Consumer Complaint No. 179 of 2016
Date of filing: 03.10.2016 Date of disposal: 17.02.2017
Complainant: Tapas Ray, S/o. Late Jnanendra Mohan Ray, 10/5, SEPCO Township, B-Zone, Durgapur – 713 205, District: Burdwan.
-V E R S U S-
Opposite Party: 1. Apollo Hospital, represented by the Administrative Manager, 21. Greams Lane, Chennai – 600 006.
2. The New India Assurance Co. Ltd., Durgapur DO (512100), Represented by the Branch Manager, Ajit Banerjee Building, Nachan Road, Bhiringi, Durgapur – 713 213.
Present: Hon’ble Member: Smt. Silpi Majumder.
Hon’ble Member: Sri Pankaj Kumar Sinha.
Appeared for the Complainant: In Person.
Appeared for the Opposite Party No. 1: Ld. Advocate,Subrata Ghosh & Debdas Rudra.
Appeared for the Opposite Party No. 2: Ld. Advocate, Ahi Bhushan De.
J U D G E M E N T
This complaint is filed by the Complainant u/S, 12 of the Consumer protection Act, 1986, alleging deficiency in service, as well as, unfair trade practice against the OPs as the OPs did not refund him the due amount to him along with banking interest.
The brief fact of the case of the Complainant is that he got admission at the Apollo Hospital, Chennai on 17.07.2015 with left Radiculopathy and after operation he was discharged on 20.07. 2015. The total expenditure for his medical treatment is of Rs.1, 74,559=00. TPA provided Rs.85, 700=00 and the remaining amount of Rs.88, 859=00 was paid by him during his discharge. TPA informed him that remaining amount paid by him will be reimbursed after receipt of the final bill from his side. Thus he forwarded the final bill to the Insurance Company including all his pre and post operation charges which amounting as Rs.92, 238=00. But the Insurance Company settled his claim and refunded him only Rs.4, 279=00. But his operation was done under PPN package and the Insurance Company having a MOU with the Apollo Hospital regarding the same at Rs.85, 700=00 and denied to pay the rest amount. When he got admission neither the OP-1 nor the TPA has informed him about the PPN package. To minimize the bill he stayed at the lowest rated bed of the hospital though after his operation he gathered news from reliable sources that as per value of his medi-claim policy, he could stay at the semi-private room. According to the Complainant if he got information regarding PPN package previously then he could have avoided paying such a huge amount, so he was cheated by both the Hospital authority as well as the Insurance Company as there exists a MOU by and between themselves regarding the same operation. During his admission process on 17.07.2015 he had to sign in the various forms where the hospital authority taking advantage of his tensed and unconscious mind took his signature in an undertaking wherein it is mentioned-‘if he wishes to undergo his treatment staying at a higher category bed/room consisting of various amenities and facilities then he will be responsible to pay the extra charges charged against those facilities.’ On 18.07.2015 the hospital authority took him to another hospital namely as Apollo Speciality Hospital by ambulance and operation was done at the said Hospital without taking any consent from him. After completion of operation he was brought at the earlier Hospital where he got admission earlier. Though it was a matter of few hours still as a serious patient he had to undergone physical and mental stress and harassment. The Complainant wants to know who is actually responsible for shifting him from the Apollo Hospital to Apollo Speciality Hospital for operation purpose only without his consent. Apollo Speciality Hospital is a non-PPN hospital/organisation, then why they took him to that speciality hospital for his operation when the hospital authority was well aware (as per MOU between Hospital & TPA) that the Complainant’s operation falls under within the PPN package. Though he stayed at lowest rated bed, but the hospital authority charged huge amount extra bill and in this manner the hospital authority had violated the PPN package. The Insurance Company also denied reimburse the extra amount as claimed by the hospital authority. It is stated by the Complainant that the Insurance Company did not bother to aware or inform him about the PPN package facility after his operation also. Subsequently he approached before the Ld. Ombudsman, who after hearing both parties gave decision in his favour by directing the TPA to clear his due payment and the Ld. Ombudsman also opined against the hospital authority as it charged excess amount to the PPN package rate and in this way the hospital authority not only violated the agreement (MOU) but also put the Complainant under immense hardship. In view of the abovementioned direction given by the Ld. Ombudsman the TPA has paid a sum of Rs.39, 207=00 out of the net payable amount of Rs.87, 959=00. After repeated queries the TPA authority told him that the remaining amount of Rs.48, 752=00 has been deducted since he stayed at higher rated bed which was not permitted for him as per policy terms and conditions. After operation the treating doctor advised me to take rest for three months, but due to such action of the Hospital Authority as well the Insurance Company he had to run from pillar to post to get back the reimbursement, for which he his physically and mentally affected. According to the Complainant such action of the OPs are certainly suffer from deficiency in service on their parts and for which he has prayed for compensation to the tune of Rs.5,00,000=00 and prays for direction upon the OPs to return his due amount along with banking interest.
