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Date of filing : 02.04.2025

Date of order : 28.05.2025
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,
DHARMAPURI @ KRISHNAGIRI.
PRESENT: Thiru. R. RAJA, B.Com., B.L., – PRESIDENT
Thiru. P.M. MUTHU KUMAR, M.A., - MEMBER I
Tmt. SHANTHY ANDIYAPPAN, B. Com, B.L., - MEMBER II
WEDNESDAY THE 28th DAY OF MAY 2025
CC.No.36/2025
Mrs. Latha, W/o. Siva Sharma,
D.No.192/49 E,
Veerappan Nagar, VI Cross,
Krishnagiri Town,
Krishnagiri District,
Tamil Nadu 635 001. … Complainant
/Versus/
The Divisional Manager,
United India Insurance Company,
Office at LBO 010600,134 SILINGI Building,
Greams Road,
Chennai – 600 006. …Opposite party
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This complaint coming for final hearing on 20.05.2025 before us in the

presence of Thiru. C.A. Gunasekar, counsel for the complainant, Thiru.A. Feroz

Bathru Khadiri counsel for the opposite party, perusing the written arguments and

records of both side, having stood over till this day for consideration, this

Commission delivered the following:

ORDER

BY THE PRESIDENT : Thiru. R. RAJA, B.Com., B.L.,

The complainant has filed this complaint u/s 35 of Consumer Protection Act

2019, by directing the opposite party to pay the balance amount of a sum of

Rs.56,220/- for the medical expenditure spent by the complainant. Opposite party to

pay a sum of Rs.30,000/- to the complainant for his sufferings and mental agony and

to pay a sum of Rs.20.000/- as case filing expenditure to the complainant. By

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granting such other reliefs as this Honourable commission may deems just and fit

under the circumstances of the case.

2. Case of the complaint:

The Complainant is a government servant working as P.G.Asst, Govt. Higher

Secondary School, Chinnamelupalli, Krishnagiri District her insurance details are

NHIS.I.D.No:KGI/104726. She is in Government service in Education Department

and is paying her family insurance premium to the opposite party regularly and which

has been deducted from the complainant's salary every month.

3. The Complainant has fell down from the stare case in her own house on

17/08/2024 evening around 3.30. PM and sustained injury in the left wrist and le hip

region, with lots of severe pain, swelling and deformity in left wrist, she took initial

treatment at Krishnagiri Medical College Hospital where X ray and C.T. Scan was

taken and first Aid was given to her. On the advice given by the Krishnagiri Medical

College Hospital doctors, the complainant has been shifted to Ganga Hospital

Coimbatore for specialised treatment and transported by Ambulance service for

Super speciality treatment.

4. The Complainant was severely affected by “CLOSED LEFT

INTEROCHANTERIC FEMER FRACTURE" problem and she was Emergently

admitted in as impatient in GANGA Medical Centre & Hospitals Mettupalayam Road,

Coimbatore 641043. on 19.08.2024 which has been listed as net work hospitals

S.No: 713-208-27 in the Employees - Consolidated list of Hospitals in G.O.Ms. No:

160, Dated 29.06.2021 and she had under gone "Surgeries for correction of fractures

of Bones and Joints", which has been enlisted as Category II Orthopaedic Surgery

S.No: 14-14 of approved treatments and Surgeries classified under broad based

specialties. She was discharged from the hospital on 24.08.2024.

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5. The Complainant has spent total Rs.1,11,660/( Rupees one Lakh and Eleven

thousand Six hundred and sixty only) towards her medical treatment. She has

applied to the concern Insurance Company through proper channel, through her

Head Master on 26.09.2024.

6. The Complainant’s Head Master of Government Higher Secondary School

Chinnamelupalli, Krishnagiri has forwarded the claim form along with all relevant

documents. Medical claim application, NHIS Form, NHIS ID Card, Medical Bills.

Cash receipts Discharge Summary to Divisional office, United India Insurance

Company. Chennai on 26.09.2024. The opposite party has given concurrence of the

receipt of all the reimbursement documents against CCN No: 41209707.

7. But instead of full claim and without the complainant's consent or concurrence

the opposite party has sanctioned only Rs.55,440/- (Rupees Fifty five thousand four

hundred and forty only) and transferred the same in the Complainant's account in

State Bank of India, Krishnagiri Account No: 31122844628 on 27.02.2025, which is

un justifiable

8. The Complainant is a government Employee and paying her insurance

premium regularly, She has under gone "Surgeries for correction of fractures of

Bones and Joints” in the network hospital, has claimed Rs.1,11,660/ towards medical

expenditure for herself and the opposite party has sanctioned only Rs 55,440/which

is against the orders issued by the Government of Tamil Nadu G.O.No: 160 of 2021

dated 29.06.2021.

