Chennai: The District Consumer Disputes Redressal Forum, Chennai (North) directed a police inspector to approach the Government to seek reimbursement under the Tamil Nadu Government Employees New Health Insurance Scheme for the medical expenses he incurred for his wife.
In the petition, P. Vijayan of Thosand Lights submitted that he was serving as Inspector in Tamil Nadu Police Department. An insurance firm Star Health and Allied Insurance Company Ltd was implementing the Tamil Nadu Government Employees New Health Insurance Scheme for benefit of government employees and their family members. He and his family members were eligible for enhanced insurance coverage upto Rs 2 lakh for every 4-year period. The period of the coverage of the scheme was up to 10.06.2012.
He said his wife Vijayalakshmi was diagnosed with sub acute appendicitis. Prashanth Multi Specialty hospital, one of the approved insurance firm’s network specialty hospitals, advised surgery and On March 2, 2012 laparoscopic appendectomy and adhesiolysis form of surgery was performed on her.
She was admitted in the hospital for two days from March 1, 2012 to March 3, 2012 and he incurred expenses of about Rs 70,231 towards hospital expenses and medical bills. His wife was as a beneficiary under the insurance scheme, was entitled for the treatment and other medical expenses.
Vijayan stated that he approached Star Health and Allied Insurance Company Ltd., Kodambakkam, for reimbursement. As there was no response, he filed the petition before the forum to direct insurance company to pay him a compensation of Rs 2 lakh and Rs 50,000 for mental agony and refund of Rs 70,231.
In its reply, the insurance firm stated that scheme operates on cashless basis alone and no reimbursement was permissible. It was a pre-requisite for the petitioner to produce the ID card or the certificate in lieu of the card issued under the scheme before availing treatment in any network hospital. He had not followed the procedure prescribed under the Scheme.
The bench comprising president, K.Jayabalan and member T.Kalaiyarasi, said following Madras High Court order dated Feb. 26, 2010 the Government issued a letter on April 10, 2012 stating the claimant’s only remedy was to approach the Government. Considering the High Court verdicts and letter of the Government, the complainant can be directed to approach the Government to make a claim in accordance with rules. While dismissing the petition, the bench accorded the inspector with the liberty to approach the Government to make a claim and get necessary orders.
