ORDER

SRI SHRINIDHI.H.N., MEMBER

1. This complaint is filed by the complainant under section 35 of the C.P.Act, 2019 against the OPs alleging deficiency of service seeking directions to OP-1 to fairly charge the hospitalization bill as per government of Karnataka circular for Covid treatment and to give refund of exorbitant charges collected and also to direct OP-2 to 4 for reimburse the balance bill amount of Rs.7,37,134/-  or the revised bill as directed by the commission with interest at 18% p.a. with effect from 31.12.2020 till realization and other costs.

2.   The brief facts of the case is as follows: 

The complainant was infected with covid-19 virus and to avoid spread of virus with a caution and for better treatment the complainant got admitted with OP-1 on 26.10.2020 and was inpatient till 17.11.2020 and the complainant was discharged on 17.11.2020 with final bill no.BL2021000227 dt.17.11.2020for Covid luxury single bed ward. The complainant states that she was attended by number of doctors and its bills shows a list of doctors who visited the complainant. It is contended that the bill states that 03 doctors have visited her daily during hospitalization which is not the true picture and only one doctors has visited her. Accordingly, the complainant sought for clarification to furnish the attendance register of 03 doctor which has not been provided to her and on request for reduction of doctors fee the same has also been denied to her. It is also the case of the complainant that exorbitant charges were levied as bed/ward chargesnot following Karnataka Government circular no.HFW 228 ACS 2020 dt.23.06.2020. The complainant states that the final bill does not indicate bed or ward number where as it mentions the same as Covid luxury single bed No.23. The final bill amount as per the hospital is Rs.10,32,141/- and the complainant is covered with medi-claim insurance policy from OP-2 to 4 which was in force at the time of hospitalization and the complainant states inspite of this fact she was made to pay theentire hospital charges by OP-1 as per the final bill. Apart from this complainant is pointing at the facilities and care which were lacking at the OP-1 and they have taken undue advantage of the situation.

3. It is also brought out in the complaint that OP-2 to 4 were informed about hospitalization and admission on 26.10.2020 as per the policy guidelines which is marked as document-3&4. The complainant objects to the fact that the OPs have failed to settle the hospital bills and with no alternative she was forced to pay the same at the time of discharge. On submission of claim to the OP-2 to 4, the OPs settled the claim through email stating that it is full and final settlement of claim with a sum of Rs.2,95,007/-  and the complainant is not satisfied and therefore has filed complaint against OP-2 to 4. Hence, the complainant is preferring a claim for the balance amount of Rs.7,37,134/- as per the bill of OP-1 from the OP-2 to 4 as per the insurance policy along with cost.

4. On admission of the complaint, notice was ordered to be issued to OPs on 13.06.2022 and  OP-1 to 4  filed appeared through counsel and  filed their version along with documents. OPs also filed affidavit along with documents.    The version filed by the OP-1  and documents marked as R1 to R6 and same avers as under:      

The OP-1 states that the complainant was admitted to their hospital on 26.10.2020 with severe of Dry nature which was increasing progressively and accordingly the RTPCR swab test for covid-19 was carried out and complainant was tested positive for Covid-19. On analysis of high resolution computed tomography and patient was seriously ill with pre-existing condition of Diabetes and decreasing Oxygen saturation and therefore was admitted as inpatient for treatment and monitoring. It is also stated that the patient was hospitalized in a luxury private suite as per the request and the tariffs and expenses were explained to the complainant, duly obtaining a consent form as prescribed by the Government of Karnataka and which was signed by the son of the complainant Sri Arun kumar, which is marked as Document-R1. Various tests were conducted on the patient and she was diagnosed with viral pneumonia and treatment was provided to her with at most care and adequate assistance. It is also stated that the complainant was attended by one General physician and an Intensivist and physiotherapist for pulmonary physiotherapy and patient was regularly monitored by Duty doctor during entire 23 days of hospitalization at OP-1 as Document-2. The OP-1 admits that in view of elaborate medication administered by and attended by number of doctors, various medical tests and Luxury private suite providedalong with other miscellaneous expenses the final bill was issued on 17.11.2020 and complainant had paid the same without any protest. Hence, the OP-1 contends that the complaint is an afterthought since the Insurance company has failed to reimburse the total cost incurred by the complainant. The OP-1 also produced the copy of notification of the Government of Karnataka for treating Covid patientswhich is produced as Document No.4. In this background the OP-1 alleges that the complainant knowingly opted for luxury suite which is covered under the insurance scheme and also was aware of charges and expenses involved. It is contended that the notification of the Government is not applicable to the complainant.