The petition of complaint has been contested by the OP-1 by filing written version contending that this OP is a well-equipped and renowned hospital having efficient doctors, RMOs and trained nurses. From the documents it would be evident that this OP has provided facilities to the patient in accordance with the procedure prescribed by the Medical Science and Law. The OP did not commit any deficiency in service. There is no iota of evidence wherefrom it would be evident that this OP had committed negligence in treating the patient as well as committed any deficiency in service. So the allegations made against this OP are all false and baseless and this OP is denying the same. The Complainant has unnecessarily impleaded this OP, thus he is not entitled to get any relief in accordance with the prayer of the petition of complaint. Prayer is made by the OP for dismissal of the complaint against this OP.
The complaint has been contested by the OP-2 by filing written version contending that the Complainant obtained a medi-claim policy with this OP for the period from 21.11.2014 to 20.11.2015. During the validity of the said policy the Complainant felt low back pain radiating to left lower limb for past two months prior to his hospitalisation in Apollo Hospital, Chennai. The disease was detected firstly on 15.06.2015 and the nature of the disease is L5 S1-IVDP with Left Radiculopathy. Being diagnosed the Complainant was admitted in the Apollo Hospital, Chennai on 17.07.2015 and underwent L-5 SILT MICRO DISECTOMY operation. The Complainant gave consent letter/pre-authorization in Apollo Hospital, Chennai seeking cashless benefit under PPN Package on account of his admission on 17.07.2015 at Apollo Hospital for his planned surgery, L-5 SILT MICRO DISECTOMY under S.K. Hegde. As per the policy condition the Heritage Health Private Limited was the TPA, who received pre-authorisation request from Apollo Hospital, Chennai, which is in the list of PPN Hospital seeking cashless benefit on account of admission of the Complainant on 17.07.2015 for his planned surgery under Dr. Hedge, who had indicated that the said patient was suffering from low back pain radiating to left lower limb for two months. The cashless request of the Apollo Hospital has been placed under the policy period of 2014-2015 and looking at the type of surgery as per PPN package and the TPA had approved Rs.85, 700=00 for cashless hospitalisation as maximum for the said disease. Thereafter the insured submitted the claim documents on 06.08.2015 seeking reimbursement of Rs.92, 238=00 including Rs.88, 859=00 towards the cost for hospitalisation period. The said claim was processed for Rs.4,279=00 including cash benefit of Rs.900=00, since the TPA had already allowed for payment of Rs.85,700=00 during hospitalisation period, as maximum payment for the said disease as per PPN package and the amount of Rs.4,279=00 has been credited to the insured’s bank account on 31.08.2015. The TPA approved Rs.85, 700=00 for cashless hospitalisation as per PPN package, which is maximum for the above disease. Thereafter the insured submitted claim documents on 06.08.2015 to the OP-2, which was sent to the TPA seeking reimbursement of Rs.88,859=00 including Rs.3,379=00 towards cost for post hospitalisation. The claim was processed for Rs.4, 279=00 had been credited in the bank account of the Complainant. Hospitalisation expenses of Rs.85, 700=00 being the maximum under the package was allowed by the TPA. The TPA requested the Apollo Hospital, Chennai on several times to provide the clarifications for extra charge of PPN package. As per hospital PPN rate (MOU) all charges including doctor’s fees, OT charge, anaesthesia charge, medicines, investigations, professional charge, room charge is Rs.85,700=00, but the hospital bill was for Rs.1,74,558=00. Though clarification sought for from the hospital by the TPA for extra expenses by issuing letter dated 29.08.2015, but no suitable reply was received by the TPA in this regard and thus the TPA though it as full and final payment to the insured against hospitalisation. The Complainant being not satisfied with the said amount of Rs.89, 979=00 (Rs.85, 700=00 + Rs.4, 279=00 =Rs.89, 979=00) had approached before the Ld. Ombudsman on 19.01.2016 for redressal of his grievance. Both