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Judgment
M. Shreesha, J
By this Revision Petition under Section 21(b) of the Consumer Protection Act, 1986 (for short the "Act") Sh. S. Lakshmanan (hereinafter referred to as "the Complainant") challenges the order dated 26.07.2012 in Appeal No. 631/2010, passed by the Tamil Nadu State Consumer Disputes Redressal Commission, Chennai (for short "the State Commission."). By the impugned order, the State Commission has partly allowed the Appeal, preferred by New India Assurance Co. Ltd. (hereinafter referred to as "the Insurance Company") and modified the order of the District Consumer Disputes Redressal Forum, Tiruchirapalli (for short "the District Forum") by setting aside the award of compensation.
Briefly put, the facts of the case are that the Complainant being an employee of the Insurance Company, during his service tenure, entered into a Group Insurance Policy with the Insurance Company. He was diagnosed with cancer in the left lobe of thyroid, he underwent treatment for Hodgkin's disease treated with radiotherapy. Due to his health condition, he had taken voluntary retirement in April, 2004 and was relieved from the service. However, he continued to pay the premium and receive the medical benefits from the Insurance Company. It was stated that since the Complainant was a cancer patient he had to take treatment regularly and he used to claim the reimbursement of the expenses incurred by him towards his treatment and medicines every month and the Insurance Company allowed and paid the same till March, 2007. However the Insurance Company, all of a sudden, stopped paying the bills raised by the Complainant w.e.f. April, 2007. On his enquiry he was told that his claim was rejected due to audit objections.
The Complainant sent a letter to the Insurance Company on 05.05.2007 which replied vide its letter dated 23.05.2007, stating therein that a person who is suffering from cancer cannot obtain benefits of mediclaim policy. It was further stated by the Complainant that on the basis of the circular dated 05.09.1990, he was entitled to claim Domiciliary Hospitalization and even though the said fact was brought to the notice of the Insurance Company, the Insurance Company failed to pay the amount to him and took the stand that the Circular dated 05.09.1990 was not applicable in his case. The Insurance Company was informed that a similarly situated employee got this benefit and in spite of that the Insurance Company did not pay him the claim amount to the tune of ₹15,919/-. Feeling aggrieved, the Complainant filed a Complaint before the District Forum seeking directions to the Opposite Party to pay a sum of ₹15,919/- along with ₹50,000/- towards damages for mental agony and ₹25,000/- towards compensation for deficiency in service together with costs.
The Insurance Company filed its Counter Affidavit stating therein that the Complainant had opted for VRS and the same was allowed in April, 2004. The Insurance Company floated a scheme titled "Group Mediclaim Policy" for the welfare of its employees and it was made applicable to the retired employees as well. Complainant had also opted for the said Scheme and was paying necessary premium year after year by renewing the said policy and the policy was in vogue till 31.03.2008. It was stated that the Complainant had filed 9 claim forms claiming reimbursement of expenses incurred on medicine for the period from April to December, 2007. He claimed the bills as reimbursement on domiciliary hospitalization expenses based on a circular of GIC dated 05.09.1990. The Insurance Company was honouring the bills under bona fide belief till the objection was raised by the audit wing. It was submitted that the bills under domiciliary hospitalization are reimbursable in such a circumstance where the condition of the patient is such that he cannot be moved to the hospital for lack of accommodation. However, for treatments like dialysis, chemotherapy, radiotherapy etc., if the patient is discharged on the same day, the treatment would be considered to be taken under hospitalization. However, under clause 2 of GIC Circular dated 05.09.1990, the benefit of domiciliary hospitalization is payable if the employee is attending office, though not confined to house and so under this clause, the claim becomes payable provided he attends to office duties. However, in the case of the Complainant, he had already retired and the question of his attending office does not arise.
The District Forum allowed the Complaint and directed the Insurance Company to pay a sum of ₹15,919/- towards the medical expenses along with ₹7500/- towards compensation for mental agony and ₹500/- towards costs.
The Insurance Company preferred an Appeal before the State Commission which, vide its impugned order, partly allowed the same and modified the order of the District Forum by directing the Insurance company to reimburse a sum of ₹15,919/- along with interest @ 9% p.a. from the date of repudiation till realization and cost of ₹500/-. However, the State Commission had set aside the award of compensation of ₹7500/-.
Aggrieved, the Complainant preferred this Revision Petition.
It is the Petitioner/ Complainant's case that the Insurance Company of which he was an employee, was covered by Mediclaim Insurance Scheme issued by the Company covering retiring employees under the special voluntary retirement scheme 2004 (for short "SVRS"). It is an admitted fact that the Petitioner opted for voluntary retirement under the SVRS and was enrolled on 05.03.2004. A clarification was sought vide letter dated 12.07.2004 from the Regional Office with respect to the liability of SVRS employees for domiciliary hospitalization and the major disease covered under the policy with specific reference to ordinary glaucoma. The Regional Office clarified vide letter dated 28.07.2004 that domiciliary hospitalisation is applicable to both serving and retired employees and does not make distinction between major and minor diseases. Even after the said refusal, between 2004 and April, 2007 the Petitioner was being reimbursed his medical bills. Learned counsel submitted that Unite India Assurance, which is a governing body of the first Respondent had issued a clarification vide a circular dated 10.08.2006 that as an employee welfare major, the post hospitalization treatment expenses beyond 60 days are to be reimbursed to the employees and that the said reimbursement is extended and applicable to only three major diseases viz., cancer, kidney replacement and bye-pass surgery/ angioplasty. Throughout this time the first Respondent kept reimbursing the claims of the Petitioner till 2007 and continue to accept premium towards medical policy till 2013. Vide letter dated 05.01.2007, the internal audit, department of the first Respondent acknowledged the reimbursement of post hospitalisation in major diseases to some retired employees.
