Date of Filing : 30.03.2022
Date of Disposal : 20.03.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU.P.MURUGAN, M.Com, ICWA(Inter), B.L., ......MEMBER-II
CC. No.25/2022
THIS MONDAY, THE 20th DAY OF MARCH 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 1st opposite party : M/s.E.Vijayakumar, Advocate
Counsel for the 2nd opposite party : Exparte.
This complaint is coming before us on various dates and finally on 27.02.2023 in the presence of complainant who appeared in person and M/s.E.Vijayakumar counsel for the 1st opposite party 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:-
Being aggrieved by the act of the opposite parties in not reimbursing the medical claim relating to the complainant’s wife the present complaint was filed. It was the case of the complainant who is a retired person from Tamil Nadu Special Police 13th Battalion Thiruvallur in PPO No.RO405945 and was having New Health Insurance ID Card No.TLR/TNHISP14-0622842. It was submitted that his wife due to sudden illness was admitted in Vijaya Hospital, Vadapazhani as inpatient and took treatment and the total expenses made was Rs.42,520.30/-. Thus for reimbursement under the New Health Insurance Scheme the complainant on 06.10.2020 filed an application to the District Collector, Thiruvallur along with original receipts with Xerox copy by post. The complainant was adviced to submit the same to United India Insurance Company Limited, Divisional office - VI for reimbursement of claim. On the same day at the time of issuance the document in the ledger against the opposite party it is given as Documents Requested – Photocopies of the – Original discharge summary, Original hospital final bill, Original hospital break bill, Original investigations reports, Original cash receipts for the payments made to the hospital, TNNHIS ID card copy/Annexure form, Pharmacy bills & receipts, photocopy of front page of bank pass book, Cancelled cheque, CT/MRI Brain report. Further when the complainant sought for originals the same was not issued by the 1st opposite party, hence a legal notice was also issued on 02.02.2022. Aggrieved by the act of the opposite parties the present complaint was filed for the relief to direct the 1st opposite party to hand over the original receipts for the medical expenses to Rs.42,520.30/- or in alternative to direct the 2nd opposite party to reimburse the claim by accepting the duplicate copy available with the complainant along with compensation and cost.
The crux of the defence put forth by the 1st opposite party:-
The 1st opposite party admitted the issuance of reference letter No.310/2021/R3 dated 28.11.2021 to the complainant advising him to hand over documents to 2nd opposite party and the District Medical Board to get the claim. Further it is submitted that the wife of the complainant had taken treatment in the net work hospital under the non-emergency condition for unapproved procedure which is not covered under the scheme. The complainant did not produce any original documents before the 2nd opposite party for which reason the claim was not settled. The opposite party submitted that there is no delay caused on their part and no response for the reimbursement of the claim sought for the complaint to be dismissed.
On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A13. On the side of 1st opposite party proof affidavit was filed but no document was submitted on their side. Despite service of sufficient notice the 2nd opposite party did not appear before this commission to file any written version and hence they were called absent and was set exparte on 10.11.2022 for non filing of written version within the mandatory period as per the statute.
Points for consideration:
Whether the alleged deficiency in service by the complainant against the opposite parties has been successfully proved by him by admissible evidence with respect to the non-reimbursement of claim?
If so to what reliefs the complainant is entitled?
Point No.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.42,520.30/- was filed as Ex.A2;
Request letter made by the complainant to Chief Minister of Tamil Nadu dated 24.07.2021 was marked as Ex.A3;
Letter from District Collector to the complainant dated 29.11.2021 was marked as Ex.A4;
The consideration made by the District Medical Board was marked as Ex.A5;
Letter of United India Insurance Company Limited dated 22.10.2021 was marked as Ex.A6;
From Serial No.6 to 11 list dated 29.11.2021 was marked as Ex.A7;
Letter given by the complainant to the District Collector dated 13.12.2021 was marked as Ex.A8;
Legal notice issued by the complainant dated 02.02.2022 was marked as Ex.A9;
Letter issued by the 1st opposite party was marked as Ex.A10;
Letter given by complainant to the 1st opposite party dated 21.12.2022 was marked as Ex.A11;
Letter issued by District Collector to Treasury Officer dated 26.12.2022 was marked as Ex.A12;
Letter issued by the 1st opposite party to the 2nd opposite party dated 12.01.2023 was marked as Ex.A13;
As the complaint was filed by the complainant as party in person this commission did not insist for filing of written arguments on the side of complainants.
