ORDER

BY SRI.H.R.SRINIVAS, PRESIDENT.

1.     This is the Complaint filed by the Complainant against the Opposite Party (herein referred to as OP) under section 35 of the Consumer Protection Act 2019 for the deficiency in service in not paying the entire amount of Rs.6,75,450/- being the hospital charges incurred by the complainant towards his wife’s treatment and for payment of same along with interest at 18% P.A. and other reliefs as the Hon’ble District Commission deems fit.

2.     The brief facts of the complaint are that; complainant No.1 is the husband of complainant No.2. She was admitted to OP0-3 hospital i.e. Fortis Hospital situated at Richmond Town for Laparoscopic Hysterectomy+ bilateral salpingo Oophorectomy + Adhesiolysis on 09.10.2019 and discharged after surgery on 12.10.2019. The surgery was performed by one Dr.Jayashree N Bhasgee and Dr. Dhatchani.  OP-1 and 6 are to pay the bills. They were waiting form 10 am onwards to be discharged and for clearance of the bill. They had to wait till 11.24 pm on 12.10.2019. Earlier, the bill was raised by OP -3 for Rs.1,38,540/- and afterwards for Rs.1,55,729/- at 502 pm and at 11.25 pm the said bill was raised to Rs.1,75,450/-. They were not allowed to come out of the hospital without paying the said amount and they were really held as hostages / confinement.  OP2 has no right to do like that.  There is no reason for OP No.2 to raise the bill arbitrarily, and without any reasons. Complainants waited from morning till midnight for discharge. During which time, they were put to mental agony and bodily torture. Even the hospital authorities threatened them that they don’t pay the charges, they would not allow them to go out of the hospital. They were scared for their life and the entire hospital staff were very rude and threatened to the complainants.  They were wrongly restrained in the hospital by the hospital authorities. There is deficiency in service on the part of OPs. The insurance people i.e. OP.1, and 6 did not pay the bill amount on time to OP.3. It resulted in their suffering mentally and physically.  Hence the complaint.

3.     Earlier this complaint was filed against 6 OPs. Afterwards, complainant made an application to delete OP-2 Shivkumar an agent Dr Jayashri Bhasgi and Dr Dattachayini and proceeded against OP-1 the insurance company, OP-2 the FORTIS hospital Op.0-3 the TPA of OP-1.

4.     The version filed by OP1 has been adopted by OP3 since OP1 is the insurance company and OP 3 is the third party administrator. 

        5.     In the version filed by OP1 it is admitted that the complainants obtained “happy family floater policy 2015” bearing No.423100/48/2020/436, valid from 23.06.2019 to 22.06.2020. The sum insured for them and dependent children was for Rs.4,00,000/-.  For the purpose of processing the claim, sum insured was taken as Rs.3,00,000/- as the remaining Rs.1,00,000/- will be effective after 48 months as per policy conditions.  The said insurance was issued subject to conditions, clauses, warranties, endorsements as applicable to the policy.  Complainant 2 was admitted to OP2 hospital for ‘laparoscopic hysterectomy bilateral salpingo Oophorectomy + adhesiolysis’ as per the final analysis. On 09.10.2019, and discharged on 12.10.2019, at 11.24 pm. The bill amount was Rs.1,75,450/-.  The allegation of the complainant that initially the bill was Rs.1,38,540/- and the same was increased to Rs.1,55,729/- and further for Rs.1,75,450/- by OP2 was not at all in its knowledge.  The allegation that the complainants paid the entire bill out of their pocket even though cashless facility was provided and the hospital refused to allow them to go out of the hospital has been denied as false, baseless and not admitted.  On receipt of the bills and necessary documents from the hospital on 12.10.2019 at 5.02 pm., OP3 the TPA an appointed IRDA licensee processed the claim and approved the cashless facility for Rs.1,09,350/- on the very day and sent the authorization.  Under the circumstance, there is no delay or deficiency on their part and they have extremely acted fastly in giving the approval.

