Tamil Nadu

South Chennai

CC/359/2015

M/s.P.Malaiswamy - Complainant(s)

Versus

MD India Health Care Service Pvt Ltd - Opp.Party(s)

M/s.G.Ramadurai

04 Jul 2016

ORDER

                                                                        Date of Filing :  06.08.2015

                                                                        Date of Order :  04.07.2016.

 

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI(SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C.Nagar, Park Town, Chennai-3

 

PRESENT: THIRU. B. RAMALINGAM M.A.M.L.,                     : PRESIDENT

                 TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

           DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II

 

C.C.NO.359/2015

MONDAY THIS  4^TH DAY OF JULY  2016

 

1. P. Malaichamy,

S/o. Palaniandi

 

2. Mrs. Selvi,

W/o. P. Malaichamy,

Both are residing at

Piranpatty Village,

Thirupathur Taluk,

Sivagangai District.                                            ..Complainants 

                                                   ..Vs..

1. MDindia Healthcare Services (TPA) Pvt. Ltd.,

Rep. by its Managing Director,

No.27, Lakshmi Towers,

3^rd Floor,

Dr.Radhakrishnan Salai,

Mylapore, Chennai 600 004.

 

2. The United India Insurance Co. Ltd.,

Rep. by its Officer-in-charge /

The Branch Manager,

No.212, Anna Salai,

Rathna Towers 5^th Floor,

Near Anand Theatre,

Chennai – 6.                                                       ..Opposite parties  

 

 

For the Complainant                  :   Mr.G.Ramadurai  

For the opposite parties 1 & 2     :   Exparte

         

ORDER

THIRU.   T.PAUL RAJASEKARAN ::    MEMBER-II      

 

1.     Complaint under section 12  of the Consumer Protection Act 1986.  The complaint is filed seeking direction against  the opposite parties to pay a sum of Rs.4,25,000/- towards medical expenses and to pay Rs.3,00,000/- as damages and mental agony and to pay cost of the complaint to the complainant.    

2.     Even after receipt of the notice from this forum in this proceeding, the opposite parties did not appear before this Forum and did not file any written version.  Hence the opposite parties were set exparte on 28.10.2015.

3.     Perused the complaint, and the documents Ex.A1 to Ex.A.20  filed by the complainant and proof affidavit and the entire C.C. records and considered the arguments of the complainant’s counsel.  

4.     The 1^st complainant took Medical Insurance Policy coined as New Health Insurance Scheme 2012 for employees of Government Department  and others under G.O.Ms.No.243, dated 29^th June 2012 and G.O.Ms.No.680, dated 29^th July 2003 bearing policy No.010700/48/12/4100000489/2012 with the ID card No.SVG/01/RE411/NHIS12/150043 issued by the 2^nd opposite party.  The 1^st opposite party is having registered office in Chennai and service provider (3^rd party administrator) who is also having his branch office in Chennai.     Though the complainants are residing in Piranpatty Village, Tirupathur Taluk, Sivagangai District where the cause of action had arisen outside Chennai the opposite party Branch office Chennai, the jurisdiction of filing the complainant  is complied with.   

5.     It is reported that the 2^nd opposite party who is member of the said medical insurance covered by her husband met with an accident, a portion of the coconut tree accidently fell on her, causing grievous injuries and gave raise to unconsciousness and immediately she had been taken to the nearest hospital and first aid was given and the police complaint also was filed by the complainant.   Then she was admitted to Vellammal Medical College Hospital & Research Institute at Madurai on 4.4.2015 and kept under intensive care unit for two days and Diagnosed as “ CENTRAL CORD SYNDROME WITH HEMATOMYELIA C2-C4 RIGHT BRACHIAL PLEXUS STRETCH INJURY RIGHT SACRAL ALAR FRACTURE PUBIC RAMI FRACTURE”.   This hospital has confirmed the cause of action as H/o accidental injury while walking in her garden but suddenly a tree branch fell over her head and she became unconscious for 30 minutes and brought to the hospital and treated with steroids and other meditation and discharge on 5.4.2015 referred to General Hospital for further management”.  

6.     Immediately the complainant approached the service provider (TPA)  for cashless facility which was denied vide their letter dated 9.4.2015 stating “Conservative Management for cord compression is not covered hence denied” (Ex.A7). The Hospital Authority addressed to the service provider for reconsidering the request stating “the patient had a severe Cervical Spinal Cord injury and is quadriplegic needs prolonged treatment” but service provider had declined the request.    The 1^st complainant took his wife for better medical revaluation and admitted her in Apollo Specialty Hospital, Chennai on 5^th April 2015 and discharged on 27^th April 2015.  This hospital also confirmed the diagnosis  as “Cervical cord injury”,  cord quadriplegia, Pelvic fracture, the date of accident is mentioned as 3.4.2015.  

7.     After prolonged treatment in Apollo Hospital, the hospital has confirmed through MRI C-spine done outside, showed small hamatomyelia, upper cervical cord confusion.  Xray pelvis  showed fracture of both sides superior and inferior public rami.  Orthopedician opinion was suggested to undergo physiotherapy at a rehabilitation  Centre and patient was discharged for further management.  Again the patient was re-admitted on 23.4.2015  in same hospital with the complaints of High Grade fever  where it was diagnosed UTI, Cervical Cord injury, Quadriplegia and she was discharged on 26^th April 2015.  

8.     The complainant filed a police complaint at Pulithipatty Police Station Sivagangai District on 19.5.2015 and it was acknowledged by the Police Department  under CSR No.48/2015 confirming the accident arose out of a fall of a tree on the head of the 2^nd complainant.   

9.     The learned counsel sent a legal notice to the opposite parties on 15.6.2015 asking both the parties to comply with the complainants request in repaying the medical expenses incurred along with the compensation amounting to Rs.6,25,000/- under Ex.A14.   

