State Consumer Disputes Redressal Commission
The Co-Ordinator, Star Health & Allied ... vs M. Pushparaj, Nehru Higher Secondary ... on 30 December, 2011
THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI (BENCH II) Present: Thiru.A.K.Annamalai, M.A., M.L., M.Phil., Presiding Judicial Member, Thiru.S.Sambandam, B.Sc., Member. F.A.No.814/2010 [Against order in C.C.No.5/2010 on the file of the DCDRF, Perambalur] FRIDAY, THE 30th DAY OF DECEMBER 2011. The Co-ordinator, Star Health & Allied Insurance Co. Ltd., (Tamilnadu Government Employees New Health Insurance Scheme), No.74, N.S.C.Bose Road, Perambalur. .. Appellant/1st opposite party /Vs/ 1. M. Pushparaj, Nehru Higher Secondary School, Eraiyur, Veepanthattai Taluk, Perambalur District. .. 1stRespondent/Complainant 2. The Managing Director, Geethanjali Medical Centre, Puthur, Trichy. (2nd Respondent given up unnecessary in FA itself) .. 2nd Respondent/2ndopposite party The appeal coming before us for hearing finally on 14.11.2011, upon hearing the arguments of both sides and perused the documents, written submissions as well as the order of the District Forum, this Commission made the following order :- Counsel for Appellant/1st opposite party : M/s. N.Vijayaraghavan, Advocates Counsel for 1st Respondent/Complainant : M/s. S.Natarajan, Advocates. 2nd Respondent/2nd opposite party : Given up. ORDER
A.K.ANNAMALAI, PRESIDING JUDICIAL MEMBER
1. 1st opposite party is the appellant.
2. Complainant enrolled with the Government Medical Insurance Scheme as a Government employee working as P.G.Teacher by payment of Rs.25/- per month as prescription for the medical scheme covering himself and for his family members. On 18.12.09 due to urgent treatment for her daughter Gayathri got admitted in the 2nd opposite partys hospital and undergone eye surgery on 19.12.09 and was discharged on 23.12.09 for which the complainant had spent Rs.52,698/- and when he claimed the same from the 1st opposite party under the insurance coverage which was repudiated on the ground that the treatment was taken without prior intimation and thereby he was compelled to pay the amount to the 2nd opposite party to get discharge of his daughter and thereby he had suffered mental agony and ordeal in this regard and thereby filed consumer complaint claiming Rs.3,00,000/- as compensation and Rs.52,698/- towards the reimbursement of the medical expenses from the opposite parties.
3. Opposite parties denied the allegations of the complainant and the 1st opposite party contended under scheme of Medical Insurance to the Government servant, the treatment could be taken only in the notified hospitals and with prior intimation to the coordinator of the company. The treatment taken by the complainants daughter ORBITATOMY ABND EVACUATION is not covered under the scheme and the scheme also not covered for reimbursement of the money and the scheme is for cashless basis. Hence the 1st opposite party is not liable to reimburse any money or for payment of any compensation. Further as per G.O Ms No.174 dated 17.4.08 the Consumer Forum has no jurisdiction to entertain the claim.
4. The 2nd opposite party contended that the complainant has not informed about the insurance of his family at the time of admission or discharge to the authorities. The Forum has no jurisdiction.
5. On the basis of both sides materials and after an enquiry the District Forum allowed the complaint by directing the 1st opposite party to reimburse Rs.52,698/- being the medical expenses incurred by the complainant and also to pay Rs.25,000/- as damages for deficiency with cost of Rs.5,000/-.
6. Aggrieved by the order of the District Forum, the 1st opposite party filed this appeal contending that the District Forum erroneously allowed the complaint without going in to the nature of the insurance scheme of the Government through 1st opposite party company and this Consumer Forum has no jurisdiction to entertain the grievances in view of the High Court ruling in this regard and thereby appeal to be allowed.
7. While considering both sides arguments, averments and contentions it is the admitted case of both sides that the complainant is being the Government Servant enrolled with the 1st opposite party to cover the medical insurance benefits for himself and for his family members and accordingly for the eye treatment of the complainants daughter the complainant claimed Rs.52,698/- towards the expenses spent for the treatment taken at 2nd opposite partys hospital. According to the appellant the scheme is for the benefit of Government employees which is cashless one and the treatment to be taken only with the notified hospitals and with the prior intimation unless for emergency or urgent natures and for the diseases covered under the scheme for which they relied upon the Star Health Medical Insurance pamphlet as Exhibit B6 and the details of the scheme under the Government instructions as Exhibit B2 and subsequent instructions in Government letter Exhibit B3 and the recent letter from the Government in letter No.17735/Salaries/2010-2 dated 10.4.2010 in which the directions of Madurai High Court Bench of Madras High Court in Writ Appeal MD No.480/2009 and 15 other Writ Petitions regarding the instructions given in which it is stated that the NHIS is on cashless basis and the insurance company is not liable to pay any amount to the petitioners/claimants. The High Court has proceeded to direct the claimants to approach the Government under the Tamilnadu Medical Attendance Rules for eligible assistance under the above rule in such cases. The High Court has also made a reference to the Redressal Committee under the NHIS in para 28 of the order which reads as follows :- If the claimants have made payments 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. If, however, before they take treatment they are informed that a particular procedure is not covered, then at that stage, they may approach the Redressal Committee where the medical expert can decide whether that procedure is covered or not.
The Redressal Committee may also go in to the complaints regarding non-availability of facility at a net work hospital, which may be available in favour of the claimant when he applies under the Rules. Otherwise, we do not think that the Redressal Committee can do much in any one of these cases, since all the petitioners/claimants before us would have made payments. But, if there is a petitioner who has not settled the claim and has come before us, then, in the event, that it is for a procedure that is not covered, he may approach the Redressal Committee.
But the District Forum without considering all the details relied upon by the opposite party invoking Sec.3 of the Act 68/1986 held that the Consumer Court has got jurisdiction to entertain the complaint without looking in to the contentions of the opposite party that the treatment undergone by the complainants daughter is not covered the diseases mentioned under the scheme and also it is the cashless scheme under which the claimant cannot claim any reimbursement of the money spent towards the expenses met in the hospital in which treatment was taken and if at all it is only for the hospital to claim the expenses from the insurance company/1st opposite party by filing relevant papers and the claim details under the scheme enumerated. In those circumstances we are of the view that the District Forum erroneously allowed the complaint which is liable to be set aside and in view of the direction given by the Honble High Court regarding the method of claim to be made in such cases.
8. In the result, the appeal is allowed by setting aside the order of the District Forum, Perambalur in C.C.No.5/2010 dated 31.8.2010 with direction to the complainant to approach Redressal Committee under the scheme as per G.O.Ms.No.430 Finance (Salaries) Dept. dt.10.9.2007 in order to consider his claim as per the guidelines issued in this regard by the Honble High Court, Madras (Madurai Bench) in W.A.(M.D) 480/2009 as reported in 2010-2-L.W. 90. There will be no order as to costs in this appeal.
S.SAMBANDAM A.K.ANNAMALAI, MEMBER PRESIDING JUDICIAL MEMBER INDEX : YES / NO sg/B-II/aka/Star Health Ins.