9. The complainant issued a legal Notice for full claim on 10.02.2025, the

opposite party has received the same on 12.2.2025, after receiving the legal notice,
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the opposite party has transferred only Rs.55,440/- to the complainants bank

account on 27.02.2025 and sent a reply on 11/3/2025 with a note that “the above

amount is the maximum amount and further enhancement for this aforesaid

hospitalization is not possible” which against the GO No: 160/2021 issued by the

government of Tamil Nadu. The opposite party cannot fix the medical claims by them

self it varies upon the hospitals and method of treatment given by the hospital.

10. The act of the opposite party the complainant has suffered by mental agony

and worries. Therefore it is necessary for the complainants to file this complaint for

the recovery of the balance Medical Expenditure of amount Rs.56.220/ (Fifty six

Thousand Two Hundred and Twenty only)

S.No Amount spent as per medical Amount deposited Balance Amount

bills By the Opp. Party
1. Rs.1,11,660 Rs.55,440 Rs.56,220

Hence this complaint.

11. Written version filed by the 1st opposite party adopted by the 2nd opposite
party in brief:
It is not disputed that the complainant is working as P.G. Assistant in
Government Higher Secondary School, Chinnamelupalli of Krishnagiri District. It is
also not disputed that she is the member in New Health Insurance Scheme bearing
I.D. No. NHIS/KGI/104726 and paying the premium in salary deduction.

12. It is not disputed that the complainant had sustained injury of 'Closed left
Intertrochantric Femur Fracture' due to fall in stair case, and took treatment in Ganga
Medical Centre and Hospitals, Coimbatore on 19.08.2024 and on 21.08.2024 she
undergone the procedure of

"Closed Reduction and Interval Fixation with STRYKER PFN Left Femur"

13. It is not disputed that the complainant incurred the total medical expenses
of Rs.1,11,660/- (Rupees One Lakh Eleven Thousand Six Hundred and Sixty Only)
and applied for the reimbursement through the Head Master etc. The 1st and
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foremost objection of this opposite party is that this complaint is bad and fatal for non
joinder of the necessary party. The MediAssit TPA is the necessary party to this
proceedings. By not impleading the MediAssit TPA Services, this complaint is liable
to be dismissed in limini.

14. The complainant has not filed the split up medical bills before this
Honourable Commission. Only filed the consolidated bill and receipt for Rs.
1,11,660/-. The complainant ought to have file the split up bill so as to enable this
Commission to adjudicate which are all the eligible amount. On the basis of claim
made by the complainant, this opposite party forwarded the same to Medi Assit TPA
for process the same. Meanwhile the complainant sent the legal notice dated
10.02.2025 to this opposite party alone.

15. The Patient name Mrs. Latha K admitted on 19/08/2024 in Ganga

hospital, Coimbatore with diagnosis of Left Intertrochanteric fracture. For which
closed reduction and internal fixation with PFN was done 21/08/2024 and discharged
on 24/08/2024. fixation with The hospital located in Coimbatore and comes under C
category. Based on the procedure, implants and hospital category, Rs. 55,440 has
been approved as per the package cost under Reimbursement CCN 41209707 and
the payment settled on 27 Feb 2025 against UTR number 25526125797 as per
TNNHIS G.O. 160. The breakdown for the approved amount is as follows.

Network Hospital – Coimbatore- C category

Package name Cost

Fracture Neck/ Shaft of Femur 37440
Implant 18000
TOTAL 55440

The same is the maximum eligible amount and the same is paid on 27.02.2025 to
the complainant.
16. Hence it is a settled claim. There is no deficiency of service committed by
this Opposite party. There is no cause of action to this complaint at all. There are no
merits to this complaint. Therefore the Opposite party prayed to dismiss this
complaint.
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17. Points for consideration:

1. Whether the opposite party has committed deficiency in service?

2. Whether the complainant is entitled to get the relief as claimed in the
complaint?
3. To what relief the complainant is entitled to?

18.Point No.1:

It is admitted facts of the both the parties the complainant availed Insurance

from New Health Insurance Scheme in I.D.No:KGI/104726and paying the premium.

