Date of Filing : 01.12.2020
Date of Disposal: 27.09.2022
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU. J.JAYASHANKAR, B.A, B.L. ..… MEMBER-I
THIRU.P.MURUGAN,M.Com. ICWA(Inter)., B.L., ....MEMBER-II
CC. No.13/2021
THIS TUESDAY, THE 27th DAY OF SEPTEMBER 2022
Mr.Govindarajalu,
S/o.K.G.Munusamy Naidu,
No.3, J.J.Nagar, Arakkonam Road,
Thiruttani Taluk, Thiruvallur District. ……Complainant.
//Vs//
1.The Branch Manager,
United India Insurance Company Limited,
Thiruvallur.
2.The Superintendent of Police,
Thiruvallur District.
3.The Directer General of Police,
The Tamil Nadu Police Benevolent Fund Committee,
Chennai -600 004. …..opposite parties.
Counsel for the complainant : Mr.A.R.Poovannan, Advocate.
Counsel for the opposite parties : exparte
This complaint is coming before us on various dates and finally on 22.09.2022 in the presence of Mr.A.R.Poovannan counsel for the complainant and the opposite parties were set exparte for non appearance and upon perusing the documents and evidences produced by the complainant this Commission delivered the following:
ORDER
PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI, PRESIDENT.
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 repudiating the medical insurance claim along with a prayer to direct the opposite parties to pay a sum of Rs.52,545.56/- spent by the complainant towards the medical expenses and to pay a sum of Rs.25,000/- compensation for the mental agony and hardship caused to the complainant and to pay a sum of Rs.3,000/- as cost of the proceedings to the complainant.
Summary of facts culminating into complaint:-
It is the case of the complainant that he was an employee of Tamil Nadu Police Service and was working as Sub-Inspector Special Grade (996) and retired from his service on 30.04.2020 and a sum of Rs.180/- was deducted from his salary towards the Health Insurance for the complainant and his family. The Tamil Nadu New Health Insurance was commenced in the year 2016 which attached the United India Insurance Company Limited and the Tamil Nadu new health insurance ID card was issued to the complainant and his family in ID card No.TLR/01/PB315/NHIS16/167063. In October 2019 the complainant’s wife had severe abdominal pain and had undergone laparoscopic assisted vaginal hysterectomy with RSO on 31.10.2019 in Billroth Hospital at Chennai and got discharged on 04.11.2019 and a sum of Rs.82,545.56/- was charged towards medical expenses. A sum of Rs.30,000/- was approved by the opposite party 1 and the balance Rs.52,545.56 was paid by the complainant. When the balance was claimed with the 1st opposite party he was informed that only Rs.30,000/- was payable under the scheme and the remaining amount will be sanctioned from the Tamil Nadu Police Benevolent fund and issued a certificate to that effect on 11.02.2020. The complainant approached the Tamil Nadu Police Benevolent fund special medical relief committee for the balance amount which was repudiated by the Superintendent of Police, Thiruvallur District arbitrarily on 19.09.2020 stating the Tamil Nadu Police Benevolent fund special medical relief not recommend for the sanction of financial assistance to the complainant from the fund as the disease for treatment is not covered under the life threatening ailment. Thus aggrieved the present complaint was filed for the following reliefs.
To direct the opposite parties to pay a sum of Rs.52,545.56/- spent by the complainant towards the medical expenses;
To pay a sum of Rs.25,000/- as compensation for the mental agony and hardship caused to the complainant;
To pay a sum of Rs.3,000/- as cost of the proceedings to the complainant.
On the side of the complainant proof affidavit was filed and documents were marked as Ex.A1 to A7. Despite service of notice the opposite parties 1 & 3 did not appear and they were called absent and set exparte for non appearance on 31.03.2022. The opposite party 2 though initially appeared through an Advocate and had filed Vakalath subsequently did not appear and hence he was also called asent and set exparte on 01.06.2022 for non appearance and for non filing of written version. Thus all the 3 opposite parties remained exparte.
Points for consideration:
1) Whether the repudiation of medical insurance claim of the complainant by the opposite parties 1 to 3 amounts to deficiency in service and whether the same has been successfully proved by the complainant?
2) If so to what relief the complainant is entitled?
Point No.1:
On the side of the complainant following documents were filed in support of his allegations;
Pay slip of the complainant for the month of January 2020 was marked as Ex.A1;
Identity card given by the United Insurance company limited was marked as Ex.A2;
Discharge summary of the complainant’s wife dated 04.11.2019 was marked as Ex.A3;
Medical bill dated 04.11.2019 was marked as Ex.A4;
Letter by the 1st opposite party to the 2nd opposite party dated 11.02.2020 was marked as Ex.A5;
Letter by the Administrative Officer Welfare Fund Committee dated 09.09.2020 was marked as Ex.A6;
Repudiation letter from the 2nd opposite party dated 19.09.2020 was marked as Ex.A7;
Written arguments filed by the complainant with an endorsement that the same may be treated as oral argument and hence this commission perused the pleadings and evidences and written arguments filed by the complainant.
