By Sri. MOHAMED ISMAYIL.C.V, MEMBER
The complaint is filed under Section 35 of the Consumer Protection Act, 2019.
1. It is averred that complainant is a retired person from State Government Service and subscribed membership in MEDISEP Scheme. As per the scheme, the complainant is entitled to get reimbursement of all treatment expenses undergone by him. On 08/09/2023, the complainant had hospitalised due to physical discomfort and it was diagnosed that he had affected with ailment of Acute Ischemic Stroke Right MCA Territory Watershed Infarcts. The complainant had underwent treatment at Aster MIMS Hospital, Kottakkal and discharged on 10/09/2023. It is averred that the complainant had submitted application before the opposite party to get reimbursed the treatment expenses incurred at Aster MIMS Hospital, Kottakkal. According to the complainant, he had spent about Rs.50,000/- for his treatment. It is alleged that even though the opposite party has received application along with required documents, no steps were taken to disburse the benefits of insurance coverage to the complainant. It is pleaded that the complainant had contacted the opposite party for several times through telephone and even issued notices, but they negligently treated the requests of the complainant. According to the complainant, the opposite party has committed deficiency in service causing mental agony and hardship to him. So the complainant prayed for directions to reimburse the expenses of treatment, to pay Rs.25,000/- as compensation for the act of deficiency in service and to pay Rs. 5000/- as cost of litigation.
2. The opposite party received notice on 06/05/2024, but failed to appear and submit version. Hence Commission treated the opposite party as exparte.
3. The complainant submitted proof affidavit in lieu of evidence. The documents from the side of the complainant are marked as Exts. A1 to A11. Ext.A1 document is the copy of ID card to show the subscription of MEDISEP Scheme by the complainant. Ext.A2 document is the copy of claim application submitted before the opposite party through Aster MIMS Hospital, Kottakkal. Ext.A3 document is the copy of discharge Summary issued from Aster MIMS Hospital, Kottakkal. Ext. A4 document is the copy of patient bill issued from Aster MIMS Hospital, Kottakkal. Ext. A5 document is the copy of Diagnostic report issued from Aster MIMS Hospital, Kottakkal. Ext. A6 document is the copy of Cardiology Investigation Report issued from Aster MIMS Hospital, Kottakkal. Ext. A7 document is the copy of Holter Monitor Report issued from Aster MIMS Hospital, Kottakkal. Ext.A8 document is the copy of Angiogram report issued from Aster MIMS Hospital, Kottakkal. Ext.A9 document is the copy of letter dated 06/06/2023 issued by the complainant to the opposite party. Ext. A10 document is the copy of letter dated 06/09/2024 issued by the complainant to the opposite party. Ext. A11 document is the copy of book let describing the details of MEDISEP Scheme.
4. Heard the complainant in detail. There was no appearance from the side of the opposite party. The Commission gone through entire documents on record and considered following points to adjudicate the matter:-
- Whether the opposite party has committed deficiency in service towards the complainant?
- Relief and cost?
5. Point No.(i) & (ii):-
The Commission is considering above points conjointly as those are correlated to each other. It has come out in evidence that as per Ext.A1 document the complainant has been subscribed MEDISEP Scheme to avail reimbursement of expenses which may incur for his treatment, if any ailment is affected. Being a retired Government Servant, it is mandatory on the part of the complainant to subscribe the said scheme. But, due to sudden physical discomfort the complainant was admitted into Aster MIMS Hospital, Kottakkal and treated for Acute Ischemic Stroke Right MCA Territory Watershed Infarcts. The date of admission was on 08/09/2023 and the date of Discharge was on 10/09/2023. The complainant has produced Ext.A3 document in that regard. Ext. A3 document would support the pleadings in the complaint. The grievance of the complainant is that the opposite party did not reimburse the amount incurred as expenses for his treatment. The complainant has produced Ext.A2 document to prove submission of application before the opposite party. Ext.A4 document produced by the complainant would show the details of expenses incurred for his treatment. Ext.A4 document explicitly reveal that the complainant had spent Rs. 29,730/- for his treatment. Ext.A5 to Ext.A8 documents also support the arguments of the complainant with regard to nature of treatment undergone by him at Aster MIMS Hospital, Kottakkal. There is no contra evidence availed in this case to rebut the evidence adduced by the complainant with respect to treatment undergone by him. So the Commission find that the complainant is eligible for reimbursement of expenses incurred for his treatment. So the act of withheld of benefit under MEDISEP Scheme is deficiency in service which had caused mental agony to the complainant.
6. The Commission find that the complainant has incurred Rs. 29,730/- as expenses for his treatment as per Ext.A4 document. So the complainant is entitled for Rs. 29,730/- from the opposite party. The Commission consider the fact that the person like that of the complainant need not run pillar to post to get redressed his grievance, after rendering service to the society during most precious time of his life. The MEDISEP Scheme is implemented to provide comprehensive insurance coverage to public servants in the State. Hence the right of the complainant cannot vitiated on frivolous excuses. The Commission find that the complainant had been made persistent attempts to get the benefit of the scheme. But no action was taken by the opposite party. It can be also seen that the opposite party had negligently treated need of the complainant even after issuance of notices which are marked as Ext.A9 and Ext.A10 documents. The opposite party is least interested in submitting the factual position of the grievance suffered by the complainant before this Commission. The Commission consider the act of the opposite party as highly arbitrary and untenable. Hence, considering sufferings of mental agony endured by the complainant, the opposite party is liable to pay compensation to the complainant. The Commission find that the opposite party is liable to pay Rs.25,000/- to the complainant as compensation for the sufferings of mental agony caused due to deficiency in service. Moreover the opposite party is also liable to pay Rs.5000/- to the complainant as cost of litigation. In the light of the deliberations made above the Commission allow the complaint in the following manner:-
- The opposite party is directed to pay Rs.29,730/- (Rupees Twenty nine thousand seven hundred and thirty only) to the complainant as cost incurred for treatment.
- The opposite party is directed to pay Rs.25,000/- (Rupees Twenty five thousandonly) as compensation for the sufferings of mental agony caused due to deficiency in service on the part of the opposite party.
- The opposite party is directed to pay Rs. 5000/- (Rupees five thousand only) to the complainant as cost of litigation.
The opposite party shall comply this order within 30 days from the date of this order otherwise entire amount shall carry interest at the rate of 9% per annum from the date of this order till the date of realisation.
Dated this 30th day of October, 2024.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A11
Ext.A1: Document is the copy of ID card to show the subscription of MEDISEP
Scheme by the complainant.
Ext.A2: Document is the copy of claim application submitted before the opposite
party through Aster MIMS Hospital, Kottakkal.
Ext.A3: Document is the copy of discharge Summary issued from Aster MIMS
Hospital, Kottakkal.
Ext.A4: Document is the copy of patient bill issued from Aster MIMS Hospital,
Kottakkal.
Ext.A5: Document is the copy of Diagnostic report issued from Aster MIMS Hospital,
Kottakkal.
Ext.A6: Document is the copy of Cardiology Investigation Report issued from Aster
MIMS Hospital, Kottakkal.
Ext.A7: Document is the copy of Holter Monitor Report issued from Aster MIMS
Hospital, Kottakkal.
Ext.A8: Document is the copy of Angiogram report issued from Aster MIMS Hospital,
Kottakkal.
Ext.A9 : Document is the copy of letter dated 06/06/2023 issued by the complainant
to the opposite party.
Ext.A10: Document is the copy of letter dated 06/09/2024 issued by the complainant
to the opposite party.
Ext.A11: Document is the copy of book let describing the details of MEDISEP
Scheme.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Nil
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
