Tamil Nadu

South Chennai

CC/85/2022

V. Nandha Gopalan - Complainant(s)

Versus

The General Manage United India Insurance and 5 others - Opp.Party(s)

T. R. Kumaravel

15 Jun 2023

ORDER

  Date of Complaint Filed:11.04.2022

  Date of Reservation     :07.06.2023

  Date of Order              :15.06.2023

          DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT: TMT. B. JIJAA, M.L.,                                              : PRESIDENT

                    THIRU. T.R. SIVAKUMHAR, B.A., B.L.,              :  MEMBER  I 

                    THIRU. S. NANDAGOPALAN., B.Sc., MBA.,       : MEMBER II

               

CONSUMER COMPLAINT No.85/2022

THURSDAY,THE 15^th DAY OF JUNE 2023

                                                       

Mr. V. Nandha Gopalan,

S/o. Venkatesan Superindent,

Block Education Office,

Cheyyar Taluk-604 407,

Residing at No. 1/17, Bajanai Kovil Street,

Perumbalai Village & Post,

Cheyyar Taluk-604 401.                                                  .. Complainant

 

-Vs-

 

1.The General Manager/Manager,

   United India Insurance Co. Ltd.,

   Divisional Office: 010600,

   5^th Floor, PLA Rathna Tower,

   (Near Aananth Theatre),

   Mount Road, No. 212,

   Anna Salai, Chennai-600 006.

 

2.The Sub-Treasury Officer,

   Cheyyar Sub-Treasury

   Cheyyar-604 407.

 

3.The Treasury Officer.

   Thiruvannamalai District Treasury,

   Thiruvannamalai.

 

4.The Principal Secretary to Government,

   Represented by Finance Department,

   Secretariat, Chennai-600009.

 

 

 

5.The Joint Director of Medical and Rural Health Department,

   Thiruvannamalai District,

   Thiruvannamalai

 

6.The Director of Medical and Rural Health Department,

   DMS Compound, Teynampet,

   Chennai-600 006.                                               .. Opposite Parties.

* * * * *

 

Counsel for the Complainant      : M/s. T.R. Kumaravel

 

Counsel for 1^st Opposite Party    : M/s. P. Sankaranarayanan

 

Counsel for 2 to 6 Opp. Parties   : M/s. R Ravi Chandran

 

On perusal of records and upon hearing the oral arguments of the counsel for Complainant and the written arguments as oral arguments on endorsement made by the Counsel for the Opposite Parties 2 to 6, this Commission delivered the following:

 

ORDER

Pronounced by Member-I, Thiru. T.R. Sivakumhar., B.A., B.L.,

(i)     The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to pay a sum of Rs.1,00,000/- for the deficiency in service and to pay a sum of Rs.1,00,000/- for the unfair trade practice and to pay a sum of Rs.1,00,000/- for the mental agony along with cost of Rs.25,000/-.

I.  The averments of Complaint in brief are as follows:-

1.     The Complainant submitted that he is currently working in the Regional Education Office in Cheiyar Taluk and he was given the ID card bearing No.TVM/01/SB561/NH1S16/2539094through the Medical Insurance Scheme in The Taluk New Health Insurance Scheme 2016 (NHIS) introduced by the Government of Tamil Nadu as per G 0. Ms. No. 202, Dated 30.06.2016. An amount of Rs. 180/- per month is deducted from the Complainant's salary and paid as insurance premium amount to United India Insurance Co. Ltd. Through this scheme he is eligible to take treatment for an amount of Rs.4,00,000/-. As he is suffering from diabetes, he was taking treatment for the same.

2.     The Complainant submitted that he had a large spread ulcer on big toe in his right leg, hence he went to Sri Ramachandra Hospital situated in Porur, Chennai-600116, for treatment of the said problem. The doctors who then examined his leg told him that if he did not remove the big toe of his  right foot and the next toe, it would spread further and will end up in the situation to remove the entire right foot. On hearing the same he was very much shocked and agreed to remove both the big toe and next toe in his right foot.

3.    The Complainant submitted that he got admitted in Sri Ramachandra Hospital on 14.06.2019 as an inpatient for surgical removal of both fingers. After completion of the said treatment he was discharged from the hospital on 20.06.2019.

4.     The Complainant submitted that the medical cost of the above said surgery is Rs.1,95,917.71p and he was asked to pay the said medical bill amount by Sri Ramachandra Hospital management, for which he gave his ID card issued to him under Medical Insurance Scheme in The New Health Insurance Scheme 2016 (NHIS) introduced by the Government of Tamil Nadu, on which Sri Ramachandra Hospital Management was paid only a sum of Rs 98,499-71/- that was approved by the United India Insurance Co. Ltd. under the said medical insurance scheme and the balance amount of Rs.97,418/- has to be paid by the Complainant. The said Sri Ramachandra Hospital management urged him to pay the balance amount of Rs. 97,418/-.

5.     The Complainant submitted that he informed Sri Ramachandra Hospital management that the Government of Tamil Nadu has stated in the New Health Insurance Scheme 2016 (NHIS) that the Complainant is eligible up to Rs.4,00,000/- for the treatment under the medical insurance. For that the Hospital management replied that they did not know the same and only a sum of Rs. 98,499-71p was approved by the United India Insurance Co. Ltd., and hence the Complainant has been urged to pay the balance amount of Rs. 97,418/-. As he did not know what to do in this situation and his son and daughter paid the balance amount of Rs. 97,418/- to Sri Ramachandra Hospital management through credit card.

