Tamil Nadu

South Chennai

CC/264/2019

Mr. D. R. Davey - Complainant(s)

Versus

Central Government Health Scheme - Opp.Party(s)

Aiyer & Dolia

09 Dec 2022

ORDER

                                                           Date of Complaint Filed : 30.09.2019

                                                           Date of Reservation      : 01.12.2022

                                                           Date of Order               : 09.12.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT:	TMT. B. JIJAA, M.L.,	:	PRESIDENT
	THIRU. T.R. SIVAKUMHAR, B.A., B.L.,	:	MEMBER  I
	THIRU. S. NANDAGOPALAN., B.Sc., MBA.,	:	MEMBER II

 

CONSUMER COMPLAINT No.264/2019

FRIDAY, THE 9^th DAY OF DECEMBER 2022

1.Mr.D. R. Davey,

2.Mrs. Chandrakanta R. Davey,

 

Both Residing at A 2, Ivory Apartment,

141/3, Purasawalkam High Road,

Purasawalkam First Street,

Kellys, Chennai – 600 010.                                                                                                           …   Complainants

 

-Vs-

1.The Additional Director,

   Central Government Health Scheme,

   Rajaji Bhavan,  Besant Nagar,

   Chennai – 600 090.

 

2.The Additional Secretary and Director General,

   Central Government Health Scheme,

   Ministry of Health and Family Welfare,

   Government of India,

   Room No.244A, Nirman Bhawan,

   Maulana Azad Road,

   New Delhi – 110 011.

 

3.Jindal Naturecure Institute,

   A Charitable Hospital,

   Represented by its Authorised Signatory,

   Jindal Nagar, Tumkur Road,

   Bangalore – 560 073.                                                                                                                             ...  Opposite Parties

 

******

Counsel for the Complainant	:	M/s. Aiyar & Dolia
Counsel for the 1St & 2 Opp. Parties	:	Exparte
Counsel for the 3rd Opposite Party	:	M/s Jindal Nature Care Institute

 

        On perusal of records and having heard the oral arguments of the Counsel for the Complainant, we delivered the following:

ORDER

Pronounced by President,  Tmt. B. Jijaa, M.L.,

1.      The Complainant has filed this complaint as against the Opposite Party under section 12 of the Consumer Protection Act, 1986 and prays to direct the Opposite Parties 1 & 2 to reimburse the balance sum of Rs.42,348/- with interest to pay a compensation of Rs.3,00,000/- for the mental agony and strain caused by its deficient service and unfair trade practice along with cost of Rs.25,000/-.

2.     The averments of Complaint in brief are as follows:-

The Complainants submitted that they are senior citizens and suffer from various chronic ailments and they have been taking medicines prescribed by the CGHS Doctors. The 2^nd Complainant was treated for Abdominal Disorders (Hyper-acidity,Gastritis), Diabetes Mellitus (Type-II) High Blood Pressure (Hypertension), High cholesterol (Hyper cholesterolaemia), Insomnia, Migraine, Obesity, Diabetic Neuropathy, Osteo Arthritis. The 1^st Complainant was treated for Abdominal Disorders (Hyper-acidity, Chronic constipation, Gastritis), (Hypertension), High Blood Pressure High cholesterol (Hyper cholesterolaemia), Irritable bowel, Osteo Arthritis, Piles from 24^th August 2018 to 31^st August 2018. As the hospital charges are to be paid in full by cash, the Complainants settled it. The Complainants state that the 3^rd Opposite Party has also issued a certificate dated 31.8.2018 acknowledging the treatment taken by them and affirmed that all pathological tests and acupuncture prescribed were conducted at Manav Charitable Hospital, which is an allopathic wing of JNI. The Complainants have been remitting insurance charges under Arogya Raksha of Indian Bank for Mediclaim. After several calls to TPA, the Complainants were informed that their claims have been rejected. The United Insurance Company and its Third Party Administrator were given advance notice on 08^th August 2018 and both have ignored the email and there was no response. All the original documents were returned to the Complainants and in all the documents the TPA had endorsed rejected without assigning any reason and the same was received by the Complainants after a period of 7 weeks since the date of their submission. The United India Insurance Company Ltd (UIC) also repudiated the Complainants claim stating that "The Company shall not be liable to make any payment under this policy in respect of any expenses incurred by any person in connection with or in respect of naturopathy treatment, experimental and unproven treatments/therapies and the claim falls outside the scope of our Insurance policy”. On 9^th August 2018, vide mails addressed to the Hon'ble Minister of State, Ministry of Ayush, New Delhi and to the Joint Secretary, Ministry of Ayush, New Delhi they intimated them the ailments suffered and their proposed treatment at Jindal Nature cure Institute and to approve and sanction when the bills are submitted for re-imbursement.  Similarly the 1^st Complainant gave representations to the Opposite Parties for reimbursement of medical expenses. In connection with the treatment taken at Jindal Naturecure Institute, Bengaluru, approved by Ayush Ministry and CGHS between 24^th August to 31^st August 2018. In the mean time, the Complainants received a mail from the 1^st Opposite Party on 27.5.2019 (the 1^st Complainant noticed it only later) informing that Rs.33,945 and Rs.36,317/- were approved and credited to the Complainants account through e-payment (on 24.05.2019 in SB Account in Indian Bank, Kellys Branch). The Complainants submit that when they are entitled to get reimbursement of the entire amounts spent, the Opposite Parties for the reasons best known to them had failed to re-imburse the same and a sum of Rs.42.348/- has been retained by the Opposite Parties 1 & 2.  Hence the complaint.

