Date of Filing 14.11.2023

                                                                                                             Date of Disposal: 21.02.2024

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

BEFORE TMT. Dr.S.M. LATHA MAHESWARI, MA. ML, Ph.D (Law),                                          …….PRESIDENT

               THIRU.P.VINODH KUMAR, B.Sc., BL,                                                                                ……MEMBER-I

               THIUR.P.MURUGAN, M.Com, (ICWA), BL.,                                                                     ……MEMBER-II

CC.No.114/2023

THIS WEDNESDAY, THE 21^st DAY OF FEBRUARY 2024

Mr.D.Palani, S/o.Mr.Damodharan,

No.116, Main Road,

Pullarambakkam Village and Post,

Thiruvallur Taluk and District 602 023.                                                ......Complainant.

                                                                                   //Vs//

1.Grievance Redressal Officer,

   Joint Director of Medical and Rural Health Services,

   Office of the Joint Director of Health Services,

   Government Medical College & Hospital,

   Jawaharlal Nehru Road,

   Thiruvallur 602 001.

2.The Divisional Manager,

   United India Insurance Company Limited,

   PLA Rathna Towers,

   No.212, Anna Salai, Chennai 600 006.                                        ……Opposite parties.

Counsel for the complainant                                        : Mr.A.R.Poovannan, Advocate.

Counsel for the opposite parties.                                : Exparte.

This complaint coming before us on various dates and finally on 14.02.2024 in the presence of Mr.A.R.Poovannan, counsel for the complainant and opposite parties were set exparte for non appearance and upon perusing the documents and evidences of complainant’s side this Commission delivered the following:

ORDER

PRONOUNCED BY TMT.Dr.S.M. LATHA MAHESWARI, PRESIDENT

1. This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the opposite parties in non reimbursement of medical insurance claim along with a prayer to direct the opposite parties to reimburse the medical expenses of the complainant at a sum of Rs.87,457/- and to pay a sum of Rs.2,00,000/- towards compensation for the mental agony and hardship caused to the complainant along with a sum of Rs.10,000/- towards litigation expenses.

Summary of facts culminating into complaint:-

2. It was the case of the complainant that he was working as a Junior Assistant in Chief Judicial Magistrate Court at Thiruvallur and met with an accident on 28.07.2022 due to which he sustained injuries all over his body and fractures in face and skull. FIR was registered in Crime No.109/2022 with the Pullarambakkam Police Station and the complainant was admitted for medical assistance in Government Hospital, Thiruvallur and later in Sri Ramachandra Medical Centre, Porur. He was also shifted to Saveetha Medical College & Hospital, Thandalam as inpatient from 29.07.2022 to 12.08.2022 and discharged on 12.08.2022.  The complainant spent a sum of Rs.1,23,269/- for his treatment at Sri Ramachandara Medical Centre and Saveetha Medical College & Hospital. It was submitted that he made a representation before the Chief Judicial Magistrate, on 13.10.2022 for making a Medi Claim and to have the reimbursement of the medical expenses through the family insurance policy (Government of Tamil Nadu New Health Insurance Scheme-2016) with M/s. United India Insurance Company limited bearing ID Card No.TLR/01/JB201/NHIS16/1212287. So far two notices were sent by the Chief Judicial Magistrate to the Divisional Manager, United India Insurance Company Limited for the reimbursement of the medical expenses through the family medical insurance policy. But there was no response.  The complainant again made a representation before the Chief Judicial Magistrate on 16.06.2023  that only a sum of Rs.35,812/- had been reimbursed out the total claim of Rs.1,23,269/- and made a request to get reimbursement of the entire claim made from the insurance company. Complainant also sent notice to the 1^st opposite party to consider the medial insurance claim made by him for the balance amount of Rs.87,457/-. But the request was repudiated by stating that the application has to be forwarded to the Insurance company by the employer. The act of the opposite parties in repudiating the claim by the 1^st opposite party and non compliance by the 2^nd opposite party and blaming each other amounts to deficiency in their service.  Thus aggrieved by the act of the opposite parties the present complaint was filed to direct the opposite parties to reimburse the balance medical expenses a sum of Rs.87,457/- and to pay a sum of Rs.2,00,000/- towards compensation for the mental agony and hardship caused to the complainant along with cost of Rs.10000/- towards litigation expenses.

3. On the side of the complainant proof affidavit was filed and documents marked as Ex.A1 to Ex A10 were submitted. Though notice was served to the opposite parties they did not appear before this commission to file any written version and hence they were called absent and set exparte on 19.01.2024 for non filing of written version within the mandatory period as per the statute.

Points for consideration:-

1)    Whether the non reimbursement of a part of the medical claim of the complainant by the opposite parties amounts to deficiency in service and if so, whether the same has been successfully proved by the complainant?

2)    To what relief the complainant is entitled?

