Date of Filing      : 24.03.2021

                                                                                                                 Date of Disposal: 18.08.2022

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

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

                 THIRU. J.JAYASHANKAR, B.A, B.L.                                                                            ..… MEMBER-I

                 THIRU.P.MURUGAN,B.Com.                                                                                      ....MEMBER-II

CC. No.32/2021

THIS THURSDAY, THE 18th DAY OF AUGUST 2022

 

L.Gunasekaran, S/o.Loganathan,

No.2/644, Tiruvallur Road,

Molachur Sunguvarchatiram,

Kanchipuram District – 602 106.                                                             ……Complainant.

                                                                               //Vs//

1.MD India Health Insurance TPA Private Limited,

    Rep. by its AGM-Operations,

    Project head, 

    Guna Complex, Door No.433&445, Old No.304&305,

    Anna Salai, Teynampet, Chennai 600 018.

 

2.Parvathy Hospitals

   Rep. by its Authorized Signatory,

   No.241, G.S.T. Main Road, Chrompet, Chennai 44.                     …..opposite parties. 

 

Counsel for the complainant                                                :   Mr.S.Muthukumaravel, Advocate.

Counsel for the opposite parties                                         :   exparte 

                         

This complaint is coming before us on various dates and finally on 17.08.2022 in the presence of  Mr.S.Muthukumaravel, Advocate counsel for the complainant and the opposite parties were set exparte and upon perusing the documents and evidences produced by the complainant this Commission delivered the following: 

ORDER

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

 

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 repudiating the claim of the complainant under the insurance policy taken from the 1st opposite party along with a prayer to direct the opposite parties to pay a sum of Rs.70,351/- towards treatment expenses and to pay a sum of Rs.1,00,000/- towards the mental agony caused to the complainant and to pay a sum of Rs.50,000/- for the unjustified repudiation of the claim of the complainant with cost of the proceedings.

Summary of facts culminating into complaint:-

 

  It was the case of the complainant that the Group Insurance Policy was taken by him with the 1st opposite party by paying premiums through the Sub-Treasury from his salary to an extent of Rs.4,00,000/- coverage.  While he was in duty on 03.04.2019 he was injured and immediately admitted in the 2nd opposite party’s hospital which was one of the listed hospitals of the 1st opposite party’s insurance policy for cash less treatment. As per norms of the 2nd opposite party inspite of the existing health insurance he was allowed to take treatment by paying cash in advance.  The treatment expenses comes to Rs.1,49,571/- out of which the 1st opposite party paid a sum of Rs.79,220/- directly to the 2nd opposite party but failed to pay the balance amount of Rs.70,351/-.  When the complainant approached the 1st opposite party for the balance amount of Rs.70351/- the 1st opposite party citing clause 12 in Annexure I of the policy declined the request of the complainant.  Thus aggrieved the present complaint was filed alleging deficiency in service on the part of the opposite parties for repudiating the claim by the 1st opposite party and receiving the cash knowing well about the policy condition by the 2nd opposite party respectively with a prayer as given below;

1. to direct the opposite parties to pay a sum of Rs.70,351/- towards treatment expenses.

2. To pay a sum of Rs.1,00,000/- towards the mental agony caused to the complainant.

3. To pay a sum of Rs.50,000/- for the unjustified repudiation of the claim of the complainant.

On the side of the complainant proof affidavit was filed and documents were marked as Ex.A1 to A5. In spite of sufficient opportunities the opposite parties did not appear and they were set ex-parte on 30.05.2022 for non appearance and for non filing of written version.

 Points for consideration:

 

Whether the complainant is successful in proving that the 1st opposite party has committed deficiency in service in repudiating the insurance claim and in demanding cash payment by the 2nd opposite party respectively;

 If so to what relief the complainant is entitled and against whom?

 Points:1&2

On the side of the complainant following documents were filed in support of his allegations;

Transfer order by Sub-Inspectors of Police dated 04.06.2019 was marked as Ex.A1;

Notice issued by the complainant to the opposite party dated 22.10.2019 was marked as Ex.A2;

Reply notice issued by the 1st opposite party to the complainant regarding repudiation of the claim dated 26.10.2019 was marked as Ex.A3;

Health card issued by the 1st opposite party to the complainant was marked as Ex.A4;

Letter issued by the 2nd opposite party to the complainant was marked as Ex.A5;

Heard the oral arguments and perused the written arguments filed by the complainant. The learned counsel appearing for the complainant argued that when the coverage under the insurance policy was for Rs.4,00,000/-, the act of the Insurance Company rejecting the claim of the complainant for reimbursement citing that the any claim for reimbursement made in deviation of Annexure I clause 12 (d) is improper.  As the hospital insisted for the balance payment of Rs.70,351/- at the time of discharge of the patient, the complainant had no other option but to pay the said amount.  

He also argued that the 2nd opposite party ought not to have received the cash from the 1st opposite party knowing fully the clause in the insurance policy. Thus he argued that the 1st opposite party having made payment of the first part was at fault in not honouring the second part of the payment which amounted to unjustified repudiation.  He also cited the order passed by the Madras High Court in batch of writ petitions dated 28.05.2019 in W.P.(MD).No.13429/2013 to 17332/2018 in support of his contention that the insurance company cannot repudiate the claim for medical expenses citing irrelevant reasons.