6.     The Complainant submitted that he was advised by the doctors to come after 5 days for an examination of his right leg. Accordingly after 5 days he also went to Sri Ramachandra Hospital on 25.06.2019. The doctors who examined his right leg and told that his right leg was further affected and that if he did not remove the right leg up to the lower part of the knee, it would spread further and take over the entire right leg. Shocked by what the doctors said, he had agreed to have his right leg amputated up to the lower part of the knee. Thereafter he got admitted in Sri Ramachandra Hospital as an inpatient for surgical for removal of his right leg up to the lower part of the knee. After completion of his treatment he was discharged from the hospital on 12.07.2019.

7.     The Complainant submitted that the medical cost of the above said surgery is Rs. 214,921.26p. Here again when the hospital management asked him to pay the medical bill amount, he had given his ID Card issued to him under the said Medical Insurance Scheme, on which only Rs.1,12,500/- was paid to Sri Ramachandra Hospital Management that was approved by the United India Insurance Co. Ltd., under the medical insurance scheme and he was asked to pay the balance amount of Rs. 1,02,421/-. Here again he had informed to Sri Ramachandra Hospital management about his eligibility for taking treatment is up to Rs.4,00,000/- which was not accepted by the said Hospital and urged him to pay the balance amount of Rs. 1,02,421-00/-and his son and daughter paid the said balance amount with their credit card to Sri Ramachandra management.

8.     The Complainant submitted that he had paid a total sum of Rs.1,99,839/- (Rs. 97,418/-& Rs.1,02,421/-) to Sri Ramachandra Hospital. Hemet the manager of the 1^st Opposite Party about the payment made for his treatment which is against the eligibility of Rs.4,00,000/- as a Government servant under the New Health Insurance Scheme 2016 (NHIS) introduced by Government of Tamil Nadu as per G. O. Ms. No. 202, Dated 30-06-2016, whereas as against the total bills of Rs. 4,10,839/-(Rs. 1,95,917-71+ Rs. 2,14,921-26) for his two medical treatments taken at Sri Ramachandra Hospital, only a sum of Rs. 2,11,000/-(Rs.98,499-71p + Rs.1,12,500/-) was approved by the medical insurance scheme for the two medical treatments and the Balance amount of Rs. 1,99,839/- (Rs.97,418/- + Rs.1,02,421/-) was paid by him. And requested the Manager of the 1^st Opposite Party to reimburse the balance amount of Rs.1,89,000/- after deducting Rs.10,839/-, for which the manager also promised him that he will take necessary action. But till date the 1^st Opposite Party have not taken any steps and the above said amount was not reimbursed to him, which clearly shows the deficiency in service and unfair trade practice of the 1^st Opposite Party.

9.     The Complainant submitted that he sent the Legal Notice on 09.07.2020 to the Opposite Parties 1 to 6, in spite of receipt of the said Legal Notice there was no reply from the Opposite Parties 1 to 6. Due to the deficiency in service and unfair trade practice of the 1^st Opposite Party the Complainant is in great loss and suffering from great mental agony. Hence the Complaint

II. Written Version filed by the 1^st Opposite Party in brief is as follows:

10.    The 1^st Opposite Party submitted that they deny all the allegations and averments made by the Complainant in his complaint and puts the Complainant to strict proof of the same. The Fact that the Complainant is suffering from Diabetes and taking treatment for the same is not known to them.

11.    The 1^st Opposite Party submitted that the Complainant Mr. Nandagopalan was admitted in Sri Ramachandra Hospital, Chennai from 04.06.2019 20.06.2019, he was diagnosed with great toe gangrene. The said hospital has raised a cashless request to the Third Party administrator of the 1^st Opposite Party i.e MD India Health Insurance TPA Pvt. Ltd., vide CC No.MDI0167360. The said request was approved for a sum of Rs.98,500/- which included RAY amputation Rs.50,000/-, SR Medical Pharmacy Rs.9,700/-, SR Surgical Pharmacy Rs.36,060/-, ECG Rs.440 and ECHO Rs.2,300/-.

12.    The 1^st Opposite Party submitted that the Complainant Mr. Nandagopalan was again admitted in Sri Ramachandra Hospital, Chennai from 25.06.2019 to 12.07.2019 wherein he was diagnosed with diabetic foot ulcer. The said hospital had again raised a cashless request to the Third Party administrator of the 1^st Opposite Party 1.e, MD India Health Insurance TPA Pvt. Ltd., vide CC No.MDI0169378. The said request was approved for a sum of Rs.1,12,500/- which included General surgery Rs.47,000/-, SR Theater Pharmacy Rs.16,449/-, SR Medical Pharmacy Rs.12,364/ SR Surgical Pharmacy Rs.22,442/-, Circumcision Rs.2,250/-, Biochemistry Rs.4,640/-, clinical pathology Rs.5,395/-, Microbiology Rs.1,280/-, ECG Rs.220 and X Ray 460/-.

13.    The 1^st Opposite Party submitted the above two claims for cashless request were processed for approval as per the coverage and terms and conditions of G.0.202 dated 30.06.2016 issued by the Finance (Salary) Department, Tamilnadu. As such both the above claims for preauthorization had totalled a sum of Rs.2,11,000/-.

14.    The 1^st Opposite Party submitted that the said scheme is a cashless scheme and the beneficiaries under the scheme need not pay any amount over and above the amount approved during the pre authorization request. As such no amount is payable by the Complainant to the hospital either at the time of admission or at the time of discharge. The Complainant being a Government Servant and knowing fully well that the scheme being a cashless scheme and that no amount is payable by the Complainant to the Hospital as made the payment in excesses of the amount approved by the Third Party Administrator of the Complainant. As such the same is not binding on the 1^st Opposite Party.