parties were present and hearing was made on 18.07.2016. After hearing the Ld. Ombudsman decided that the Insurance Company will pay the residual claim amounting to Rs.87, 959=00 less any inadmissible expenses to the insured as per policy terms and conditions towards full and final and settlement of the claim dated 22.07.2016. The Complainant submitted his consent letter dated 09.08.2016 to this OP accepting the award in full and final settlement of the claim and accordingly the Complainant got the said award through his bank account. The OP-2 satisfied the award for Rs.39, 207=00 after deducting inadmissible expenses from the due claim amount as per the policy terms and conditions. This OP had complied with the direction of the Ld. Ombudsman in this manner. According to the OP the present claim of the Complainant untenable, misconceived and vexatious one and hence the Complainant is not entitled to get any amount from this OP as prayed for. It is stated by the OP-2 that this complaint against this OP is frivolous and vexatious one and for this reason the OP has prayed for dismissal of the complaint with cost of Rs.10, 000=00 payable by the Complainant to it.
The OP has filed written notes of argument with a copy to the other side. The OP has also filed several documents in support of its case by way of ‘firisty’. The Complainant has filed some documents in favour of his averment.
We have carefully perused the record; documents as filed by the contesting parties in support of their respective contentions and heard argument at length as advanced by the complainant in person and the OPs through their respective Ld. Advocates. It is seen by us that admittedly the complainant obtained a medi-claim policy from the OP-2, the policy was valid for the period from 21.11.2014 to 20.11.2015, during validity of the said policy the complainant felt low back pain radiating to the left lower limb, he got admission at Apollo Hospital, Chennai, the disease was detected on 15.06.2015, it was diagnosed as L-5 S-1-IVDP with left Radiculopathy, the patient was admitted on 17.07.2015 at Apollo Hospital, he underwent L-5 SILT MICRO DISECTOMY operation under Dr. S. Hegde, in the said hospital the operation of the Complainant was under PPN package as per the insurance policy as in this respect the OP-1 and 2 have entered in to a MOU, the Complainant sought for cashless benefit at the time of his admission, the same was turned down by both the OPs, before operation the Complainant was taken at the Apollo Speciality Hospital, Chennai , at the said hospital surgical intervention was done, after operation the Complainant was brought to the Apollo Hospital where he got admission, without taking his consent the Complainant was taken at the Apollo Speciality Hospital, before operation the OP obtained an undertaking from the Complainant whereby the Complainant undertook bear all the expenses even in case of excess expenditure, the OP-1 did not disclose that the surgical intervention will be done at Apollo Speciality Hospital, the Apollo Speciality Hospital being not a network hospital in connection with the insurance policy hence the operation of the Complainant was not under PPN package as per the policy condition, at the time of discharge a sum of Rs. 1,74,559=00 was raised by the OP-1 as hospital bill, out of which Rs.85,700=00 was approved by the TPA as PPN package for cashless hospitalisation as maximum for the said disease, the Complainant had to bear the remaining amount and paid the same out of his own pocket to the OP-1 before getting discharge, subsequently claim lodged with the OP-2, the OP-2 denied to pay the remaining amount of the hospital bill, the Complainant approached before the ld. Ombudsman the Insurance Company, in view of the order passed by the ld. Ombudsman ultimately the Complainant got the admissible amount towards his medical expenditure. The allegation of the Complainant is that due to deficiency in service as well as unfair trade practice he had to face physical strain, mental agony, harassment during the period when he was advised by the treating doctor for bed rest, at that time he had to run from pillar to post for getting the residual amount. Alleging such deficiency in service against the OPs the Complainant has sought for compensation.