        6.     It is further contended that the complainants submitted bill for Rs.1,75,450/- on 04.11.2019 seeking reimbursement of the expenses during hospitalization.  Though they provided cashless facility they did not avail the same. Against the bill of Rs.1,75,450/- as per the PPN package as per agreement with the hospital, the claim was processed and a sum of Rs.1,08,000/- was approved against the bill for Rs.1,55,000/- for laparoscopic assisted virginal hysterectomy and Rs.47,000/- was disallowed.  For ‘adhesiolysis’ the bill amount was Rs.20,450/- and since the said item was already included in PPN package as per GIPSA tariff, the same was completely disallowed.  Hence a sum of Rs.1,08,000/- was approved and as the complainant has agreed for compulsory co-payment of 10% of the admissible claim, a sum of Rs.97,200/- was sanctioned as full and final settlement of the amount claimed and communicated the same on 18.11.2019 and the same was sent through NEFT.  The said claim was settled within 15 days and they have rendered a very quick and prompt service to the complainant. This is as per the terms and conditions of the policy.  Hence there is no reason to treat the services of OP 1 and 3 as deficiency in service and unfair trade.  It is not within the knowledge as to why the OP 3 has raised the bill. The allegations made against OP2 hospital has to be answered by the hospital only and also regarding the hospital making the complainants to wait till the midnight.  The hospital has to answer why they were not allowed to go out of the hospital and the threat by the hospital authorities.  They are not liable to pay Rs.1,75,450/- along with interest at 18% p.a., as claimed in respect of hospital charges or Rs.5,00,000/- as compensation claimed by them. 

7.     It is further contended that under the three plans of silver, gold and diamond policy, reasonable and customary charges in respect of hospitalization domiciliary hospitalization for medically necessary treatment or deceases contracted or suffered or injury sustained during the policy period upto the limit of sum insured would be charged.  In this case, the complainant have opted silver cover for the sum of Rs.3,00,000/-.  As per condition A1, the expenses towards the room rent is 1% of the sum insured i.e., Rs.3,000/- per day, whereas the room occupied by the complainant was charged Rs.7,500/- per day which is more than 1½ times than the entitlement.  Keeping the above in view PPN charges are taken at Rs.1,08,000/- for both the items, as against the charge of Rs.1,75,450/- charged by the hospital.  Hence there is no deficiency or unfair trade on their part and prayed this commission to dismiss the complaint.

8.     In the version filed by OP2, the hospital, it is contended that they are running the hospital in the name of Fortis and the complainant2 was admitted to their hospital at Richmond Road, on 9^th October 2019 and she underwent “laparoscopic surgery of hysterectomy bilateral salpingo Oophorectomy on 10.10.2019”.  The estimate for the said surgery was given at Rs.1,50,000/- in respect of the said surgery.  The cost is inclusive of instrument charges, blood component, associate charges.  The brake up for each cost has been communicated to the complainant by OP2.  She underwent surgery in the hospital.  During the surgery in order to reduce the risk of injury to other organs, certain additions on the anterior abdominal wall were removed, for which additional cost of Rs.20,450/- has been charged.  Immediately the same was informed to the complainant.  Only when they agreed to bear the expenses they proceed to claim the total amount incurred for the surgery.  They were waiting for the approval of the amount by insurance company i.e., OP3.  They received the approval at 11 pm only on that day and the same was intimated to the complainants that the approval has been obtained for Rs.1,09,350/- which they refused to accept on the ground that they would pay the entire amount in respect of the hospital charges and claim with the insurance company.  They were utterly shocked to receive legal notice from the complainants therein have made false allegation and claim.  They also made allegations against the doctor who were not at all involved in the billing process.  They issued a reply to the said notice clarifying the entire incident and requesting them to withdraw their notice.  Inspite of it, complainants have filed this complaint.  There is no cause of action against them and the complainants have no locus-standi to file the complaint against them. Denying each and every allegations made against them in the complaint, it prayed this commission to dismiss the same.

9.      In order to prove the case, both the parties filed their affidavit evidence and produced documents. Arguments Heard. The following points arise for our consideration:-

1) Whether the complainants have proved deficiency in service on the part of the Opposite Parties?

2) Whether the complainants are entitled to the relief prayed for in the complaint?

10.   Our answers to the above points are:-

POINT NO.1:            In the Affirmative

POINT NO.2:            Partly in the affirmative.

                                For the following.

REASONS

11.   POINT No.1:-

   It is not in dispute that the complainants were having medical insurance which was in force as on the date of complainant No.2 undergoing laparoscopic hysterectomy and related surgery within OP2’s hospital.  It is also not in dispute that the complainants did not avail the cashless facility, whereas, they paid the entire amount of Rs.1,75,450/- to OP2 upon raising the bill, as they were not satisfied with the approval of OP1 for Rs.1,08,000/- less 10% of it, which comes to about 97,200/-.  They wanted to claim the entire amount of expenses incurred by them in respect of the hospital charges they paid to OP2. 

