Date of Filing : 25.11.2021
Date of Disposal : 28.02.2023
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION
THIRUVALLUR
BEFORE TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law) .…. PRESIDENT
THIRU.P.MURUGAN,M.Com.ICWA(Inter),B.L., ....MEMBER-II
CC. No.08/2022
THIS TUESDAY, THE 28th DAY OF FEBRUARY 2023
Mr.D.Aaron, S/o.Devaraj,
No.31, STP Nagar,
New Thirupachur Village & Post,
Thiruvallur Taluk & District. ……Complainant.
//Vs//
1.The Branch Manager,
United India Insurance Company Limited,
No.168, J.N.Road, Thiruvallur – 602 001.
2.The Chief Educational Officer,
Thiruvallur District, Office of the Chief Educational officer,
Master plan Complex, Thiruvallur Town & District.
3.The District Dreasury Officer,
Thiruvallur District,
Office of the District Treasure Officer,
Taluk Office Campus,
Thiruvallur Town & District. …..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 27.02.2023 in the presence of Mr.A.R.Poovannan, Advocate counsel for the complainant and upon perusing the documents and evidences of complainant this Commission delivered the following:
ORDER
PRONOUNCED BY TMT. 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 non reimbursing the medical claim amount to Rs.2,28,525/- claimed by the complainant along with a prayer to direct the opposite parties to pay a sum of Rs.2,28,525/- spent by the complainant towards the medical expenses and to pay a sum of Rs.50,000/- towards compensation for the mental agony and hardship caused to the complainant and to pay a sum of Rs.3,000/- towards cost of the complaint.
Summary of facts culminating into complaint:-
It was the case of the complainant that he was working as Junior Assistant in Sundaram Higher Secondary School, Thirumizhisai, Thiruvallur District. It was submitted that a sum of Rs.180/- was detected from his salary towards the Health Insurance for him and his family. The Government of Tamil Nadu New Health Insurance was commenced in the year 2015 attached with the United India Insurance Company Limited. The New Health Insurance Identity Card was issued to the complainant and his family. During the month of October 2016 the complainant developed some pain in his legs and underwent a major surgery (Gangrene Right Great Toe with Necrotising fascilitis dorsal foot with planter abscess and Right great Toe amputation with major debridement) at Dr.V.Seshian Diabetes Research Institute at Chennai -29. It was submitted that he had spent more than Rs.2,28,525/- towards the medical expenses. Thereafter the complainant made a claim with the 3rd opposite party for the payment of the insurance amount through 2nd opposite party but the claim was repudiated by a letter of the 1st opposite party dated 03.03.2020. The complainant issued a legal notice to the opposite parties to take steps to sanction a sum of Rs.2,28,525/- spent by the complainant towards the medical expenses. As there was no response aggrieved by the act of the opposite parties the present complaint was filed for the following reliefs as mentioned below;
To direct the opposite parties to pay a sum of Rs.2,28,525/- spent by the complainant towards the medical expenses;
To pay a sum of Rs.50,000/- towards compensation for the mental agony and hardship caused to the complainant;
To pay a sum of Rs.3,000/- towards cost of the complaint.
On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A9. Though the 2nd opposite party filed Vakalath he has not filed any written version and hence he was called absent and set exparte on 30.05.2022. The 1st & 3rd opposite parties has not filed any Vakalath and written version and hence they were called absent and set exparte on 30.05.2022.
Points for consideration:
Whether the act of non reimbursement of the medical claim amount of Rs.2,28,525/- as claimed by the complainant by the opposite parties amounted to deficiency in service and whether the same has been successfully proved by him?
If so to what reliefs the complainant is entitled?
