Tamil Nadu

South Chennai

CC/326/2013

P.Devarajan, - Complainant(s)

Versus

The United India Insurance Company Ltd., - Opp.Party(s)

T.Fennwalter Associates

02 Jan 2018

ORDER

                                                                                                                           Date of Filing  : 08.07.2013

                                                                          Date of Order : 05.01.2018

DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, CHENNA (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

CC. NO.326/2013

FRIDAY THE 5^th DAY OF JANUARY 2018

P. Devarajan,

C/o. P.Sudharsanam,

F-2, 1^st Floor, Miraa,

Ram Nagar, 6^th Main Road,

North Extension,

Velachery, Chennai 600 042.                    .. Complainant.

 

                                      ..Vs..

1.  The Manager,

The United India Insurance Company Ltd.,

First floor Silingi Building,

No.134, Greams Road,

Chennai -6.

 

2. The Manager,

The Management of Tamil Nadu,

State Transport Corporation

Coimbatore Ltd.,

No.37, Mettupalayam Road,

Coimbatore 43.

 

3. The District Collector,

Coimbatore District,

Coimbatore.                                             .. Opposite parties. 

 

 

Counsel for complainant                 :  M/s. T.Fenna Walter Associates

Counsel for opposite parties 1 & 3 :  Exparte.

Counsel for opposite party-2          :  M/s.D.Narayanakumar

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 seeking direction to pay a sum of Rs.1,55,000/- as medical reimbursement with interest and also to pay a sum of Rs.5,00,000/- as compensation for mental agony and to pay cost of the complaint.

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

          The complainant submit that  he is an employee as a Driver coverage  of Star Health Insurance Scheme.  The 2^nd opposite party also deducted a sum of Rs.25/- p.m.  from the salary of the complainant till  2012.  As per the New Health Insurance  Scheme 2012  the 2^nd opposite party introduced to recover a sum of Rs.150/- p.m.  towards the said scheme and issued  I.D.  card.  On 2.7.2012 when the complainant had heart attack.  The complainant undergone  treatment  went  to Heart specialist  one D. Suresh Kumar and undergone immediate surgery Aortic Valve Replacement surgery in Sree Ramakrishna Hospital at Coimbatore.   He was admitted as inpatient  from 9.7.2012 to 18.7.2012 and completed the surgery.  The expenses comes a sum of Rs.1,55,000/- for treatment,  surgery, doctor fees, etc.   The complainant further state that on  5.7.2012 the complainant went to Welfare Officer of the 2^nd opposite party claiming cash less treatment for such heart disease.   But the 2^nd opposite party refused.   Hence the complainant after availing a loan of Rs.1,00,000/- from the Mettupalayam Co-operative Urban  bank Limited  and undergone treatment.  As such the act of the opposite parties amounts to deficiency in service which caused mental agony and hardship to the complainant. 

2.     Inspite of service of notice the opposite parties 1 & 3 is called absent and set  exparte.  

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

The 2^nd opposite party deny each and every allegations except those that are specifically admitted herein.   The 2^nd opposite party submit that the G.O. Ms.No.243 dated 29.6.2012 Finance (Salaries)  Department  in Annexure-1 Implementation procedure for New Health Insurance  Scheme 2012 clearly states that any complaint about any difficulty in availing treatment has to be submitted to the Commissioner of Treasuries and Accounts in Chennai and the Joint Director of the Medical and Rural Health Services  Department at the District Head quarters.   The above said rules deals with Redressal of grievances and any complaint about any difficulty in availing  treatment, non-availability of facilities, bogus  ailment of treatment for ineligible individuals will be submitted to the Joint Director of the Medical and Rural Health Services Department at the District Headquarters.   They will be placed for decision before the Empowered  District Level Committee, headed by the District Collector and having the Joint Director  of Medical and Rural Health Services  Department  and the District Treasury officer as members and appeal provision was made against the  decision of the Empowered District Level Committee, which is to the State Level Empowered committee.  Finance Department, Secretary to Government, Health and Family Welfare Department, Secretary to Government and the  representative of the Insurance company.  If even after the dispute remains unresolved, the civil court in Chennai will have exclusive Jurisdiction.     Where there is a specific rule with regard for submission of complaint without exhausting it on the part of the complainant.   Hence there is no deficiency in service on the part of the opposite  party and the complaint is liable to be dismissed.

