Tamil Nadu

South Chennai

CC/95/2016

R.Jayalakshmi - Complainant(s)

Versus

M/s.Pension Pay Officer, E.V.K.Sampath Building - Opp.Party(s)

Jayalakshmi

09 Feb 2018

ORDER

                                                                                                                           Date of Filing  : 03.03.2016

                                                                          Date of Order : 09.02.2018

DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, CHENNA (SOUTH)

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

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, 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                                                CC. NO.95 /2016

MONDAY THE 9^TH DAY OF FEBRUARY 2018

                                              

R. Jayalakshmi,

NO.6/3, Rajaratnam Street,

Tambaram (West),

Chennai 600 045.                                               .. Complainant

                                      ..Vs..

 

1. Pension Pay Officer,

Pension Pay office,

EVK Sampath Building College Road,

Chennai 600 006.

 

2. M/s. United India Insurance Company Ltd.,

Divisional Office VI,

V Floor, P.L.A. Rathna Towers,

No.212, Ann Salai,

Chennai 600 006.                                     ..  Opposite parties.

 

Counsel for complainant         :  M/s.V.Shankar & Lavanaya Shankar 

For opposite party-1               :  Exparte.

Counsel for opposite party-2  :  M/s. P.Sankaranarayanan & another   

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section  12 of the Consumer Protection Act 1986 seeking direction to reimburse a sum of Rs.1,42,974/- with interest and also to pay a sum of Rs.2,00,000/- towards compensation for mental agony and Rs.30,000/- as cost of the complaint.  

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

          The complainant submit that  complainant is a senior person and her late husband entitled for medical reimbursement scheme offered by the Government of Tamilnadu Health Fund scheme since her husband T.R. Raghavan who was a retired employee in Judicial Ministerial Service who predeceased the complainant. In the Tamilnadu Health Fund scheme the 1^st opposite party has tied up with the 2^nd opposite party which cover the complainant also.   After the death of the complainant’s husband the New Health Insurance Scheme, Chennai continued the service.    The premium for Tamilnadu Health fund scheme is duly deducted from the complainant’s pension by the 1^st opposite party regularly without any default.  On 9.11.2014 the complainant fell down and sustained fracture of her thigh bone caused grievous injury .  Immediately the complainant was taken to Orthopedic surgeon Dr. M.Subramanian and the patient is admitted as inpatient in Isabel’s Hospital, Mylapore, Chennai. Wherein after investigations and diagnosed due surgery on thigh bone was conducted by Dr. M.Subramanian on 14.11.2014 and was discharged on 25.11.2014.   Further the complainant state that she  is entitled to cashless treatment. Since the opposite parties has not taken suitable steps for such treatment,   the complainant was constrained to pay all medical expenses to the tune of Rs.1,42,974/-.   Immediately after discharged from the hospital on 1.12.2014 the complainant submitted due claim for reimbursement of the medical expenses before the 1^st opposite party.   On 3.12.2014 the 2^nd opposite party repudiated the claim stating that the said  Isabel’s Hospital, Mylapore, Chennai is not listed in G.O.No.171 therefore the 1^st opposite party has not settled the claim.   As such the act of the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant.  Hence this complaint is filed.    

2.     Even after service of notice the opposite party-1 called absent and he was set exparte.

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

The  2^nd opposite party deny each and every allegations except those that are specifically admitted herein.  The 2^nd opposite party state that  the  Government of Tamilnadu has implemented the New Health Insurance Scheme 2014 on 1.7.2014 for pensioners of Government  of Tamilnadu and had issued G.O.No.171 Finance dated 26.6.2014 with guidelines and procedures.  As per the G.O. there is no privity of contract between the complainant and this opposite party insurance company. Further the 2^nd opposite party state that the scheme is a cashless scheme and no payment is to be made by the pensioners to the approved hospitals and the payment will be made by the insurance company, directly to the hospitals  only for approved treatment procedure as mentioned in the G.O.    The payment will be made only after the pre-authorization approval obtained.  In this case, the complainant who is the pensioner have taken treatment without any pre authorization  and not in the Net work hospitals.   The complainant availed treatment before St. Isabels Hospital, Mylapore, Chennai which is not an approved hospital under NHIS 2014 and not listed in G.O. No.171.  The complainant has availed treatment in Isabel Hospital, Chennai-4 while she is residing at  Tambaram which his more than 30 kms away from the hospital.    As per decision reported in 2016 (3) CTC page 394 where the petitioners have taken treatment in non network hospitals or for non listed procedures the insurance company cannot be made liable to reimburse expenditure and it is  only the State Government  which has to sanction and reimburse the medical expenditure.   Hence there is no deficiency in service on the part of the 2^nd opposite  party and the complaint is liable to be dismissed.