12.   It is also not in dispute that the OP1 on the advise of OP3 has paid only Rs.97,200/- being the full and final settlement in respect of the claim made by the complainant in respect of the hospital charges of Rs.1,75,450/- incurred by them.

13.   It is the contention of OP 1 that the complainants have obtained silver scheme insurance policy and they have a contract with PPN i.e., Preferred Provider Network Hospital, wherein the rates for each surgeries is predetermined.  Rates of GIPSA-PPN for which complainants have agreed by affixing their signature to the document.  Hence the complainant is only entitled for reimbursement of the amount which they have agreed to in respect of the surgeries or hospital charges with the hospital.  Hence, under the circumstances, though the complainants have paid Rs.1,75,450/- to the hospital towards the hospital charges, since as per the GIPSA-PPN, they are only liable to pay Rs.1,08,350/- towards the expenses.

14.   Further since in the insurance policy complainants have undertaken that compulsory co-payment is 10% for each and every claim, and the room, or boarding and nursing expenses, the limit is only 1% of the sum insured per day, they have deducted Rs.10,800/- out of Rs.1,08,000/- and paid Rs.97,200/-. 

15.   It is also the case of the OP1 that as per the expenses covered in respect of room and boarding, complainant is entitled for Rs.3,000/- per day as room/ward charges. Whereas, the charges levied by OP2 is Rs.7,500/- and hence complainant has to bear the excess amount and further compulsory co-payment of 10% of the charges. 

16.   The claim made by the complainant, the correspondences, the bill raised, notice exchanged are not at all in dispute.  On perusing the insurance policy produced, which is marked as Ex.R1 the sum assured is of Rs.3,00,000/- and the plan is ‘silver plan’ and the co-pay is 10%. There is no mention that the amount payable by insurance company is as per GIPSA-PPN. Only in the PPN network declaration by patient or patient attendance, the signature of the complainant No.2 is forthcoming which is marked as Ex.R3, wherein it is ticked in respect of declaration that I do not have any insurance policy. The said document is not at all filled up in its enterity.  It has been left blank. It is to be noted and in the line of the decision rendered by the various State Commissions the NCDRC and by the Hon’ble Supreme Court of India, that when the complainant was made to sign on the dotted lines, the said agreement/declaration has no value at all.  OP1 is in a dominant position whereas the complainants are in a helpless position and hence they have to put their signature on the dotted lines on the directions or on the force exerted by OP1 otherwise, they would lose the facility of obtaining the insurance.

17.   Under these circumstances, we have to hold that Ex.R3 the PPN network declaration has no value at all and it has been obtained under the circumstances which the complainants were put to and it is not a free consent and not binding on them.  The documents produced by OP2 dated 14.09.2021 shows the details of the billing, wherein, the surgery cost is mentioned as Rs.1,09,500/-, Room rent Rs.22,500/- and  all other expenses totaling to Rs.1,72,236/- adhesiolysis laparoscopic second procedure Rs.20,450/-, total Rs.1,92,686/-.  Package bill is charged for patient Mrs.Uma Anandamurthy, Rs.1,55,000/-  if billing it would have cost Rs.1,72,236/- TLH surgery.

18.   Again in the document produced stating that package for adhesiolysis laparoscopic Rs.20,450/0- and laparoscopic assisted hysterectomy Rs.1,55,000/- in all Rs.1,75,450/-.  There is lot of difference between these two bills.  Which means OP2 is not consistent and it is to be held that there is connivance between the insurance company and the hospital to raise the bill and to make profit which is unholy and unethical.

19.   The charges in respect of room rent, OP2 has claimed Rs.22,500/- for four days, which comes to about Rs.5,650/-.  Whereas as per OP1, she was entitled to Rs.3,000/- per day.  Hence the complainant has to bear the difference of Rs.2,650/- in respect of the ward/room rent.  Since it is a package as per OP1 the entire amount ought to have been included. Whereas, OP2 has excluded a sum of Rs.20,450/- out of the package and charged the said amount as extra/separately.  The package for surgery of laparoscopic assisted hysterectomy was Rs.1,55,000/-. That means OP1 is liable to pay Rs.1,55,000/- for the said hospitalization charges in respect of the package it has entered into with the PPN hospitals.  It is not made known either by OP1 or 2 as to what is exactly the package for the surgeries with the complainant underwent.  It is mentioned that the package bill is Rs.1,55,000/- and open billing it is Rs.1,72,236/-. It is also mentioned that for the second procedure it has charged Rs.20,450/-.  That means the said amount is not included in the package. OP1 has claimed GIPSA-PPN under which it will pay the said amount only and all the extra amount to be borne by the complainant.  As already pointed out nowhere in the insurance policy the same has been mentioned and as we have held Ex.R3 is incomplete and cannot be recognized as duly executed by the complainant out of free will, we are of the opinion that there is deficiency in service on the part of OP1 and 2 in raising the bill exorbitantly by OP2 without taking into consideration the package and also deficiency in service and unfair trade by OP1 in not paying the hospital charges incurred by the complainant when the insured amount is Rs.3,00,000/-.  Hence we answer point No.1 in the affirmative against OP1 and 2.

