Date of Filing      : 15.09.2022

                                                                                                                 Date of Disposal : 31.01.2023

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

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

                 THIRU.J.JAYASHANKSR. B.A., B.L.,                                                                      ......MEMBER-I

 

CC. No.175/2022

THIS TUESDAY, THE 31st  DAY OF JANUARY 2023

 

Mr.M.Jesuraj, S/o.KC.Micheal,

No.31, 8th Cross Street South Side,

Thendral Nagar West,

Thirumullaivoyal, Chennai – 600 062.                                              ……Complainant.  

                                                                                 //Vs//

1.P.A to Collector (Accounts),

   Collectrate, Thiruvallur District.

 

2.The Divisional Manager, 

    Unitied India Insurance Company, Divisional Office VI,

    PLA Rathna Towers, 5th Floor,

    No.212, Anna Salai, Chennai 600 006.                                  …..opposite parties.

 

Counsel for the complainant                                                    :   party in person

Counsel for the opposite parties                                             :   exparte 

                         

This complaint is coming before us on various dates and finally on 20.01.2023 in the presence of complainant who appeared in person and the opposite parties were set exparte for non appearance and upon perusing the documents and evidences of the complainant this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. 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 not honouring the reimbursement of medical expenses along with a prayer to honour the medical claim along with cost of the complaint to the complainant.

Summary of facts culminating into complaint:-

The crux of the complaint was that the he was a retired person from Tamil Nadu Special Police 13th battalion Thiruvallur and had taken treatment with Vijaya Medical & Educational Trust for the following ailments “L4 & L5 VERTEBRAE SHOW ALTERED MARROW SIGNALS IN PARADISCAL, REGION WITH REDUCED HEIGHT OF L4-L5 DISC, INFECTIVE PATHOLOGY, DEGENERATIVE DISCOGENIC MARROW CHANGES, OLD CVA/SEIZURE DISORDER / HYPERTENSION/ DYSLIPIDEMIA” for which an amount of Rs.68,684.20/- was spent by the complainant towards the treatment.  When the complainant claimed the same from the Health Insurance Claim via Tamil Nadu New Health Insurance Scheme ID Card No.TLR/T/NHISP14-0622842 the same was rejected by the opposite parties.  On submission of a petition to the District Collector along with the Medical bills on 05.10.2020 the same was considered by the Medical team on 12.03.2021 and an order was passed considering the decision rendered in W.P.(MD).No.13429/2013 titled S.Marimuthu Vs Govt. Of Tamil Nadu before Madurai Bench of Madras High Court dated 28.05.2019 suggesting for the reimbursement of the medical claim.  However, again when the request was made along with the recommendation letter the same was rejected by the opposite parties vide a letter dated 03.08.2022 issued by the Thiruvallur District Treasury.  Thus aggrieved the present complaint was filed for reimbursement of the medical claim along with the cost of the complaint.

 On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A5. Despite service of sufficient notice both the opposite parties did not appear before this commission to file any written version and hence they were called absent and were set exparte on 07.12.2022 for non filing of written version within the mandatory period.

Points for consideration:

Whether the rejection of Health Insurance Claim made by the complainant with regard to the medical reimbursement expenses of Rs.68,684.20/- under the New Health Insurance Scheme Pensioners/Family Pensioners amounted to deficiency in service by the opposite parties?

If so to what reliefs the complainant is entitled?

  Point:1

The following documents were filed on the side of complainant in support of his contentions;

New Health Insurance Scheme pensioners/Family pensioners Card was marked as Ex.A1;

Request letter made by the complainant to the District Collector, Thiruvallur District requesting to reimburse the medical expenses of Rs.68,684.20/- was filed as Ex.A2;

The consideration made by the District Medical Board was marked as Ex.A3;

Letter issued by the District Medical Board was marked as Ex.A4;

Letter was issued by the District Treasury dated 03.08.2022 was marked as Ex.A5;

 

 

As the complaint was filed by the complainant as party in person this commission did not insist for filing of written arguments.  Hence on hearing the oral arguments of the complainant and on perusing material evidence produced by him this commission decided the complaint on merits.

The complainant submitted the copy of ID card issued to him under the Government of Tamil Nadu, New Health Insurance Scheme pensioners/Family pensioners as Ex.A1.  Further the request letter made by the complainant to the District Collector, Thiruvallur District requesting to reimburse the medical expenses of Rs.68,684.20/- was filed as Ex.A2.  The consideration made by the District Medical Board was marked as Ex.A3 in which it is stated that the medical records verified and found genuine and also the medical expenditure vouchers verified and they have also acknowledged that the procedure is done in the empanelled list of treatment. Thus after considering the claim they recommended for the medical reimbursement.  However vide another letter the request of the complainant was declined as it could not be processed stating certain reasons.  The letter issued by the District Treasury was marked as Ex.A5 dated 03.08.2022 wherein it has been informed that the United India Insurance has rejected the medical claim of the complainant as treatment procedure not covered.  

