Date of filing : 10.03.2021
Date of order : 13.10.2022
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, VELLORE
PRESENT: THIRU. A. MEENAKSHI SUNDARAM, B.A., B.L. PRESIDENT
THIRU. R. ASGHAR KHAN, B.Sc., B.L. MEMBER – I
SELVI. I. MARIAN RAJAM ANUGRAHA, M.B.A., MEMBER-II
THURSDAY THE 13th DAY OF OCTOBER 2022
CONSUMER COMPLAINANT NO. 5/2021
A.V. Balaji,
Son of A.M. Venkatesan,
No. 1/168, Thirumalai Nagar,
Anadalai Village, Walaja Taluk,
Ranipet District. ...Complainant
-Vs-
The United India Insurance Co. Ltd.,
Represented by its Present Divisional Manager,
Divisional Office, PLA Ratna Towers,
5th Floor, 212, Annasalai,
Chennai – 600 006. ...Opposite party
Counsel for complainant : Thiru. N. Maruthi Jayakumar
Counsel for opposite party : Thiru. L. Pandurangan
ORDER
THIRU. A. MEENAKSHI SUNDARAM, B.A.,B.L. PRESIDENT
This complaint has been filed Under Section 35 of Consumer Protection Act 2019. The complainant has prayed this Hon’ble Commission to direct the opposite party to pay a sum of Rs.1,71,000/- incurred by the complainant for the treatment of his mother, and to pay a sum of 1,00,000/- as compensation for the mental agony, physical torture and loss caused by the deficiency of service by the opposite party.
1.The case of the complaint is briefly as follows:
The complainant is a government employee, the complainant and his eligible family members are covered under the New Health Insurance Scheme 2016 framed and floated by the Government of Tamil Nadu through the opposite party Insurance company. The said scheme provides health care assistance for employee and their eligible members with a provision to avail assistance upto the limit of Rupees Four Lakh in a block period of four years commencing from 01.07.2016. The government servants shall avail assistance in the hospitals approved by the opposite party and the Xerox copy of Go.Ms.No. 202 dated 30.06.2016 is also filed herewith for the perusal of this Hon’ble court. The complainant’s mother’s namely Valliyammai suffered from Degenerative Grade-I Spondylolisthesis with L-4 L-5 with Right Caludication. Since the said Valliyammal is suffering from the ailment, the complainant admitted her in Gleneagles Global Health City, No.439, Cheran Nagar, Sholinganallur-Medvakkam Road, Perumbakkam, Chennai. She underwent a surgery of Right interlaminar L4-L5 percutaneous Endoscopic Lumbar Decompression and over the top Decompression done under GA on 30.6.2020. A sum of Rs.2,46,000/- incurred for the said treatment and the said Hospital sent proposal to the opposite party through the help line, namely MD India Health Insurance TPA Private Limited, Guna Complex, No.433 & 445, Anna Salai, Tenampet Chennai as the said Valliyammal is covered under the New Health Insurance Scheme 2016, as she is the mother of the complaint who is a Government employee. Under the said Insurance scheme, the opposite party settled only a sum of Rs.75,000/- even though the treatment given for the said Valliyammal is a sum of Rs.2,46,000/- and also policy covers a sum of Rs.4,00,000/- to the Government employee and his eligible members. Since, the opposite party failed, evaded and neglected to settle the remaining sum of Rs.1,71,000/- the complainant had paid the said sum out of his pocket and due to the irresponsible act of the opposite party, the complainant had been put to untold hardship and mental agony. Though the said Valliyammal is a eligible member of the family of the complainant and also the fact that she had not undergone similar kind of surgery for the past four years, the opposite party should have settled the entire medical expenses incurred by my client for her, viz., Rs.2,46,000/- to the said hospital. The receipt given by the said Hospital for the sum of Rs.1,71,000/- for the perusal of this Hon’ble Commission. The authorisation letter-2 from Gleneageles Global Health City Hospital showing the payment made by the complainant. The act of not paying the entire medical bill by the opposite party is highly illegal and unlawful and it has no sanction at law. The complainant is a Consumer as defined under section 2 (d) of the Consumer Protection Act. Therefore, the opposite party had committed deficiency of service towards the complainant who is and whose eligible family members are covered under the said Health care Insurance scheme 2016. Hence, the complainant had been forced to issue a notice dated 09.07.2020 to the opposite party calling upon him to pay the said sum of Rs.1,71,000/- to the complainant and the copy of the said notice had been sent to the Chief Minister’s special cell. The opposite party received the said notice but failed and neglected to comply with the contents of the same. The opposite party has not chosen to give reply notice also. The opposite party had committed deficiency of service towards the complainant by not paying the entire bill amount incurred for the treatment is the mother of the complainant in terms of the above said G.O Ms.No.202, dated 30.06.2016. The complainant has no other way to get back the amount partially incurred by him for a sum of Rs.1,71,000/- for the treatment of his mother from the opposite party. since, the opposite party failed, neglected and evaded to pay the remaining bill amount of Rs.1,71,000/-, it amounts to deficiency of service and therefore filing of this complaint Under section 35 of the Consumer protection Act as against the opposite party herein has been necessitated. The complainant claims a sum of Rs.1,00,000/- as compensation for the deficiency of service committed by the opposite party towards the complainant. Hence this complaint.