15.    The 1^st Opposite Party submitted that it is true in GO.MS. 202 dated 30.06.2016 and the maximum eligible amount for treatment of the petitioner is Rs.4,00,000/- only as per G.O.No.202.

16.    The 1^st Opposite Party submitted that they are not bound and liable to repay the balance amount of Rs.1,02,421/- to the Complainant and submits that in view of the above denial of averments, the scheme being a cashless scheme they are not bound and liable to repay the said sum.

17.  The 1^st Opposite Party submitted that there is no cause of action that survives the above complaint and as such the Complainant is not entitled to any sum from the said hospital. Hence prayed to dismiss the above complaint with exemplary cost.

III. Written Version filed by the 4^th Opposite Party and the same was adopted by 2^nd, 3^rd, 5^th and 6^th Opposite Parties:

18.    The 4^th Opposite Party submitted that all the material allegations made in the complaint are false and frivolous and the complaint is neither maintainable on facts nor in law against this Opposite Party,

19.    The 4^th Opposite Party submitted that the Complainant is to be dismissed against this Opposite Party on the ground that there is no consumer and service provider relationship between the Complainant and this Opposite Party. The 4^thOpposite Party submits that he is discharging duties as the Principal Secretary to Government, Finance Department (Now, Additional Chief Secretary to Government, Finance Department) as provided in the statute and had done all duties without any default or deficiency. It is further submitted that service was provided to him and also submits that no any consideration was paid by the Complainant to this Opposite Party and hence, the Complainant cannot invoke the provisions of the Consumer Protection Act.

20.    The 4^th Opposite Party submitted that the contention raised by the Complainant related to the service particulars enrolment of the Complainant under the New Health Insurance Scheme recovery of the premium under the Scheme etc., for which the Complainant is put to the strict proof of the same.

21.    The 4^th Opposite Party submitted that the Complainant stated that he was suffering from large spread ulcer on big toe and hence he was admitted in Sri Ramachandra Hospital situated in Porur, Chennai on 14.06.2019 as in patient for surgical removal of both fingers. The Complainant further stated that after the surgery was over, he was discharged from the Hospital on 20.06.2019. The Complainant further stated that for the above said treatment the Hospital has charged a sum of Rs.1,95,917.71/- When the Hospital authority demanded the payment from the Complainant, the Complainant has informed the Hospital that he is covered under the Tamil Nadu New Health Insurance Scheme and hence requested to get the amount from the Insurance Company.

22.    It is further submitted that the Hospital had informed the Complainant that the Insurance Company has paid a sum of Rs.98,499.71/- and demanded the Complainant to pay the balance amount of Rs.97,418/- The Complainant has stated that the balance amount has been paid by him through his son and daughter. The Complainant has further stated that though he had informed to the Hospital that he is eligible for entire charged amount under the Insurance Scheme, but the Insurance Company has paid the above said amount of Rs.98,499.71/- only. The contention of the Complainant is not correct. The Insurance Company/TPA is the assessing authority and hence the Complainant has to be paid the balance amount apart from the eligible amount for the instant treatment.

23.    The 4^th Opposite Party further submitted that the Complainant has further stated that the hospital authority has informed to come after 5 days for examination and accordingly the Complainant went to the hospital and on examination of his legs the hospital authority had informed him that he has to remove his lower part of the right leg, since the same has also been affected. The Complainant has also agreed for the operation. For this operation / treatment, the hospital again charged Rs.2,14,921.26/. For the said amount the Insurance Company has paid only Rs.1,12,500/-. The Complainant has further stated that again the hospital had demanded the Complainant to pay the balance amount of Rs.1,02,421/-. The Complainant stated that he managed to pay the amount again through his daughter and son. In this connection it is submitted that the Complainant has been paid the eligible amount by the Insurance Company

24.    It is submitted that the 1^st Opposite Party in their letter dated: 31.05.2022 has stated that the patient Mr.V.Nanda Gopalan, the Complainant herein was admitted in Sri Ramachandra Hospital, Chennai from 14.06.2019 to 20.06.2019 with the diagnosis of Great Toe Gangrene against CCN No.MDI0167360. TPA has received cashless request from the hospital and they have approved the amount of Rs.98,500/- for the covered illness and break up details are given below:

Ra Amputation            -  Rs 50,000.00

SR Medical Pharmacy   -  Rs. 9,700.00

SR Surgical Pharmacy  -  Rs.36,060.00

ECG                           -  Rs.    440,00

Echo                          - Rs.   2,300.00

Total                         - Rs. 98,500,00

Subsequently, Mr.V.Nandha Gopalan, the Complainant herein was admitted in Sri Ramachandra Hospital from 25.06.2019 to 12.07.2019 with the diagnosis of Diabetic Foot Ulcer against CCN No.MD10169378. TPA has received pe authorization documents from the hospital and they have approved an amount of Rs.1,12,500/- for the covered illness and breakup details are given below;

General Surgery          - Rs. 47,000.00

SR Theatre Pharmacy  - Rs. 16,449.00

SR Medical Pharmacy   - Rs. 12,364.00

SR Surgical Pharmacy  - Rs. 22,442.00

Circumcision               - Rs.   2,250.00

Bio Chemistry             - Rs.   4,640.00

Clinical Pathology -         Rs.   5,395.00

Microbiology               - Rs.   1,280.00

ECG                           - Rs.      220.00

X Rays                       - Rs.      460.00

Total                         - Rs.1,12,500.00

The above approval is processed as per the coverage and terms and conditions of G.O.Ms.No.202 Dated 30.06.2016 issued by Finance (Salaries) Department, Government of Tamil Nadu. Total eligible amount comes to Rs.2,11,000/-.

