Date of Filing      : 09.06.2023

 Date of Disposal : 06.10.2023

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

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

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

CC. No.53/2023

THIS FRIDAY, THE 06^th DAY OF OCTOBER 2023

Mr.R.S.Murugan,

S/o.M.SivathanuPillai,

No.6, Kalaivanar Street,

Vivekanadha Nagar,

Tiruvallur – 602 001.……Complainant.

                                                                                 //Vs//

United India Insurance Company Limited,

Rep. by its Senior Divisional Manager,

Door No.6, PLA,

Rathna Towers, 5^th Floor,

212, Anna Salai,  Chennai 600 006.…..opposite party.

Counsel for the complainant                        :   M/s.S.Muthukumaravel, Advocate.

Counsel for the opposite party    :   exparte

This complaint coming before us on various dates and finally on 26.09.2023 in the presence of M/s.S.Muthukumaravel counsel for the complainant and the opposite party was set ex-parte for non-appearance and for non-filing written version and upon perusing the documents and evidences of the complainant’s side 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 party fornon-reimbursement of the Medical Insurance Claim made by the complainant along with a prayer to direct the opposite party to pay a sum of Rs.65,246/- being the balance payment towards the treatment expenses, to pay a sum of Rs.50,000/- towards compensation for the mental agony and pain caused to the complainant, to pay a  sum of Rs.50,000/- towards compensation for the unjustified refusal of the claim of the complainant, to pay a sum of Rs.50,000/- towards compensation for delayed payment or payments through the instalments for the claim of the complainant along with cost of the proceedings to the complainant.

Summary of facts culminating into complaint:-

2. Complainant was a pensioner vide Pensioner Identity No.C325978/PW.  The complainant had taken a policy with the opposite party according to G.O.No.222 dated 30.06.2018 under New Health Scheme for pensioners. Premiums were deducted through Treasury where the complainant’s pension was credited and thus availed policy No.010600/28/18/P104512726 with coverage to an extent of Rs.4,00,000/- for the period of 2018 till 2022.  Complainant had suffered stomach Pain and approachedBillrothHospital, Chennai where he was diagnosed with CA-SIGMODCOLON and on 11.02.2020 surgery was done by Doctor S.M.Sivaraj and discharged on 21.02.2020 which was one of the listed Hospital of the opposite partyfor cash less treatment. Complainant was allowed to take the treatment as per the norms of the opposite party by paying cash in advance and the total treatment expenses comes to Rs.3,12,925/-.  Out of the said amount the complainant had paid Rs.2,87,926/- in advance to the Billroth Hospital and the opposite party settled a sum of Rs.1,75,000/- directly to the Billroth Hospital but failed to pay the balance amount of Rs.1,37,926/-. Complainant made request for reimbursementof Rs.1,37,926/- but there was no reply from the opposite party.  A reminder letter was posted on 15.03.2021 to the District Collector for sanction of balance claim of Rs.1,37,926/- and after several reminder letters an amount of Rs.72,679/- was paid on 25.06.2021. After several communications and through the RTI the complainant had got reply from the opposite party dated 18.04.2022 stating that maximum amount of Rs.72,679/- was already paid and there was no further amount to be paid. Thus aggrieved by the act of the opposite party the present complaint was filed to direct the opposite party for thereliefs as mentioned above.

3. On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A11.  Though notice was served to the opposite party on 26.06.2023 he did not appear before this Commission to file any written version and hence he was called absent and was set ex-parte on 04.08.2023 for non-appearance and non-filing of written version within the mandatory period.

Points for consideration:

1. Whether refusal by the opposite party for reimbursement of the Medical Insurance Claim made by the complainant amounts to deficiency in service on the part of the opposite party and whether the same has been successfully proved by the complainant by admissible evidence?
2. To what reliefs the complainant is entitled?

