State Consumer Disputes Redressal Commission
General Manager,Star Health And Allied ... vs T. Dharmarajan,Trichy District-621 ... on 22 January, 2014
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, B.Sc, Member
F.A.No.288/2012
(Against the order in C.C.No. 154/2010, dated 11.10.2011 on the file of DCDRF, Tiruchirapalli.)
WEDNESDAY, 22nd DAY OF JANURARY 2014.
1. Star Health and Allied Insurance
Company Limited,
Rep. by its General Manager,
(Tamil Nadu Govt.Employees New
Health Insurance Scheme),
No.2 -A, (Old No.64-A), Ganga Nagar Road,
Opposite to BSNL Office,
Kodambakkam, Chennai-600 024.
2. Star Health and Allied Insurance
Company Ltd.,
Rep.by its Regional Coordinator,
(Tamil Nadu Govt.Employees New Health
Insurance Scheme),
Area Office, No.95, Vaigarai Block,
St.Paul's Complex, Opp.Head Post Office,
Bharathiyar Road, Trichy-620 001. Appellants/Opp.Parties 1 & 2
Vs
T. Dharmarajan,
Thathan Pillai Temple Street,
Narasingamangalam Village,
Samayapuram Post,
Trichy District-621 112. Respondent/Complainant
Counsel for Appellants/Opposite Parties : Mr.S.Suresh, Advocate.
Counsel for Respondent/Complainant : Mr. A.John Vincent, Advocate.
2
This appeal coming before us for final hearing on 18.12.2013 and on
hearing the arguments of appellant side and upon perusing the material records
this Commission made the following:
ORDER
THIRU. A.K.ANNAMALAI, PRESIDING JUDICIAL MEMBER.
1. The opposite parties 1 and 2 are the appellants.
2. The case of the complainant is that the complainant was employed as Head Constable in Trichy District. He has availed a Health Insurance Policy and the Policy No. is TRY/01/PB302/1395695. Consequently a monthly subscription of Rs.25/- is paid by the complainant from November 2008. The subscription is deducted from his salary and paid to the opposite parties. The Health Policy covers all medical expenses. The complainant had massive GI Bleeding and he underwent Segmental Ileal Resection and he was admitted at ABC Hospital, Trichy on 01-05-09 and treated as in-patient till 26-05-09. He was also treated at KMC Hospital, Trichy. Surgery was performed and he incurred medical expenses at AB Hospital, Trichy is Rs.68,801 + 1,03,595 and KMC Hospital, Trichy is Rs.13,250/- altogether he paid Rs.1,85,646/-. After discharging, the complainant applied for reimbursement of medical expenses from the opposite parties. The complainant submitted all medical records, bills, prescriptions, test results and other relevant records. But the opposite parties without going through the health insurance policy provisions denied the claim of the complainant. The surgery he has undergone will cover the health insurance policy. But the 3 opposite parties even after receiving the notice gave evasive and false reply and negatived the just claim of the complainant. Therefore, the complainant preferred the consumer complaint to direct the opposite parties to pay Rs.1,85,646/- with interest at the rate of 24% per annum from the date of claim till the date of realization; to pay a sum of Rs.1,00,000/-towards compensation for mental agony; and to award cost of the complaint.
3. The opposite parties denied the allegations by contending that the insurance claim is cashless one as per the Government Rules framed under the New Health Insurance Scheme notified in G.O.Ms.No.174, dated 28.04.2008 for the specific diseases only the coverage would be applicable and in this case, since the complainant had treatment for the diseases not covered under the provisions of the Scheme the claim was not entertained and thereby there was no unfair trade practice or negligence on their part.
4. On the basis of both sides materials and after an enquiry, the District Forum allowed the complaint by directing the opposite parties to pay a sum of Rs.1,16,845/- being the cost of medical expenses with 8.5% interest from the date of filing of the complaint and to pay Rs.5000/- as compensation for mental agony with costs of Rs.2000/-.