25.    In this connection, it is submitted that the Insurance Schemes (For Employee/Pensioner) have been designed as Cashless Schemes, under which a Government servant or Pensioner/Family Pensioner and his/her spouse can undergo specified list of medical procedures and surgeries in empanelled hospitals (referred to as network hospitals to signify hospitals included in the Insurance coverage network) after obtaining the pre-authorization of the Insurance company, without having to make any payment to the hospital in cash. However, in the said Insurance Schemes it is explicitly stated that the benefit of cashless treatment would not cover unlisted medical procedures, surgeries and treatments undergone in network or non-network hospitals or listed treatments and surgeries undergone in non-network hospitals. In the said Insurance Schemes there is no provision for reimbursement of any medical expenses and cashless treatment alone is permitted. However, in case the network hospitals charged the subscriber for undergoing any of the approved treatment or surgeries, a mechanism for making complaints to District and State Redressal Committees was made in the said Insurance Schemes itself, so that if such instances were proved, the Insurance Company will reimburse such payments to the subscribers and in turn the Insurance Company could recover the same from the network hospitals under their bilateral agreements with the network hospitals.

26.    It is further submitted that the implementation of the Tamil Nadu New Health Insurance Scheme is entrusted to the United India Insurance Company/TPA. The Insurance Company in turn entered into agreement with the approved hospital and giving the CASHLESS treatment. The Complainant's case has also been entertained by the Insurance Company and the above said eligible amount stated above has been paid by the Insurance Company

27.    It is further submitted that the Complainant herein has not preferred any appeal to the District Level Empowered Committee if he is not satisfied with the act of the United India Insurance Company Limited, or the amount sanctioned to him, as per the provisions of the Insurance Scheme. Even if the Complainant has not received any satisfactory orders from said committee then he has the chances of appealing the said order in the State Level Empowered Committee/ High Level Empowered Committee in the hierarchy manner to get redressal of his grievances. But, without exhausting the appeal remedies available the Complainant has straight away approached this Hon'ble Commission for getting redressal of the grievances. Thus the Complainant has not exhausted the appeal remedy available under the Insurance Scheme. If any dispute arises in availing the medical reimbursement claim under the Tamil Nadu New Health Insurance Scheme, the grievances should be resolved under the suitable appeal mechanism. Further for an approved treatment / surgery undertaken in a Network hospital, either a part of the claim or no claim has been settled by the Insurance Company the petitioner can very well make an appeal before the District Level Empowered Committee and appeal before State Level Empowered Committee as provided under the scheme and clarified vide Finance DepartmentD.O.LetterNo.37012/Finance (Salaries)/2019-1, dated: 01.11.2019. The Complainant herein has not at all followed any of the systematic procedure but made a complaint before this Hon'ble Commission for getting redressal of his grievances. Hence the case of the Complainant before this Commission deserves no merit. Hence prayed to dismiss the complaint with exemplary costs.

IV.    The Complainant has filed his proof affidavit and Written Arguments,  in support of his claim in the complaint has filed documents which are marked as Ex.A1 to A9. The 1^st Opposite Party filed its Proof Affidavit and Written Arguments, document Ex.B-4 was marked on the side of the 1^st Opposite Party. The 4^th Opposite Party filed their Proof Affidavit and Written Arguments and the same was adopted by 2^nd, 3^rd, 5^th and 6^th Opposite Parties, documents Ex.B-1 to B-3 were marked on the side of the 4^th Opposite Party.

 

 

V. Points for Consideration:-

1. Whether there is deficiency in service on the Part of the Opposite Parties 1 to 6?

2. Whether the Complainant is entitled for the reliefs claimed in the complaint?

3. Whether the Complainant is entitled for any other relief/s?

POINT NO. 1 :-

28.    It is an undisputed that the Complainant is a Government Servant and as per GO.MS. 202 dated 30.06.2016 the New Health Insurance Scheme was implemented by the Government of Tamil Nadu through the 1^st Opposite Party, as an insurer, and the maximum eligible amount for treatment of the Complainant and his family members under the New Health Insurance Scheme is Rs.4,00,000/-. It is also not in dispute that the Complainant has taken treatment twice at Sri Ramachandra Hospital for his Right Toe Gangrene.

29.    The Contentions of the Complainant are that though he was eligible for medical treatment up to Rs.4,00,000/- as a Government Servant under the Insurance Scheme introduced by the Government of Tamil Nadu as per GO.MS. 202 dated 30.06.2016, the 1^st Opposite Party as the Insurer had settled only a sum of Rs.98,499.71p as against the total medical bill of Rs.1,95,917.71p for the surgery of removal of right toe which was done on 15.06.2019 at Sri Ramachandra Hospital and he was made to pay the balance sum of Rs.97,418/- to the said Hospital. Further for the surgery of removal of right leg up to lower part of the knee done was on 28.06.2019 at Sri Ramachandra Hospital, the 1^st Opposite Party as the Insurer had settled only a sum of Rs.1,12,500/- as against the total medical bill of Rs.2,14,921.26p and he was made to pay the balance sum of Rs.1,02,421/- to the said Hospital. Further contended that he had met the manager of the 1^st Opposite Party regarding reimbursement of a sum of Rs.1,89,000/- as he is entitled under the said Medical Insurance Scheme, though the 1^st Opposite Party had assured to take necessary action, as the same was done, he had sent a legal notice dated 09.07.2020 to the Opposite Parties 1 to 6 and the Opposite Parties 1 to 6 in spite of receipt of the said legal notice had not chosen to reply and redress his grievance.

