SMT. RAVI SUSHA  : PRESIDENT

      Complainant filed this complaint U/S 35 of the  Consumer Protection Act 2019 for getting an order directing opposite parties  to reimburse Rs.1,41,314.24/- the medical  bill together with Rs.50,000/- towards compensation.

     complainant’s case  is  that he is having ESIC insurance from  2017 upto 2020 and his parents are also  covered under  the said insurance.  Complainant’s father had undergone angioplasty in OP hospital.  Complainant alleged that his claim for getting reimbursement of his father’s treatment bill for an amount of Rs.1,30,807.98/- was rejected by the ESI corporation.  He further alleged that the reason for  rejection was due to non-submission of the stent bill.  According to complainant though he approached OPs for getting bill of stent, OPs failed to give it.  So he could not get reimbursement of the  medical bill from ESIC.  Complainant alleged that action of OPs amounts to deficiency in service on the part of OPs.

      After receiving notices OPs 1&2 filed separate written version.  1^st OP hospital submitted that  1^st OP hospital does not have procedure to issue separate bills for materials used during treatment since it will be included in the patient bill issued by 1^st OP  It is further submits that the complainant’s father undergone treatment from them on 30/4/2019 and was discharged  on 3/5/19 and the complainant does not have any complaint about  the services provided by 1^st OP and  they have not any knowledge about the rejection of claim by ESIC.  The materials used for surgery will be  purchased together in wholesale and will be stocked in the hospital. The materials will be taken for surgery from such stocks.  So there will not be any separate bill for each and every materials used for surgery. It is further submits that 1^st OP is validly insured with United India Insurance company ltd against the damages likely to arise out of the professional duty by reason  of any negligent act  error or omission whenever committed or alleged to have committed.  Insurance  company is a necessary party  to the above case.  Without  impleading the insurance company  the complaint is bad for non joinder of necessary parties.  So the  insurance company is bound to pay the compensation.  There is no  deficiency of service on the part of 1^st OP, hence prayed for the  dismissal of the complaint.

      2^nd OP has stated that the complaint is barred by limitation that the claim was rejected by the ESIC on 18/5/2023 that means his claim was rejected after 4 years of surgery.  So it is probable  that the complainant  submitted  his claim after a long period.  The OP has no knowledge about the rejection of the claim by the ESIC.  Even if any claim is rejected the OP is not responsible . It is  submitted that the complainant did not mention any shortcomings on the side of the OP in treatment.  So the complaint is  not maintainable  against this OP. The  complaint alleges that the complainant’s claim was rejected due to the non-submission of the stent bill.  The amount  for the  stent  was included in the  bill dtd.3/5/2019. The hospital does not have a procedure to issue separate bills for materials used during treatment.  There was no deficiency in service on the part of 2^nd  OP and prayed for the  dismissal of the complaint.

       At the evidence stage, complainant has filed his chief affidavit and documents.  He was examined as PW1.  Marked the documents as Exts.A1 to A8 series.  On the side of OPs, the legal officer of 1^st OP hospital filed his chief  affidavit and his authorization letter.  He was examined as DW1 and authorization was marked as Ext.B1.  After that the complainant and the learned counsel of OP made argument.

   We have perused the evidence tendered by the parties, documents available and also the submission of the parties.

  Complainant’s case is that he is having ESIC insurance from  2017 upto 2020 and his parents are also  covered under  the said insurance.  Complainant’s father had undergone angioplasty in OP hospital.  Complainant alleged that his claim for getting reimbursement of his father’s treatment bill for an amount of Rs.1,30,807.98/- was rejected by the ESI corporation.  He further alleged that the reason for  rejection was due to non-submission of the stent bill.  According to complainant though he approached OPs for getting bill of stent, OPs failed to give it.  So he could not get reimbursement of the  medical bill from ESIC.  Complainant alleged that action of OPs amounts to deficiency in service on their part .