5. Aggrieved by the impugned order, the opposite parties have come forward with this appeal by contending that the District Forum erroneously allowed the complaint without going into the merits of the case and in view of the Scheme under the Government of Tamil Nadu and as per the scheme, the 4 benefits are cashless in nature and payable only to the hospitals and on the basis of the claim made by the complainant the disease must be covered under the scheme and in those circumstances when the diseases are not covered and as per the directions of Writ Appeal (MD) No.480 of 2009 and its connected cases of Madurai Bench of Madras High Court, dated 26.02.2010, the persons who have not covered under the insurance must have approached the authorities, i.e., Redressal Committee under the Scheme as per G.O.Ms.No.430, Finance (Salaries) Department, dated 10.09.2007, as per the guidelines issued in this regard by the Hon'ble High Curt of Madras, Madurai Bench in Writ Appeal No.480/2009.
6. The respondent in this appeal since remained absent, after hearing the appellant side argument's order being passed on merits on the basis of materials placed before this Commission.
7. We have considered both sides' materials and contentions and the order of the District Forum in this regard. It is the admitted case of both sides that the complainant is covered under the Health Scheme coverage of Insurance, Tamil Nadu Employees Government Insurance Scheme provided by the opposite parties in which the complainant being a member of policy holders' claming benefits for the treatment undertaken by him. The opposite parties repudiated the claim by stating that the diseases for the treatment undergone by the complainant for the diseases of Ileal Telangiectasia and not due to any form of ulcer as alleged in the complaint and biopsy report of resected ileal segment 5 shows no evidence of malignancy or ulcer bit only congestion and haemorrhage due to chronic Hepatitis with Cirrhosis and hence that disease was not covered under the terms and conditions of the policy and thereby the complainant is not entitled for which the appellants relied upon the of Medical Literature from Wikipedia, the free encyclopedia (Redirected from Oesophageal varices), relating to " Esophageal varices" in which it is pointed out as follows: " In medicine (gastroenterology), esophageal varices ( or esophageal varices) are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis; patients with esophageal varices have a strong tendency to develop bleeding. Esophageal varices are diagnosed with endoscopy.". "Telangiectasias or angioectasias are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. They can also develop on the legs, specifically on the upper thigh, below the knee joint, and around the ankles. Many patients who suffer with spider veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians are called phlebologists or interventional radiologists."
"An ulcer is a discontinuity or break in a bodily membrane that impedes the organ of which that membrane is a part from continuing its normal functions."
Hence, the complainant is not entitled for the claim. Further, they relied on the 6 order pronounced by this Commission in a similar case in F.A.No.814/2010 presided by the same members of this present Bench themselves in which in para 7 it is observed as follows:
"that the NHIS is on cashless basis and the insurance company is not liable to ay 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 maybe available in favour of the claimant when he applies under the Rules. Otherwise, we do not think that the Redresssal 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".
It is cashless scheme under which claimant cannot claim any reimbursement of money spent towards expenses made in the hospital in which the treatment was 7 taken and if at all it is only for the hospital to claim the expenses from the insurance company by filing relevant papers and the claim details under the scheme enumerated. Further, as per the above Hon'ble High Court directions and in view of the facts and circumstances of the case, we are of the view that the District Forum erroneously allowed the complaint in stead of directing the complaint to approach the Redressal Committee for getting relief and hence the order of the District Forum is liable to be set aside.
8. In the result, the appeal is allowed by setting aside the order of the District Forum, Tiruchirappalli passed in C.C.No.154/2010, dated 11.10.2011 with the direction to the complainant to approach the Redressal Committee under the scheme as per the G.O.Ms.No.430, Finance (Salaries) Department, dated 10.09.2007 and as per the guidelines issued in this regard by the Hon'ble High Court of Madras, Madurai Bench in Writ Appeal No.480/2009, dated 26.02.2010 and on the basis, the Redressal Committee shall consider the claim of the complainant in this regard. There will be no order as to costs in this appeal.
The Registry is directed to refund the mandatory Fixed Deposit with accrued interest duly discharged in favour of the appellants/opposite parties 1 & 2.
Sd/- S. SAMBANDAM, Sd/- A.K. ANNAMALAI,
MEMBER. PRESIDING JUDUCIAL MEMBER.
INDEX: YES / NO
TCM/Mdu Bench/Orders- 2014/Jan