On perusal of the documents filed by the complainant we could see that the complainant had filed his pay slip for the month of January 2020 to show that an amount of Rs.180/- has been deducted towards New Health Insurance Scheme. Ex.A2 is the ID card for the Health Insurance of the entire family members of the complainant which was issued by United India Insurance Company Limited under the Government of Tamil Nadu New Health Insurance Scheme – 2016. The proof of surgery undergone by the complainant’s wife Mrs.G.Kokila in the Billroth Hospital was submitted by way of Discharge Summary dated 04.11.2019 and the same marked as Ex.A3. In the said document under operative procedure it has been mentioned as “LAPAROSCOPIC ASSISSTED VAGINAL HYSTERECTOMY WITH RSO DONE UNDER GA ON 31.10.2019” and it is also seen that the complainant’s wife was admitted on 13.10.2019 and got discharged on 04.11.2019. The amount spent towards the surgery by way of in-patient final bill dated 04.11.2019 was produced by the complainant as Ex.A4 wherein the total bill amount was mentioned as Rs.82,545.56/- and it is also seen that Rs.52,546/- was paid as advance and Rs.30,000/- was the net amount payable. It is seen that the repudiation letter sent by the office of the Director General of Police, Tamil Nadu rejected the claim of the complainant stating that treatment undergone by the complainant’s wife was not covered under the life threatening aliment as the Tamil Nadu Police Benevolent Fund Medical Relief Central Committee which has not recommended for sanction of the same and it is also stated that the treatment does not satisfy the conditions stipulated in Chief Office circular memo in Rc.No.106867/TNPBF(1)/2009 dated 13.04.2010. But it was the case of the complainant that when the opposite party 1 issued a certificate dated 11.02.2020 stating that they have approved an amount of Rs.30,000/- based on the request from the Billroth Hospital which is a network hospital and that the procedure was covered under the scheme and also that they have No Objection in claiming the medical expenses apart from the Rs.30,000/- from the Tamil Nadu Police Benevolent Fund Medical Relief Central Committee/3rd opposite party, the 3rd opposite party should not to have rejected the claim of the complainant.
On appreciation of the documents and evidences produced by the complainant.
We are of the view that the claim of complainant has to be honoured under the New Health Insurance Scheme 2016, we could find that under the LIST OF DISEASES, TREATMENTS AND SURGERIES CLASSIFIED UNDER THE BROAD BASED SPECIALITIES under sub heading,
XI. GYNAECOLOGY
49. (a) Surgery for Removal of Uterus and under
50. (b) Surgery for Removal of Ovaries and Ovarian Cysts has been provided.
Further as per GO.Ms.No.202 FINANCE [Salaries] DEPARTMENT Dated 30th June 2016 it was provided that the enrolment under New Health Insurance Scheme, 2016 shall be compulsory to the employees and their eligible family members and that the employees and their eligible family members covered under the scheme shall avail assistance up to the limit of Rs.4,00,000/- in a block of four years commencing from 1-7-2016 as a CASHLESS model for the approved treatments/surgeries listed in the Annexure-II to this order, in the hospitals approved by the United India Insurance Company/Third Party Administrator. Thus, as per Ex.A2 it is amply proved that the wife of the complainant was very well covered under New Health Insurance Scheme and that as per the treatment papers the surgery undergone by the complainant’s wife was covered under the Insurance Scheme. As per the Annexure – III BILLROTH HOSPITAL, No.43, Lakshmi Talkies Road, Shenoy Nagar, Chennai-600 030 was recognised for treatment of Gynaecology and hence this commission finds that the repudiation of the medical claim for the balance amount by the 2nd opposite party on behalf of the 3rd opposite party in spite of recommendation by the 1st opposite party on the ground that the said treatment was not covered could not be accepted and the same amounts to deficiency in service. It is the view of the commission that when the policy has coverage for the medical claim of the complainant’s wife and when the treatment undergone is covered under Annexure –II of the concerned GO.Ms.No.202 FINANCE [Salaries] DEPARTMENT Dated 30th June 2016 and the hospital was also an approved hospital under the New Health Insurance Scheme 2016, the opposite parties ought not have been rejected the claim of the complainant. Thus we answer the point accordingly holding that the opposite parties 1 to 3 had committed deficiency in service in rejecting the medical claim of the complainant on some unreasonable ground against the G.O.Ms.No.202 dated 30.06.2016. Thus the point answered accordingly.
Point No.2:
With regard to the relief to be granted to the complainant as we have already held above that the rejection of the medical insurance claim was not proper, we direct the opposite parties to sanction a sum of Rs.52,546/- being the amount spent by the complainant towards the treatment. Further for the mental agony and hardship caused to the complainant by rejecting the insurance claim we award a sum of Rs.10,000/- as compensation and also we award Rs.3,000/- towards litigation expenses to the complainant.
In the result, the complaint is partly allowed directing the opposite parties 1 to 3;
a) to sanction a sum of Rs.52,545.56/- to the complainant within six weeks from the date of receipt of copy of this order;
b) to pay a sum of Rs.10,000/- (Rupees ten thousand only) towards compensation for mental agony caused to the complainant;
c) to pay a sum of Rs.3,000/- (Rupees three thousand only) towards litigation expenses to the complainant.
d) Amount in clause (a) to be paid within six weeks from the date of receipt of copy of this order failing which an interest of 6% will be levied on the said amount from date of 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 27th day of September 2022
Sd/- Sd/- Sd/-
MEMBER-II MEMBER-I PRESIDENT
List of document filed by the complainant:-
Ex.A1 ............... Pay slip of the complainant for the month of January 2020. Xerox
Ex.A2 ................ Identity card. Xerox
Ex.A3 04.11.2019 Discharge Summary. Xerox
Ex.A4 04.11.2019 Medical Bill. Xerox
Ex.A5 11.02.2020 Letter by the 1st opposite party. Xerox
Ex.A6 09.09.2020 Letter by the Administrative officer welfare fund committee. Xerox
Ex.A7 09.09.2020 Repudiation letter from the 2nd opposite party. Xerox
List of documents filed by the opposite parties:- Nil
Sd/- Sd/- Sd/-
MEMBER-II MEMBER-I PRESIDENT