We have perused the documents, pleadings and the citation produced by the complainant.  As both the opposite parties did not appear, they were set ex-parte and hence there is no contra evidence produced for the complainant’s allegation. But the Commission cannot allow the complaint unless the complainant had well established that the opposite parties had committed deficiency in service.  The reason cited by the insurance company for repudiating the claim of reimbursement made by the complainant is as follows. 

“This is with reference to your letter received on 25.10.2019, regarding, reimbursement claim of Mr.Gnanasekaran who has taken treatment in Parvathy Ortho Hospital Private Limited from 10.04.2019 to 13.04.2019 with the diagnosis of Right ACL insufficiency and under want Surgery.  We have received pre-auth request from the Hospital and we have approved procedure cost of Rs.79,220/- and hence we are unable to process your reimbursement claim as per the GO No.202, dated 30th 2016 issued by the Finance (Salaries) department, Government of Tamil Nadu has clearly mentioned about the procedures to be adopted for cashless treatment.

Annexure I Clause 12, States that,

The procedure to be follow at the time of admitting employees and /or their eligible family members for approved treatments/surgeries are as follows:

The hospital approved by the insurance company/Third part administrator under this scheme alone should be approached for availing assistance.

(d) This scheme is on cashless basis and no payment for approved cost need to be made by the employee or their eligible family members to the approved hospitals.

(f) Any claim for reimbursement made in deviation of the above procedure shall be rejected”.

Thus it is made clear by the insurance company/1st opposite party that pre authorization request from the hospital has been received and they have approved procedure cost of Rs.79,220/- and hence they could not reimburse the further amount spent towards the treatment of expenses, it is made clear that the cost of treatment approved for the complainant is only 79,220/- and not 1,49,571/- as contended by the complainant. Further when it is cited that “this scheme is on cashless basis and no payment for approved cost need to be made by the employee or their eligible family members to the approved hospitals”, it is made clear that no payment for the approved cost need to be made by the employee making it clear that the scheme infers only the accrued cost which in the case of the complainant is only Rs.79,220/- and not more than that.  It is also made clear that if the complainant was aggrieved he can place the claim before the “District Level Empowered Committee”. The complainant if not satisfied that the approved cost of Rs.79,200/- it is for him to approach the District Level Empowered Committee who will decide whether the claim has to approved or not. The citation made by the complainant is not in supportive to the facts and circumstances of the case as the Writ Petitions were filed against the reasons given either by the insurance company or by the District Level Empowered Committee for repudiation of the claim.  However in the present case the complainant has not approached the District Level Empowered Committee questioning the non approval of the balance amount of Rs.70,351/- and hence no deficiency in service by the 1st opposite party was found by this Commission for not approving the entire treatment expenses.  The document Ex.A5 also go to show that out of the total bill amount of Rs.1,49,571/-, the sanctioned amount by the (MDINDIA-GOVT) was only 79,220/-.  When such is the case, this Commission is of the view that the complainant cannot claim for the unapproved cost of treatment under the insurance scheme.  He has the remedy to approach the appropriate forum questioning the non-approval of the balance treatment expenses made by him.  Therefore in such circumstances we could not hold any deficiency in service on the part of the 1st opposite party in repudiating the claim of reimbursement and on the part of the 2nd opposite party in receiving the balance payment other than the approved cost of Rs.79,220/- at the time of discharge of the complainant towards the medical expenses respectively.

Complainant submitted in support of his case the order passed by the Apex Court in Shiva Kant Jha V. Union of India reported in 2018 5 MLJ 317 (SC), wherein it has been held that before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and that the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned and once it is established, the claim cannot be denied on technical grounds. The same will not apply to the facts of this case as in our case the claim for Rs.1,49,571/- was not established as the approved cost and as per the records Ex.A3 and Ex.A5 the approved cost was only Rs.79,220/- which has to be considered as the approved/scheme amount under the insurance claim.  Thus, we answer the points against the complainant holding that he has not proved any deficiency in service against both opposite parties and hence not entitled to any claim.

In the result, the complaint is dismissed.  No order as to cost.

 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 the 18th day of August 2022.

  

   Sd/-                                                      Sd/-                                                           Sd/-

MEMBER-II                                      MEMBER-I                                           PRESIDENT

 

List of document filed by the complainant:-

 

Ex.A1 04.06.2019 Transfer order by SP. Xerox

Ex.A2 22.10.2019 Notice by complainant. Xerox

Ex.A3 26.10.2019 Reply notice by 1st opposit party. Xerox

Ex.A4 ................ Heal card issued by the 1st opposite party to the complainant. Xerox

Ex.A5 ................ Letter issued by the 2nd opposite party. Xerox

 

 

List of documents filed by the opposite parties:

 

 

Nil

      Sd/-                                                         Sd/-                                                           Sd/- 

MEMBER-II                                          MEMBER-I                                               PRESIDENT