 Point No.1:-

The following documents were filed on the side of complainant in support of their contentions;

a)     Medical prescription and Bills at SRMC, Chennai was marked as Ex.A1;

b)    Medical prescription and Bills at Saveetha Hospital, Thandalam, Chennai was marked as Ex.A2;

c)     Health Insurance/ Family Identity card was marked as Ex.A3;

d)    Letter by the Chief Judicial Magistrate, Thiruvallur to the 2^nd opposite party dated 09.12.2022 was marked as Ex.A4;

e)     Letter by the complainant to the Chief Judicial Magistrate, Thiruvallur dated 13.10.2023 was marked as Ex.A5;

f)      Letter by the Chief Judicial Magistrate, Thiruvallur to the 2^nd opposite party dated 24.03.2023 was marked as Ex.A6;

g)     Letter by the complainant to the Chief Judicial Magistrate, Thiruvallur dated 16.06.2023 was marked as Ex.A7;

h)    Letter by the Chief Judicial Magistrate, Thiruvallur to the 2^nd opposite party dated 06.07.2023 was marked as Ex.A8;

i)       Letter by the complainant to the 1^st opposite party dated 21.8.2023 was marked as Ex.A9;

j)       Reply by the 1^st opposite party to the complainant dated 05.09.2024 was marked as Ex.A10;

 4. The complainant had filed written submissions with endorsement that the same may be treated as oral arguments and hence we perused the written arguments and other documents submitted by the complainant to decide the complaint on merits.

5. The case of the complainant is that he met with an accident in Thiruvallur on 28.07.2022 while travelling in his motor bike and was admitted at Sri Ramachandra Medical Centre, Chennai and subsequently at Saveetha Medical College & Hospital, Thandalam.  It is his submissions that he had spent around Rs.1,23,269/- for which he had submitted bills vide Ex.A1 & Ex.A2.  Further the complainant being an employee under the Government of Tamil Nadu was having a health insurance for cashless treatment under the Government of Tamil Nadu New Health Insurance Scheme -2016 which was established by Ex.A3.  Therefore it is his case that he was entitled for reimbursement of the entire medical expenses. However, when the complainant submitted the claim through is employer to the 2^nd opposite party who is the insurer only a sum of Rs.35,812/- was reimbursed by the 2^nd opposite party.  Hence, complainant again approached through his employer for the balance claim amount of Rs.87,457/-.  When there was no response for the letter sent by the Chief Judicial Magistrate to the 2^nd opposite party dated 24.03.2023, the complainant again requested his employer to sought for the reimbursement of the balance claim amount.  Accordingly a letter was sent vide Ex.A8 by the Chief Judicial Magistrate to the 2^nd opposite party calling upon them to submit the particulars of claim made and reimbursement made and also the balance amount to be reimbursed and it is also requested that in case of non disbursal of the balance amount the relevant original medical bills may be returned to the department for further proceedings.  No reply was given by the 2^nd opposite party to the said letter.  Therefore the complainant again approached the 1^st opposite party who was the Grievance Redressal Officer to consider the reimbursement of medical claim made by him vide Ex.A9. The 1^st opposite party replied vide Ex.A10 dated 05.09.2023 stating that the Insurance Claim has to be obtained by directly making a claim through the Drawing Officer from the 2^nd opposite party and thus returned the claim of the complainant.

6.  In the said facts and circumstances when Go.Ms.No.202 dated 30.06.2016 and Go.Ms.No.106 dated 09.06.2016 was considered, it has been clearly provided as follows;

4 (v)The coverage of medical assistance under the scheme shall be extended to accident cases where the patient got approved treatment/undergone surgery in a non-network hospital;

5(b) Claims relating to treatment / surgery included in the approved list undergone in non-network hospital consequent on accidents shall be covered under NHIS, 2016 and settlement made through a suitable mechanism. 

7. Further under surgeries it has been clearly covered for the surgeries needed in Accident and Trauma vide chapted XIII (54).  Therefore when the claim of the complainant was covered under the Family Health Insurance availed by the complainant there is no impediment for the medical claim to be honoured by the 2^nd opposite party/Insurer.  Thus the non reimbursement of the balance claim clearly amounts to deficiency in service. It is also to be appreciated that when a part of the claim has been given by the 2^nd opposite party they are estopped from denying the balance claim of the complainant.  If at all the 2^nd opposite party did not pay the balance amount for some valid reasons they ought to have provided and substantiated the reasons for not paying the balance amount.  But they did not give any reply to the letter sent by the employer of the complainant.  In such circumstances we hold that the 2^nd opposite party had committed clear deficiency in service in not paying the balance amount towards the medical insurance claim made by the complainant.  It is also to be noted that the 1^st opposite party who is the Grievance Redressal Officer has no role to play in the reimbursement of medical insurance claim and hence the complaint is dismissed against the 1^st opposite party.  Thus we answer the point accordingly in favour of the complainant and as against the 2^nd opposite party.

Point No.2:-

8. As we have held above that the 2^nd opposite party had committed clear deficiency in service we direct them to reimburse the balance medical claim to the complainant being a sum of Rs.87,457/-.  Further by not replying to the letter written by the Judicial Department citing any valid reasons for not honouring the claim thereby causing hardship and mental agony to the complainant, we award a sum of Rs.20,000/- towards compensation to be paid to the complainant by the 2^nd opposite party along with a sum of Rs.5,000/- towards litigation expenses.

In the result, the complaint is dismissed against the 1^st opposite party and partly allowed against the 2^nd opposite party directing them

a) To reimburse the medical expenses to the complainant a sum of Rs.87,457/- (Rupees eighty seven thousand four hundred and fifty seven only) within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.20,000/- (Rupees twenty thousand only) towards compensation for the mental agony and hardship caused to the complainant;

 c) To pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant;

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this 21^st day of February 2024.

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 MEMBER-II                                        MEMBER-I                                              PRESIDENT

List of document filed by the complainant:-

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MEMBER-II                                              MEMBER-I                                      PRESIDENT