We perused the material evidences, pleadings and documents produced by both parties and also heard the oral arguments adduced by the Party in Person/complainant and the learned counsel appearing for the 1st opposite party. The crux of the complaint allegations filed by the complainant/party in person is that the original documents submitted with the 1st opposite party was not forwarded to the Medical Board nor it was returned to the complainant enabling him to produce it before the 2nd opposite party for obtaining the medical reimbursement for his wife’s treatment. However, the 1st opposite party denied the receipt of original bills from the complainant. The matter was referred to District Legal Services Authority for settlement and at that time the complainant who appeared before the Legal Services Authority had produced a document marked as Ex.A13 which was duly served on the 1st opposite party and was received by this commission as additional document with proof affidavit to show that the original documents were submitted with the 1st opposite party. In the said document the 1st opposite party had written a letter to the 2nd opposite party as follows,
kDjhuu; jpU.N[Ruh[; vd;gtu; jdJ kidtp jpUkjp. Nkhl;rNkup vd;gtupd; cly; eyk; ghjpf;fg;gl;L rpfpr;ir ngw;wjw;fhd mry; Mtzq;fs; kUj;Jt nrytPdj;jpid jpUk;g ngWk; nghUl;L 16.10.2020 md;W ,t;tYtyfj;jpy; rku;g;gpf;fg;gl;lij njhlu;e;J Nky; eltbf;iff;fhf ghu;it 2-y; fhZk; ,;t;tYtyff; fbj e.f.vz.21655-2020-Mu;3ehs; 21.10.2020-d; gb khtl;l fUT+yk; jpUts;Su; mtu;fSf;F kDjhuu; rku;gpj;j midj;J mry; Mtzq;fisAk; mDg;gp itf;fg;gl;lJ. Nkw;gb fUT+y mYtyf;j;jpypUe;J ,iz ,af;Feu; (kUj;Jtk; kw;Wk; Rfhjhuk;) jpUts;Su; mYtyfj;jpw;S kUj;Jt FOtpw;fhf mDg;gp itf;fg;gl;Ls;sJ. Mdhy; Nkw;gb ,iz ,af;Feu; jpUts;Su; mYtyfj;jpy; rku;gpf;fg;gl;l mry; Mtzq;fs; United India Insurance Co. Ltd., epWtdj;jpw;F mDg;gg;gljjhy; Nkw;gb Insurance epWtdk; kUj;Jt nrytPdj;jpw;fhd njhifapid kDjhuUf;F mspf;f fhyjhkjk; Vw;gLj;jpajhy; kDjhuuhd jpU.N[Ruh[; vd;gtu; jpUts;Su; Efu;Nthu; ePjpkd;w Nfl;G vz;.25-2022 d; gb tof;F njhlu;e;jij njhlu;e;J khtl;l Efu;Nthu; ePjpkdwj;jpy; tprhuidf;F M[uhfg;gl;lJ. Nkw;gb tprhuidf;Fg; gpd; tof;fhdJ kf;fs; ePjpkd;wj;jpw;F khw;wg;gl;l 12.12.2022 kw;Wk; 19.12.2022 Mfpa Njjpfspy; Nkw;gb ePjpkd;wj;jpy; tprhuid Nkw;nfhs;sg;gl;ljpy; kDjhhu; rku;g;gpj;j mry; Mtzq;fs; jpUts;Su; ,iz ,af;Feu; kUj;Jtk; kw;Wk; fpuhkGwk; Rfhjhu mYtyfj;jpy; njhiye;J tpl;ljhy; kDjhuuplk; nghWg;Ngw;G fbjk; ngw;w kUj;Jt nrytPdj;jpw;fhd efy;fis Insurance epWtdj;jplk; rku;gpj;J kUj;Jt nrytPdj;jpid jpUk;g ngw toptif nra;AkhW njuptpf;fg;gl;lij njhlu;e;J ghu;it 7 y; fhZk; ,t;tYtyff; fbj vz; e.f.vz.21655-Mu;3-2020 ehs; 19.12.2022 d; gb kDjhuu; rku;gpf;Fk; Mtzq;fspd; mbg;gilapy; kUj;Jt nrytPdj; njhifapid tpLtpf;FkhW njuptpf;fg;gl;lJ. Mdhy; ,Jehs; tiuapy; jhq;fs; mYtyfj;jpypUe;J vt;tpj gjpYk; tug;ngwtpy;iy.