In these circumstances due to sudden fall the complainant incurred ““CLOSED

LEFT INTEROCHANTERIC FEMER FRACTURE" problem and she was Emergently

admitted in as impatient in GANGA Medical Centre & Hospitals Mettupalayam Road,

Coimbatore 641043. on 19.08.2024 which has been listed as net work hospitals

S.No: 713-208-27 in the Employees - Consolidated list of Hospitals in G.O.Ms. No:

160, Dated 29.06.2021 and she had under gone "Surgeries for correction of fractures

of Bones and Joints", which has been enlisted as Category II Orthopaedic Surgery

S.No: 14-14 of approved treatments and Surgeries classified under broad based

specialties. She was discharged from the hospital on 24.08.2024.and incurred

medical expenses of Rs.1,11,660/-. For that the complainant made insurance claim

to the opposite party through proper channel and the opposite party also imburse the

medical expenses of Rs.55,440/-, as full and final settlement.

19. The complainant vehemently argued that as per G.O.Ms. that she is eligible

for full medical expenses of Rs.1,11,660/- as per G.O.Ms. No: 160, Dated

29.06.2021 . But the opposite party approved only Rs.55,440/- and the same was

deposited into the complainants account but the balance medical expenses amount

of Rs.56,220/- was not paid by the opposite party and it amounts to deficiency

service. Hence this complaint.

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20. The opposite party refute the claim of the complainant and contented that

the complainant not impleaded the Medi Assist (TPA), District Treasury Officer and

the Joint Director of Rural and Health Service as parties to these proceedings.

Moreover, as per the G.O. No.160, the maximum eligibility amount .as per package

cost for fracture neck/ shaft of femur Rs.37,440/- and implant cost Rs.18,000/-,

totally Rs.55,440/-, has been credited to the complainant’s account under UTR

No.25526125797 on 27.02.2025. Hence this is the settled claim. Therefore no

deficiency on the part of the opposite party and the complaint is liable to be

dismissed.

21. Heard both side and the records placed before us carefully considered.

That there is no dispute between the parties about the treatment availed by the

complainant and insurance coverage. The complainant claims medical

reimbursement of Rs.1,11,660/-, to prove the medical bills the complainant relied

Ex.A5. Upon careful consideration of Ex.A5 reveals that the complainant incurred

medical expenses of Rs.1,11,660/-, The said amount was not at all disputed by the

opposite party. But they claim eligible package amount was paid as per G.O.160,

but upon careful perusal of the above G.O. no package rate was fixed for the

treatment of femur fracture. The relevant terms of above G.O. also reproduce here

under.

5. The recommendation of the Tender Scrutinising Committee has been

considered and the tender has been awarded to the United India Insurance Company

Limited, Chennai. The said Company shall execute an agreement with the Government of

Tamil Nadu for the implementation of the New Health Insurance Scheme, 2021.

6. The Government after careful consideration directs that:-

(1) “New Health Insurance Scheme, 2021 for Employees of Government

Departments, State Public Sector Undertakings, Statutory Boards, Local Bodies, State

Government Universities etc., and their eligible family members be implemented

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through the United India Insurance Company Limited, Chennai as set out in “The

Guidelines for implementation of the New Health Insurance Scheme, 2021 for

Employees of Government Departments, State Public Sector Undertakings, Statutory

Boards, Local Bodies, State Government Universities etc., and their eligible family

members appended to this order in Annexure -A;

(2) The Commissioner of Treasuries and Accounts shall be the

administrator of the New Health Insurance Scheme, 2021;

(3)The enrolment under New Health Insurance Scheme, 2021 shall be

compulsory, which is a separate scheme for all the employees irrespective of the fact

that their spouse is a Central Government Employee covered under Central

Government Health Insurance Scheme (CGHS) as detailed in para 3 of Annexure-A to

this order;

(4) The employees of Government Departments, State Public Sector

Undertakings, Statutory Boards, Local Bodies, State Government Universities etc., and

their eligible family members covered under the scheme shall avail assistance upto the

limit of Rupees Five Lakh in a block of four years commencing from 01-07-2021 to 30-

06-2025 as a CASHLESS model for the approved treatments / surgeries listed in the

Annexure-I to this order, in the hospitals approved by the United India Insurance

Company / Third Party Administrator and listed in the Annexure-II to this order;

(a) However, the assistance shall be upto Rupees Ten Lakh for Specified

illnesses listed out in Annexure I-A to this order; 2

(b) The upper limit of medical assistance for cataract surgery shall be

Rs.30,000/- per eye. In respect of Hysterectomy (uterus removal surgery) the upper

limit of medical assistance shall be Rs.50,000/-.

(c) The overall limit of assistance, in any case shall not exceed Rupees Ten

Lakh for a family in a block of four years under this scheme.

