Tamil Nadu

South Chennai

340/2010

G.Ethiraj - Complainant(s)

Versus

The Star Health & allied Insurance Ltd., - Opp.Party(s)

M/s.S.Ravi

03 Jan 2022

ORDER

                                                      Date of Complaint Filed: 13.09.2010

                                                      Date of Reservation     : 25.11.2021

                                                      Date of Order              : 03.01.2022

                                                                     

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

Present:    Thiru. R.V.R. Deenadayalan, B.A., B.L.           : President

                  Thiru. T. Vinodh Kumar, B.A., B.L.                  : Member

 

CONSUMER COMPLAINT No.340/2010

MONDAY, THE 3^rd DAY OF JANUARY 2022

G. Ethiraj

1/11, Padvattamman Koil Street,

Aalamaati Red Hills,

Chennai – 600 053.                                                   .. Complainant.                                               

..Versus..

 

The Star Health & Allied Insurance Ltd,

Tamil Nadu Government Employee

New Health Insurance Scheme,

Old No.64/A, New No.2A,

Ganga Nagar Road, Opposite BSNL Office,

Kodambakkamm

Chennai – 600 024.                                                 .. Opposite party.

 

 

Counsel for the complainant    : M/s. S. Ravi

Counsel for the opposite party : M/s. N. Vijayaraghavan

 

        On perusal of records and after having heard the oral arguments of Oppoiste party  and having treated the written arguments of Complainant    as oral arguments of the complainant and we delivered the following:

 

ORDER

Pronounced by the President Thiru. R.V.R. Deenadayalan, B.A.,B.L.

1.     The complainant has filed this complaint as against the opposite party under section 12 of the Consumer Protection Act, 1986 and prays to pay a sum of Rs.85,000/- with 12% interest from 07.02.2010  and to pay compensation of Rs.5,00,000/- for damages and for mental agony suffered by the complainant’s wife along with cost.

2.     The complainant submitted his Proof Affidavit and written argument.  On the side of the complainant, documents Ex.A1 to Ex.A8 are marked.   The opposite party has submitted his version, proof affidavit and written arguments and on the side of the opposite party documents Ex.B1 to Ex.B13 are marked.

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

        The complainant is an employee in Chennai Metropolitan Sewage Board and he is one of the member of Group Insurance Policy with the opposite party. The complainant’s wife also covered under this policy. The Complainant wife namely E.Vijayalakshimi suddenly developed pain in stomach and she was admitted at CSI RainY Multi Specialty Hospital, Chennai on 06.10.2007 and she underwent lapacotomy bowl resection anastomosis apentisictomi. She was discharged on 28.10.2007. The complainant has spent Rs.85,000/- towards her treatment. The complainant claimed the above amount from the opposite party but his claim was repudiated by the opposite party. Hence this complaint is filed.

4.      Written version of the Opposite party in brief:-

        The State of Tamilnadu introduced the new health insurance scheme basically on cashless basis in order to ensure that no employee was required to pay medical expenses upfront and that they can simply get admitted in the networked hospitals for covered illness and get treated in such hospital and this opposite party for pay the money directly to the hospitals. The new health insurance scheme was therefore founded upon cashless basis alone as was made clear in GO.MS.No.174 dt. 28.04.2008 before the commencement of the insurance scheme itself. Further the Government in the letter dt. 11.10.2008 made it amply clear to all employees / beneficiaries that in no circumstances they can seek claim on reimbursement basis and if they did so, the insurance / opposite party would not be liable to meet the payments so made. Hence it is very clear that the present complaint is not maintainable since the complainant had sought reimbursement of alleged medical expenses incurred which was not tenable one.

5.     The claim was in relation to hospitalisation for treatment “Laprotomy  and Adhision Release done for Acute Intestinal Obstruction due to Adhesions” between 06.10.2008 to 20.10.2008 in CSI RainY Multi Speciality Hospital, Chennai. On the face of it, the claim was for a treatment / surgery which was not one of the 13 perils / risks covered under the contract of insurance. In addition there to, the said hospital was not one of the Networked Hospital as on 06.10.2008 i.e., date of admission of E.Vijayalakshmi in CSI Raine Hopsital. For both these reasons the claim was not admissible, besides the claim was made on reimbursement basis, the same was  found not payable. The said hospital was networked only on and from 10.12.2008.