4.      In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A6 marked.  Proof affidavit of the opposite party filed and Ex.B1 to Ex.B2  marked on the side of the  opposite party.

 

5.      The points for consideration is :

1. Whether the complainant is entitled to a sum of Rs.1,42,974/-    with interest as prayed for?

2. Whether the complainant is entitled to a sum of Rs.2,00,000/- towards compensation for mental agony with cost of Rs.30,000/- as prayed for ?

6.   POINTS 1 & 2:

 

        The 1^st opposite party remain exparte in this case.  Heard both paties.   Perused the records (viz) complaint, written version, proof affidavit and documents.   The learned counsel for the complainant contended that the complainant is a senior citizen and her late husband  entitled for medical reimbursement scheme offered by the Government of Tamilnadu Health Fund scheme since her spouse and husband T.R. Raghavan who was a retired employee in Judicial Ministerial Services who predeceased the complainant.  In the Tamilnadu Health Fund scheme the 1^st opposite party has tied up with the 2^nd opposite party which cover the complainant also.   After the death of the complainant’s husband the New Health Insurance Scheme, Chennai continued the services as per Ex.A1.    The premium for Tamilnadu Health fund scheme is duly deducted from the complainants pension by the 1^st opposite party regularly without any default and the scheme is still in force.   On 9.11.2014 the complainant fell down and sustained fracture of her thigh bone caused grievous injury.  Immediately the complainant was taken to Orthopedic surgeon Dr. M.Subramanian to get treatment and was admitted as inpatient in Isabel’s Hospital, Mylapore, Chennai.   Wherein after due investigations and diagnosed due surgery on thigh bone was conducted by Dr. M.Subramanian on 14.11.2014 and was discharged on 25.11.2014.  Ex.A4 is the discharge summary.   As per Ex.A1 the complainant is entitled to cashless treatment.  Since the opposite parties not taken suitable steps for such treatment, the complainant was constrained to pay all medical expenses to the tune of Rs.1,42,974/- as per Ex.A2.   Immediately after discharged from the hospital,  on 1.12.2014 the complainant submitted due claim for reimbursement of the medical expenses before the 1^st opposite party.   On 3.12.2014 the 2^nd opposite party repudiated the claim on flimsy grounds stating that the said  Isabel’s Hospital, Mylapore, Chennai is not listed in G.O.No.171 therefore the 1^st opposite party returned the complainant’s claim form.  

7.    As per the  decision reported in

1.                         1996 AIR 1388, 1996scc (2) 336

SURJIT SINGH

..Vs..

STATE OF PUNJAB AND OHTERS

 

 

2)                               III (2016) CPJ 277 (NC)

ADDL. DIRECTOR (NORTH ZONE), CGHS

..Vs..

JAGDISH SINGH CHAUHAN

 

The complainant is entitled the medical expenses incurred.  Further the learned counsel for the complainant contended that the opposite parties are jointly and severally liable to pay the actual medical expense of Rs.1,42,974/- with interest and compensation of Rs.2,00,000/-;  Since the opposite parties drove the complainant from pillar to post at this advance age of 91 years.  Complainant sustained great mental agony.