3.   Written Version filed by the 3^rd Opposite Party in brief is as follows:-

The 3^rd Opposite Party is a well established naturopathy centre treating the needy with drugless, non invasive naturopathy treatments without involving any surgery or operation. In order to work for a better system of health rejuvenation and healing, the 3^rd Opposite Party institute imparts naturopathy treatments based on the theory of vitality, toxaemia and self-healing capacity of the human body. That the 3^rd Opposite Party is unaware of all the averments contained in the above Complaint except the fact that that the Complainants had taken naturopathy treatment in its institute. The 3^rd Opposite Party have not received any legal notice dated 25.09.2019 purported to have been issued by the Complainants as alleged in the complaint. The 3^rd Opposite Party submits that the complaint is regarding reimbursement of treatment charges and for payment of compensation to the Complainants from the 1^st Opposite Party and the 2^nd Opposite Party and hence the 3^rd Opposite Party is a formal party to the above Complaint and no claim/relief is sought against the 3^rd Opposite Party as reiterated in the Para 14 of the Complaint. Hence prayed to dismiss the complaint.

4.   The Complainants submitted their Proof Affidavit and Written Arguments. On the side of the Complainant, documents were marked as  Ex.A-1 to Ex.A-22. The 1^st and 2^nd Opposite Parties did not appear before this Commission even after sufficient notice was served on them and hence the 1^st and 2^nd Opposite Parties were set exparte. Proof Affidavit of 3^rd Opposite Party was closed.

Points for Consideration:-

1. Whether there is deficiency in service on the part of the Opposite Parties?

2. Whether the Complainants are entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No.1 :-

The contention of the Complainants is that they are Central Government Health Scheme (CGHS) beneficiary having Card No.6631-P and beneficiary ID 1495115 and 1495116. As the Complainants believed in Naturopathy treatment, they got admitted with the 3^rd Opposite Party for treatment from 24.08.2018 to 31.08.2018 and as the Hospital charges are to be paid in cash the same was paid.  The 3^rd Opposite Party had also given a certificate dated 31.08.2018 acknowledging the treatment taken by the Complainants and affirmed that the pathological test and acupuncture prescribed were conducted at Manav Charitable Hospital, which is an allopathy clinic of J.N.I.  The Complainants have been remitting insurance charges under Aroyia Raksha of Indian Bank for Mediclaim.  The Complainants have submitted their claim to the United India Insurance company, who repudiated the claim stating that the claim falls outside the scope of the Insurance Policy as the Complainant has taken naturopathy treatment. On 09.08.2018 the Complainants had addressed mails to the Ministry of Ayush, New Delhi intimating the aliments and treatment taken by them at the 3^rd Opposite Party and to approve and to sanction the bills.  It was contended by the Complainant that communications were sent to the 1^st and 2^nd Opposite Parties requesting them to process the above claim for reimbursement. On 06.12.2018 intimation was sent to the 1^st Opposite Party furnishing the details of the bills submitted and to furnish information under the RTI Act. The 1^st Opposite Party sent a reply dated 29.01.2019 stating that the claim submitted was not in order and the same was returned.  Further representation was sent on 27.03.2019 to the 2^nd Opposite Party, which was never responded. Again on 10.11.2018 an intimation was sent to the 1^st Opposite Party submitting all the original documents and to approve the claim for reimbursement. As the 1^st Opposite Party did not respond, a letter dated 06.12.2018 was sent seeking information under the RTI Act requiring the status of action taken. As there was no response from the Opposite Parties a legal notice dated 29.05.2019 was issued calling upon the Opposite Party to settle a sum of Rs.1,12,610/- incurred towards medical expenses in connection with the treatment taken at the 3^rd Opposite Party.  The 1^st Complainant received a mail from the 1^st Opposite Party on 27.05.2019 informing that Rs.33,945/- and Rs.36,317/- were approved and credited to the Complainants account through e-payment. The Complainant has filed this complaint for the balance payment of Rs.42,348/- with interest.