It is pertinent to mention that the audit department made categoric noting that the circular dated 20.01.2006 issued by United India Assurance, Madurai RO was relied upon for allowing the reimbursement of post hospitalisation beyond 60 days for major disease inter-alia cancer. It is alleged that vide circular dated 05.01.2007, the audit department sought clarification if there was any directive from the Head Office. The said letter dated 05.01.2007 contains a hand written noting that no directive has been passed by the Insurance Company and that the clarification on the issue should be sought from the respective HRM. Apart from the vague and cryptic noting on the said circular there is no clarification whatsoever. On 30.04.2007, the first Respondent once again rejected the reimbursement of claim stating that the clarification sought by the internal audit department. On 05.05.2007, the Petitioner sought reimbursement of medical expenses, which were rejected by the first Respondent on 23.05.2007. Despite repeated requests the claims were not paid.
Despite giving an opportunity to the Respondent to file written submissions vide order dated 27.09.2018, not only was there no representation but also the written submissions were not filed.
Admittedly, the Respondents have been continuously accepting the premiums payable towards the said mediclaim policy and the learned counsel contended that the Petitioner should be entitled to the benefits of the Insurance Policy till 31.03.2013. A brief perusal of the prayer of the Complainant shows that he is seeking the direction for reimbursement of the medical bills from April,2007 to December, 2007 and till date and thereon.
Having regard to the Respondents continuously accepting the premiums payable towards the said mediclaim policy; the several representation made by the Petitioner to comply with the provisions of the Insurance Policy, we find force in the contention of the learned counsel for the Petitioner that there is no documentary evidence on record that the circular relied upon by the Petitioner was either cancelled or modified or withdrawn, the only reply sent by the Respondents is a letter dated 23.05.2017. For better understanding of the case, the said letter is reproduced as hereunder:
"The New India Assurance Company Limited
Divisional Office, Trichy Division- 720700
23.5.2007
Mr. S. Lakshmanan
24/3A Railway Station road
Srirangam
Trichy 620006
Dear Sir,
Re: Mediclaim payment
We are in receipt of your letter dt.5.5.07 seeking mediclaim reimbursement for your illness. Our Audit incharge vide their letter, to HO, no. CBE RO: IAD:2007 DT.5.1.2007 has blamed us marking a copy to Chief Regional Manager, Coimbatore RO., that we have been reimbursing some of our regular/ retired employees against major diseases like Cancer of any nature, Kidney transplantation, Bypass surgery/ Angioplasty for heart, under the head of Post hospitalization beyond 60 days. Hence, we have no other alternative but to respond to their remarks. But, despite being retired, your letter was not at all considerate. Your care on our clearance of audit query is highly unwarranted and shows your arrogant approach. We have taken up your subjected letter with our higher ups. In turn, we are advised to act according to the latest decision of HO, which was already conveyed, to you. Moreover, they have advised to recover the amount of reimbursed to you inadvertently.
Besides the above, your acquisition on me is intentional and would have adverse consequences, in case of its recurrence.
Sr. Divisional Manager"
A perusal of the material on record also shows that vide letter dated 30.04.2007 Petitioner was informed that the matter was discussed with the EWS department and he was informed that no directive was issued for payment of post hospitalisation beyond 60 days. Learned counsel for the Petitioner relies on the circular dated 05.01.2007, which reads as follows:
THE NEW INDIA ASSURANCE COMPANY LIMITED
INTERNAL AUDIT DEPARTMENT
Regional Office : 720000
"Obli Towers"
No. 594, D.B. Road,
R.S. Puram, Coimbatore-641002
Phone:0422-2540442, 2547375, 2546969
Fax: 0422-2508979
EOR RO:IOA:2007
5th January 2007
Mr. T.T. Narayanan
Manager
Internal Audit Department
Head Office
Mumbai
Re: Reimbursement of post-hospitalisation expenses for major diseases beyond 60 days
This has reference to the telephonic discussion we had with you today in connection with the above.
Our Trichy DO (720700) is in the habit of reimbursing post hospitalisation medical expenses beyond 60 days of hospitalization in respect of major diseases to some of their employees/ retired employees.
We have pointed out this query in our last audit report and also in the recent POM. In reply, they have given a circular dated 20.01.2006 issued by United India, Madurai RO (copy enclosed) which allows reimbursement of post hospitalization expenses beyond 60 days for major disease like
Cancer of any nature
Kidney transplantation
Bye pass surgery/ Angioplasty for heart
We would request you to clarify whether there is any directive from GIPSA or any circular issued by our HO in this regard.
We await your reply.
Sd/-
(P. Natesan)
Audit in-charge
CC: The Chief Regional Manager/ Coimbatore RO"
Keeping in view the aforenoted circulars, facts and circumstances of the case together with submissions of the learned counsel for the Petitioner we are of the view that the Insurance Company, keeping in view the principle of natural justice should clarify to the Petitioner with respect of the withdrawal of any circular and also clarify if any such expenses can be given to the Petitioner, who is an employee of their own company. Apart from the reimbursement of expenses we are of the considered view that the Petitioner is entitled to a compensation of ₹50,000/- for having not been informed at an appropriate time regarding any cancellation or withdrawal of the circular relied upon by him and also with respect to any new circular/ rules if issued by the Insurance Company and also for continuously accepting the premium amount.
With the aforenoted directions, this Revision Petition is disposed of. It is pertinent to note that the Respondent did not preferred any Revision Petition therefore the observations of both the fora below have attained finality.