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Judgment
THE complainant/respondent who retired from service on 30 -06 -2003 is entitled to the benefits of Tamil Nadu Health Fund Scheme to which he is contributing a sum of Rs.100/ - as per rules. Under the scheme, the subscriber is entitled to medical assistance by way of reimbursement of the medical expenses incurred by him upto a maximum of Rs.1,00,000/ - during his life time. The complainant underwent coronary angiography followed by aortic valve replacement and coronary artery bypass coronary surgery in the year 2010 at Madras Medical Mission Hospital which is an institution accredited by the Government of Tamil Nadu. The aforesaid hospital raised a bill of Rs.3,28,000/ - for the treatment of the complainant out of which a sum of Rs.2,00,000/ - was paid to him by an insurance company under an insurance card which it had given to the son of the complainant who was employed in a private company. The complainant thereafter submitted a claim of Rs.99,492/ - to the petitioner for reimbursement under the aforesaid scheme. The application seeking reimbursement, however, was returned to the complainant on 21 -12 -2010. When the complainant sought to know the reasons for the application being returned to him he was handed over a xerox copy of a letter addressed to another pensioner whereby the application of the said pensioner for reimbursement was rejected on the ground that the expenses incurred by him had already been paid by a private insurance company. Being aggrieved, the complainant approached the concerned District Forum seeking reimbursement of the aforesaid amount of Rs.99,492/ - along with compensation and cost of litigation.
THE complaint was resisted by the petitioner on the ground that the complainant had already received a sum of Rs.2,00,000/ - from the insurance company out of the expenditure of Rs.3,00,000/ - incurred by him on his treatment at Madras Medical Mission Hospital at Chennai and in view of the said reimbursement he was not eligible to claim any further reimbursement from the petitioner. Reliance was placed upon an earlier precedent where the claim of another pensioner seeking reimbursement was rejected by the Government.
VIDE its order dated 29 -04 -2013 the District Forum directed the opposite parties to pay the aforesaid amount of Rs.99,492/ - to the complainant along with compensation amounting to Rs.10,000/ - and cost of litigation amounting to Rs.3,000/ -. It was also directed that if the aforesaid amount was not paid within six weeks it shall carry interest at the rate of 9% per annum till the date of payment. Being aggrieved from the order passed by the District Forum the petitioner approached the concerned State Commission by way of an appeal. The said appeal having been dismissed vide impugned order dated 17 -09 -2014 the petitioner is before us by way of this revision petition.
IT is not in dispute that the complainant has been contributing a sum of Rs.100/ - in terms of the scheme under which reimbursement was claimed by him. Therefore, he undoubtedly is a consumer within the meaning of Section 2(1)(d) of the Consumer Protection Act and in case of any deficiency in the services rendered to him the concerned District Forum would have jurisdiction to pass an appropriate order against the service provider.
IT is not in dispute that the complainant incurred expenditure of Rs.3,00,000/ - on his treatment in Madras Medical Mission Hospital at Chennai. It is also not in dispute that the aforesaid hospital has been accredited by the Government of Tamil Nadu. The only ground on which his application seeking reimbursement was rejected was payment of Rs.2,00,000/ - to him by an insurance company which had issued a cashless card to the complainant, on account of his being covered under the insurance policy which the said company had issued to his son, who was employed in a private company. During the course of hearing we specifically asked the learned counsel for the petitioner as to whether the scheme under which reimbursement was claimed by the complainant disentitle a subscriber to the scheme from seeking any reimbursement if he had already been partly reimbursed by an insurance company even in a case where the reimbursement by the insurance company was not full and he is seeking reimbursement from the petitioner only to the extent of the amount which he paid from his own pocket after adjusting the amount paid by the insurance company. The learned counsel fairly stated that she has no knowledge in this regard. Moreover, the aforesaid scheme has not been placed on record by the petitioner. I have examined the reply which the petitioner had filed before the District Forum. Nowhere in the reply the petitioner claimed that the scheme disentitled a subscriber from seeking reimbursement in a case where he had been partly reimbursed by an insurance company even if the claim submitted under the scheme was restricted to that portion of the expenditure, which had not been reimbursed by the said insurance company. Neither before the District Forum nor before the State Commission the petitioner claimed that the scheme disentitled a subscriber from any reimbursement in such circumstances. We, therefore, conclude by holding that the scheme by itself did not disentitled a person from seeking reimbursement under the said scheme to the extent incurred by the subscriber was not reimbursed/paid by an insurance company.
AS regards precedent relied upon by the petitioner, the said precedent in my view cannot be a substitute for the provisions of the scheme. In the absence of the scheme its disentitling the subscriber from such reimbursement, it would be difficult to justify the denial of the reimbursement partly when the scheme envisages life time payment not exceeding Rs.1,00,000/ - to a subscriber. Moreover, it is not known under what circumstances and on what facts the claim of the aforesaid pensioner was rejected by the Government.
FOR the reasons stated hereinabove, I find no justification to interfere with the concurrent view taken by the District Forum and the State Commission and accordingly hold that in a case where the subscriber to the scheme seeks reimbursement under the scheme restricted to that part of the expenditure incurred by him which has not been paid/reimbursed by an insurance company, the claim cannot be denied. Consequently, no ground for interference with the order passed by the fora below is made out. The revision petition is devoid of any merit and is hereby dismissed.