State Consumer Disputes Redressal Commission
The Manager, Star Health And Allied ... vs Dr.S.Thilagar, Assistant Professor Of ... on 28 January, 2015
IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, MADURAI BENCH.
Present: Thiru.A.K. ANNAMALAI, M.A.M.L.,M.Phil.,Presiding Judicial Member.
Thiru.S.SAMBANDAM, Member.
F.A.No.289/2012
(F.A.No.1006/2011 on the file of State Consumer Disputes
Redressal Commission, Chennai)
(Against the order in C.C.No.26/2011 dated 14.10.2011 on the file of DCDRF,
Kanyakumari @ Nagercoil.)
WEDNESDAY, THE 28th DAY OF JANUARY 2015.
Manager,
Star Health and Allied Insurance Company Ltd.,
No.-2 - A, (Old No.64-A),
Ganga Nagar Road,
Opposite to BSNL Office,
Kodambakkam,
Chennai - 600 024. Appellant/1st Opposite party
Vs
1. Dr.S. Thilagar,
Assistant Professor of Medicine,
Kanyakumari Government
Medical College Hospital,
Acharipallam, Kanyakumari District. 1st Respondent/Complainant
2. District Collector,
Kanyakumari District.
Nagercoil. 2nd Respondent/2nd Opposite Party
Counsel for Appellants/1st Opposite Party : Mr. S.Suresh, Advocate.
Counsel for 1st Respondent/Complainant : M/s. V. Janaki Ramulu, Advocates.
Counsel for 2nd Respondent/2nd OP : Mr.M. Alaguthevan, Advocate.
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This appeal is coming before us for final hearing on 14.10.2014 and on
hearing the arguments of both sides and upon perusing the material records this
Commission made the following:
ORDER
THIRU. A.K.ANNAMALAI, PRESIDING JUDICIAL MEMBER.
1. The 1st opposite party is the appellant.
2. The complainant/1st respondent filed a complaint before the District Forum alleging negligence and deficiency in service against the opposite parties in non-sanctioning of mediclaim amount for the treatment taken for his deceased son from the 1st opposite party through the insurance claim.
3. When the complaint enquired by the District Forum, on the basis of both sides materials among the President and two Members of the Forum, Two Members have passed a majority order by allowing the complaint directing the opposite parties to pay a sum of Rs.78,301/-towards the claim amount and Rs.10,000/-as compensation for mental agony with costs of Rs.1000/-.
4. Per contra, the President of the Forum having minority view dismissed the complaint by accepting the contentions of the opposite parties.
5. Against the contra order passed by the Members and the President, aggrieved by the impugned order the 1st opposite party alone has come forward with this appeal contending that the majority order passed by the District Forum by allowing the complaint is not sustainable since the claim of the complainant is relating to the cashless treatment scheme of the insurance and thereby the 3 complainant cannot claim any reimbursement of the amount spent towards his deceased son treatment without producing permitted medi-claim identity card to avail the cashless benefits treatment and thereby he claimed the amount belatedly for the treatment and thereby the complaint is to be dismissed by setting aside the majority order passed by the Members of the District Forum.
6. We have heard both sides' arguments, contentions and perused the written statements and considered the materials placed before us in this regard. The learned counsel for the 1st respondent/complainant argued that due to grief of the complainant's son, he was not in a position to inform the 1st opposite party immediately regarding the treatment taken and claim to be made and in this regard relied on a ruling of the State Consumer Disputes Redressal Commission, Punjab, Chandigarh in the case of National Insurance Co., Ltd., & Ors. - Vs - Balwant Singh, dated 29.10.2013, (as per the Page-1, Mobile View taken from internet), it is held as follows: "Since the complainant had suffered a heart attack and was taken to the hospital under emergent conditions where he underwent International Cardiology Operation it can be easily understood that the attendants of the complainant may not be in a position to produce the ID card or they were even not aware of the fact that the complainant was covered under any medi-claim policy. There is no provision in the terms and conditions of the policy dealing with such emergent situation where the complainant or his attendants failed to produce the ID card at the time of admission in hospital. When the complainant is duly entitled for cashless treatment, he cannot be 4 denied the benefit of scheme just because the ID card could not be produced or the treating hospital could not get the permission of the TPA for cashless treatment. No prejudice has been caused to the appellants on account of expenditure for the treatment having been borne by the complainant in the first instance instead of availing the cashless facility. It is obvious that the claim of the complainant has been declined purely on the technical ground which was otherwise admissible. He cannot be deprived of the benefit under the scheme merely on insignificant technical lapse on the part of the attendants of the complainant". While considering the facts and circumstances of the case, the ruling though applicable in general may not be helpful to the complainant since our case is relates to the medical benefits given by the Government of Tamil Nadu under the Tamil Nadu Government Employees New Health Insurance Schemes medi-claim policy for which reimbursement to be made to the hospital by the 1st opposite party unless the beneficiary shall comply the rules and regulations under the Tamil Nadu Medical Rules within the prescribed time limit otherwise the beneficiary has to approach the Government in this regard and thereby the above ruling will not be helpful to the complainant.