5. The OP-1 denies all other allegations of the complainant and states that the complainant was attended by them with utmost care and following all the medical procedures and protocols and therefore, the complaint is with an ulterior motive and is an effort to defame the OP-1 under the abuse of process of law. Hence, prays for dismissal of the complaint with cost in the interest of justice and equity.

6. The OP-2 to 5 accepts the fact that the complainant is covered by the Senior citizens Red Carpet Heath Insurance policy vide policy bearing No.P/141116/01/2021/001277 from 30.06.2020 to 29.06.2021 with a pre-existing disease Diabetes Mellitus. The OPs state that the policy is a contractual one and the claims arising therein are subject to terms and conditions of the policy and this policy claims as arised in the 3^rd year of policy with covid-19 infection. The OPs vehemently deny any deficiency in service since the claim of the complainant was settled for a sum of Rs.2,95,007/- as per the final bill with certain disallowances as per the terms and conditions of the policy and the reasons for such disallowance were also intimated to the complainant and the hospital. The OPs  state that a  maximum  for ICU with ventilator allowed upto Rs.25,000/- per day, and Room rent allowed upto Rs.12,500/- and hence an amount of Rs.6,19,641/- claimed as per the bill  is deducted.  Further, the complainant is required to bear 50% of Co-payment charges as per clause-J of the policy  in respect of pre-existing diseases and 30% for all the claims. Therefore, a sum of Rs.1,23,750/- was  disallowed along with pre-hospitalization expenses of Rs.1,773/- with a net payment.  The OP-2 to 5 take a contention that inspite of  the complainant  raising an issue of overcharge with the Hospital, the OPs however have allowed the claim as permissible under the policy conditions and request for dismissal of claim  as there is no deficiency in service on their part and the claim has been settled as per the scrutiny of the claim by qualified doctor. It is also contended that insurance is based on at most good faith and the insured is expected to read and understand the entire policy contents before signing the contract which is the final say in case of a dispute as to the claim against the policy.  Finally, the OPs deny their liability to an extent of Rs.6,19,641/- as claimed by the complainant and pray for dismissal of the complaint. The OP-2 to 5 filed original insurance policy and premium paid receipts as document No.1 to 3.

7. Heard arguments and complaint was posted for orders after hearing the arguments.

8. Considering the contentions and documents filed by the complainants  and OP, the following points arise for consideration by the commission are:

1. Whether the Complainant proves that there is deficiency of service on the part of the OPs as alleged in the complaint and thereby prove that she is entitled for the relief sought?
2. What order?

9. The findings on the above points are as under:

Point No.1              :       Negative.

Point No.2              :       As per final order

REASONS

10. POINT NO.1:-   In this complaint the complainant points at deficiency of service  on the part of OP-1 hospital  and also the deficiency in service by OP-2 to 5 who are the insurers for the medi-claim policy taken by the complainant after paying the prescribed insurance premium which is current as on date of admission of the complaint with  OP hospital. The complainant got admitted to the hospital due to Covid infection on 26.10.2020 and was treated till 17.11.2020 as an inpatient. The main contention in the complaint is that he has been charged exorbitantly by the OP-1 hospital  towards ward charges and other tests and treatment given during the stay of the complainant as an inpatient. The complainant has been billed for a sum of Rs.10,32,141/- by the OP-1 hospital and the complainant places her claim based on the Government of Karnataka dt.23.06.2020 which prescribes the scales of fee liveable for the covid-19, by the private hospital under various circumstances.  Further, the complainant is also praying for order for refund of a sum of Rs.7,37,134/- which is the amount disallowed by the OP-2 to  5 who are the insurers for the said medi-claim policy. The complainant submits that she has been paid a sum of Rs.2,95,007/-  as  against the Hospital bill of Rs.10,32,141/- by the OP-2 to 5 and prays for direction for payment of the balance amount of Rs.7,37,134/-.