10.    As per the advice given by the Apollo Specialty Hospital, the patient took the treatment at Live Well Institute of Rehabilitation Medicine at Poovanthi, Sivagangai District and submitted the expenses incurred in the hospital amounting to Rs.1,03,981/- vide letter dated 9.7.2015.  

11.    The opposite party-2 had sent a letter to the counsel of the complainant dated 14.7.2015 under Ex.A18, the procedure is not included in the 113 net work hospital given under G.O.243, dt.29.6.2012 hence the denial of request for reimbursement of medical expenses.

12.    The opposite parties 1 & 2 neither submitted their written version nor proof affidavit nor physical presence to explain about the denial of reimbursement a notice also was served vide Dis.No.440/2015, dated 12.10.2015  before this forum,  it is treated as exparte on 28.10.2015.

13.    Pursuant on the complaint, proof affidavit and hearing the learned counsel argument along with the documents on scrutiny of all the paper we judiciously found the opposite parties neither bothered to honor claim of the complainant nor to respect the forum it is the basic need of the opposite parties to comply or appear to the forum and ventilate whatever the allegations or averments against the complainant. They had failed to do so.  

14.    On scrutiny of the paper submitted by the complainant we calculated the medical bills paid by the complainant as detailed below :

1. Vellammal medical college and Research Ins (Ex.A3):       13,456.00

2. Apollo Specialty Hospital, (Ex.A6)                            :    1,33,021.96

3. Aurowell Health System Pvt. Ltd (Ex.A8)                  :       74,114.00

4. Apollo Specialty Hospital (2^nd Admission)                  :      16,505.00

5. Live well Institute (Ex.A9)                                    :        3,314.00       

6. Chemists bills (Ex.A11)                                         :       6,306.55

7. Live Well Institute (Ex.A17)                                     :   1,03,981.00

                                                                                   -

 Total                                                                :  3,50,698.51

The reason given by the service provider for denying of the claim “Conservative Management for cord compression is not covered hence denied,”  could not be accepted as a valid reason by this forum.  Because this case is a medical Legal case furnished by the Hospital and also the accident was confirmed by the police official, it is genuine cause where patient underwent treatment resulting in severe  Cervical Spinal Cord injury and confirmation of longer duration of treatment is needed, specified by the medical team.  Hence the treatment took by the patient  is only under the medical advice. The compression of Cervical Spinal Cord injury, is not disease as construed by the service provider the compression or the fracture in the spine and the pelvic region arose as a result out of accident.  COPRA 1986 Under section 2 (i) (g) and 14 (i) (d) Insurance of Medi claim denial of claim, nature of ailment and cause of action has to be considered.   Hence we are of the considered view that the denial of the claim is not justifiable and the opposite parties 1 & 2 are directed to pay a sum of Rs.3,50,698.51/- rounded to Rs.3,50,699/- as reimbursement along with interest at the rate of 9% p.a. from date of complaint i.e. 6.8.2015 to till the date of payment and also to pay a sum of Rs.5,000/- as litigation charges to the complainant. Considering the facts and circumstances of the case we are not inclined to award any compensation. 

        In the result the complaint is partly allowed.  The opposite parties 1 & 2 are jointly and severally directed to pay a sum of Rs.3,50,699/- (Rupees Three lakhs fifty thousand six hundred and ninty nine only)  towards reimbursement along with interest at the rate of 9% p.a. from  6.8.2015 to till the date of payment and also to pay a sum of Rs.5,000/- (Rupees Five thousand only) towards  litigation charges to the complainant.     

               Dictated to the Assistant transcribed and typed by her corrected and pronounced by us on this the  4^th   day  of  July  2016.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

Complainant’s side documents:

Ex.A1 -        -       - Copy of Health card issued by the complainants and

                             opposite parties

 

Ex.A2-         -       - Copy of Aadhaar Card of 2^nd complainant.

Ex.A3- 4.4.2015    - Copy of Vellammal Hospital Treatment Bills.

Ex.A4- 4.4.2015    - Copy of KGS Scan Report.

Ex.A5- 5.4.2015    - Copy of Vellammal Hospital Discharge summary report.

Ex.A6- 5.4.2015    - Copy of Apollo Hospital Treatment bills.

Ex.A7- 9.4.2016    - Copy of Denial of complainant’s claim by 2^nd opposite party.

Ex.A8- 22.4.2015  - Copy of Aurowell Health System receipt.

Ex.A9- 23.4.2015  - Copy of Live well Institute Medicine Bills.

 

Ex.A10- 26.4.2015         - Copy of Apollo Hospital Discharge summary.

Ex.A11- 26.4.2015         - Copy of Apollo Hospital  Bills & Receipts.

Ex.A12- 1.5.2015  - Copy of Daisy Medical bills.

Ex.A13- 19.5.2015         - Copy of Police complaint with CSR receipt.

Ex.A14- 15.6.2015         - Copy of lawyer notice to opposite parties

Ex.A15- 19.6.2015         - Copy of Acknowledgment card by the 1^st opposite party.

Ex.A16- 19.6.2015         - Copy of India Post Deliver receipt.

Ex.A17- 9.7.2015  - Copy of Treatment bill.

Ex.A18- 14.7.2015         - Copy of Reply by the 2^nd opposite party.

Ex.A19-       -       - New Health Insurance Scheme 2012 user Handbook.

Ex.A20- 9.1.2016  - Copy  of Livewell Institute of Rehabilitation Medicine bills.  

 

 

Opposite parties’ Exhibits:-   

 

(Exparte)  .. Nil..

 

                                                             

 

MEMBER-I                        MEMBER-II                             PRESIDENT.