Date of Filing     22.03.2024

                                                                                                             Date of Disposal: 19.07.2024

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

CC.No.126/2024

THIS FRIDAY, THE 19^th DAY OF JULY 2024

Mr.N.Dhanavel,

S/o.Natesan,

Residing at No.4, Bannariamman Street,

Thomurar Nagar,

Rajajipuram, Thiruvallur.                                                                       ......Complainant.

                                                                            //Vs//

1.M/s. The Manager,

   United India Insurance Company Limited,

   J.N.Road, Oilmill, Thiruvallur 602 001.

2.United India Insurance Company Limited,

LBO-010600,

No.134, Silingi Buildings,

IDBI Bank back side,

Greams Road, Chennai 600 006.                                                     .…..Opposite Parties.

Counsel for the complainant                      :    M/s.E.Thamizharasan, Advocate.

Counsel for the 1^st opposite party             :    Exparte

Counsel for the 2^nd opposite party            :     M/s. J.Chelladurai Caldwell, Advocate.

This complaint coming before us on various dates and finally on 04.07.2024 in the presence of M/s.E.Thamizharasan, counsel for the complainant and   M/s.J.Chelladurai Caldwell, counsel for the 2^nd opposite party and 1^st opposite party was  set exparte for non appearance and upon perusing the documents and evidences of both sides 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 not honouring the reimbursement claim for medical expenses along with a prayer to honour the medical claim along with compensation to the complainant.

Summary of facts culminating into complaint:-

2. Being aggrieved by the act of the opposite parties in not reimbursing the medical claim relating to the medical expenses of the complainant’s wife the present complaint was filed.

3. Complainant who as a retired Inspector of Police had got insured with the Government of Tamil Nadu New Health Insurance Scheme Pensioners/family pension and the opposite parties debit monthly Rs.495/- towards premium from the pension amount.  Complainant’s wife took treatment from Astra Ortho N Spine Center for Bilateral Tri Compartmental and osteoarthritis knee with various deformity and spent Rs.4,62,970/-.  When approached for reimbursement the opposite parties admitted to pay in two days on 02.01.2024.  But afterwards did not respond.  Hence the present complaint was filed claiming for reimbursement of expenses along with compensation.

The crux of the defence put forth by the 2^nd opposite party:-

4. Admitting the insurance taken and the medical expenses made, it was submitted that the wife of complainant was not made a party to the proceedings.  That this commission does not have jurisdiction to try the complaint. That the Complainant's wife has done unnecessary medical procedures for the condition which could be easily cured by proper medication and exercise and therefore her claim could not be fully processed. As per the New Health Insurance Scheme 2016 according to the G.O. Ms.No. 202, dated 30.06.2016, request for reimbursement for treatment taken for Bilateral Tricompartmental and osteoarthritis Knee with Varus deformity was not eligible. The Finance (Salaries) Dept., Secretariat, Chennai addressed to The Director of Treasuries and accounts, has issued orders that reimbursement shall be made only in cases for treatment taken and have occurred in the commencement stage subject to treatment taken in approved hospital's for approved listed procedures as per GO No.202 dated 30.06.2016. The Complainant has failed to explain the necessity of the medical procedures which his wife has undergone and hence the denial of the claim amount to the Complainant was just and genuine. The claim of Rs. 4,62,970/- was clearly excluded by the terms and conditions of the Policy and thus there is no deficiency of service and therefore complaint is liable to be dismissed.  If the Complainant is aggrieved by the claim amount issued by the Insurance Company/Opposite Party, remedy is available to him before the Insurance Ombudsman and while an alternative remedy is available to the Complainant herein, he is not entitled to approach this Hon'ble Consumer Disputes Redressal Commission. Thus they sought for the dismissal of the complaint.

5. On the side of complainant proof affidavit was filed along with documents marked as Ex.A1 to EX.A6. On the side of 2^nd opposite party proof affidavit was filed but no document was submitted on their side. The 1^st opposite party did not appear and file written version and hence he was called absent and set exparte on 04.06.2024 for non appearance and non filing of written version with in the mandatory period as per the statue.

Points for consideration:-

1. Whether the rejection of the medical insurance reimbursement claim made by the complainant for his wife’s medical expenses amounts to deficiency in service on the part of opposite parties?
2. If so to what reliefs the complainant is entitled?

Point No.1:-

6. Heard complainant and considered the written arguments of 2^nd opposite party as oral arguments as per their endorsement.

7. The complainant being a retired Government Servant had availed Health Insurance with the opposite parties vide ID Card No.TLR/T/NHIS)22/00798596 which aspect was not disputed.  However, the claim for medical expenses reimbursement made for his wife was rejected on the ground that the treatment was taken at a non-network hospital.