2.The written version of opposite party is as follows:
As per the G.O.Ms.No.202 dated 30.06.2016 in Annexure–I para-18, incorporated hereunder for clear reading and to get understand that “The Civil Courts situated in Chennai shall have exclusive jurisdiction over any grievance / dispute, remaining unresolved after following the procedures stated in para 15 to 17”. Hence, this Hon’ble Commission is barred to take this case on file. The above contention stated in the complaint of the complainant that he and his family members covered under the New Health Insurance Scheme introduced by the Tamil Nadu Government Under I.D. Card No.VEL/01/SB5 H0/NH1S16/2053511 in view of the G.O. 202 dated 30.06.2016 for the slot and block period of 4 years commencing from 01.07.2016 to 30.06.2020 on cashless treatment for the diseases mentioned, in the Empanel Hospital on specified cost for those diseases implemented through the United India Insurance Company Ltd., Chennai who are specifically having an officer the third party administrator as per Annexure-I and II of the said G.O. The cost of bill of expenditure treated for the disease up to Rs.4,50,000/- and Rs.7,50,000/- for the total block period to the persons of the I.D.Card Holder in total. In the above circumstances, that the mother of the policy holder, seems to have admitted for known ailment on 29.06.2020 and got surgery on 30.06.2020 in the Empanelled Hospital at Perumbakkam and said to be incurred to cost of Rs.2,46,000/- by the opposite party paid only Rs.75,000/- is true. Because that third party administration officer approved only to the above extent on the alleged expenditure incurred, and recommended by the Hospital authority. Because, the recommended and approval made by TPA, only to clear and pay a sum of Rs.75,000/- as the charges fixed on the Tabulation of diseases for operation and for surgeries in the empanelled Hospital as G.O.Ms.No.202 dated 01.07.2016. Hence, that there was no deficiency in service on the part of this opposite party and hence not chosen to give reply notice to the complainant’s notice dated 09.07.2020. Further, if any dispute arose in view of the above the party grievance as stated in para 15,16 and 17 mentioned in the said G.O.Ms.202 dated 30.06.2016 committees organized under District level, State level and then grievance on prima facie. Even if any against this opposite party this commission has no jurisdiction as per para 18 of the said G.O. Hence, this Hon’ble Commission has no jurisdiction to entertain the case of this complaint against law and on facts of the above. If at all spent or given or paid more money beyond the fixed and agreed rates for the surgeries mentioning in the empanel Hospital of this opposite party as per the G.O., the same to be reimburse from the said hospital only who charged in excess and no doubts that this opposite party will not bound to pays in excess beyond the authorized amount by the third party administrator. Hence, in such case, in the above circumstances that the Tamil Nadu Government and the Hospital given treatment to the patient should also be as proper and necessary parties before the Civil Court at Chennai and not before this commission as per para 18 of the G.O. No negligence, deficiency nor delay in any kind towards the complainant, and this opposite party paid and cleared the amount of Rs.75,000/- towards hospital bills on the recommendation of the third party officer/administrator of NHIS-2016 implemented by Tamil Nadu Government. This opposite party is not liable to pay any amount to the complainant as mentioned in the complaint Rs.2,71,000/- medical expenditure balance amount Rs.1,71,000/- and the alleged compensation estimated. Hence, this Hon’ble commission may be dismissed the complaint.
3. Proof affidavit of complainant filed. Ex.A1 to Ex.A12. Proof affidavit of opposite party filed. No Document was not filed by the opposite party. Written arguments of both sides filed. Oral argument of opposite party side heard.
4.The points that of arises for consideration are:
1. Whether there is any deficiency in service on the part of the opposite
party?
2. Whether the complainant is entitled for relief as claimed in the complaint?
3. To what relief complainant is entitled to?
5. Point Nos. 1&2: The complainant is a Government servant, as per the G.O. Ms. No. 202 dated 30.06.2016. The complainant and his eligible Family Members are covered under the New Health Insurance Scheme -2016 framed by the Government of Tamil Nadu through the opposite party herein. For easy understating the relevant portion of G.O. opposite party hereunder:-
Ex.A4 (iv) The employee and their eligible family members covered under the scheme shall avail assistance upto the limit of Rupees four Lakh in a block of four years commencing from 01.07.2016 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 and listed in the Annexure –III to this order;
However, the assistance shall be upto Rupees Seven Lakh and Fifty Thousand for illnesses listed out in Annexure II-A to the order;
The upper limit of medical assistance for cataract surgery shall be Rs.25,000/- per eye. In respect of Hysterectomy (uterus removal surgery) the upper limit of medical assistance shall be Rs.45,000/-.