8.     The contention of the 2^nd opposite party is that the  Government of Tamilnadu has implemented the New Health Insurance Scheme 2014 on 1.7.2014 for pensioners of Government  of Tamilnadu and had issued G.O.No.171 Finance dated 26.6.2014 with guidelines and procedures is admitted.  As per the G.O. there is no privity of contract between the complainant and this opposite party insurance company.   But on a careful perusal of the entire records it is very clear that the 1^st opposite party is a Government body has duly informed and forwarded the claim to the 2^nd opposite party insurance company who is the 3^rd party administrator as under New Health Insurance Scheme 2014 for pensioners.   Further the contention of the 2^nd opposite party is that the scheme is a cashless scheme and no payment is to be made by the pensioners to the approved hospitals and the payment will be made by the insurance company, directly to the hospitals  only for approved treatment procedures as mentioned in the G.O.    and the payment will be made only after obtaining the pre-authorization approval.  In this case, the complainant who is the pensioner have taken treatment without any pre authorization  and not in the Net work hospitals.   The complainant availed treatment before St. Isabels Hospital, Mylapore, Chennai which is not an approved hospital under NHIS 2014 and not listed in G.O. No.171.    But on a careful perusal of the records it is apparently clear that the complainant was fell ill at this advanced age of 91 year and  sustained fracture of her thigh bone requires immediate surgery and treatment.  The complainant cannot search the network hospitals in the city at this critical time and age.   As per the G.O. it is not required to take treatment only before the Net work hospitals under emergent situation.    Further the learned counsel for the 2^nd opposite party contended that the complainant availed treatment in Isabel Hospital, Chennai-4 while she is residing at  Tambaram which his more than 30 kms away from the hospital.  But it is not denied that the said hospital is one of the repudiated hospital in city.   The said argument also cannot be considered even  for a single moment because nowhere in the complaint, the opposite party pleaded that the complainant is  well aware of the network hospital.   Equally the opposite party also has not stated the conditions related to the network hospitals to the pensioners at this advanced age of 91 years.   Further the learned counsel for the 2^nd opposite party contended that as per the decision reported in 2016 (3) CTC page 394 where the petitioners have taken treatment in non network hospitals or for non listed procedures the insurance company cannot be made liable to reimburse the medical expenses and it is the duty of the State Government  which has to sanction and reimburse the medical expenditure.   But admittedly the 2^nd opposite party is the insurance company in which the NHIS 2014 had a tie up.   Considering the facts and circumstances of the case this forum is of the considered view that the opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.1,42,974/ towards medical expenses with interest at the rate of 9% p.a. from the date of complaint i.e. 25.11.2014 to till the date of this order i.e. 9.2.2018  and also shall pay compensation of Rs.25,000/- for mental agony with cost of Rs.10000/- and points are answered accordingly.  

In the result the complaint is allowed in part.   The opposite parties 1 & 2 are jointly and severally liable to pay a sum of Rs.1,42,974/ (Rupees one lakh forty two thousand nine hundred and seventy four only ) towards medical expenses with interest at the rate of 9% p.a. from the date of complaint i.e. 3.3.2016 to till the date of this order i.e. 9.2.2018  and also shall pay compensation of Rs.25,000/- (Rupees twenty five thousand only)  for mental agony with cost of Rs.10000/- (Rupees ten thousand only) to the complainant. 

The above  amounts shall be payable within six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a to till the date of payment.

Dictated  by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 9^th  day of February 2018. 

 

MEMBER –I                       MEMBER-II                              PRESIDENT.

COMPLAINANT SIDE DOCUMENTS:

Ex.A1-           - Copy of Form and New Health Insurance scheme.

Ex.A2. 25.11.2014- Copy of receipt for a sum of Rs.1,42,974/-.

Ex.A3- 25.11.2014 – Copy of Brake up for Rs.1,42,974/- given by St.Isabels

                               Hospital, Mylapore, Chennai.

Ex.A4- 25.11.2014 – Copy of discharge summary.

Ex.A5- 3.12.2014    - Copy of repudiation letter issued by the 2^nd opp. party.

Ex.A6- 4.12.2014    - Copy of communication addressed by the 1^st opp.party. 

OPPOSITE  PARTY SIDE DOCUMENTS:  

Ex.B1- 26.6.2014   - Copy of G.O.Ms.No.171 (Finance)

Ex.B2- 1.7.2015     -  Copy of instruction from Finance Secretary.

MEMBER –I                       MEMBER-II                              PRESIDENT.