Date of Filing     21.03.2024

                                                                                                             Date of Disposal: 23.07.2024

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.137/2024

THIS TUESDAY, THE 23^rd DAY OF JULY 2024

Mr.S.K.Pari, S/o.S.C.Kanniyappan,

Residing at No.119, Middle Street,

Podaturpettai town and post.

Palluputtu Taluk, Thiruvllur District.                                                     ......Complainant.

                                                                            //Vs//

The Divisional Manager,

United India Insurance Company,

5^th Floor, PLA Ratna Towers,

No.212, Anna Salai, Chennai 600 016.                                              .…..Opposite Party

Counsel for the complainant                        :    M/s.B.Thennarasu, Advocate.

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

This complaint coming before us on various dates and finally on 12.07.2024 in the presence of M/s.B.Thennarasu, counsel for the complainant and   M/s. J.Chelladurai Caldwell, counsel for the opposite party 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

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 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 party in not reimbursing the medical claim relating to the medical expenses of the complainant the present complaint was filed.

3. Complainant was working as Computer Instructor Grade-1 at Podadurpettai Government Girls Higher Secondary School under the control of Head Master of Government Girls Higher Secondary School, Podaturpettai. Being a Government servant he was a member of NHIS medical insurance scheme. His NHIS ID card number was TLR\01\SB555 NHIS16\1734476 and was paying monthly premium to the opposite party. On 01/09/2022 blood bleeding started through his urine, it was found that the complainant has got 0.10 Lakh/Cumm platelets count alone out of from 1, 50,000 Lakh/Cumm to 4,00,000 Lakh/Cumm. Therefore he was advised to take urgent immediate treatment at Chennai Sundram Medical Foundation, Anna Nagar. The complainant was admitted as an inpatient on 02/09/2022 in the Sundaram Hospital, Shanthi colony, Anna Nagar, Chennai as advised by the doctor for Immunoglobulin Therapy-IV. After due medication and treatment he was discharged on 05/09/2022 and as on the date of his discharge, his count of platelets was 2.35 Lakh/Cumm. For the aforesaid 4 days treatment he was charged Rs.5, 34, 055/- towards medical expenses and treatment and he was having bills for the same. Complainant is entitled to claim reimbursement of medical bills and all the expenses for medical treatment under the NHIS medical insurance policy scheme with the opposite party as a member of medical insurance policy scheme for the aforesaid amounts met by him for medical treatment The complainant has filed a claim petition through his drawing officer to the opposite party on 30/09/2022 to get reimbursement of the amount spent for his medical treatment but the opposite party refused to pay the amount and sent a letter to the complainant on 12/05/2023 and stated that he cannot claim entire bills stating above as per G.O.No.160 dated 30/06/2021 and returned the complainant’s request. The complainant submits that the date of G.O.NO.160 is not 30/06/2021 and the correct date of G.O.NO.160 is 29/06/2021 but the opposite party falsely stated as 30/06/2021 in his letter dated 12/05/2023 and further as per the said G.O.NO. 160 dated 29/06/2021, the complainant is entitled to get medical claim under the head of Medical care (1)(vii) Neurology, serial No. 171(55)(b) Immunoglobulin Therapy-IV as per Annexure-1 of List of Approved treatments and surgeries classified under the Board of Based specialties. The opposite party wantonly and negligently returned the claim petition knowing fully well that the complainant is eligible to get reimbursement of his medical bills of Rs. 5,34, 055/- from the opposite party, as per G.O.NO. 160 dated 29/06/2021. Hence, the complainant had issued a legal notice on 30/06/2023 through his counsel to the opposite party and demanded reimbursement of medical bills of Rs. 5,34, 055/- but the opposite party has not even sent any reply to the complainant's notice as on date. Thus aggrieved by the act of the opposite parties the present complaint was filed for the relief as mentioned above.

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

4. Admitting the insurance taken and the medical expenses made, it was submitted by the opposite party that this commission does not have jurisdiction to try the complaint. The Complainant's wife has done unnecessary medical procedures for the condition which could be easily cured by proper medication and exercise and therefore her claim could not be fully processed. As per the New Health Insurance Scheme 2016 according to the G.O. Ms.No. 160, dated 30.06.2021, to consider request for reimbursement as a case for treatment taken for Immune Thrombocytopenia and Steriod Induced Diabetes Mellitus is not eligible as per the GO.No.160 dated 30.06.2021. The Finance (Salaries) Dept., Secretariat, Chennai addressed to The Director of Treasuries and accounts, has issued orders that reimbursement shall be made only in cases for treatment taken and have occurred in the commencement stage subject to treatment taken in approved hospital's for approved listed procedures as per GO No.160 dated 30.06.2021. The 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 is just and genuine. The claim of Rs. 5,34,055/- is clearly excluded by the terms and conditions of the Policy and thus there is no deficiency of service and therefore complaint is liable to be dismissed.  If the Complainant was aggrieved by the claim amount issued by the Insurance Company/Opposite Party, remedy is available to him before the Insurance Ombudsman and while an alternative remedy is available to the Complainant herein, he is not entitled to approach this Hon'ble Consumer Disputes Redressal Commission. Thus they sought for the dismissal of the complaint.

5. On the side of complainant proof affidavit was filed and submitted documents marked as Ex.A1 to A10. On the side of opposite party proof affidavit was filed but no document was submitted on their side.

Points for consideration:-

1. Whether the rejection of the medical insurance reimbursement claim made by the complainant for his medical expenses amounts to deficiency in service on the part of opposite parties?
2. If so to what reliefs the complainant is entitled?

Point No.1:-

6. The complainant endorsed that their written arguments may be treated as oral arguments and hence the written arguments filed by the complainant was considered as oral arguments along with evidences produced by him. The main grievance of the complainant is that the medical claim was declined by the opposite party on the ground that the treatment was not covered as per GO.Ms.160 dated 30.06.2021. Vide Ex.A8 the complainant had submitted the letter received from the opposite party with respect to the complainant’s claim stating that the claim has been rejected as the complainant diagnosis of Immune Thrombocytopenia & Steriod Induced Diabetes Mellitus was not covered as per GO.Ms.160 dated 30.06.2021.

7. 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 of Government employees Under Health Insurance Scheme.  The impugned orders rejecting the medical claims were quashed and remanded with direction to the concerned District Level Empowered Committee for reconsideration.  In the said judgment direction has been issued for grant of claims 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 given 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 case, suitable orders shall be passed directing/recommending the State authorities to reimburse the claim under Medical Attendance Rules.”

 In view of the above directions 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 ejection the same in the facts and circumstances clearly amounted to deficiency in service.  In such circumstances, this commission holds that the opposite party had committed deficiency in service in not reimbursing the medical of the complainant without any valid reason for which he is legally entitled to.

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 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 as per Section 100 of the said Act.

Point No.2:-

8. As we have held above that the opposite party had committed deficiency in service we direct the opposite party to consider the claim of the complainant and to pass necessary orders for reimbursement of the claim for Rs.5,34,055/-based on the medical bills within 6 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.  We also award Rs.5,000/- as litigation expenses to the complainant.

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

a) To consider the claim of the complainant and to pass necessary orders for reimbursement of the medical claim for Rs.5,34,055/- 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.5,000/- (Rupees five 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 23^th day of July 2024.

      -Sd-                                                                                                                    -Sd-

  MEMBER-I                                                                                                      PRESIDENT

List of document filed by the complainant:-

       -Sd-                                                                                                                  -Sd-

MEMBER-I                                                                                                       PRESIDENT