It is s seen by us that a MOU was signed by and between the OP-1 and the OP-2 wherein it was settled that for such operation from which the Complainant was suffering from and ultimately operation was done, the insured is entitled to get a sum of Rs.85, 700=00 as maximum towards the medical expenditure as the said treatment was under PPN Package. The Complainant got admission at the Apollo Hospital, Chennai which was under the coverage of the PPN package. Therefore, in our opinion the Complainant was entitled to get a sum of Rs.85, 700=00 towards his medical expenditure in view of the terms and conditions of the insurance policy as the said hospital was under PPN package. But is seen by us that though the Complainant got admission at the OP-1, but during operation he was taken to the Apollo Speciality Hospital, Chennai which was not covered under PPN package without taking consent from him as well as without giving any prior intimation and taking consent from the Insurance Company. No reason has been assigned by the OP-1 as to why the Complainant was taken at the Apollo Speciality Hospital, Chennai for such procedure. The Apollo Speciality Hospital being a very costly hospital and as the charges and rates for treatment are higher than the Apollo Hospital, hence the said hospital raised the medical bill at a higher rate, though the same was not necessary as the Complainant got admission at the Apollo Hospital, Chennai for his operation. At the time of admission the Complainant was not told by the authority of the OP-1 that such procedure could be possible therein and he may be taken at separate hospital. Moreover keeping him in dark and without taking his consent as well as the consent and prior notice to the OP-2, the Complainant was taken at the separate costly hospital where the PPN package was not available by the OP-1 arbitrarily and whimsically. In the written version nowhere it is stated by the OP-1 the reason for shifting the patient for the said procedure at a separate, costly hospital being not a network hospital as per the insurance policy. During argument the OP-1 has argued that as the Complainant undertook to bear all the expenses, even in case of excess expenditure, hence he is under obligation to pay the entire amount as per the hospital bill raised by it and such action of the OP cannot be termed as deficiency in service on its part. But we noticed that for this operation the OP-1 is not at all entitled to claim more than Rs.85, 700=00 in view of the MOU wherein it is settled that for such operation and treatment the insured patient will get a sum of Rs.85, 700=00 as maximum towards hospital and treatment bill, but the OP-1 raised bill for Rs.1,74,559=00. According to the OP-1 as per undertaking given by the Complainant, he is under obligation to pay the entire amount of the bill. In our view as the OP-1 had knowledge that the Apollo Speciality Hospital is not covered under PPN Package, then taking of the patient at the said hospital for the time being was made by the OP-1 to gain more money in an illegal, improper and unauthorised manner, not only that the OP-1 had also violated the terms and the conditions of the MOU executed by and between it and the Insurance Company. In this manner the OP-1 harassed the Complainant as at the time of discharge a sum of Rs. 1, 74,559=00 was claimed by the OP-1 from the Complainant, where the OP-1 had knowledge that for such operation the PPN Package is permitted within Rs. 85,700=00. Knowing it very well that beyond Rs. 85,700=00 the OP-1 is entitled to claim any farthing from any patient like the Complainant , insptie of this it claimed a hefty amount from the Complainant, going beyond the terms and conditions of the MOU, which reveals the unfair trade practice of the OP-1.