(d) The medical treatment taken by the employees of Government

Departments, Local Bodies, State Public Sector Undertakings, Statutory Boards and

State Government Universities etc., and their eligible family members in Non-Network

hospital under Non-Emergency situation shall also be covered on reimbursement

basis. However, since the quality of treatment and facilities provided in a Non-network

Hospital is not known and the employee is consciously choosing to avail treatment in

such hospital, the quantum of reimbursement in such cases shall be restricted to 75%

of the package rate of similar procedure in the lowest grade Network hospital.
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(e) This scheme covers 203 approved treatments and surgeries with 1,169

empanelled hospitals. (f) The scheme is also extended to the parents of

the employee, in case of unmarried employee until the employee gets married, in case

of a divorced employee not having children until such employee gets re-married.

g)The payment of annual premium shall be regulated as per the terms and

conditions of the agreement between the Government of Tamil Nadu and the United

India Insurance Company Limited, Chennai;

At the same time, in the above G.O No package rate was fixed for femur fracture.

The opposite party does not disputed the medical expenses incurred by the

complainant and also they fail to explain how they fix they package rate. .

22. In this regard, we on our part like to refer the Judgement of The

Hon'ble Supreme Court of India in Shiva Kant Jha -vs- Union of India [2018 (5) MLJ

317], dealing with unfair treatment meted out to Government servants for medical

reimbursement under similar provisions of the Central Government Health Scheme,

held in paragraph 14 as follows:

“14. It is a settled legal position that the Government employee during his life time
or after his retirement is entitled to get the benefit of the medical facilities and no
fetters can be placed on his rights. It is acceptable to common sense, that ultimate
decision as to how a patient should be treated vests only with the Doctor, who is
well versed and expert both on academic qualification and experience gained. Very
little scope is left to the patient or his relative to decide as to the manner in which
the ailment should be treated. Speciality Hospitals are established for treatment of
specified ailments and services of Doctors specialized in a discipline are availed by
patients only to ensure proper, required and safe treatment. Can it be said that
taking treatment in Speciality Hospital by itself would deprive a person to claim
reimbursement solely on the http://www.judis.nic.in ground that the said Hospital is
not included in the Government Order. The right to medical claim cannot be denied
merely because the name of the hospital is not included in the Government Order.
The real test must be the factum of treatment. Before any medical claim is
honoured, the authorities are bound to ensure as to whether the Claimant had
actually taken treatment and the factum of treatment is supported by records duly
certified by Doctors/Hospitals concerned. Once, it is established, the claim cannot
be denied on technical grounds. Clearly, in the present case, by taking a very
inhuman approach, the officials of the CGHS have denied the grant of medical
reimbursement in full to the Petitioner forcing him to approach this Court”

The above case law is squarely applicable to the fact of this case, in this case in

hand also the opposite party does not disputes the manner of treatment and medical
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bills. Moreover, the opposite party does not disputes the medical bills are exorbitant.

Further the complainant being the insured undergone the treatment from the

network hospital. The opposite party also does not disputed the hospital authorities

made unnecessary tests & charges. In the absence of any such evidence, it is

bounden duty of the insurance company to honour the medical claim within the limits

of insurance coverage. Moreover the opposite party failed to explain how they fixed

the package rate for the another approved hospital. As per G.O. No.160 the

complainant shall eligible to avail medical assistance up to Rs.10 lakhs for the

commencing period from 01-07-2021 to 30-06-2025. .

23. The complainant is clearly proved his case by placing documents Ex.A1 to

Ex.A11, that she incurred medical expenses and he is eligible to claim

reimbursement as per G.O. Now the burden of proof shifted to opposite party,

however the opposite party failed to produce any documents, orders or any G.O.

regarding fixing of packages for medical treatments. Moreover, that there are no

fixed packages for treatment and it varies upon the hospital and the insurance

company does not have right or jurisdiction to decide on the nature of expenses that

are necessary for medical treatment or fix maximum cap on such expense. Further

some expert doctors claim more fees than normal doctors. That experience of

doctors cannot be equated with the cost and in medical profession no standard fee’s

structure was not fixed as on date in the manner known to law. Anyhow the

complainant claim in admissible expenses of Rs.1,11,660/-. But the opposite party

only honor the part amount of Rs,55,440/- and the complainant eligible to claim

balance amount of Rs.54,220. However the opposite party not turns to reimburse

the balance amount of medical expenses. The opposite party insurance company

ought to have paid the balance claim amount of Rs. 54,220/-and non-payment of the
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said balance amount is nothing but shortcoming and imperfection in their services to

the complainant.

