Date of Filing     06.03.2024

                                                                                                             Date of Disposal: 30.07.2024

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

BEFORE TMT. Dr.S.M. LATHA MAHESWARI, MA. ML, Ph.D (Law),                                         …….PRESIDENT

               THIRU.P.VINODH KUMAR, B.Sc., BL.,                                                                             ...….MEMBER-I

CC.No.115/2024

THIS TUESDAY, THE 30^th DAY OF JULY 2024

Mr.K.Narayana Moorthy,

S/o.Kumarasami,

Residing at No.2/119, Lakshmi Nagar,

Karthikeyapuram,

Tiruvallur District 631 211.                                                                     ......Complainant.

                                                                            //Vs//

1.M/s. The Manager,

   United India Insurance Company Limited,

   J.N.Road, Oilmill, Thiruvallur 602 001.

2.United India Insurance Company Limited,

LBO-010600,

No.134, Silingi Buildings,

IDBI Bank back side,

Greams Road, Chennai 600 006.                                                     .…..Opposite Parties.

Counsel for the complainant                       :     M/s.E.Thamizharasan, Advocate.

Counsel for the opposite parties                 :    M/s.J.Chelladurai Caldwell, Advocate.

This complaint coming before us on various dates and finally on 27.06.2024 in the presence of M/s.E.Thamizharasan, counsel for the complainant and   M/s.J.Chelladurai Caldwell, counsel for the opposite parties and upon perusing the documents and evidences of both sides this Commission delivered the following

ORDER

PRONOUNCED BY TMT.Dr.S.M. LATHA MAHESWARI, PRESIDENT

1. This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the opposite parties in not honouring the reimbursement claim for medical expenses along with a prayer to honour the medical claim along with compensation to the complainant.

Summary of facts culminating into complaint:-

 2. Being aggrieved by the act of the opposite parties in not reimbursing the medical claim relating to the medical expenses of the complainant’s wife the present complaint was filed.

3. Complainant had taken New Health Insurance Scheme for pensioners/family pension with Government of Tamil Nadu by paying monthly premium of Rs.495/- which was deducted from complainant’s pension. Complainant’s wife sustained injuries and took treatment at Peacock Hospital, Tiruttani as inpatient from 04.07.2018 to 06.07.2018 and surgery was conducted on 07.07.2018. Further in Apollo Hospitals Vanagaram, Chennai treated as inpatient from 21.12.2023 to 26.12.2023 and surgery was conducted on 23.12.2023 by totally spending a sum of Rs.4,01,343/- towards medical expenses.  Out of the total expenses the opposite parties paid only a sum of Rs.1,21,680/- and did not pay the balance of Rs.2,79,663/-.  Thus aggrieved the present complaint was filed alleging deficiency in service and unfair trade practice on the part of opposite parties and to direct them to pay the balance amount with Rs.1,00,000/- compensation. 

The crux of the defence put forth by the opposite parties:-

4. The opposite parties admitted that the complainant had availed insurance service from the opposite parties based on G.O.No.202.  As the policy was based on the Government order, it was disputed that this commission does not possess the requisite jurisdiction to decide the cases relating to disputes in payment of claim amount. According to the Government orders governing the issuance, processing and payment of claim amount in the insurance policy, the complainant does not fall under the category of a consumer and therefore complainant not entitled to file any complaint before this commission. Complainant has done unnecessary medical procedures for the condition which could be easily cured by proper medication and exercise and therefore claim could not be fully processed. As per the New Health Insurance Scheme 2016 according to the G.O.Ms.No.202 dated 30.06.2016 to consider request for reimbursement as a case of special nature for treatment taken due commencement stage subject to treatment taken in approved hospitals for approved listed dated 30.06.2016.  The Finance(Salaries) Department, Secretariat, Treasuries and accounts, had issued orders that reimbursement shall be made only in cases of special nature for treatment taken and have occurred in the commencement stage subject to treatment taken in approved hospitals for approved listed procedures as per GO No.202 dated 30.06.2016. It was submitted that the complainant’s wife Mrs.N.Jaya was admitted in hospital due to Gynac and neuro Problem and had incurred a bill of Rs.3,49,953/- at Peacock Hospital and Rs.51,390/- at Apollo Hospital. It was right in issuance of a sum of Rs.1,12,680/- and had rightfully denied the payment of Rs.2,79,663/- as it has been decided only after several rounds of scrutiny by experts. Complainant has failed to explain the necessity of the medical procedures which his wife has undergone and hence the denial of the claim amount to the complainant was just and genuine. The additional claim of Rs.2,79,663/- was clearly excluded by the terms and condition of the policy and thus there is no deficiency in service and therefore complaint was liable to be dismissed. If the complainant was aggrieved by the claim amount issued by the Insurance Company, remedy was available to him before the Insurance Ombudsman and while an alternative remedy was available to the complainant, he is not entitled to approach this Commission and therefore there is no deficiency in service on the part of opposite parties.

5. On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A7. On the side of opposite parties proof affidavit was filed but no document was submitted on their side.

Points for consideration:-

1. Whether the deficiency in service alleged by the complainant against the opposite parties has been successfully proved by him by admissible evidence with respect to the non-reimbursement of medical claim amounting to deficiency in service?
2. If so to what reliefs the complainant is entitled?

