Insurance Co. Ltd., has filed a version stating that the Government of Tamil Nadu framed New Health Insurance Scheme for employees of Government, Local Bodies, Public Sector Undertakings, Statutory Boards, State Government, Universities and notified the same as G.O.Ms. No. 174 dt. 28.04.2008. The complainant paid a monthly contribution of Rs.25/- from his salary towards the said scheme for the years 2008 to 2012.  An ID card was issued to the complainant under the new medical insurance scheme floated by Government of Tamil Nadu in collaboration with the 2^nd opposite party vide No.DPI/03/01027/1752942.   Though the ID card issued was valid upto 2012, as per G.O.Ms.No.243 dated 29.06.2012, issued by the Finance Department, Government of Tamil Nadu, it has been made clear that during the transition period of preparation and distribution of new ID cards, the 3^rd opposite party shall authorise acceptance of the existing ID cards already issued under the Scheme for the year 2008-2012, for the time being.  The alleged date of accident namely, 29.09.2012 , falls during the interim period specified in the G.O.  The 2^nd opposite party has nothing to do with the treatment taken by the complainant and the medical expenses incurred during hospitalisation.  The 2^nd opposite party covers only the period from 11.06.2008 to 10.06.2012 and the period of contract for the 2^nd opposite party with the Government of Tamil Nadu, is only 4 years.   So the complainant’s admission in the 4^th opposite party/Sparsh Hospital on 29.09.2012 is not covered by the 2^nd opposite party.  In paragraph 6 of the complaint, it is stated that the District Level Committee had sent a recommendation dated 11.09.2011 in Ref. Na.Ka.No.9764/2015/Q2 to the 3^rd opposite party for payment of Rs.2,00,000/- to the complainant, which confirms the liability on the part of the 3^rd opposite party.   The 2^nd opposite party has nothing to do with the same.  Therefore, the 2^nd opposite party cannot be made liable since there was no contractual liability between the 2^nd opposite party and the complainant.  Thus, sought for dismissal of the complaint as against them.

 

                5.   The opposite parties 1, 3 & 4 remained absent and hence they were set ex-parte before the District Forum.

 

        6.  In order to prove the case, along with proof affidavit, the complainant has filed 29 documents, which were marked as Exhibits A1 to A29.  On the side of the opposite parties, the 2^nd opposite party filed proof affidavit but no documents were marked.

 

        7.  After analyzing the evidence filed on the side of the complainant, the District Forum had come to the conclusion that the claim of the complainant has been rejected by the 3^rd opposite party mainly on the ground that the complainant had taken treatment in a non-network hospital.  But, the treatment was taken in the non-network hospital under the emergency situation.  Thus, by relying upon the judgment of the Madurai Bench of Madras High Court, in the cases of S.Marimuthu Vs. The Government of Tamil Nadu & 2 Ors., in W.P.(MD) No.13429/2013 and other connected writ petitions, dt.28.05.2019,  has allowed the complaint.  Aggrieved over the same, the present appeal is filed by the 3^rd opposite party. 

 

        7.   Heard the counsel for the parties and the 1^st respondent/complainant in person, and perused the material available on record.

 

        8.  The only submission of the counsel for the appellant/ 3^rd opposite party is that the 1^st respondent/ complainant had taken treatment in Sparsh Hospital, Bangalore.  The said Hospital is a non-network hospital.  Therefore, the appellant/3^rd opposite party is not liable to pay the claim amount. 

 

9. On perusal of the records, we find that the complainant, is an employee of the 1^st opposite party and that a sum of Rs.150/- per month has been deducted from the salary of the complainant, under the Group Insurance Scheme.  The said scheme was valid from the year 2008 to 2012.  The ID card issued under the said Scheme was valid upto 30.09.2012.  Thereafter, the Tamil Nadu Government authorized the 3^rd opposite party to accept the existing ID cards that has been already issued under the Scheme for the years 2008 to 2012, till the new ID cards are prepared and distributed.  The complainant had met with an accident on 29.09.2012, during this interim period, when the new Scheme was in force.  Since the new ID cards were not distributed, the 3^rd opposite party was directed to accept the ID cards that were already issued under the scheme for the period 2008-2012.  But, this fact was not denied by the 3^rd opposite party in any of the letters sent by them.  But the denial is on the ground that the complainant had taken treatment in a non-network hospital.  But the facts of the case would show that the complainant was admitted in Sparsh Hospital, Bangalore in an emergency situation.  When the complainant sustained injuries in a road accident, he cannot search for a nearby network hospital, by keeping the list of network hospitals, in his hand.  When the 3^rd opposite party has not denied the fact that the complainant had met with an accident and treatment was taken by him, the direction given by the District Forum cannot be found fault with.  In fact, the District Forum has given the direction based on the judgment of the Madurai Bench of Madras High Court, in the cases of S.Marimuthu Vs. The Government of Tamil Nadu & 2 Ors., in W.P.(MD) No.13429/2013 and other connected writ petitions, on 28.05.2019.  Therefore, we do not find any infirmity in the order passed by the District Forum. 

 

         10.  In the result, the appeal is dismissed and the order dated 18.07.2019 passed in C.C. No.53 of 2016 by the District Consumer Disputes Redressal Forum, Dharmapuri @ Krishnagiri, is confirmed.  Consequently, the appeal is dismissed.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

 

R  VENKATESAPERUMAL                                    R.SUBBIAH

         MEMBER                                                  PRESIDENT

 

 

Index :  Yes/ No

AVR/SCDRC/Chennai/Orders/January/2023

 

 

 

 

 

 

 

F.A. No. 71 of 2021

HON’BLE  THIRU

JUSTICE R.SUBBIAH, PRESIDENT

   In the result, the appeal is dismissed and the order dated 18.07.2019 passed in C.C. No.53 of 2016 by the District Consumer Disputes Redressal Forum, Dharmapuri @ Krishnagiri, is confirmed.  Consequently, the appeal is dismissed.

 

 

MEMBER             PRESIDENT

   25.01.2023            25.01.2023