8.  It was stated by the opposite parties that wife of complainant was not a party to the complaint which affects the maintainability of the case.  When the policy was taken in the name of complainant and when both husband and wife was issued a common policy, the husband could very well file a complaint for the rejection of claim for his wife’s medical expenses.  Therefore, when complainant being the card holder had filed the complaint, it was very well maintainable in the absence of wife being a party to the proceedings.

9. The other defence taken by 2^nd opposite party was that the treatment was taken unnecessarily and that it could have been treated by medication and exercise.  The opposite parties did not submit any supportive documents for the same. Thus, the opposite parties being not medically qualified persons could not contend that the treatment was unnecessary.

10. On perusal of the report issued by the District Medical Board, Office of the Joint Director of Health Services, Thiruvallur the diagnosis was found as BILATERAL TRICOMPARTMENTAL OSTEOARTHRITIS KNEE WITH VARUS DEFORMITY and the procedure done as LEFT KNEE TOTAL REPLACEMENT – CRUCIATE DONE 30.07.2021, RIGHT KNEE TOTAL REPLACEMENT –CRUCIATE RETAINING DONE ON 02.08.2021.  It is seen that the medical records where verified and the required medical expenditure vouchers were also verified. The procedure done was in the Empanelled List was also admitted.  However, the Hospitals were treatment taken was mentioned as non-network hospital.  It was also found that it was mentioned “Emergency” and under Medical Reimbursement Recommendation, the claim was approved as “Yes”.  Therefore, when the Medical Board itself had approved the claim, there is no reason for the opposite parties to reject the claim on any other ground. 

11. Also WP (MD).Nos.13429/2023 in Madurai Bench of Madras High Court dated 28.05.2019 wherein it has been held that

54. Assuming that, the treatment has been taken in non network hospital, it is the duty of the District Level Empowered Committee or at least at the State Level high power committee to go in to the claim of such employee / pensioner and to see whether the treatment had been taken in a non network hospital for any plausible reason like emergency or immediate non-availability of the network hospital in the locality. If those issues have been gone in to in each of the case and acceptable or plausible reasons are given for rejecting the claim of the medical reimbursement by the Insurance Company, even then the claimant is entitled to get reimbursement under the Medical Attendance Rules.

   80. In order to reconsider all these claim made by the respective writ petitioners for medical reimbursement, by remitting the matters back, the following directions are issued: 

 (i) All the impugned orders in the respective writ petitions in this batch of cases, are hereby quashed.

 (ii) The writ petitions where impugned orders are quashed as well as the writ petitions where mandamus sought for, are hereby remanded with directions to the concerned District Level Empowered Committee, before whom, these matters shall be placed and the Committee shall reconsider every individual case. 

 (iii) While reconsidering, the Committee shall not reject any claim merely on the reason of non network hospital or non listed disease.  

Therefore, the rejection of the reimbursement medial claim by the opposite parties inspite of the order passed in the above Writ petition clearly amounts to deficiency in service. 

With regard to the defence that alternate remedy is available, in Civil Appeal No. 3581-3590 of 2020 (@ Civil Appeal Diary No.9796 of 2019) and Civil Appeal No.3591 of 2020 (@ Civil Appeal Diary No.9793 of 2019). D/d. 02.11.2020 in M/s. Imperia Structures Ltd.  Vs Anil Patni and others it has been held as,

21. It has consistently been held by this Court that the remedies available under the provisions of the CP Act are additional remedies over and above the other remedies including those made available under any special statutes; and that the availability of an alternate remedy is no bar in entertaining a complaint under the CP Act.

 Therefore, complaint is maintainable irrespective of alternate remedy as provisions of Consumer Protection Act, 2019 shall be in addition to and not in derogation of the provisions of any other law as per Section 100 of the said Act. Thus we answer the point accordingly.

Point No.2:-

12. As we have held above that the rejection of Medical Insurance Claim is not in accordance with law and amounts to deficiency in service, we direct the opposite parties to process the claim and to pay the amount to the complainant within 6 weeks from the date of receipt of copy of this order along with compensation of Rs.10,000/- towards for the mental agony caused to the complainant.  We also award Rs.3,000/- towards cost of the proceedings to the complainant.

In the result, the complaint is partly allowed against the opposite parties 1 & 2 jointly and severally directing them

a) To consider the claim of the complainant and to pass necessary orders for reimbursement of the claim for Rs.4,62,970/- based on the medical bills submitted by the complainant within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.10,000/-(Rupees ten thousand only) towards compensation for the mental agony and hardship caused to the complainant;

c) To pay a sum of Rs.3,000/- (Rupees three 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 the 19^th day of July 2024.

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  MEMBER-I                                                                                                      PRESIDENT

List of documents filed by the complainant:-

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MEMBER-I                                                                                                       PRESIDENT