Point No.1:-

            6. Heard the oral arguments adduced by the learned counsels appearing for the complainant and the opposite parties and perused the material evidences, pleadings and documents produced by both parties.

7. The crux of the oral arguments adduced by the complainant is that the Complainant had taken a New Health Insurance Scheme for him and his family by paying from his Account a monthly premium of Rs.495/- which was deducted from complainant’s pension. Complainant’s wife sustained injuries and took treatment with Peacock Hospital and Apollo Hospitals and had spent a sum of Rs.4,01,343/- towards medical expenses.  Out of the total expenses the opposite parties paid only a sum of Rs.1,21,680/- and did not pay the balance amount of Rs.2,79,663/-.  Thus alleging deficiency in service and unfair trade practice committed on the part of opposite parties, the complainant prays for the complaint to be allowed. 

8. The learned counsel appearing for the opposite parties argued that according to the G.O.Ms.No.202 dated 30.06.2016 the request to be considered for reimbursement was subject to treatment taken in approved hospitals. But the complainant had done unnecessary medical procedures for the condition which could be easily cured by proper medication and exercise.  Thus they paid only a sum of Rs.1,21,680/- to the complainant as Medical insurance claim. Thus he sought for the dismissal of the complaint.

9. We perused the documents submitted by the complainant.  Ex.A1 & Ex.A2 were the Discharge summaries and Bills issued by the Peacock Hospital and Apollo Hospitals. The opposite parties referred the GO.Ms.No.202 dated 30.06.2016 to deny the medical claim and argued that the medical procedure for complainant’s wife’s health condition was done unnecessarily which could be easily cured by proper medication and exercise and hence the claim could not be fully processed and paid.

10. At this juncture, we come across a judgment rendered by the Hon’ble High Court, Madurai Bench in Marimuthu Vs Government of Tamil Nadu in W.P.(MD).No.13429/2013 dated 28.05.2019 relating to Medical reimbursement claims of the Government employees Under Health Insurance Scheme wherein the impugned orders rejecting claims on mere technical grounds were quashed and remanded with directions to the concerned District Level Empowered Committee for reconsideration.   In the said judgment directions has been issued for grant of claim as follows, 

“While reconsidering, the Committee shall not reject any claim merely on the reason of non-network hospital or non listed disease.

The Committee, wherever possible, shall give suitable direction to the Insurance Company to reimburse the claim made by the respective claimant / employee / pensioner.

If the Committee finds some cases where the Insurance Company cannot be directed to reimburse, in those cases, suitable orders shall be passed directing/recommending the State authorities to reimburse the claim under Medical Attendance Rules.”

In view of the above directions issued in the order passed by the Hon’ble High Court, Madurai Bench binding upon us, this commission holds that the claim of the complainant also has to be considered and allowed based on the said directions.  Non consideration of the claim and rejecting the same on some trivial grounds in the facts and circumstances clearly amounted to deficiency in service on the part of opposite parties.  In such circumstances, this commission holds that the opposite party had committed deficiency in service in not reimbursing the medical claim of the complainant without any valid reason for which he was legally entitled to as the treatment was very well covered under Annexure II, XI under the G.O.Ms.No.202, dated 30.06.2016.

With regard to the defence that alternate remedy is available, in Civil Appeal No. 3581-3590 of 2020 (@ Civil Appeal Diary No.9796 of 2019) and Civil Appeal No.3591 of 2020 (@ Civil Appeal Diary No.9793 of 2019). D/d. 02.11.2020 in M/s. Imperia Structures Ltd.  Vs Anil Patni and others it has been held as,

21. It has consistently been held by this Court that the remedies available under the provisions of the CP Act are additional remedies over and above the other remedies including those made available under any special statutes; and that the availability of an alternate remedy is no bar in entertaining a complaint under the CP Act.

 Therefore, complaint is maintainable irrespective of presence of alternate remedy, as provisions of Consumer Protection Act, 2019 shall be in addition to and not in derogation of the provisions of any other law under Section 100 of the said Act.

Point No.2:-

11. As we have held above that the opposite parties had committed deficiency in service we direct them to consider the claim of the complainant and to pass necessary orders for reimbursement of the medical claim for Rs.2,79,663/- based on the medical bills within six weeks from the date of receipt of copy of this order.  Further for causing mental agony and hardship to the complainant we award Rs.25,000/- as compensation which we thought would be appropriate in the facts and circumstances and also award Rs.5,000/- as litigation expenses to the complainant.

In the result, the complaint is partly allowed against the opposite parties directing them  

a) To reimburse the balance amount of Rs.2,79,663/-(Rupees two lakhs seventy nine thousand six hundred sixty three only) to the complainant by the opposite parties within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.25,000/- (Rupees twenty five thousand only) towards compensation for the mental agony and hardship caused to the complainant; 

c)  To pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant; 

d) Amount in clause (a) if not paid by the opposite parties within six weeks from the date of receipt of copy of this order, the amount shall carry interest at the rate of 9% per annum from the date complaint till realization.

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 30^th day of July 2024.

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  MEMBER-I                                                                                                         PRESIDENT

List of documents filed by the complainant:-

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MEMBER-I                                                                                                          PRESIDENT