Thus it is evident from the above said letter that the originals were submitted to the 1st opposite party by the District Collector Office. In such circumstances the 1st opposite party cannot deny the receipt of the original bills. In the facts and circumstances we hold that the 1st opposite party receiving the original bills from the complainant and later denying the same amounts to clear deficiency in service. Due to the non availability of original bills the complainant could not get the medical remibursement. Thus we answer the point holding that the 1st opposite party had committed deficiency in service.
Point No.2:-
As we have held above that the original bills at present was with the 1st opposite party which aspect was proved by the complainant we direct the 1st opposite party to hand over the original bills to the complainant along with a nominal compensation of Rs.10,000/- for the mental agony and hardship suffered by the complainant. Further if the 1st opposite party could not trace out the original documents the 1st opposite party should direct the 2nd opposite party to honour the insurance claim of the complainant wife‘s medical expenses on production of the duplicate bills filed by the complainant.
In the result, the complaint is partly allowed against the 1st opposite party directing them
a) To hand over the original bills to the complainant within four weeks from the date of receipt of copy of this order or in alternative to direct the 2nd opposite party to honour the claim with the duplicate bills available with the complainant and the 2nd opposite party herein is directed to pay the claim to the complainant on production of the duplicate bills;
b) Directing the 1st opposite party 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) Directing the 1st opposite party to pay a sum of Rs.5,000/- (Rupees five 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 20th day of March 2023.
Sd/- Sd/-
MEMBER-II PRESIDENT
List of document filed by the complainant:-
Ex.A1 ................ New Health Insurance Scheme pensioners/Family pensioners Card. Xerox
Ex.A2 ............. Request letter made by the complainant to the District Collector, Thiruvallur District requesting to reimburse the medical expenses of Rs.42,520.30/-. Xerox
Ex.A3 24.07.2021 Request letter made by the complainant to Chief Minister of Tamil Nadu. Xerox
Ex.A4 29.11.2021 Letter from District Collector to the complainant. Xerox
Ex.A5 ............. The consideration made by the District Medical Board Xerox
Ex.A6 22.10.2021 Letter of United India Insurance Company Limited. Xerox
Ex.A7 29.11.2021 From Serial No.6 to 11 list. Xerox
Ex.A8 13.12.2021 Letter given by the complainant to the District Collector. Xerox
Ex.A9 02.02.2022 Legal notice issued by the complainant. Xerox
Ex.A10 .............. Letter issued by the 1st opposite party Xerox
Ex.A11 21.12.2022 Letter given by complainant to the 1st opposite party. Xerox
Ex.A12 26.12.2022 Letter issued by District Collector to Treasury Officer. Xerox
Ex.A13 12.01.2023 Letter issued by the 1st opposite party to the 2nd opposite party. Xerox
List of documents filed by the 2nd opposite party:-
Nil
Sd/- Sd/-
MEMBER-II PRESIDENT
