Tamil Nadu

South Chennai

CC/255/2013

P.Manickam - Complainant(s)

Versus

M/s. Star Health & Allied Insurance Co Ltd - Opp.Party(s)

S.Palanivelayutham

08 May 2019

ORDER

                                                                        Date of Filing  : 01.08.2013

                                                                          Date of Order : 08.05.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.255/2013

DATED THIS WEDNESDAY THE 08^TH DAY OF MAY 2019

                                 

P. Manickam,

S/o. Mr. Paramanantham,

No.11/13, Valayalkarath Street,

Kamuthi,

Ramanathapuram District.                                            .. Complainant.                                                     

 

    ..Versus..

 

M/s. Star Health & Allied Insurance Co. Ltd.,

(Tamil Nadu Government Employees

New Health Insurance Scheme),

Rep. by its Manager,

Old No.64A, New No.2A, Ganga Nagar Road,

Kodambakkam,

Chennai – 600 024.                                                    ..  Opposite party.

 

Counsel for the complainant      : M/s. S. Palanivelayutham & another

Counsel for the opposite party  : M/s. N. Vijayaraghavan

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite party under section 12 of the Consumer Protection Act, 1986 prays to pay a sum of Rs.2,00,000/- towards the sum assured as per the policy issued by the opposite party along with interest at the rate of 18% p.a. till the date of filing of this complaint to till the date of realization of the amount and to pay a sum of Rs.5,00,000/- towards compensation for mental agony and torture with cost of Rs.5,000/- to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he is working as a Head Constable in Dhanuskodi Police Station, Dhanuskodi, Ramanathapuram District.   While he was working in Palavoor Police Station, Tirunelvei District, he joined the opposite party’s health insurance scheme introduced by the State Government of Tamil Nadu.  He has joined the opposite party M/s. Star Health and Allied Insurance Policy which was introduced by the State Government of Tamil Nadu for the benefits of the employees and paid the premium regularly from the salary.    The complainant’s reference Number is RMD/01/PB 301/182793. As per the insurance, the opposite party undertakes to provide cashless health cover, Hospitalization facilities etc.  The complainant submits that on 02.01.2012, his wife was admitted in the Apollo Hospital, Madurai for the sudden severe head ache and undergone treatment and after investigation administered ‘intra venal fluid’.  The Apollo Hospital also sent a claim form to the opposite party insurance company as per the policy since, the patient is entitled such medical treatment.  But the opposite party rejected the claim on 10.01.2012 on the ground that “the diagnosis is not confirmed by both clinical features and investigations.  Hence, it is not possible to authorize”.  Thereby, the claim of the complainant was repudiated which caused great mental agony.  The complainant submits that after availing the policy and payment of premium without any default through his salary and on production of medical records without any substantial reason repudiated the claim.  The act of the opposite party amounts to deficiency in service and unfair trade practice which caused great mental agony.   Hence, the complaint is filed.

2.      The brief averments in the written version filed by opposite party is as follows:

The opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.   The opposite party states that the complainant has enrolled himself as a beneficiary under Tamil Nadu Health Insurance Scheme made available to government servants.  The said Health Insurance Scheme is subjected to the following conditions:

i. The scheme is confined to diseases/ailments/procedures identified and notified by GO Ms No.174 datd:28.04.2008 and for procedures undergone in a network hospital alone;

ii. Operates on cashless basis alone;

ii. Under the scheme, reimbursement is not permissible.

The opposite party states that the complainant’s wife was admitted in Apollo Specialty Hospital, Madurai on 02.01.2012.  The treating hospital made a pre-authorization request with the opposite party for claiming Hospitalization expenses.  On receipt of the request, the opposite party observed that the insured was presented with the complaints of head ache since 2 weeks and history of nausea since 3 weeks and provisional diagnosis was chronic meningistrs, vasculitre disease. The opposite party in his letter dated:09.01.2012 requested the hospital to select the appropriate procedure.   But the hospital authorities neglected and failed to do so.  The scheme of health insurance is only confined to diseases, ailments/ procedures notified by GO Ms No.174 dated:28.04.2008. Accordingly, the opposite party is not liable to pay any hospitalization expenses.  Therefore, there is no deficiency in service on the part of the opposite party and hence, the complaint is liable to be dismissed.

3.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A5 are marked.  Proof affidavit of the opposite party is filed and document Ex.B1 to Ex.B11 are marked on the side of the opposite party. 

4.      The points for consideration is:-

1. Whether the complainant is entitled to a sum of Rs.2,00,000/- towards medical expenses with interest at the rate of 18% p.a. as prayed for?