The overall limit of assistance, in any case shall not exceed Rupees Seven Lakh and Fifty Thousand for a family in a block of four years under this scheme.
In view of the aforesaid claim, the employee and his family members are eligible to avail financial assistance upto Rs.4,00,000/- for a period of four year from 01.07.2016. In the present case, the mother of the complainant suffered from Degenerative Grade-I Spondylolisthesis for which he has incurred Rs.2,46,000/- for her treatment. The complainant communicated the same to the opposite party. The opposite party also approved the treatment given to the complainant’s mother and expense incurred by the complainant, the only defence raised by the opposite party is that whatever amount approved by the third opposite party administrator we have paid. The third opposite party administrator approved only 72,000/- same was paid to the complainant. In this regard we have perused Annexure-I of the G.O. which read as follows:
12 (b) The approved Hospitals, the Liaison Officers of the United India Insurance
Company Limited / Third party Administrator and the Toll Free Helpline No.1800
233 5666 of Insurance Company / Third Party Administrator shall be informed for
the approved treatments / surgeries to be undertaken so that pre-authorisation is
given by the Insurance Company / Third Party Administrator under the control of
the United India Insurance Company Limited, Chennai. In case of emergency
only, the approval of the Insurance Company / Third Party Administrator for the
accredited treatments / surgeries undertaken in the approved hospitals shall be
obtained for settlement on CASHLESS basis during the period commencing from
the date of admission in the approved hospitals as in-patient to the date before
discharge from the hospital.
On plain reading of the aforesaid claim we find that approval may be given either by the Insurance Company or by the third party administrator. Therefore, the defence raised by the opposite party cannot be sustained. Further, the complainant gave a complaint to the Chief Minister’s Special Cell in this regard. In the reply dated 25.08.2020 given by the Government Tamil Nadu mentioned that the complainant medical expenses towards his mother’s treatment was fully approved. Therefore, we find that the opposite party cannot raise the defence that the claim was not approved by the Government. Hence, we find that there is a deficiency in service on the part of the opposite party. Hence, these Point Nos.1 and 2 are decided in favour of the complainant.
6. POINT NO.3: As we have decided in Point Nos.1 and 2 that there is deficiency in service on the part of the opposite party. The opposite party is hereby directed to pay Rs.1,71,000/- (Rupees One Lakh Seventy One Thousand only) and to pay a sum of Rs.1,00,000/- (Rupees One Lakh only) as compensation for deficiency in service and mental agony and also to pay a sum of Rs.25,000/- (Rupees Twenty Five Thousand only) towards cost to the complainant. Hence, this Point. No.3 is also answered accordingly.
7. In the result, this complaint is allowed. The opposite party is hereby directed to pay Rs.1,71,000/- (Rupees One Lakh Seventy One Thousand only) and to pay a sum of Rs.1,00,000/- (Rupees One Lakh only) as compensation for deficiency in service and mental agony and also to pay a sum of Rs.25,000/- (Rupees Twenty Five Thousand only) towards cost to the complainant, within one month from the date of receipt of this order, failing which the above amounts shall carry interest at the rate of 9% per annum from the date of this order to till the date of realization.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us in the open Commission on this the 13th October 2022.
Sd/- Sd/- Sd/-
MEMBER –I MEMBER-II PRESIDENT
LIST OF COMPLAINANT SIDE DOCUMENTS:
Ex.A1 - Copy of the Aadhar card of the complainant
Ex.A2 - Copy of identity card of the complainant
Ex.A3 - Copy of the Health Insurance ID card of the complainant
Ex.A4-30.06.2016 - Copy of G.O. Ms. No. 202
Ex.A5 - Copy of Discharge Summary of the Complainant’s mother
namely Valliyammal
Ex.A6-29.06.2020 - Copy of receipt for a sum of Rs.30,000/-
Ex.A7-30.07.2020 - Copy of receipt for sum of Rs.30.07.2020
Ex.A8-30.7.2020 - Copy of the receipt for a sum of Rs.41,000/-
Ex.A9-03.07.2020 - Copy of Authorisation letter given by gleneageles global Health
Chennai - 600 100.
Ex.A10-09.07.2020- Office copy of the lawyer’s notice along with postal receipt
Ex.A11 - Copy of postal Acknowledgement of the Chief Minister’s Special
Cell, Chennai
Ex.A12 - Copy of reply delivered from Chief Minister’s Special Cell
LIST OF OPPOSITE PARTY SIDE DOCUMENTS: -NIL-
Sd/- Sd/- Sd/-
MEMBER –I MEMBER-II PRESIDENT