11. This commission after considering the submissions made by all the parties and version filed by the OP-1to5 has considered the issues raised by the complainant in depth. The  commission observed that the document not.2 produced by OP-1 which is the specific form prescribed by the Government of Karnataka for Covid-19 patients admitted in private hospital identified by the government, with specific prescription of treatment under government scheme(if Eligible) or at the own cost of the patient, for which patient’s relative is required to give an undertaking. In this document the patient’s relative( i.e. the son)  has duly signed to this form, undertaking to pay ward charges at Rs.15,500/-, doctor consultation Rs.5,700/- and Lab investigations and Pharmacy bills on actual basis. The signatory to this claim and all other subsequent bills is one Mr.Arun Kumar, who is the son of the complainant.

12. Apart from this, the OP-1 have also furnished entire case history of the complainant as Document No.2 and  summary of individual pharmacy and other charges which were levied by them based on actual as per the credit bill submitted as Document No.3. The other most important document is the notification No.HFW228 ACS 2020 dt.23.06.2020 which is the notification of the Government of Karnataka exclusively prescribing the package rates for treatment of Covid patients under various circumstances, as per which standard rates are levied for patients referred by Pubic Health Authority and a different package for patients directly admitted for private hospitals making cash payments. It is very important  here to note that para-3(i) on page-2 of this circular stipulates that the rates prescribed by the government is “NOT APPLICABLE FOR PATIENTS SUBSCRIBING TO INSURANCE PACKAGES”. Hence, the claim of the complainant in this case based on the circular or the actual billing cannot sustain. This is due to the fact that the claim based on the government circular and its application to the complainant is ruled out as per the terms and conditions prescribed in the said circular. Secondly, the allegation of excess charges by the OP-1 hospital as alleged by the complainant also gets defeated due to the clear undertaking given by the son of the complainant at the time of admission to the OP-1 hospital agreeing to pay the ward charges and consultation as mentioned therein. As far as the other claim of payment of balance amount of Rs.7,37,134/- by the insurer as prayed in the complaint is concerned, it is an accepted fact that a sum of Rs.2,95,007/- has already been settled by the insurance company as against the total claim of Rs.10,32,141/- as per the bill issued by OP-1. The OP-2 to 5 have justified their  action in disallowing a sum of Rs.7,37,134/- stating the same is as per policy terms and conditions duly explaining each and every claim which is denied by them along with reasons. Hence, the commission is of the clear opinion that the case on hand deserves to be dismissed in view of the discussions and reasons as above. Accordingly, we answer the Point No.1 in Negative.

13. POINT NO.2:- In the result, for the forgoing reasons,  we passed the following:

                                      ORDER

1. The complaint  filed by the complainant is hereby dismissed. No costs.
2. Furnish free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 28^th June  2024)

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                   (SHRINIDHI.H.N)            

                                                                          MEMBER                                         MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Smt.Sulochana -Who being the complainant.

Documents produced by the complainant:

Witness examined on behalf of the OPs by way of affidavit:

1. Sri Bharatesh Krishna.P-Who being the Administrator of OP-1.
2. Smt. Prema – Who being the Asst. Manager of OP-2 to 5.

     Documents produced by the OP-1:

     Documents produced by the OP-2 to 5:

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                 (SHRINIDHI.H.N)            

              MEMBER                                           MEMBER

*S.K.A.