4. Point No.1:-

The following documents were filed on the side of complainant in support of her contentions;

1. Discharge Summary issued by the Billroth Hospital dated 21.02.2020 was marked as Ex.A1;
2. Copy of Bill was marked as Ex.A2;
3. In-Patient Final Bill dated 21.02.2020 was marked as Ex.A3;
4. Letter issued by District Medical Board Office of the Joint Director of Health Services to the complainant dated 03.12.2020 was marked as Ex.A4;
5. Claim payment statement dated 21.03.2020 was marked as Ex.A5;
6. Letter from the complainant to the District Treasury Officer dated 10.03.2020 was marked as Ex.A6;
7. Letter to sanction of reimbursement of medical bills to the opposite party dated 17.02.2021 was marked as Ex.A7;
8. Reminder letter to sanction of reimbursement of medical bills to the opposite party dated 15.03.2021 was marked as Ex.A8;
9. Letter from opposite party to the District Collector, Thiruvallur dated 19.03.2021 was marked as Ex.A9;
10. Reference letter Na.Ka.No.14801/2020/R3 from Collectorate, Thiruvallur dated 16.04.2021 was marked as Ex.A10;
11. Letter from RTI department of opposite party regarding RTI was marked as Ex.A11;

5. The complainant filed written arguments with an endorsement to treat the same as oral arguments.

6. We perused the pleadings and material evidences produced by the complainant in support of his claim.   The crux of the complainant is that he had taken policy with the opposite party as per G.O.Ms.No.222 dated 30.06.2018 under the New Health Scheme for pensioners.  The premium amounts were deducted from Bank Account directly where the pension amounts were credited.  The policy period covered from 2018 to 2022 for a total coverage amount of Rs.4,00,000/-.  While so, the complainant took treatment for CA-SIGMODCOLON in Billroth Hospitalsand the date of admission was 10.02.2020 and discharged on 21.02.2020 well within the period of coverage.  The date of surgery was 12.02.2020 and total Medical expenses comes to  Rs.3,12,925/- out of which Rs.2,87,926/- was paid in advance by the complainant.  The opposite party refunded and settled a sum of Rs.1,75,000/- directly to the Billroth Hospital but failed to pay Rs.1,37,926/-.  However, after several representation to various authorities an amount of Rs.72,679/-was paid on 25.06.2021 out of Rs.1,37,926/-.  Thus for the remaining amount of Rs.65,246/- the present complaint was filed.

7.  The argument by the complainant was that he had produced all the necessary original documents to the opposite party for reimbursement and had provided all necessary informations before availing the policy and hence the opposite party’s act of non-reimbursement of the Medical Claim in entirety for the complainant amounts to clear deficiency in service.  Further he submitted that from the year 2018 to 2022 there was no irregularity in the submission of documents by the complainant to the opposite party.  Thus he sought for the complaint to be allowed as prayed for.

8. On appreciation of the entire pleadings and evidences submitted by complainant we could see that as per medical records vide Ex.A1, the complainant had undergone Medical procedure “DIAGNOSTIC LAP ANTERIOR RESECTION UNDER SPINAL ANESTHESIA DONE ON 12.02.2020” in Billroth Hospital.  Further vide Ex.A3 In-patient Final Bill, the total amount spent by the complainant towards the surgery was mentioned as Rs.3,12,925/-.  The complainant approached the District Medical Board, Office of the Joint Director of Health Services which document was also submitted as Ex.A4 wherein the decision rendered by the High Court Madurai Bench in W.P.(MD).No.13429/2013 in S.MarisuthuVs Government of Tamil Nadu dated 28.05.2019 has been highlighted.  Ex.A9 is the letter sent by the opposite party to the District Collector where it was mentioned that the reason for non-reimbursement as “documents requested”.