30.    Further contended that under Clause 4 (iv) of Ex.A-7 and Ex.B-4, G.O.Ms.No.202 dated 30.06.2016, it is mentioned that “The employees and their eligible family members covered under the scheme shall avail assistance upto the limit of Rupees Four Lakh in a block of four years commencing from 01.07.2016 as a cashless model for the approved treatments/surgeries listed in Annexure-II to this order, in the Hospitals approved by the United India Insurance Company/Third Party Administrator and listed in the Annexure -III to this order.” And under Clause 5 (a) of Annexure-I it is mentioned that “The Diseases, Treatments and Surgeries under the Broad Based Specialities approved under the New health Insurance Scheme, 2016 are listed in the Annexure-II and Annexure II-A to this order and the scope of the Scheme shall be to provide coverage for the eligible expenses incurred by the employee on behalf of himself/herself or any eligible his/her family members on such treatments and surgeries. The coverage will include the cost of medicines, laparoscopic or open surgeries, doctor and attendant fees, room charges, diagnostic charges, dietary charges availed in the approved hospitals. The coverage shall also include pre-existing illnesses which have been included in the above said list. The Transport Charges shall be excluded.” Hence the Complainant is entitled for the entire expenses incurred by him and as claimed in the complaint. 

31.    The contentions of the 1^st Opposite Party are that for the treatment taken by the Complainant between 04.06.2019 20.06.2019 at Sri Ramachandra Hospital, Chennai, he was diagnosed with great toe gangrene and the said hospital has raised a cashless request to their Third Party administrator, namely, MD India Health Insurance TPA Pvt. Ltd., vide CC No.MDI0167360 and the said request was approved for a sum of Rs.98,500/- which included RAY amputation Rs.50,000/-, SR Medical Pharmacy Rs.9,700/-, SR Surgical Pharmacy Rs.36,060/-, ECG Rs.440 and ECHO Rs.2,300/-. Further contended that the Complainant was again admitted in Sri Ramachandra Hospital, Chennai from 25.06.2019 to 12.07.2019 wherein he was diagnosed with diabetic foot ulcer and the said hospital had again raised a cashless request to their Third Party administrator, vide CC No.MDI0169378 and the said request was approved for a sum of Rs.1,12,500/- which included General surgery Rs.47,000/-, SR Theater Pharmacy Rs.16,449/-, SR Medical Pharmacy Rs.12,364/ SR Surgical Pharmacy Rs.22,442/-, Circumcision Rs.2,250/-, Biochemistry Rs.4,640/-, clinical pathology Rs.5,395/-, Microbiology Rs.1,280/-, ECG Rs.220 and X Ray 460/-.

32.    Further contended that the above two claims for cashless request were processed for approval as per the coverage and terms and conditions of G.0.202 dated 30.06.2016 issued by the Finance (Salary) Department, Tamilnadu. As such both the above claims for preauthorization had totalled a sum of Rs.2,11,000/-.

33.    Further contended that the said scheme is a cashless scheme and the beneficiaries under the scheme need not pay any amount over and above the amount approved during the pre-authorization request. As such no amount is payable by the Complainant to the hospital either at the time of admission or at the time of discharge. The Complainant being a Government Servant and knowing fully well that the scheme being a cashless scheme and that no amount is payable by the Complainant to the Hospital as made the payment in excesses of the amount approved by the Third Party Administrator of the Complainant. As such the same is not binding on the 1^st Opposite Party. In support of the said contentions had cited clause 11 of Annexure-I of G.O.Ms.No.202 dated 30.06.2016 that “The employee and their eligible family members under this scheme shall not be required to make any payment for the approved cost to the hospitals upto the eligible limit. The hospitals approved by the Insurance Company/Third Party Administrator under this Scheme shall extend treatment to the employees and their eligible family members on a cashless model”. Hence they are not bound and liable to repay the balance amount of Rs.1,02,421/- to the Complainant and submits that in view of the above denial of averments, the scheme being a cashless scheme they are not bound and liable to repay the said sum.

34.    Further contended that as per clause 15 of Annexure – I that any grievance/complaint about difficulty in availing treatments, non-availability of facilities, availing of bogus treatment for ineligible individuals etc., shall be submitted to the Joint Director of Medical and Rural health service of the District concerned for placing before District Level empowered Committee for redressal. The District Level Empowered Medical and Rural health Services, the District Treasury officer and a representative of the Insurance Company as members. In support of the said contention, Reliance has been placed on the Judgment of our Hon’ble High Court of Madras (Madurai Bench) passed in Star Health Insurance and Allied Insurance Co Ltd Vs- A.Chokkar and others.

35.    The contentions of the 4^th Opposite Party are that the submissions of the Complainant that he has taken treatment for large spread ulcer on big toe and he was admitted in Sri Ramachandra Hospital situated in Porur, Chennai on 14.06.2019 as in patient for surgical removal of both fingers, after the surgery was over, he was discharged from the Hospital on 20.06.2019. For the above said treatment the Hospital has charged a sum of Rs.1,95,917.71/- When the Hospital authority demanded the payment from him, he has informed the Hospital that he is covered under the Tamil Nadu New Health Insurance Scheme and hence requested to get the amount from the Insurance Company. The Hospital had informed the Complainant that the Insurance Company has paid a sum of Rs.98,499.71/- and demanded the Complainant to pay the balance amount of Rs.97,418/-. The balance amount has been paid by him through his son and daughter. The Complainant has further submitted that though he had informed to the Hospital that he is eligible for entire charged amount under the Insurance Scheme, but the Insurance Company has paid the above said amount of Rs.98,499.71/- only. The contention of the Complainant is not correct. The Insurance Company/TPA is the assessing authority and hence the Complainant has to be paid the balance amount apart from the eligible amount for the instant treatment.