 

2. Whether the complainant is entitled to a sum Rs.5,00,000/- towards compensation for mental agony with cost of Rs.5,000/- as prayed for?

 

5.      On point:-

The written arguments of the opposite party is filed.  Heard both sides. Perused the records namely; the complaint, written version, proof affidavits and documents.  The complainant pleaded and contended that he is working as a Head Constable under Tamil Nadu Police Department.  He has joined the opposite party M/s. Star Health and Allied Insurance Policy which was introduced by the State Government of Tamil Nadu for the benefits of the employees and paid the premium regularly from the salary.  Ex.A1 is the copy of insurance scheme submitted by the complainant.  The complainant’s reference Number is RMD/01/PB 301/182793. As per the insurance, the opposite party undertakes to provide cashless health cover, Hospitalization facilities etc.  Further the contention of the complainant is that on 02.01.2012, his wife was admitted in the Apollo Hospital, Madurai for the sudden severe head ache and undergone treatment and after investigation administered ‘intra venal fluid’.  The Apollo Hospital also sent a claim form to the opposite party insurance company as per the policy since, the patient is entitled such medical treatment.  But the opposite party rejected the claim on 10.01.2012 on the ground that “the diagnosis is not confirmed by both on clinical features and investigations.  Hence, it is not possible to authorize” as per Ex.A2.  Thereby, the claim of the complainant was repudiated which caused great mental agony.   Further the contention of the complainant is that after availing the policy and payment of premium without any default through his salary and on production of medical records without any substantial reason repudiated the claim amounts to negligence and unfair trade practice. The complainant is claiming a sum of Rs.2,00,000/- to assured policy amount with a compensation of Rs.5,00,000/-.  But on a careful perusal of records, the complaint has not produced any medical bills in this case to prove the medical treatment given to his wife.

6.     The learned Counsel for the opposite party would contend that the complainant has enrolled himself as a beneficiary under Tamil Nadu Health Insurance Scheme made available to government servants.  The said Health Insurance Scheme is subjected to the following conditions:

i. The scheme is confined to diseases/ailments/procedures identified and notified by GO Ms No.174 datd:28.04.2008 and for procedures undergone in a network hospital alone;

ii. Operates on cashless basis alone;

ii. Under the scheme, reimbursement is not permissible.

 Further the contention of the opposite party is that the complainant’s wife was admitted in Apollo Specialty Hospital, Madurai on 02.01.2012.  The treating hospital made a pre-authorization request with the opposite party for claiming Hospitalization expenses.  On receipt of the request, the opposite party observed that the insured was presented with the complaints of head ache since 2 weeks and history of nausea since 3 weeks and provisional diagnosis was chronic meningistrs, vasculitre disease.  The opposite party in Ex.B10, letter dated:09.01.2012 requested the hospital to select the appropriate procedure.   But the hospital authorities neglected and failed to do so.  The scheme of health insurance is only confined to diseases, ailments/ procedures notified by GO Ms No.174 dated:28.04.2008 as per Ex.B3. Accordingly, the opposite party is not liable to pay any hospitalization expenses. But the complainant is entitled to recover the hospitalization expenses from the government.  In this case, the complainant has not added the Government as a party. 

The learned Counsel for the opposite party cited the decision reported in:

THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MADURAI BENCH

F. A. No.289/2012

Between

The Manager

-Versus-

Dr. S. Thilagar & another

Held that

          “It is the case of the complainant that he was a member of the Tamil Nadu Government Employees New Health Insurance Scheme covering his family members as beneficiaries and for which the premium being recovered from his salary as Assistant Professor of Medical College and his son one T.K. Dinesh sustained head injury due to accident on 29.03.2010 was admitted in Thiraviam Hospital, Nagercoil and subsequently shifted to Ananthapuri Hospital, Thiruvananthapuram and he was not in a position to inform about the accident to the 1^st opposite party and subsequently his son died on 31.03.2010 and due to his death he was in confused stage and restless manner and not in a position to communicate immediately to the 1^st respondent and thereafter on 24.05.2010, the complainant sent a letter for claiming refund of expenses through the 2^nd opposite party and it was rejected by the 1^st opposite party on 26.10.2010 and sent to the 2^nd opposite party by stating that since the conditions of the claim was violated and the accident was not immediately informed since the patient was admitted in the hospital and thereby alleging negligence claimed the amounts.  The 1^st opposite party explainaing the scheme as per the G.O. Ms. No.174, Finance (Salaries) Department dated:28.04.2008, the members are entitled for upto Rs.2,00,000/- for 4 years as cashless basis without paying any amount at the time of admission in the hospital and the 1^st opposite party being the insurer was paying the amount directly to the hospital and thereby the complainant’s request was received on 01.06.2010  for the treatment taken from 29.05.2010 to 31.03.2010 which was not intimated to the appellant and also not followed the rules as per Government Order without producing the identity card, Pay Drawing Officers certificate in the hospital to take the treatment and thereby the request of the complainant for refund of the amount cannot be entertained and thereby only remedy is available to approach the Government in this regard and for this the appellant relied on the rulings and precendents of this Commission and as per the order passed in Writ Appeal No.480/2009 by Hon’be High court of Madras, Madurai Bench, in which it is observed as follows:

