Tamil Nadu

South Chennai

223/2010

P.Jayaprakash - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd.,Managing Director - Opp.Party(s)

C.Thamilarasan

11 Sep 2018

ORDER

                                                                        Date of Filing  : 05.05.2010

                                                                          Date of Order : 11.09.2018

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (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

 

C.C. No.223 /2010

DATED THIS MONDAY THE 11^TH DAY OF SEPTEMBER 2018

                                 

P. Jayapraksh,

S/o. Mr. Palaniyandi,

No.65, Muthu Vinayagar Street,

Police Quarters,

Thiruvannamalai.                                                       .. Complainant.                                                       

 

     ..Versus..

 

STAR HEALTH AND ALLIED INSURANCE CO. LTD.,                                         Represented by its Managing Director,

No.2 A, Ganga Nagar Main Road,

Kodambakkam,

Chennai – 600 024.                                                  ..  Opposite party.

          

Counsel for complainant      :  M/s. C. Thamilarasan

Counsel for opposite party  :  M/s. N. Vijayaraghavan & 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 praying to refund a sum of Rs.2,01,527/- paid by the complainant to the MIOT Hospital and to pay a sum of Rs.10,00,000/- towards compensation for mental agony with cost to the complainant.

 

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

The complainant submits that he is a Government Servant working as a Sub-Inspector of Police having the benefit of Tamil Nadu Employees New Health Insurance Scheme vide ID No.TVM/01 PC 301/1402981 issued by the opposite party.  On 10.12.2009, the complainant was admitted in MIOT Hospital for treatment of Right Hernio Plasty.  After due operation, the complainant was discharged on 24.12.2009.  Further the complainant submits that when he was admitted in the hospital for treatment, he had shown the ID card.  But the hospital authorities not considered the ID card and refused to extend the  cashless treatment.  The representative of the opposite party stationed in the hospital also did not come forward to help the complainant for due cashless treatment.  Further the complainant submits that once again, the complainant was admitted in the said hospital on 26.12.2009 since he had a stroke and was inpatient till 18.01.2010.  At that time also, the complainant requested both the hospital authorities and opposite party for cashless treatment which was refused.  Hence the complainant paid a total sum of Rs.2,01,527/- towards medical expenses.  Further the complainant submits that as per the scheme in Rule 9 (d) the insurance company shall ensure that the beneficiaries are treated free of cost i.e. cashless treatment as per the list of surgeries annexed to the rule.   Further the complainant submits that he is entitled to have a cashless treatment upto the limit of Rs.2,00,000/- in any hospital muchless, the network / approved hospitals.  Since the opposite party refused to extend cashless treatment, the complainant was constrained to pay the medical expenses for a sum of Rs.2,01,527/- and requested for claim form for claiming such amount.  The opposite party refused to issue claim form also.  Hence the complainant was constrained to issue legal notice dated:13.03.2010 for which, the opposite party sent a reply dated:30.03.2010.   The act of the opposite party caused great mental agony.  Hence, the complaint is filed.

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

The opposite party specifically denies each and every allegation made in the complaint and puts the complainant to strict proof of the same.   The opposite party states that the Tamil Nadu Government have floated a New Insurance Scheme on 01.06.2008 by entering into a contract of insurance with the opposite party for specified 13 diseased and for treatments to be availed in network / approved hospitals identified from time to time.  The Tamil Nadu Government also has introduced the New Health Insurance Scheme on cashless basis in order to ensure that no employee was required to pay medical expenses and they can simply get admitted in the network hospitals for covered illness and get treated.  The opposite party would pay the amount directly to the hospital to the tune of Rs.2,00,000/- for one block of 4 years period.  The state of Tamil Nadu in its letter No.62991 Finance (Salaries) Department dated:11.10.2008, widely circulated to all the Government servants and benefited under the insurance scheme that the scheme was envisaged under cashless basis alone and that the employee did not have to or were prevented from making any payment to the hospitals.  The network hospitals alone has to lodge the claim on the insurer and get the sum reimbursed directly.  The complainant sought reimburse of medical expenses incurred was not maintainable as per the specific G.O.M.S No.174 and instructions and letter dated:11.10.2008 of the Government of Tamil Nadu and as such the question of maintaining this complaint does not and cannot arise at all.  The employee’s claim is hit by this lack of cashless basis on the face of it and therefore, liable to be dismissed in limine.  The insurer has promptly replied to the legal notice of the complainant by its reply letter dated:30.03.2010.  It is therefore obvious that the claim has already been considered on merits and found inadmissible as being on reimbursement basis which is not tenable also and therefore rejected.  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.A11 are marked.  Proof affidavit of the opposite party is filed and documents Ex.B1 to Ex.B13 are  filed and 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.2,01,527/- paid towards medical expenses as prayed for?
2. Whether the complainant is entitled to a sum of Rs.10,00,000/- towards compensation for mental agony with cost as prayed for?

5.      On point:-

Both parties filed their respective written arguments.  Perused the records namely the complaint, written version, proof affidavits, documents etc.  Admittedly, the complainant is a Government Servant working as Sub-Inspector of Police having the benefit of Tamil Nadu Employees New Health Insurance Scheme vide ID No.TVM/01 PC 301/1402981 issued by the opposite party as per Ex.A9.   The complainant pleaded and contended that on 10.12.2009, the complainant was admitted in MIOT Hospital for treatment of his Right Hernio Plasty.  After due operation, the complainant was discharged on 24.12.2009.  Ex.A2 is the Discharge Summary.   Further the complainant contended that when he was admitted in the hospital for treatment, he had shown his ID card.  But the hospital authorities not considered the ID card and refused to extend the  cashless treatment.  The representative of the opposite party stationed in the said hospital also did not come forward to help the complainant for due cashless treatment.   Hence the complainant was constrained to pay the medical expenses against the benefit under the Tamil Nadu Employees New Health Insurance Scheme.

6.  Further the contention of the complainant is that once again, the complainant was compelled to admit in the said hospital on 26.12.2009, since he had a stroke and was inpatient till 18.01.2010.  Ex.A4 is the Discharge Summary.   At that time also, the complainant requested both the hospital authorities and opposite party for cashless treatment which was refused by both the hospital authorities and the opposite party.  Hence the complainant was constrained to pay a total sum of Rs.2,01,527/- towards medical expenses as per Ex.A3 & Ex.A5.  the surgery and treatment of the complainant comes under the caption of V. Neurology (5) “Management of Cerebro-vascular accident (Stroke) and XIII. General other Surgeries (2) I “Surgeries (2) for various Hernias”.  Hence the opposite party shall indemnify the loss suffered by the complainant due to the negligence of both hospital authorities and the opposite party.   Further the contention of the complainant is that as per the scheme in Rule 9 (d) the Insurance Company shall ensure that the beneficiaries shall be treated free of cost i.e. cashless treatment as per the list of surgeries annexed to the rules.   In this case, the complainant was denied such benefits.  Further the contention of the complainant is that he is entitled to have a cashless treatment upto the limit of Rs.2,00,000/- in any hospital muchless, the network / approved hospitals.  Since the opposite party refused to extend the cashless treatment, the complainant was constrained to pay the medical expenses for a sum of Rs.2,01,527/- and requested the opposite party for due submission of the claim form for claiming such medical expenses.  The opposite party refused to issue claim form also without any reason.  Hence the complainant was constrained to issue legal notice as per Ex.A6 for which the opposite party sent a reply as per Ex.A8 with untenable contentions.  So, this complaint is filed for claiming medical expenses and compensation for such mental agony and  deficiency in service.

7.     The contention of the opposite party is that the Tamil Nadu Government have floated a New Insurance Scheme on 01.06.2008 by entering into a contract of insurance with the opposite party for specified 13 diseased and for treatments to be availed in network / approved hospitals identified from time to time.  The Tamil Nadu Government also has introduced the New Health Insurance Scheme on cashless basis in order to ensure that no employee was required to pay medical expenses and they can simply get admitted in the network hospitals for covered illness and get treated.  The opposite party would pay the amount directly to the hospital to the tune of Rs.2,00,000/- for one block of 4 years period.  The state of Tamil Nadu in its letter NO.62991 Finance (Salaries) Department dated:11.10.2008, widely circulated to all the Government servants and benefited under the insurance scheme that the scheme was envisaged under cashless basis alone and that the employee did not have to or were prevented from making any payment to the hospitals.  The network hospitals alone has to lodge the claim on the insurer and get the sum reimbursed directly.  In this case, the complainant filed this complaint for reimbursement of medical expenses incurred was not maintainable as per the specific G.O.M.S No.174 and instructions as per Ex.B11 and letter dated:11.10.2008 of the Government of Tamil Nadu as per Ex.B12.  But the opposite party has not denied that the complainant while admitted for treatment shown the ID card for due benefits under the New Health Insurance Scheme which was refused by both hospital and opposite party.

8.     The learned Counsel of the opposite party cited the decision reported in:

2010 (2) Law Weekly 90 (Mad) (DB)

Held that

“Issues raised in Writ Petitions were as to the extent to which the Insurance Company will be bound to indemnify the claims made by the beneficiaries; whether the Insurance Company and the beneficiaries were bound strictly by the terms of the contract; etc. – Held: In this case, we are faced with a claim that should be decided against the terms and conditions of the contract – Relationship of Insurance Company  with the claimant is purely contractual – covered by the Scheme – Insurance Company is strictly bound to satisfy the claims if they arise out of the procedures / treatments that are listed and if the beneficiaries are treated in Network Hospitals and not otherwise”.

9.     Further the contention of the opposite party is that in order to reimburse the amount paid towards medical expenses the complainant has to approach the Government alone and which are cited as follows:

IN THE TAMIL NADU STATE CONSUMER DISPUTES REDRESSAL COMMMISSION, MADURAI BENCH

F.A. No.288/2012 in C.C. No.154/2010

Between

Star Health and Allied Insurance Company Limited and another

-Versus-

T. Dharmarajan

Held that

“The opposite parties repudiated the claim by staging that the diseases for the treatment undergone by the complainant for the diseases of Ileal Telangiectasia and not due to any form of ulcer as alleged in the complaint and biopsy report to resected ileal segment shows no evidence of malignancy or ulcer bit only...”.

and

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, MADURAI BENCH

F.A. No.289/2012 in C.C. No.26/2011

Between

The MANAGER, Star Health and Allied Insurance Company Limited

-Versus-

Dr. S. Thilagar, Asst. Professor of Medicine and another

Held that

          “.. 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 the District Forum of the complaint in C.C. No.26/2011 dated:14.10.2011  by the District Forum, Kanyakumari District at Nagercoil”.

and

IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI

F.A. No.814/2010 in C.C. No.05/2010

Between

The Co-ordinator, Star Health & Allied Insurance Co. Ltd.

-Versus-

M. Pusparaj and another

Held that

“.. payments 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 network hospital, their only remedy is to approach the Government under the Rules”.

The Counsel for the complainant submitted that in emergency situation one cannot approach a particular hospital to get medical treatment.  The opposite party cannot escape from their liability by just pointing out the condition in the policy.  Medical reimbursement should not be denied on the ground that the complainant failed to get treatment in Network Hospital.   

10.    The complainant cited the decision held in:

1996 AIR 1388, 1996 SCC (2) 336

Between

Surjit Singh

-Versus-

State of Punjab and others

Held that

“In such an urgency one cannot sit at home and think in a cool and calm atmosphere for getting medical treatment at a particular hospital or wait for admission in some Government Medical Institute.  In such a situation, decision has to be taken forthwith by the person or his attendants if precious life has to be saved”.

and

The Madurai Bench of Madras High Court

in

N. Chidambaram

-Versus-

The Secretary, Dindigul Market Committee

 

Held that

          “(2007 (3) MLJ 385), held that medical reimbursement should not be denied on the ground that the petitioner failed to undergo heart surgery in the hospital recognised by Government of Tamil Nadu”.

11.    Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite party committed deficiency in service by refusing to extend the benefit under the New Health Insurance Scheme.  Hence the complainant is entitled for reimbursement of medical expenses.   Though the complainant produced the medical bills to the tune of Rs.2,01,596/-, he is entitled to claim only Rs.2,00,000/- as per Ex.B11 Government G.O. Hence this Forum is of the considered view that, the complainant is entitled a sum of Rs.2,00,000/- towards medical expenses and a compensation of Rs.15,000/- with cost of Rs.5,000/-.

In the result, this complaint is allowed in part. The opposite party is directed to pay a sum of Rs.2,00,000/- (Rupees Two lakhs only) towards medical expenses and to pay a sum of Rs.15,000/- (Rupees Fifteen thousand only) towards compensation for mental agony with cost of Rs.5,000/- (Rupees Five 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 Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 11^th day of September 2018. 

 

MEMBER –I                                                                      PRESIDENT

COMPLAINANT SIDE DOCUMENTS:

Ex.A1	17.11.2009	Copy of Discharge Summary
Ex.A2	10.12.2009	Copy of Discharge Summary
Ex.A3	09.11.2009 to 24.12.2009	Copy of Medical bills
Ex.A4	26.12.2009	Copy of Discharge Summary
Ex.A5	26.12.2009 to 08.01.2010	Copy of medical bills
Ex.A6	13.03.2010	Copy of legal notice issued by the complainant to the opposite party
Ex.A7	16.03.2010	Copy of acknowledgment card
Ex.A8	30.03.2010	Copy of reply letter by the opposite party
Ex.A9		Copy of Health Insurance ID card
Ex.A10		Copy of Brochure
Ex.A11		Copy of complaint

 

OPPOSITE  PARTY SIDE DOCUMENTS:  

Ex.B1		Copy of TN Medical Attendance Rules
Ex.B2	17.06.1980	Copy of GOMS No.1023
Ex.B3	09.01.1992	Copy of GOMS No.18
Ex.B4	16.03.1993	Copy of GOMS No.194
Ex.B5	29.08.2000	Copy of GOMS No.400
Ex.B6	28.09.2001	Copy of GOMS No.383
Ex.B7	02.01.2007	Copy of GOMS No.1
Ex.B8	18.01.2007	Copy of GOMS No.19
Ex.B9	10.09.2007	Copy of GOMS No.430
Ex.B10		Copy of New Health Insurance Scheme Rules, 2007
Ex.B11	28.04.2008	Copy of GOMS No.174
Ex.B12	11.10.2008	Copy of letter of TN Government
Ex.B13	26.02.2010	Copy of 2010 (2) LW 90

 

                                                         

MEMBER –I                                                                      PRESIDENT