36. The 4^th Opposite Party further contended that the Complainant had submitted that the hospital authority has informed to come after 5 days for examination and accordingly the Complainant went to the hospital and on examination of his legs the hospital authority had informed him that he has to remove his lower part of the right leg, since the same has also been affected. The Complainant has also agreed for the operation. For this operation / treatment, the hospital again charged Rs.2,14,921.26/. For the said amount the Insurance Company has paid only Rs.1,12,500/-. The Complainant has further submitted that again the hospital had demanded the Complainant to pay the balance amount of Rs.1,02,421/-. The Complainant submitted that he managed to pay the amount again through his daughter and son. In this connection it is submitted that the Complainant has been paid the eligible amount by the Insurance Company.

37.    It is further contended that the 1^st Opposite Party in their letter dated 31.05.2022 has stated that the patient Mr.V.Nanda Gopalan, the Complainant herein was admitted in Sri Ramachandra Hospital, Chennai from 14.06.2019 to 20.06.2019 with the diagnosis of Great Toe Gangrene against CCN No.MDI0167360. TPA has received cashless request from the hospital and they have approved the amount of Rs.98,500/- for the covered illness and break up details are given below:

Ra Amputation            -  Rs 50,000.00

SR Medical Pharmacy   - Rs.  9,700.00

SR Surgical Pharmacy - Rs. 36,060.00

ECG                           - Rs.     440.00

Echo                          - Rs.   2,300.00

Total                         - Rs.  98,500.00

Subsequently, Mr.V.Nandha Gopalan, the Complainant herein was admitted in Sri Ramachandra Hospital from 25.06.2019 to 12.07.2019 with the diagnosis of Diabetic Foot Ulcer against CCN No.MD10169378. TPA has received pe authorization documents from the hospital and they have approved an amount of Rs. 1,12,500/- for the covered illness and breakup details are given below;

General Surgery          - Rs.    47,000.00

SR Theatre Pharmacy - Rs.   16,449.00

SR Medical Pharmacy   - Rs.   12,364.00

SR Surgical Pharmacy - Rs.    22,442.00

Circumcision               - Rs.     2,250.00

Bio Chemistry             - Rs.     4,640.00

Clinical Pathology        - Rs.     5,395.00

Microbiology               - Rs.     1,280.00

ECG                           - Rs.        220.00

X Rays                       - Rs.        460.00

Total                         - Rs. 1,12,500.00

The above approval is processed as per the coverage and terms and conditions of G.O.Ms.No.202 Dated 30.06.2016 issued by Finance (Salaries) Department, Government of Tamil Nadu. Total eligible amount comes to Rs.2,11,000/-.

38.    It is further contended that the Insurance Schemes (For Employee/Pensioner) have been designed as Cashless Schemes, under which a Government servant or Pensioner/Family Pensioner and his/her spouse can undergo specified list of medical procedures and surgeries in empanelled hospitals (referred to as network hospitals to signify hospitals included in the Insurance coverage network) after obtaining the pre-authorization of the Insurance company, without having to make any payment to the hospital in cash. However, in the said Insurance Schemes it is explicitly stated that the benefit of cashless treatment would not cover unlisted medical procedures, surgeries and treatments undergone in network or non-network hospitals or listed treatments and surgeries undergone in non-network hospitals. In the said Insurance Schemes there is no provision for reimbursement of any medical expenses and cashless treatment alone is permitted. However, in case the network hospitals charged the subscriber for undergoing any of the approved treatment or surgeries, a mechanism for making complaints to District and State Redressal Committees was made in the said Insurance Schemes itself, so that if such instances were proved, the Insurance Company will reimburse such payments to the subscribers and in turn the Insurance Company could recover the same from the network hospitals under their bilateral agreements with the network hospitals.

39.    It is further contended that the implementation of the Tamil Nadu New Health Insurance Scheme is entrusted to the United India Insurance Company/TPA. The Insurance Company in turn entered into agreement with the approved hospital and giving the CASHLESS treatment. The Complainant's case has also been entertained by the Insurance Company and the above said eligible amount stated above has been paid by the Insurance Company.

40.    It is further contended that the Complainant herein has not preferred any appeal to the District Level Empowered Committee if he is not satisfied with the act of the United India Insurance Company Limited, or the amount sanctioned to him, as per the provisions of the Insurance Scheme. Even if the Complainant has not received any satisfactory orders from said committee then he has the chances of appealing the said order in the State Level Empowered Committee/ High Level Empowered Committee in the hierarchy manner to get redressal of his grievances. But, without exhausting the appeal remedies available the Complainant has straight away approached this Hon'ble Commission for getting redressal of the grievances. Thus the Complainant has not exhausted the appeal remedy available under the Insurance Scheme. If any dispute arises in availing the medical reimbursement claim under the Tamil Nadu New Health Insurance Scheme, the grievances should be resolved under the suitable appeal mechanism. Further for an approved treatment / surgery undertaken in a Network hospital, either a part of the claim or no claim has been settled by the Insurance Company the petitioner can very well make an appeal before the District Level Empowered Committee and appeal before State Level Empowered Committee as provided under the scheme and clarified vide Finance Department D.O.Letter No.37012/Finance(Salaries)/2019-1, dated: 01.11.2019. The Complainant herein has not at all followed any of the systematic procedure but made a complaint before this Hon'ble Commission for getting redressal of his grievances. Hence the case of the Complainant before this Commission deserves no merit.