20.   In the result and in furtherance of the terms of the insurance policy, complainants are only entitled for room rent @ Rs.3,000/- per day and further they have to pay 10% as co-payment.  In view of this as per their letter given by OP2, the package bill for surgery taken as Rs.1,55,000/- of which Rs.22,500/- is levied as room rent, whereas, complainant is entitled for Rs.3,000/- per day which amounts to Rs.12,000/- and the complainant has to bear the difference of Rs.10,500/- out of the said amount.  As per the terms and conditions 10% of Rs.1,55,000/- works out to be Rs.15,500/-.  The said GIPSA-PPN package is not included Rs.20,450/-, which has been given by the complainants in respect of the second procedure, which OP1 has to pay to the complainants.  Here also complainant has to bear 10% of the said amount which works out to be Rs.2,045/- when the same is deducted it amounts to Rs.18,405/-.  Hence the complainant is entitled for Rs.50,205/-(Total amount Rs.1,75,450/- - 17.545/- =157905/- - Rs.10,500/- = Rs.1,47,405/- - Rs.97,200/- = 50,205/-)  along with interest at 12% p.a., from date of discharge 12.10.2019, till the payment of the entire amount.  Further in not honoring the said amount complainants were put to lot of inconvenience, mental tension and physical exercising.  Further they were made to wait in the hospital till late in the night, even though they were told to discharge in the morning itself.  It is the usual practice of the hospital to delay the discharge, so that they can charge one days ward rent.  Inspite of it the complainants were put to more inconvenience and hence we direct OP2 to pay a sum of Rs.10,000/- towards the inconvenience caused to the complainant. Further the repudiation of the part of the amount by OP1 made the complainants to undergo mental agony and strain for which we direct OP1 to pay a sum of Rs.10,000/- as damages and further to pay a sum of Rs.5,000/- towards litigation expenses. Hence we answer point No.2 partly in the affirmative and pass the following;

ORDER

1. Complaint is allowed in part with cost.
2. OP1 is directed to pay a sum of Rs.50,205/- along with interest at 12% p.a., from 12.10.2019 till the payment of the entire amount(if Rs.97,200/- is paid already, if not to pay the same along with interest at 12% from 12.10.2019).
3. OP1 is also pay a sum of Rs.10,000/- towards damages for causing mental agony and hardship and Rs.5,000/- towards litigation expenses to the complainants.
4. OP2 is directed to pay a sum of Rs.10,000/- to the complainants for making them to wait till the midnight of 12.10.2019 even though the bill was raised initially at 5.20 pm on that date.
5. OPs are further directed comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
6. Send a copy of this order to both parties free of cost.

Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order failing which the same will be weeded out/destroyed.

(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 08^TH  DAY OF DECEMBER 2021)

MEMBER                                PRESIDENT

ANNEXURES

1. Witness examined on behalf of the Complainant/s by way of affidavit:

Copies of Documents produced on behalf of Complainant/s:

Ex P1: Estimation copy given by the Fortis Hospital

Ex P2: Inpatient detail bill

Ex. P3: Payment advise

Ex P4: Discharge summary

Ex P5: Operation notes

Es P6: Copy of the legal notice

Ex P7: Copy of the Reply notice

2. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Sri.A.P.Sreekantha

Copies of Documents produced on behalf of Opposite Party/s

Ex R1: The certified copy of the Happy Family Floater 2015 policy schedule

Ex R2: Policy with conditions

Ex R3: PPA network declaration

3. Witness examined on behalf of the Opposite party/s by way of affidavit:

RW-1: Sri.Srikant Subudhi

Copies of Documents produced on behalf of Opposite Party/s

Ex R4: Copy of the inpatient bill

MEMBER                                        PRESIDENT

HAV*