24. At this juncture we on our part would like to refer to Section 2 (11)

provided in the Consumer Protection Act – 2019 which defines deficiency as

elucidated here below : -

Section 2 (11) defines

"deficiency" means any fault, imperfection, shortcoming or inadequacy in the quality, nature and
manner of performance which is required to be maintained by or under any law for the time
being in force or has been undertaken to be performed by a person in pursuance of a contract
or otherwise in relation to any service and includes—
(i). any act of negligence or omission or commission by such person which causes loss or injury to the
consumer; and

(ii) deliberate withholding of relevant information by such person to the consumer;

25. In this case in hand the complainant clearly proved their case with

relevant records and we inclined to decide the opposite party’s service is

shortcoming and imperfection and thereby committed deficiency in service on their

part. This point is answered accordingly.

26. Point Nos. 2 & 3:

From the above findings and discussions, the opposite party committed

deficiency in service. The remedy for the same is an amount of compensation as to

the actual loss or injury, which includes mental agony, emotional suffering,

harassment and physical discomfort due to negligence or deficiency in service on the

part of the service provider. Such a relief is available to the consumer by virtue of

Section 39 of the Consumer Protection Act – 2019.

27. We are of the view that the word deficiency defined by the legislature

prescribes very high standard of service which means that service provided by the

opposite party should be in very prefect and in flawless manner. Such an insensitivity
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or casual or indifferent attitude of the opposite parties had left the

complainant/consumer high and dry and suffer immensely for her no fault. It was for

keeping opposite party/service providers on tenterhook and to protect the interests of

the consumers that very stern standards of ‘service’, ‘deficiency’ were provided.

Every act of omission or commission by the opposite party/service provider has to be

ascertained on the anvil of definition of ‘deficiency’ as provided in the Consumer

Protection Act and not on any other premise.

28. In view of the above discussion we are of the opinion that the deficient act

of the opposite party would have definitely resulted in high degree of mental pain

accompanying mixed feelings of distress, fright, and anxiety to the complainants. It is

more than mere disappointment but mental sensation of pain resulting from such

emotions of grief, indignation to the complainant.

29. Therefore complainant is entitled to claim compensation for mental agony

and pain suffered by him due to the deficiency in service of the opposite party. We

had taken all this aspect into consideration while quantifying the compensation to the

complainant. Taking into account the overall facts and circumstances of the case

and in view of the above deliberation, we are of the considered opinion that the

complainant is entitled to reimburse the cost of non-settled balance medical

expenses of Rs. Rs. 54,220/-and a sum of Rs. 3,000/- as compensation would be

just and proper to be paid by the opposite party along with cost of Rs.5,000/- to the

complainant. These points are answered accordingly.

In the result, the complaint is allowed on following terms:

(a) We direct the opposite party to pay Rs. 54,220/- towards balance
medical expenses to the complainant
(b) We direct the opposite party to pay Rs.3,000/- towards compensation
for deficiency in service and mental agony to the complainant
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(c) We direct the opposite party to pay Rs.5,000/- towards cost of this
complaint to the complainant within two months from the date of this
order, failing which the above award amount except cost shall carry
interest at the rate of 9% p.a. from the date of this order till
realization.
Dictated by the President to steno-typist and directly typed by her and
corrected by the president and pronounced by us on 28th day of May 2025

-Sd- -Sd- -Sd-

MEMBER - I MEMBER - II PRESIDENT

List of documents marked by the complainant:

Exhibit A1! - Complainant’s service Register Details Xerox

Exhibit A2! - Complainant’s NHIS Details Xerox
Exhibit A3! Discharge summary by Ganga Medical Centre
24.08.2024 Xerox
& Hospitals Coimbatore
Exhibit A4! Complainants Aadhaar Card Details Xerox
Exhibit A5! 24.08.2024 Medical Bill Receipt Xerox
Exhibit A6! 26.09.2024 Letter to the opposite party by the Head Master Xerox

Exhibit A7 10.02.2025 Legal Notice sent to the opposite party Xerox

Exhibit A8 Postal Acknowledgement from the opposite Original

-
party
Exhibit A9 11.03.2025 Reply letter sent by the opposite party Original

Exhibit A10 Complainant’s Bank passbook Details Xerox

Exhibit A11 24.08.2024 Split Bills Xerox

List of documents marked by the opposite parties : Nil

-Sd- -Sd- -Sd-

MEMBER - I MEMBER - II PRESIDENT