   Through complainant, the existence of policy of complainant, during the disputed  treatment period with  ESIC is proved(Ext.A1).  Through Ext.A1 it is also proved that  complainant’s father and mother are also the beneficiaries of the policy.  There is no dispute that the  complainant’s  father Mr.Thomas has availed treatment from 1^st OP hospital under inpatient  from 30/4/2019 to 3/5/2019 in IP No.19/1417, coronary angioplasty was done on 3/5/2019 and issued in  patient bill(Ext.A2) for an amount of Rs.1,30,807.98.  Ext.A7 shows the submission of re-imbursement of the cost of medicine/spectacle etc of insured person by the insurance medical officer to the Deputy Director(ESI), Health and Family welfare Services, dtd.17/6/2019.  Ext.A3 is the letter given from ESI dispensary to the complainant dtd.18/5/2023 for re-submitting the medical bill with stent original bill and IP No. in all bill certificate.  Ext.A6 is the e-mail request given by the insured to OP hospital for providing original stent bill and  IP certificate dtd. 24/6/2023.   

     OP’s specific contention is that the complainant had paid the bill amount Rs.1,30,807.98/- to 1^st OP hospital and original discharge bill was issued  in which  2^nd OP doctor has put signature.  1^st OP submitted that the materials used for surgery will be purchased together  in whole sale and will be stocked in the hospital.  Materials will be taken for surgery from such stocks.  So there will not be any separate bill for each and  every materials used for  surgery.  Further submits that 1^st OP  hospital does not have procedure to issue separate bills for materials used during treatment since it will  be included in the patient bill issued by 1^st OP.

     Here Ext.A2 is the original patient bill issued by 1^st OP hospital.  On perusal of Ext.A2 bill, we can see that  item ”package coronary angioplasty 1- rate-Rs.60,000/-.  Through insurance company, the insured is certified  to get the expense incurred to the insured for the surgery material as well as treatment expense.  In Ext.A2, Rs.60,000/- is mentioned for the surgery material and for the surgery expense ie  a package.  So there is no meaning for demanding the separate original bill for the stent used for surgery.  Moreover Ext.A7 is the submission of the claim of complainant, by ESI dispensary to the Deputy Director(ESI) Health and Family Welfare services dtd.17/6/2019.  Ext.A3 is the letter given by ESI dispensary to the insured complainant demanding stent original bill and  IP NO. in all bill certificate dtd.18/5/2023 ie after about  4 years from the submission of the claim application.  It is a settled position that the insurance company shall allow or  repudiate the claim without delay from its submission.  Moreover, here   the repudiation letter sent by ESI corporation (insurance) is not seen  attached with Ext.A3.  So there is  extra ordinary delay from the side of insurance corporation as well as ESI dispensary.

  In the instant case complainant does not have  case of medical negligence from the side of treating doctor or from the side of hospital.  It is seen that the treating doctor 2^nd OP has put his signature on the  back side of each medical bill.  With regard to mentioning  of inpatient  number in each bill, the discharge summary   Ext.A2 carries the IP number of the patient.

   It is a fact that OP hospital  is a super specialty hospital, conducting number of surgery  in each department every day.  So it is impossible to issue bills for each and every surgery material etc.

   Moreover, if the complainant impleaded the ESI corporation as a party in this complaint, the real facts  will be revealed.  So without impleading necessary party, this complaint has a defect of non-joinder of necessary party also.

   Considering the entire facts and circumstances and from the available evidence, we could not find deficiency in service on the part of OPs 1&2.

   In the result, complaint fails and hence the same is dismissed.  No order as to cost.

Exts:

A1- ESIC insurance policy dt.21/3/17

A2-Discharge bill dtd 3/5/19

A3- Reply ESI dispensary dtd.18/5/23

A4&A5-Amala hospital OP ticket dtd.8/4/19,14/6/23

A6- E-mail communication

A7- Insurance claim /proposal dtd.17/6/19

A8series- Medical bills

B1-Authorisation letter(Board resolution)

PW1- Jain Thomas- Complainant

DW1-Rajesh.A.V- 1^st  OP

  Sd/                                                               Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                   MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                      /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR