Tamil Nadu

North Chennai

217/2012

Mr Vijayan P - Complainant(s)

Versus

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

R Abdul Nubeen

29 Apr 2016

ORDER

 

 

                                                            Complaint presented on:  10.09.2012

                                                                Order pronounced on:  29.04.2016

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (NORTH)

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

 

PRESENT: THIRU.K.JAYABALAN, B.Sc., B.L.,        PRESIDENT

                    TMT.T.KALAIYARASI, B.A.B.L.,           MEMBER II

 

FRIDAY THE 29^th    DAY OF APRIL 2016

 

C.C.NO.217/2012

 

 

Mr.Vijayan P.,

S/o. N.Palani,

No.22, Mansion Sight Police Quarters,

Thousand Lights,

Chennai – 600 006.

                                                                             ..... Complainant

 

..Vs..

	Star Health and Allied Insurance Company Ltd., No.2A/64A, 4th Cross Street, Ganga Nagar Main Road, (Opp to BSNL Tel, Exchange) Kodambakkam, Chennai – 600 024.   Also at – No.8, 2nd floor, New Tank Street, Valluvar Kotam High Road, Nungambakkam, Chennai – 600 034.
	...Opposite Party     \

Date of complaint                                  : 28.09.2012

Counsel for Complainant                      :M/S. R.Abdul Mubeen

Counsel for   Opposite Party                    :N.Vijayaraghavan

 

O R D E R

 

BY PRESIDENT THIRU. K.JAYABALAN B.SC., B.L.,

          This complaint is filed by the complainant u/s 12 of the Consumer Protection Act.1986.

1. THE COMPLAINT IN BRIEF:

          The Complainant submits that the Complainant is a Government Employee in the rank of Inspector of Police with the Tamil Nadu Police. While so the Opposite Party had brought out a new Health Insurance Scheme for the government employee and their family members. The Complainant submits that the Complainant and his family members are therefore covered under the scheme and further are eligible for enhanced coverage up to Rs.2,00,000/-  for every 4 years period. The period of coverage of the said scheme is up to 10.06.2012. The Complainant’s wife was diagnosed by one of the approved network specialty hospital M/s. Prashanth Multi Specialty Hospitals with sub acute appendicitis and further the doctor of the said hospital advised surgery and hence immediately on 02.03.2012 the Laparoscopic Appendectomy and adhesiolysis form of surgery was held. The Complainant’s wife is a beneficiary under the said Health Insurance Scheme and the Complainant’s wife has been an in-patient in the hospital for the past   2 days from 01.03.2012 to 03.03.2012. The Complainant further submits that the Complainant had incurred expenses of about Rs.70,231/- towards hospital expenses and medical bills. The Complainant’s wife is a beneficiary and he is entitled for the Laparoscopic charges, medicine charges, doctor fees, room charges, diagnostic charges, dietary charges. The Complainant had to shell out the said amount from his personal savings. The Complainant had approached the Opposite Party to pay the said amount, since his family is an eligible beneficiary for the treatment in the listed hospital. Till date the Opposite Party have failed to keep up their promise under the scheme to the Complainant and without any  bonafide reason. The Complainant was put to severe mental agony as he had to clear the Hospital dues from his pocket by availing credit facility such act of the Opposite Party had led to serve trauma and stress to the Complainant. Apart from monetary loss the Complainant had to undergo mental agony irreparable loss and untold hardship, by such of the attitude of the Opposite Party and failure to entail the Complainant to benefit under Medical Insurance Scheme. The Complainant further submits that  by such of the acts of the Opposite Party as stated above, they have committed Deficiency in Service against the Complainant and thus the Opposite Party is liable to compensate the Complainant a sum of Rs.2,00,000/- together with repayment of the total sum of Rs.70,231/-  incurred by the Complainant towards Laparoscopic charges. Hence the Complaint is filed.

2.WRITTEN VERSION OF THE OPPOSITE PARTY IN BRIEF:

          The Tamil Nadu Government Employees New Health Insurance Scheme notified by the State Government is implemented by the Opposite Party as per the orders issued in GO Ms.No.174 Finance (Salaries) Department dated 28^th April 2008. The operation of the scheme is on cashless basis alone and no reimbursement is permissible. It is also a pre-requisite for the Complainant to produce the ID card or the certificate in lieu of the 10 card issued under the scheme before availing treatment in any net work hospital as per the provision of paragraph 5 of Annexure 1 of G.O.Ms.No.174 Finance (Salaries) Department in cashless manner. The Complainant made a claim with the Opposite Party as a beneficiary under the New Health Insurance Scheme for Government Employee implemented by this Opposite Party with reference to the orders issued in G.O.Ms.No.174 Finance (Salaries) Department for a sum of Rs.70,231/- towards the expenses for the treatment undergone by the Complainant’s  wife. The Complainant has not followed the procedure prescribed under the Scheme, particularly the production of ID card issued under the Scheme before availing treatment has not been followed and the Complainant’s wife has underwent treatment by paying  cash which is also not permitted. The Complainant has not furnished the ID number that would have been generated at the time of uploading the employee data by the pay drawing officer. The detail of the data in which it was uploaded has also not been furnished. In the absence of the ID number of the employee data, the Complainant cannot process the claim regarding the coverage or otherwise the Complainant and his family members for the benefits of the scheme. The Opposite Party received a legal notice dated 20.03.2012 from the Complainant’s counsel claiming a sum of Rs.70,231/- towards medical expense under the scheme. The Opposite Party immediately replied to the letter on 31.03.2012 wherein it has been accepted to examine claim subject to the rights under the scheme and also requested the Complainant’s counsel to advise the Complainant to furnish his unique identification number without which his claim cannot be processed. It was also specifically mentioned in the letter that in respect of Government Officials including the Complainant and their family members in respect of whom the unique identification number has not been generated, are not covered under for the benefits of the scheme. The Government by its letter No.15689/ Finance (Salaries)/2011-1 dated 25.03.2011 fixed 31.03.2011 as the last date for uploading on the designate website of the Treasuries and Accounts Department, the details of family members of those who were appointed prior to that date. Subsequently the Government refixed as 31.05.2011, as the last date for uploading the said employee data on the designated website vide Letter No.1218/FS/T/Finance (Salaries)   2011-2 dated 24.05.2011. Thus the officials and their family members in respect of whom the details of family members were not uploaded by the pay drawing officers concerned on the designated website before 31.05.2011 are not covered for the benefits under the Scheme. The claim for reimbursement of Rs.70,231/- towards medical expenses is not sustainable, since the scheme  is only on cashless basis and not on reimbursement basis. The Claim of Rs.2,00,000/- towards deficiency in service and sufferings etc and Rs.50,000/- towards litigation charges are all baseless and exaggerated and prays to dismiss the Complaint .

3. POINTS FOR CONSIDERATION:

          1. Whether there is deficiency in service on the part of the opposite parties?

          2. Whether the complainant is entitled to any relief? If so to what relief?

4. POINT:1

          The admitted facts are that the Complainant is a Government Employee in the Rank of Inspector of Police and he was insured New Health Insurance Scheme  for the Government Employees and his family members and he is eligible for coverage up to Rs.2,00,000/-. The Complainant’s wife was admitted in one of the network hospital M/s. Prashanth Multi Specialty Hospital for treatment for  treatment of  Appendicitis and on 02.03.2012  the Laparoscopic Appendectomy and adhesiolysis form of surgery was held and he was treated as inpatient for the period 01.03.2012 to 03.03.2012  during that time he incurred expenses of Rs.70,231/- towards hospital and for medicines. The  Complainant paid that amount   from his pocket and thereafter  the Complainant approached the Opposite Party to pay the said amount, since his family members are eligible for such treatment and however the Opposite Party rejected the claim.

          5. The Complainant wife M/s. Vijayalakshmi was admitted as in-patient   M/s. Prashanth Multi Specialty Hospital. Ex.A2 is the in-patient receipt issued to the Complainant and he paid an advance amount of Rs.25,000/-. Ex.A3 to Ex.A5 is the cash bills issued for the purchase of medicines, Ex.A6 is the final in-patient settlement bill and Ex.A8 discharge summary issued by the hospital. The Opposite Party did not dispute the treatment taken by the Complainant’s wife and however dispute that the Complainant is not entitled for the amount incurred by the Complainant for his wife.

          6. The Star Health Insurance Scheme was introduced with the object to give cashless treatment to the insured who are the Government Employees. The Complainant though paid the amount at the time of admitting his wife, he did not ask for cashless treatment by producing the Identity Card which was given for the cashless treatment. Since the Complainant paid the amount he is not entitled to get refund of the said amount of Rs.70,231/- as per the scheme of  the Opposite Party.