        Though the Complainant contended that they are beneficiaries under the CGHS, they have not produced any document to that effect. The Complainants had not produced any document to show that they have been remitting insurance charges under the Arokia Raksha of Indian Bank for Mediclaim. The Complainant failed to prove with supporting documents that the 1^st and 2^nd Opposite Parties are liable to pay for the medical expenses incurred. Further the contention that they have received partial amount from the 1^st Opposite Party towards the medical expenses incurred for the treatment taken from the 3^rd Opposite Party is also not supported by any document except the Medical bills and representations to the Opposite Parties no other document is produced by the Complainant. The Complainants have failed to prove their case that they are entitled for the balance sum of Rs.42,348/- with interest from the 1^st and 2^nd Opposite Parties and had also failed to prove that there was deficiency on the part of the Opposite Parties. Accordingly, Point No.1 is answered against the Complainant.

Point Nos.2 and 3 :-

As discussed and decided Point No.1 that there is no deficiency on the part of the Opposite Parties, the Complainants are not entitled for the reliefs claimed in the complaint or for any other reliefs. Accordingly Point Nos.2 and 3 are answered.

        In the result the complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 9^th of December 2022. 

 

S. NANDAGOPALAN	T.R. SIVAKUMHAR	B.JIJAA
MEMBER II	MEMBER I	PRESIDENT

 

List of documents filed on the side of the Complainant:-

 

Ex.A1		JNI Admission Rules and Regulations long with details of diseases treated
Ex.A2	09.08.2018	E-mail from 1st Complainant sent to the Hon’ble Minister of State Ministry of Ayush and others
Ex.A3	17.08.2018	Email from 1st Complainant to the 1st Opposite Party
Ex.A4	24.08.2018	Receipt issued by Jindal Naturecure Institute for Rs.72,000/-
Ex.A5	25.08.2018	Meridian Balnce Report of Chandrakanta Rasiklal Davay
Ex.A6	30.08.2018	Invoice submitted by Jindal Naturecure Institute
Ex.A7	30.08.2018	Cash Bill issued by Manav Charitable Hospital, a wing of 3rd Opposite Party
Ex.A8	30.08.2018	MCH invoice detail report bearing Bill No.GST06247201808
Ex.A9	31.08.2018	Certificate issued by Jindal Naturecure Institute
Ex.A10	31.08.2018	Letter from Complainants to the Chief Medical Officer in charges, CGHS, Anna Nagar, Chennai
Ex.A11	10.11.2018	Letter from 1st Complainant addressed to 1st Opposite Party
Ex.A12	06.12.2018	Information sought by 1st Complainant under RTI Act
Ex.A13	06.12.2018	Information sought by st Complainant under RTI Act addressed to the Secretary, Department of Ayush, Ministry of Health and Family Welfare, New Delhi
Ex.A14	05.01.2019	Information sought by 1st Complainant under RTI Act
Ex.A15	08.01.2019	Intimation from 1st Opposite Party to the 1st Complainant
Ex.A16	22.01.2019	Reply from Department of Health with annexure
Ex.A17	29.01.2019	Reply from Government of India CGHS
Ex.A18	27.03.2019	Letter from the 1st Complainant to 2nd Opposite Party
Ex.A19	-	Synopsis of claim with CGHS by the Complainants
Ex.A20	-	Paper cutting of Times of India pertaining to the Supreme Court ruling with regard to CGHS cover for non listed hospitals
Ex.A21	29.05.2019	Legal notice issued to Opposite Parties 1 and 2 with acknowledgement cards
Ex.A22	25.07.2019	Reminder notice with Ack. cards

 

List of documents filed on the side of the Opposite Parties:-

 

NIL

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                   B.JIJAA

         MEMBER II                       MEMBER I                         PRESIDENT