During argument the ld. Counsel for the OP-2 has attracted our notice to the order passed by the ld. Ombudsman of the Insurance Company wherein the ld. Ombudsman after hearing from the both parties has ordered which runs follows:
“From the discharge summary it is observed that although the undergone procedure of L-5-S1 SILT MICRO DISECTOMY is listed under PPN package, yet the final bill of Rs.1, 74,559=00 raised by the Hospital authority exceeds the pre-authorized amount of Rs.85,700=00 being the all inclusive charges stipulated jointly by the Insurance Company and the hospital authority for the said procedure. It is opined that while providing undertaking to bear excess expenses Complainant-patient was ignorant of shifting to non-PPN speciality hospital, being done purely at the behest of the hospital authority. Hence it is illegal on the part of the hospital authority to discharge the patient after receiving the excess. By charging in excess of the PPN rate the hospital authority has not only violated the agreement but also put the Complainant under immense hardship. Hence, insurer’s repudiation of claim is irrational.
Taking into account the facts and circumstances of the case the submission made by both parties during the course of hearing, residual claim amount to Rs. 89,959=00 less in any admissible expenses as per policy terms and conditions, is hereby awarded to be paid by the insurer to the insured towards full and final settlement of the claim. Hence the complaint is treated as allowed”.
During hearing the Complainant has submitted that he has already get the admissible amount in view of the abovementioned order passed by the ld. Ombudsman but this complaint is filed by him claiming compensation from the OPs. In our view that the complainant has failed to prove any deficiency in service or inaction on behalf of the OP-2 because admittedly the OP-2 has repudiated the claim of the Complainant lodged by him towards the residual claim amount as per the terms and the conditions of the policy as well the MOU. As per the MOU beyond Rs.85, 700=00 could not be granted in respect of such claim and the OP-2 had acted accordingly. Further admitted fact is that as the total claim had crossed the maximum limit as per the PPN package, hence the claim of the Complainant was repudiated by the OP-2. Such repudiation of the claim within the stipulated period cannot be termed as deficiency in service and the OP-2 has no authority to act going beyond the terms and the conditions of the MOU as executed by and between the both parties. So the Complainant is not entitled to get any amount as compensation and other consequential losses from the OP-2 as sought for. But in respect of the OP-1 we are to say that there was deficiency in service on behalf of the OP-1 as it neither disclosed that the operation of the Complainant is listed under the PPN package and the OP-1 itself is also under the said package as per the MOU, but knowing the same the Complainant was taken by it for the time being for surgical intervention at Apollo Speciality Hospital wherein the said package was not allowable. Hence such transfer of the patient at the separate hospital by the OP-1 as also keeping in dark the Complainant and the OP-2 OP-1 had done the same with a view to earn more profit from the insured as the OP-1 received the entire bill amount from the Complainant raised by it going beyond the MOU and violating the terms and conditions of the same. Hence such action of the OP-1 cannot be tolerated and in our view such action can easily be termed as deficiency in service on the part of the OP-1. For this reason the Complainant is very much entitled to get compensation from the OP-1. In view of the Section 14 of the Consumer Protection Act, 1986 we are inclined to direct the OP-1 to pay compensation and as due to such action of the OP-1 the Complainant has approached before this Ld. Forum by filing this complaint, hence for such proceedings the Complainant had to incur some expenses, so in our view the Complainant is also entitled to get litigation cost from the OP-1.
Going by the foregoing discussion hence, it is
O r d e r e d
that the complaint is allowed on contest with cost against the OP-1 and dismissed on contest without any cost against the OP-2. The OP-1 is directed to pay a sum of Rs.10, 000=00 to the Complainant as compensation due to deficiency in service for which the Complainant had to face mental agony, pain and harassment and litigation cost of Rs.1, 000=00 to the Complainant within a period of 45 days from the date of passing of this judgment, in default, the Complainant will be at liberty to put the award in execution as per provisions of law.
Let plain copies of this order be supplied to the parties free of cost as per provisions of law.
Dictated and corrected by me.
(Silpi Majumder)
Member
DCDRF, Burdwan
(Pankaj Kumar Sinha) (Silpi Majumder)
Member Member
DCDRF, Burdwan DCDRF, Burdwan