7. It is the case of the complainant that he was a member of the Tamil Nadu Government Employees New Health Insurance Scheme covering his family members as beneficiaries and for which the premium being recovered from his salary as Assistant Professor of Medical College and his son one T.K. Dinesh sustained head injury due to accident on 29.03.2010 was admitted in Thiraviam 5 Hospital, Nagercoil and subsequently shifted to Ananthapuri Hospital, Thiruvananthapuram and he was not in a position to inform about the accident to the 1st opposite party and subsequently his son died on 31.03.2010 and due to his death he was in confused stage and restless manner and not in a position to communicate immediately to the 1st respondent and thereafter on 24.05.2010, the complainant sent a letter for claiming refund of expenses through the 2 nd opposite party and it was rejected by the 1st opposite party on 26.10.2010 and sent to the 2nd opposite party by stating that since the conditions of the claim was violated and the accident was not immediately informed since the patient was admitted in the hospital and thereby alleging negligence claimed the amounts. The 1st opposite party explaining the scheme as per the G.O.Ms.No.174, Finance (Salaries) Department dated 28.04.2008, the members are entitled for up to Rs.2,00,000/- for 4 years as cashless basis without paying any amount at the time of admission in the hospital and the 1st opposite party being the insurer was paying the amount directly to the hospital and thereby the complainant's request was received on 01.06.2010 for the treatment taken from 29.05.2010 to 31.03.2010 which was not intimated to the appellant and also not followed the rules as per Government Order without producing the identity card, Pay Drawing Officers certificate in the hospital to take the treatment and thereby the request of the complainant for refund of the amount cannot be entertained and thereby only remedy is available to approach the Government in this regard and for this the appellant relied on the rulings and precedents of this Commission 6 and as per the order passed in Writ Appeal No. 480/2009 by Hon'ble High Court of Madras, Madurai Bench, in which it is observed as follows:
"Therefore, if the claimants have made payment whether for a procedure not covered or whether at a non-network hospital or they have paid when they have been treated for a covered procedure in a network hospital, their only remedy is to approach the Government under the Rules (Tamilnadu Medical Attendance Rules").
and thereby the complainant has to approach only the Government for his remedy. On the basis of the same, this Commission also passed an order in its judgments in F.A.No.814/2010, dated 30.12.2011, Bench-II and F.A.No.288/2012 (Madurai Bench), dated 22.01.2014 in the case of the Coordinator, Star Health & Allied Insurance Co., Ltd., (Tamilnadu Government Employees New Health Insurance Scheme) - Vs - M. Pushparaj and another decided on 30.12.2011 and another matter, this Commission in the case of Star Health and Allied Insurance Company Limited., Represented by its General Manager and another - Vs - T. Dharmarajan, dated 22.01.2014 in F.A.No.288/2012, following the directions of the Hon'ble High Court of Madras, (Madurai Bench) and given direction to the complainant to approach the Redressal Committee under the scheme as per G.O.Ms.No.430, Finance (Salaries) Department dated 10.09.2007 in order to consider his claim as per the guidelines issued in this regard by the Hon'ble High Court, Madras (Madurai Bench) in W.A. (M.D) 480/2009 as reported in 2010-2 L.W. 90. 7
8. Hence, in view of the same in this case also, we find that the majority order passed erroneously by the Members of the District Forum is liable to be set aside accepting the minority order passed by the President dismissing the complaint with a direction to the complainant to approach the Government for proper remedy and thereby this appeal is to be allowed by setting aside the order passed by the two Members of the District Forum, confirming the order passed by the President of the District Forum confirming the dismissal of the complaint in C.C.No.26/2011 dated 14.10.2011 by the District Forum, Kanyakumari District at Nagercoil.
9. In the result, the appeal is allowed by setting aside the majority order passed by the two Members and confirming the order passed by the President of the District Forum, Kanyakumari at Nagercoil, dismissing the complaint in C.C.No.26/2011 dated 14.10.2011 with direction to the complainant/1st respondent to approach the Redressal Committee under the Scheme as per G.O.Ms.No.430, Finance (Salaries) Department dated 10.09.2007 in order to consider his claim as per the guidelines issued in this regard by the Hon'ble High Court, Madras (Madurai Bench) in W.A. (M.D) 480/2009 as reported in 2010-2 L.W. 90 and the Government may consider favourably in this regard. There will be no order as to costs in this appeal.
Sd/-xxxxxxx Sd/-xxxxxxx
S. SAMBANDAM, A.K. ANNAMALAI,
MEMBER. PRESIDING JUDICIAL MEMBER.
INDEX: YES / NO
TCM/Mdu Bench/Orders- 2015/Oct
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