6.     It is submitted that no request for authorisation for any claim was received either from the hospital in which the complainant’s wife underwent treatment or from the complainant on 07.10.2008  as claimed by  the complainant. A representation of the employee dt. 28.10.2008 was received by this opposite party on 03.11.2008 and the same was rejected after due consideration of all these facts and medical records relating to the treatment. Hence it is requested to dismiss this petition.

7.      The Points for consideration are:-

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

2. Whether the complaint is entitled to get reliefs as claimed in the complaint?

3.To what relief, the complaint is entitled to?

 

8.     Point No.1

        On perusal of Ex.A4, discharge summary of CSI Rainy Multi Speciality Hospital, Chennai diagnosis the case of “Acute Intestinal Obsyrudtion Due To Adhesions. Laprotomy And Adhesion Release Done”. Further under the topic of “treatment given” it is mentioned as “Laparotomy and Adhesion Release due to adhesions on 08.10.2008”.

9.     As per Ex.B5 Go.Ms.No.400 dt. 29.10.2000in Annexure, Schedule II the list of private hospital accredited against the speciality in Chennai City was given. In the above approved Net-Worked Hospital.  CSI Rainy Multi Speciality Hospital, Chennai was not found. Therefore complainant’s wife was not taken treatment in the Net – Worked Hospital, published by the State of Tamilnadu.  Further as per Ex.B9 the Go.Ms.No.430 dt. 10.09.2007 in the annexure the list of diseases, treatments / surgeries classified under the broad basis speciality. Totally 13 kinds of diseases, treatments / surgeries are listed.  In the above list of disease  the surgery under went by the complainant’s wife i.e., “Laparotomy and Adhesion Release due to adhesions” was not found. Therefore complainant is not entitled either for  cashless treatment or reimbursement from the opposite party. Further there is no proof that the complainant has claimed cashless insurance through the opposite party. It is an admitted fact that the complainant has claimed only reimbursement. But the insurance company  was restrained to award insurance for reimbursement. Apart from that the opposite party submitted a case law before the Madurai Bench of Madras High Court in Writ Appeal (MD) No.480 / 2009 and other in between Star Health and Allied Insurance Company Vs. A. Chokkan and Another dt. 26.06.2010  Justice Prabha Sridevan and Justice B. Rajendran observed as follows: “If the claim 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 their rules. If, however, before the date 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 the procedure is covered or not. The Redressal Committee may also go into the complaints regarding the 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 settle 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 Redrassal Committee. In view of the fact that there are the above lacunae in the scheme, the Government shall not deny any claim  where validly made under the rules only because the claimant is the member of the scheme. The above verdict also applied to the complainant. The Complainnat may approach the Redressal Commission or the Government of Tamil Nadu instead of this opposite party. Therefore we found that there is no deficiency in service on the part of the  opposite party.  Accordingly point No.1 is answered.

10.    Point Nos. 2 & 3

        We have discussed and decided that there is no deficiency in service on the part of the opposite party and therefore the complainant is not entitled to get any reliefs  as claimed in the complaint and as against the opposite party.  Accordingly Point Nos.2 & 3 are answered.

  In the result, this complaint is dismissed.  No costs.

      Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on this the 03^rd  day of January  2022.

  

 

T.VINODH KUMAR                                       R.V.R.DEENADAYALAN                                                                                     

      MEMBER                                                       PRESIDENT

 

 

 

List of documents filed on the side of the complainant:

 

Ex.A1	16.02.2009	Circular by the employer
Ex.A2	07.10.2008	Claim form
Ex.A3		Identify card issued by the Opposite party
Ex.A4		Hospital discharge summary and bills
Ex.A5	18.04.2009	Letter from Complainant to the Opposite party
Ex.A6	31.07.2009	Letter rejecting the claim of the complainant
Ex.A7	05.10.2009	Medical Certificate
Ex.A8	28.06.2010	Reply by the Opposite party

 

List of documents filed on the side of the opposite parties :-

 

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

       

         -Sd/-                                                                   -Sd/-

   T.VINODH KUMAR                                            R.V.R.DEENADAYALAN                                                                                       

MEMBER                                                              PRESIDENT