4.     In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A.11. marked.  Proof affidavit of the 2^nd opposite party not filed and no documents   marked on the side of the 2^nd opposite party.

5. The points for consideration is :

1. Whether the complainant is entitled to a sum of Rs.1,55,000/- as medical reimbursement  with interest as prayed for ?

2. Whether the complainant is entitled to a sum of Rs.5,00,000/- as compensation  for mental agony with cost as prayed for ?

 

 

6.    POINTS 1 & 2:

          The opposite party after receipt of notice filed written version.   But failed and neglected to file proof affidavit, document  to prove the contents in the written version.   The complainant filed written arguments.   Perused the records namely complaint, written version and documents etc.    The complainant pleaded and contended that he is a Government employee working as a Driver coverage of Star Health Insurance Scheme.  The 2^nd opposite party also deducted a sum of Rs.25/- p.m.  from the salary of the complainant till 2012.  As per the New Health Insurance  Scheme 2012  the 2^nd opposite party introduced recover a sum of Rs.150/- p.m.  towards the said scheme and issued  I.D.  card.  On 2.7.2012 when the complainant had heart attack in his heavy pain.  The complainant  went  to Heard specialist  one Dr. Suresh Kumar and admitted as inpatient from 9.7.2012 to 18.7.2012 and undergone immediate surgery of Aortic Valve Replacement  in Sree Ramakrishna Hospital, Coimbatore.   The surgery  expenses  to a tune of Rs.1,55,000/- for treatment,  surgery, doctor fees, etc.  as per Ex.A2.    On  5.7.2012 the complainant went to the Welfare Officer of the 2^nd opposite party and claimed cash less treatment for such heart disease.   But the 2^nd opposite party refused.   Hence the complainant after availing a loan of Rs.1,00,000/- from the Mettupalayam Co-operative Urban  bank Limited  and undergone treatment.    As per G.O. is as follows:

        “During the interim period of preparation and distribution of the new identity cards, the insurance company / Third party Administrator shall authorize acceptance of the existing Identity Cards already issued under the scheme for 2008-2012 for time  being i.e. upto 30.9.2012.”

7.     The opposite party has not turned up to hide proof affidavit and documents to prove the contentions raised in the written version.   The complainant is claiming a sum of Rs.1,55,000/-  towards medical expenses and a sum of Rs.5,00,000/- towards compensation  for mental agony.   Considering the facts and circumstances of the case this forum is of the considered view that the opposite parties 1 to 3 are jointly and severally liable to pay a sum of Rs.1,55,000/- towards  medical reimbursement with interest at the rate of 9% p.a. from the date of this complaint i.e. 8.7.2013 and to till the date of this order i.e. 5.1.2018  and shall pay compensation of Rs.25,000/-  towards mental agony with cost of Rs.5,000/- and the points are answered accordingly.

In the result the complaint is allowed in part.  The  opposite parties 1 to 3 are jointly and severally liable to pay a sum of Rs.1,55,000/- (Rupees one lakh and fifty five thousand only) towards  medical reimbursement with interest at the rate of 9% p.a. from the date of this complaint i.e. 8.7.2013 and to till the date of this order i.e. 5.1.2018  and shall pay compensation of Rs.25,000/- (Rupees twenty five thousand only) towards 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 Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 5^th day of January 2018. 

MEMBER –I                                                                           PRESIDENT.

COMPLAINANT’S SIDE DOCUMENTS:

Ex.A1- 29.6.2012  - Copy of G.O.No.243

Ex.A2- 18.7.2012  - Copy of medical bills.

Ex.A3-                - Copy of salary slip.

Ex.A4- 21.8.2012  - Copy of representation to the Commissioner.

Ex.A5- 4.9.2012    - Copy of reply by the Commissioner.

Ex.A6- 1.10.2012  - Copy of communication for Medical & Rural Health Dept.

                               To the 3^rd Respondent.

Ex.A7-                - Copy of Star Health Insurance Card.

Ex.A8-         -        - Copy of List approved Hospital,

Ex.A9- 30.11.2012         - Copy of letter by the 1^st opp. to the petitioner.

Ex.A10- 17.12.2012       - Copy of reply to the 1^st opposite party.

Ex.A11-            -  Certificate issued by Urban Bank, Mettupalayam

 

OPPOSITE  PARTIES SIDE DOCUMENTS:  .. Nil..

 

MEMBER –I                                                                           PRESIDENT.