9. However, it was the specific case of the complainant that he had already produced all the necessary original documents with the opposite party and in Ex.A10, the letter sent by the District Collector, Thiruvallur dated 16.04.2021 it has been clearly mentioned as follows;

gzpahsu;fs; kw;Wk; Xa;T+jpau;fSf;fhdGjpakUj;Jtfhg;gPLjpl;lj;jpd; khtl;lmstpyhdNky;KiwaPl;L FO $l;lk; 06.01.2021 md;Wkhtl;lMl;rpau; (khtl;lmstpyhdmjpfhukspf;fg;gl;l FO $l;ljiytu;) mtu;fs; jiyikapy; cWg;gpdu; nrayu; (JDES)>cWg;gpdu; (TO) mtu;fSld; eilngw;wJ. ,f;$l;lj;jpy; rku;g;gpf;fg;gl;ljq;fspd; Nky; KiwaPl;LkDkPJkhtl;lMl;rpau; jpUts;Su; (khtl;lmstpyhdmjpfhukspf;fg;gl;l FO $l;ljiytu;) mtu;fshy; ,izg;gpy; fz;Ls;sthWKbTNkw;nfhs;sg;gLfpwJ.

vdNt>Nkw;gb ,izg;gpy; mry; Mtzq;fSk; ,j;Jld; jpUg;gpaDg;gLfpwJ.  ,izg;gpy; Nfhug;gl;Ls;smidj;JMtzq;fisAk; ghu;it– 2y; (United India Insurance Co.Ltd., Divisional Office VI, PLA Rathina Towers, 5^th Floor, 212, Anna Salai, Chennai-06) njuptpf;fg;gl;Ls;skUj;Jtfhg;gPLepWtdj;jplk; Neupilahfrku;g;gpj;J>kUj;Jtepthuznjhifngw;Wf; nfhs;snjuptpf;fg;gLfpwJ.

10. Thus when the entire original documents were submitted with the opposite party and when the total coverage for the expenses is Rs.4,00,000/- and when there is no evidence that the complainant had utilized any amount out of Rs.4,00,000/-, there is no valid reason for the opposite party to restrict the reimbursement claim of the complainant to only Rs.72,679/-.

11.  In Ex.A11 the opposite party had stated as follows;

The reimbursement claim of Mr.R.S.Murugan for the treatment taken in Billroth Hospital during the period of 10.02.2020 to 20.02.2020 has been processed vide MD 14186487 and maximum eligible expense for this treatment as per GO.No.222 dated 30.06.2018 has been processed and the claim has been settled for Rs.72,679/- vide UTR No.21192506615 dated 24.06.2021.

12. The opposite party had not appeared and no plausible explanation or reason was given for restricting the reimbursement claim to Rs.72,679/-.  Thus, when the opposite party had not disputed the coverage for the surgery undergone by the complainant and the place of treatment/Network Hospital there is no reason for the opposite party to restrict the claim to a certain amount when the entire expenses of Rs.3,12,925/-could be covered under 4,00,000/-, the act of the opposite party in not reimbursing the entire Medical insurance claim of the complainant amounts to clear deficiency in service.

13. In such circumstances the claim of the complainant for the balance amount of Rs.65,246/- could not be termed as out of coverage when the complainant had taken treatment in a network Hospital as provided in the GO and also that the aliment was covered under G.O.Ms.No.202 dated 30.06.2016.  Thus we answer the point accordingly in favour of the complainant and as against the opposite party.

Point No.2:-

14. As we have held above that the opposite party had committed deficiency in service we direct the opposite party to reimburse the balance amount to the complainant and for the mental agony and hardship caused to the complainant making him to approach several authorities pillar to post we award a compensation of Rs.25,000/- to be paid by the opposite party along with cost of Rs.5,000/- towards litigation expenses to the complainant.

In the result, the complaint is partly allowed against the opposite party directing him

a) To reimburse the balance amount of Rs.65,246/- (Rupees sixty five thousand two hundred forty six only) to the complainant by the opposite party 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 party within six weeks from the date of receipt of copy of this order the amount shall carry interest at the rate of 9% from the 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 06^th day of October 2023.

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MEMBER-I                                                                                                   PRESIDENT

List of document filed by the complainant:-

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MEMBER-I                                                                                                    PRESIDENT