41.    On discussion made above and on perusal of records, the Complainant was issued with an Identity Card under the Medical Insurance Scheme by the 1^st Opposite Party as evidenced from Ex.A-1 and A-2. The First surgery undergone by the Complainant in Sri Ramachandra Medical Centre on 15.06.2019 is evidenced from the Discharge Summary, Ex.A-3. Bill of supply/Inpatient Bill Summary issued by said Sri Ramachandra Hospital for a sum of Rs.1,95,917.71p found in page no.9 of Ex.A-4, for the treatment undergone by the Complainant between 14.06.2019 to 20.06.2019 and the payment of Rs.97,418/- made through Credit Card by the Complainant found in Page no.8 of Ex.A-4 with an endorsement of Sanction Approved for a sum of Rs.98,500/-. Ex.A-5 is the Discharge Summary issued by Sri Ramachandra Medical Centre for the Second surgery undergone by the Complainant on 28.06.2019.Ex.A-6 is the Bill of supply/Inpatient Bill Summary issued by said Sri Ramachandra Hospital, for the treatment undergone by the Complainant between 25.06.2019 to 12.07.2019 and it is evidenced that a sum of Rs.1,02,421/- made through Credit Card by the Complainant with an endorsement of Sanction Approved for a sum of Rs.1,12,500/-. Ex.A-7 is the Legal notice dated 09.07.2020 sent to Opposite Parties 1 to 6 with postal receipts and Ex.A-8 are the Acknowledgement cards for the receipt of Ex.A-7. Ex.A-9 is the G.O.Ms.No.202 dated 30.06.2016 issued by Finance (Salaries) Department, Government of Tamil Nadu, whereby the New health Insurance Scheme, 2016 (NHIS) sanctioned to be implemented by the United India Insurance Company Ltd, the 1^st Opposite Party.

42.    It is to be noted on the contentions of the Complainant that under Clause 4 (iv) of Ex.A-7 and Ex.B-4, G.O.Ms.No.202 dated 30.06.2016, it is mentioned that “The employees and their eligible family members covered under the scheme shall avail assistance upto the limit of Rupees Four Lakh in a block of four years commencing from 01.07.2016 as a cashless model for the approved treatments/surgeries listed in Annexure-II to this order, in the Hospitals approved by the United India Insurance Company/Third Party Administrator and listed in the Annexure -III to this order.” And under Clause 5 (a) of Annexure-I it is mentioned that “ The Diseases, Treatments and Surgeries under the Broad Based Specialities approved under the New health Insurance Scheme, 2016 are listed in the Annexure-II and Annexure II-A to this order and the scope of the Scheme shall be to provide coverage for the eligible expenses incurred by the employee on behalf of himself/herself or any eligible his/her family members on such treatments and surgeries. The coverage will include the cost of medicines, laparoscopic or open surgeries, doctor and attendant fees, room charges, diagnostic charges, dietary charges availed in the approved hospitals. The coverage shall also include pre-existing illnesses which have been included in the above said list. The Transport Charges shall be excluded.”

43.    It is to be noted on the contention made by the 1^st Opposite Party under clause 11 of Annexure-I it is mentioned that “The employee and their eligible family members under this scheme shall not be required to make any payment for the approved cost to the hospitals upto the eligible limit. The hospitals approved by the Insurance Company/Third Party Administrator under this Scheme shall extend treatment to the employees and their eligible family members on a cashless model”. And further as per clause 15 of Annexure – I that any grievance/complaint about difficulty in availing treatments, non-availability of facilities, availing of bogus treatment for ineligible individuals etc., shall be submitted to the Joint Director of Medical and Rural health service of the District concerned for placing before District Level empowered Committee for redressal. The District Level Empowered Medical and Rural health Services, the District Treasury officer and a representative of the Insurance Company as members. In support of the said contention, Reliance has been placed on the Judgment of our Hon’ble High Court of Madras (Madurai Bench) passed in Star Health Insurance and Allied Insurance Co Ltd Vs- A.Chokkar and others, wherein the treatment taken in Non-network hospitals were dealt with and it was observed that the insurance company is strictly bound by the terms and conditions of the contract and cannot be asked to settle a claim which does not fall within the terms of the contract and therefore the claim made by the beneficiaries in respect of treatments that were taken in a non-network hospital or for reimbursement of the claim made the insurance company is not liable and observed that the insurance company would settle the claim if the beneficiary has taken treatment in network hospitals and more importantly the facility itself is a cashless facility. Further observed that 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. Further observed that 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. Further observed that otherwise the Redressal Committee can do much in any one of the cases, since all the petitioners/claimants would have made payments and it was made clear that if a petitioner who has not settled the claim for the procedure that is not covered, he may approach the Redressal Committee and the Government was directed not to deny any claim validly made under the Rules only because the claimant is a member of the Scheme.