          7.  The Division Bench Judgment (Star Health and Allied Insurance Co.Ltd., rep. by its Project Officer Vs. A Chokkar and another) of the Madurai Bench of Madras High Court dated 26.02.2010, in the said judgment the Hon’ble High Court held in Para 28 as follows.  

Therefore, if the claimants have made 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 a network hospital, their only remedy is to approach the Government under the Rules. If, however, before they take treatment they are informed that a particular procedure is not covered, then at that stage, they may approach the Redressal Committee where the medical expert can decide whether that procedure is covered or not. The Redressal committee may also go into the complaints regarding non-availability of facility at a network hospital, which may be available in favour of the claimant when he applies under the Rules. Otherwise, we do not think that the Redressal committee can do much in any one of these cases, since all the petitioners/claimants before us would have made payments. But if there is a petitioner who has not settled the claim and has come before us, then, in the event, that it is for a procedure that is not covered, he may approach the Redressal Committee. In view of the fact that there are lacunae in the scheme, the Government shall not deny any claim validly made under the Rules only because the claimant is a member of the scheme.

This Judgment is followed by a single Judge of the Madras High Court rendered in WP No. 23762/2009 dated 30.03.2010 (G. Banumathy Vs. The General Manager, Star Health and Allied Insurance Co. Ltd., and  four others)  the Madras High Court has held that the payment have been made and treated for a covered procedure in a net work Hospital and the  only remedy is to approach the Government under the rules. Following the Division Bench Judgment of the High Court, Madras the Government issued letter dated 10.04.2012 that the claimants only remedy is approach the Government under rules. Considering the above referred Judgments of the Hon’ble High Court and letter of the Government that the complainant can be directed to approach the Government to make a claim in accordance with rules and in view of such conclusion the complaint is liable to be rejected as the Opposite Party has not committed any deficiency in service.

8. POINT:2

          Since the Opposite Party has not committed any deficiency in service, the complainant is not entitled for any relief in this complaint.

          In the result the complaint is dismissed with liberty to the complainant to approach the Government to make claim and get necessary orders in accordance with Division Bench Judgment of the Madras High Court and    the letter dated 10.04.2010 of the Government. There will be no order as to cost.

          Dictated to the Steno-Typist transcribed and typed by her corrected and pronounced by us on this 29^th day of April 2016.

 

MEMBER – II                                                               PRESIDENT

LIST OF DOCUMENTS FILED BY THE COMPLAINANT:

Ex.A1 dated 11.06.2008     To 10.06.2012	The Policy Book for the period
Ex.A2 dated 01.03.2012	In-Patient receipt for advance deposit
Ex.A3 dated 01.03.2012	Cash Bills Nos. 109338, 109621, 109449
Ex.A4 dated 02.03.2012	Cash Bills No. 109639, 109819, 109912
Ex.A5 dated 03.03.2012	Cash Bills Nos. 110002, 110043
Ex.A6 dated  03.03.2012	In-Patient Cash Bill for final settlement
Ex.A7 dated 03.03.2012	Receipt for Professional Service
Ex.A8 dated 03.03.2012	Discharge Summary
Ex.A9 dated 30.03.2012	Notice to Star Health Allied Insurance Co.Ltd.,
Ex.A10 dated 31.03.2012	Acknowledgement Due Card

                                     

LIST OF DOCUMENTS FILED BY THE OPPOSITE PARTY:

Ex.B1 dated 10.09.2007	G.o.Ms.No.430
Ex.B2 dated 21.04.2008	Agreement

Ex.B3 dated 28.04.2008                      G.O.Ms. No.174

Ex.B4 dated 11.06.2008                      Insurance Policy

Ex.B5 dated NIL                        New Health Insurance Scheme Rules, 2007

Ex.B6 dated 26.02.2010                      Order in W.A.No.480/2009 (2010 (2) LW 90)

Ex.B7 dated 30.03.2010                      Order in WP No.23762/2009

Ex.B8 dated 10.04.2010                      Letter of Special Secretary to Government

Ex.B9 dated 2.03.2011              Letter No. 15689/Fimamce Salaries/2011-1

Ex.B10 dated 24.05.2011                    Letter No. 15689/Fimamce Salaries/2011-2

Ex.B11 dated 30.03.2012                    Legal Notice from Complainant

Ex.B12 dated 31.03.2012                    Reply by Opposite Party

 

MEMBER – II                                                               PRESIDENT