          “Therefore, if the claimants have made payment whether for  a procedure not covered or whether at a non-network hospital or they have paid when they have been treated for a covered procedure in a network hospital, their only remedy is to approach the Government under the Rules (Tamil Nadu Medical Attendance Rules”).

and thereby the complainant has to approach only the Government for his remedy.  On the basis of the same, this Commission also passed an order in its judgments in F.A.No.814/2010, dated:30.12.2011, Bench-II and F.A. No.288/2012 (Madurai Bench), dated:22.01.2014 in the case of the Co-ordinator, Star Health & Allied Insurance Co. Ltd. (Tamil Nadu Government Employees New Health Insurance Scheme) –Vs- M. Pushparaj and another decided on 30.12.2011 and another matter, this Commission in the case of Star Health and Allied Insurance Company Limited., Represented by its General Manager and another –Vs- T. Dharmarajan, dated:22.01.2014 in F.A. No.288/2012, following the directions of the Hon’ble High Court of Madras, (Madurai Bench) and given direction to the complainant to approach the Redressal Committee under the scheme as per G.O. Ms. No.430, Finance (Salaries) Department dated:10.09.2007 in order to consider his claim as per the guidelines issued in this regard by the Hon’ble High Court, Madras (Madurai Bench) in W.A. (M.D) 480/2009 as reported in 2010-2 L.V. 90.

8. Hence, ini view of the same in this case also, we find that the majority order passed erroneously by the Members of the District Forum is liable to be set aside accepting the majority order passed by the President dismissing the complaint with a direction to the complainant to approach the Government for proper remedy and thereby this appeal is to be allowed by setting aside the order passed by the two Members of the District Forum, confirming the order passed by the President of District Forum confirming the dismissal of the complaint in C.C. No.26/2011 dated:14.10.2011 by the District Forum, Kanyakumari District at Nagercoil.

9. In the result, the appeal is allowed by setting aside the majority order passed by the two Members and confirming the order passed by the President of the District Forum, Kanyakumari at Nagercoil, dismissing the complaint in C.C. No.26/2011 dated:14.10.2011 with direction to the complainant /1^st respondent to approach the Redressal Committee under the Scheme as per G.O. Ms. No.430, Finance (Salaries) Department dated:10.09.2007 in order to consider his claim as per the guidelines issued in this regard by the Hon’ble High Court, Madras (Madurai Bench), in W.A (M.D) 480/2009 as reported in 2010-2 L.W. 90 and Government may consider favourably in this regard.  There will be no order as to costs in this appeal”.

Considering the facts and circumstances of the case, this Forum is of the considered view that this complaint has to be dismissed.

In the result, this complaint is dismissed.  No costs.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 06^th day of May 2019. 

 

MEMBER                                                                                PRESIDENT

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	06.01.2012	Copy of the insurance scheme issued by the opposite party
Ex.A2	10.01.2012	Copy of the rejection letter issued by the opposite party
Ex.A3	28.03.2013	Copy of the legal notice issued by the complainant
Ex.A4		Copy of the acknowledgement card
Ex.A5	12.04.2013	Copy of the reply notice

 

OPPOSITE PARTY SIDE DOCUMENTS:-

Ex.B1	10.09.2007	Copy of G.O. Ms No.430
Ex.B2	21.04.2008	Copy of Agreement
Ex.B3	28.04.2008	Copy of G.O. Ms. No.174
Ex.B4	11.06.2008	Copy of Insurance Policy
Ex.B5		Copy of New Health Insurance Scheme Rules, 2007
Ex.B6	26.02.2010	Copy of Order in WA. No.480/2009 (2010 (2) LW 90)
Ex.B7	30.03.2010	Copy of Order in WP. No.23762/2009
Ex.B8	10.04.2010	Copy of letter of Special Secretary to Government
Ex.B9		Copy of Pre-authorization request Form
Ex.B10	09.01.2012	Copy of letter from the 1st opposite party to 2nd opposite party
Ex.B11	10.01.2012	Copy of Claim Rejection Letter

 

 

MEMBER                                                                                PRESIDENT