On perusing the available records and also considering the judgment made in W.P.(MD).No.13429/2013 S.Marimuthu Vs Govt. Of Tamil Nadu before Madurai Bench of Madras High Court dated 28.05.2019, we could see that the Hon’ble High Court had categorically held that no Health Insurance Claim could be rejected merely on the reason of non network hospital or non listed disease in their words as follows;

“While reconsidering, the committee shall not reject any claim merely on the reason of non network hospital or non listed disease.   

The committee, wherever possible, shall give suitable direction to the Insurance Company to reimburse the claim made by the respective claimant/employee/pensioner.

The committee finds some cases where the Insurance Company cannot be directed to reimburse, in those cases, suitable order shall be passed directing/recommending the State authorities to reimburse the claim under Medical Attendance Rules.”

We found that inspite of bringing the said judgement to the knowledge of the Medical Board, still the claim was not honoured by the Medical Board holding that the conservative treatment done by the complainant was not covered and hence the claim of the complainant could not be processed. Further we perused the G.O.Ms.No.202 dated 30th June 2016 FINANCE [Salaries] DEPARTMENT and appraised that under Serial No.26 under the caption of Neurology clause (d) provides Inter-vertebral Disc Prolapse related Surgeries. Therefore when diagnosed by the Vijaya Medical & Educational Trust relates to L4 & L5 VERTEBRAE SHOW ALTERED MARROW SIGNALS IN PARADISCAL, REGION WITH REDUCED HEIGHT OF L4-L5 DISC, INFECTIVE PATHOLOGY, DEGENERATIVE DISCOGENIC MARROW CHANGES, OLD CVA/SEIZURE DISORDER/HYPERTENSION/DYSLIPIDEMIA, we are of the view that the rejection of medical reimbursement claim is not proper on the part of the opposite parties when it was found that the surgeries were covered.  Thus the act of the opposite parties even after issuance of guidelines by the Hon’ble High Court in W.P.(MD).No.13429/2013 S.Marimuthu Vs Govt. Of Tamil Nadu before Madurai Bench of Madras High Court dated 28.05.2019 amounted to clear deficiency in service in rejecting the health Insurance Claim of the complainant.  Thus we answer the point accordingly in favour of the complainant and as against the opposite parties. 

Point No.2:

 

With regard to relief to be granted to the complainant as we have already held above that the opposite parties had committed deficiency in service in rejecting the Health Insurance claim of the complainant on the ground that the treatment was not covered we feel it is appropriate to direct them to honour the claim of Rs.68,684.20/- to be paid to the complainant. For the mental agony and hardship suffered by the complainant by the rejection of Health Insurance Claim we award a nominal compensation of Rs.10,000/- to be paid by the opposite parties which we thought would be of a solace to the complainant.  Further litigation cost of Rs.5,000/- was also awarded to the complainant.

In the result, the complaint is partly allowed and the opposite parties 1 & 2 are jointly and severely directed to issue necessary orders; 

a) To reimburse the Health Insurance claim of the complainant amounting to Rs.68,684.20/- (Rupees sixty eight thousand six hundred eighty four only) based on the medical bills produced 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 caused to the complainant; 

c)  to pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant; 

d) Amount in clause (a) if not paid within six weeks from the date of receipt of copy of this order, interest at the rate of 6% will be levied on the said amount from date of complaint till realization. 

 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 31st day of January 2023.

      Sd/-                                                                                                          Sd/-

    MEMBER-I                                                                                            PRESIDENT

List of document filed by the complainant:-

 

Ex.A1 ............... New Health Insurance Scheme pensioners/Family pensioners ID Card. Xerox

Ex.A2 29.12.2020 Request letter made by the complainant to the District Collector, Thiruvallur District requesting to reimburse the medical expenses of Rs.68,684.20/- Xerox

Ex.A3 12.03.2021 Consideration made by the District Medical Board. Xerox

Ex.A4 ................ Letter issued by the District Medical Board to the complainant Xerox

Ex.A5 03.08.2022 Letter was issued by the District Treasury to the complainant. Xerox

 

List of documents filed by the opposite parties:-

 

 

Nil

 

 

   Sd/-                                                                                                               Sd/-

MEMBER-I                                                                                                  PRESIDENT