Point No.1:-
The following documents were filed on the side of complainant in support of his contentions;
Letter to District Treasury Officer, Thiruvallur and its Proceedings and correspondence dated 06.03.2017 was marked as Ex.A1;
Pay Statement of the complainant for the month of October 2019 was filed as Ex.A2;
Pharmacy Bill was marked as Ex.A3;
Pharmacy Bill was marked as Ex.A4;
Inpatient invoice summary dated 11.11.2016 was marked as Ex.A5;
Petition to the District Collector, Thiruvallur by the complainant dated 10.06.2019 was marked as Ex.A6;
Letter to District Collector, Thiruvallur by the 1st opposite party dated 03.03.2020 was marked as Ex.A7;
Legal notice issued by the complainant to the opposite parties dated 12.05.2021 was marked as Ex.A8;
Acknowledgement card for proof of delivery for the 3rd opposite party was marked as Ex.A9;
On the side of the 2nd and 3rd opposite parties the following document was filed in support of thie defence;
Copy of G.O.Ms.No.202 dated 30.06.2016 was marked as Ex.B1;
Heard the oral arguments adduced by the learned counsel appearing for the complainant and perused the written arguments, pleadings and evidences produced by him. The crux of the oral arguments adduced by the complainant is that the medical claim was declined by the opposite parties on the ground that the treatment was not taken in the net work hospital. Vide Ex.A7 the complainant had submitted the letter received from the 1st opposite party with respect to the complainant’s claim stating that the claim has been rejected as the patient admitted with the diagnosis of Gangrene left great toe and underwent great toe amputation in Dr.V.Seshiah Hospital, Chennai which is a non-network hospital. The diagnosis and line of management is not an emergency and hence the claim cannot be considered as per the GO 202 dated 30.06.2016. At this juncture, we come across a judgment rendered by the Hon’ble High Court, Madurai Bench in Marimuthu Vs Government of Tamil Nadu relating to Medical reimbursement of Government employees Under Health Insurance Scheme the impugned orders rejecting claim 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 in the order passed by the Hon’ble High Court, Madurai Bench, this commission holds that the claim of the complainant has to be considered and allowed based on the said directions. Non consideration of the claim and rejecting the same in the facts and circumstances clearly amounted to deficiency in service. Further it is also seen that amputation of Legs, Arms, Toes and Foot is covered very well under clause VII VASCULAR SURGERY in Serial No.37 of the G.O.Ms.No.202 dt.30.06.2016. In such circumstances, this commission holds that the opposite parties had committed deficiency in service in non reimbursement of the claim of the complainant.
Point No.2:-
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 claim for Rs.2,28,525/- 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.10,000/- as compensation which we thought would be appropriate in the facts and circumstances and also award Rs.3,000/- as litigation expenses to the complainant.
In the result, the complaint is partly allowed and the opposite parties 1 to 3 directing them jointly and severally
a) To consider the claim of the complainant and to pass necessary orders for remibursement of the claim for Rs.2,28,525/- based on the medical bills submitted by 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 the mental agony and hardship caused to the complainant;
c) to pay a sum of Rs.3,000/- (Rupees three thousand only) towards litigation expenses to the complainant;
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 28th day of February 2023.
Sd/- Sd/-
MEMBER-I PRESIDENT
List of document filed by the complainant:-
Ex.A1 06.03.2017 Letter to Disctict Treasury Officer, Thiruvallur and its proceedings and correspondence. Xerox
Ex.A2 ............... Pay slip of the complainant for the month of Oct 2019. Xerox
Ex.A3 11.10.2016 Pharmacy Bill. Xerox
Ex.A4 11.11.2016 Pharmacy Bill. Xerox
Ex.A5 11.11.2016 Inpatient Invoice Summary. Xerox
Ex.A6 10.06.2019 Petition to the District Collection, Thiruvallur by the complainant. Xerox
Ex.A7 03.03.2020 Letter to District Collector, Thiruvallur by 1st opposite party. Xerox
Ex.A8 12.05.2021 Legal notice issued by the complainant. Xerox
Ex.A9 Acknowledgement card. Original
Sd/- Sd/-
MEMBER-I PRESIDENT