44.    The above judgment referred by the 1^st Opposite Party distinguishes from the facts and circumstances of the Instant case, as the present case is a direct case where the Insurance Company is bound to act as per the terms and conditions of the G.O.Ms.No.202 dated 20.06.2016 and the arguments advanced by the 1^st Opposite Party that as the approved Hospitals under guise of the Scheme charges heavily, they pay the approved cost and the beneficiaries as per the scheme need not have pay the excess cost that has been charged by the Approved Hospitals, are not legally sustainable, as there are no such clauses in the terms and conditions of the said G.O. and the clauses are very direct covering the treatments as mentioned in Clause No.5 of Annexure-I as discussed above and further the 1^st Opposite Party has not placed any substantial material to show on what basis the costs/bills for the treatments taken in the Approved Hospitals, are calculated and approved by the 1^st Opposite Party, as highlighted by the Complainant that bills charged for Bio Chemistry to the tune of Rs.10,835/- was not approved by the 1^st Opposite Party for the first treatment, whereas the 1^st Opposite Party had approved Bio Chemistry charges of Rs.4,640/- claimed by the Hospital, as found in Ex.B-2.

45.    Further it has to be made clear that clause 15 of Annexure – I speaks about any grievance/complaint about difficulty in availing treatments, non-availability of facilities, availing of bogus treatment for ineligible individuals etc., shall be submitted to the Joint Director of Medical and Rural health service of the District concerned for placing before District Level empowered Committee for redressal and not with regard to the payments charged by the Approved Hospitals for approved treatments and balance payments made by the beneficiaries under the Scheme. Hence the contention of the 1^st Opposite Party that the Complainant has to approach the Redressal Committee for the present claim made before this Commission and without exhausting such remedy he cannot approach this Commission, though the same was not pleaded in the Written Version filed by the 1^st Opposite Party or taken out such a ground in their Proof affidavit or in the written arguments, though the same was pleaded by the 4^th Opposite Party in their written version which was adopted by Opposite Parties 2 to 6, the said contention is not legally sustainable on the discussions made above and also on the ground that the provisions of the Consumer Protection Act shall be in addition to and not in derogation of the provisions of any other law.

46.    In the present case as there was no denial made by the 1^st Opposite Party with regard to the treatment taken by the Complainant and further under Clause 10 of Annexure-I to the said G.O.the Insurance Company/Third Party Administrator shall ensure that the patient i.e., employee and their family members who are eligible under this scheme are given coverage for approved treatments / surgeries including pre-existing diseases in the approved hospitals for this purpose upto the limit of Rupees Four Lakh in respect of diseases covered in Annexure -II and under clause 11 of Annexure-I that the employee and their eligible family members under this scheme shall not be required to make any payment for the approved cost to the hospitals up to the eligible limit and shall extend treatment to the employees and their eligible family members on a cashless model. Hence it is clear that the 1^st Opposite Party in violation of the said terms and conditions of the Health Insurance Scheme implemented under G.O.Ms.No.202 dated 30.06.2016 by the Government of Tamil Nadu to benefit its employees and their family members, had acted negligently and had failed to settle the legal claim of the Complainant. Therefore this Commission is of the considered view that there is deficiency of service on the part of the 1^st Opposite Party in settling the legal claim of the Complainant. And as there is no existence of Consumer and service provider relationship between the Complainant and the Opposite Parties 2 to 6, as no consideration was paid to Opposite Parties 2 to 6 and as only to benefit the Complainant and his family members, monthly premium is deducted from the salary of the Complainant and paid to the 1^st Opposite Party. Hence there is no cause of action to maintain the complaint as against 2^nd to 6^th Opposite Parties, who are in no way liable and responsible for the negligent act of the 1^st Opposite Party, hence the complaint filed against 2^nd to 6^th Opposite Parties stands dismissed. Accordingly Point No.1 is answered. 

POINTS NO 2 & 3

47.    As discussed and decided in  Point No.1, The 1^st Opposite Party is directed to pay a sum of Rs.1,89,000/-  being the amount paid to Sri Ramachandra Hospital by the Complainant and to pay a sum of Rs.50,000/- towards deficiency of service and mental agony, along with cost of Rs.5,000/- to the Complainant. Accordingly, Point Nos 2 and 3 are answered.

In the result, the complaint is allowed in part. The 1^st Opposite Party is directed to pay a sum of Rs.1,89,000/- (Rupees One Lakh Eighty Nine Thousand Only) being the amount paid to Sri Ramachandra Hospital by the Complainant and to pay a sum of Rs.50,000/- (Rupees Fifty Thousand Only) towards deficiency of service and mental agony, along with cost of Rs.5,000/- (Rupees Five Thousand Only) to the Complainant, within 8 weeks from the date of receipt of this order, failing which the above amount of Rs.1,89,000/- shall carry interest at the rate of 9% from the date of receipt of this order till the date of realisation.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 15^th of June 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                         MEMBER I                        PRESIDENT

 

List of documents filed on the side of the Complainant:-

Ex.A1		Office ID Card
Ex.A2		Medical Insurance ID Card
Ex.A3	20.06.2019	Discharge summary
Ex.A4	20.06.2019	Bills
Ex.A5	12.07.2019	Discharge Summary
Ex.A6	12.07.2019	Bills
Ex.A7	09.07.2020	Legal Notice
Ex.A8		Acknowledgement Cards
Ex.A9	30.06.2016	G.O

 

 

List of documents filed on the side of the 4^th Opposite Party:-

Ex.B1	30.06.2016	G.O Ms. No.202 Finance (Salaries) Department dated 30.06.2016
Ex.B2	31.05.2022	United India Insurance Co. ltd. Letter No.010600/health/3105/2022 dated 31.05.2022
Ex.B3	01.11.2019	D.O. Letter No.37012/Finance (Salaries)/ 2019-1 dated 01.11.2019

 

List of documents filed on the side of the 1^st  Opposite Party:-

Ex.B4

30.06.2016

The copy  of the G.O No.202

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                    B.JIJAA

      MEMBER II                          MEMBER I                            PRESIDENT