Date of Filing 18.10.2019

                                                                                                             Date of Disposal: 08.04.2024

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

BEFORE TMT. Dr.S.M. LATHA MAHESWARI, MA. ML, Ph.D (Law),                                          …….PRESIDENT

               THIRU.P.VINODH KUMAR, B.Sc., BL,                                                                                ……MEMBER-I

               THIUR.P.MURUGAN, M.Com, ICWA (Inter), BL.,                                                           ……MEMBER-II

RBT/CC.No.48/2024

THIS MONDAY, THE 08^th DAY OF APRIL 2024

Mr.S.Rajendran,

No.14/27-B, Mettu Street,

Kaladipet, Chennai 600 019.                                                                  ......Complainant.

                                                                                   //Vs//

1.Bilroth Educational Trust,

    Rep. by its Chairman,

    Mr.Rajesh Jaganathan,

    No.43, Lakshmi Talkies Road,

    Shenoy Nagar, Chennai 600 030.

2.Dr.Arunkumar Krishnamurthy,

   Consultant,

   Cardiothorasic Surgeon,

   Bilroth Hospital,

   No.43, Lakshmi Talkies Road,

   Shenoy Nagar, Chennai 600 030.

3.The Chief Secretary to Tamil Nadu,

   Secretariat, Chennai.                                                                      ……Opposite parties.

Counsel for the complainant                                         : M/s.V.Kannan, Advocate.

Counsel for the 1^st opposite party                                : M/s.V.Shankar, Advocate.

Counsel for the 2^nd opposite party                               : M/s.S.Rajalakshmi, Advocate.

Counsel for the 3^rd opposite party                               : exparte.

This complaint has been filed before DCDRC, Chennai (North) as CC.No.18/2020 and transferred to this commission by the administrative order in RC.No.J1/3145/2023 dated 09.11.2023 of the Hon’ble State Consumer Disputes Redressal Commission, Chennai and taken on file as RBT/CC.No.48/2024 and this complaint coming before us finally on 12.03.2024 in the presence of M/s.V.Kannan, counsel for the complainant and M/s.V.Shankar counsel for the 1^st opposite party and M/s.S.Rajalakshmi, counsel for the 2^nd opposite party and 3^rd opposite party was set exparte on 11.05.2022 for non appearance and upon perusing the documents and evidences of both sides this Commission delivered the following:

ORDER

PRONOUNCED BY Tmt. Dr.S.M. LATHA MAHESWARI, PRESIDENT

1. This complaint has been filed by the complainant u/s 35 of the Consumer Protection Act, 2019 alleging deficiency in service against the opposite parties along with a prayer to direct the opposite parties to pay a sum of Rs.10,00,000/- towards compensation for the mental agony and hardship caused to the complainant along with cost of the proceedings to the complainant.

Summary of facts culminating into complaint:-

2. Alleging deficiency in service and unfair trade practice on the part of opposite parties the present complaint was filed seeking Rs.10,00,000/- as compensation.

3. It was the case of the complainant that he got admitted on the 1^st opposite party Hospital for Heart surgery.  At the time of admission the complainant produced the Chief Ministers Medical Insurance Welfare Scheme card bearing No.013301001 00478003066 and also the Prime Minister’s Medical Welfare Scheme card issued under Ayshman Bharat Scheme.  A public notice was also found within the Hospital premises for acceptance of the Chief Ministers Medical Insurance Welfare Scheme card.  However the opposite party Hospital refused to accept the same and the complainant was made to pay Rs.3,64,673/- towards medical expenses.  Thus stating that refusal by the Hospital Authorities to accept the Welfare Scheme cards amounts to deficiency in service and unfair trade practice the present complaint was filed for the reliefs as mentioned above.

The crux of the defence put forth by the 1^st opposite party:-

4. The 1^st opposite party filed written version stating that the complaint is an abuse of process of this commission and that the 2^nd opposite party never counseled the complainant to undergo Heart surgery immediately failing which the same would become life threatening.  It is out rightly denied that they in violation of the Chief Ministers Medical Insurance Welfare Scheme unlawfully demanded money from the complainant. Further it was stated that neither the patient nor his attenders did inform the Authorities/Billing Department/treating Doctor about the availability of the Chief Ministers Medical Insurance Welfare Scheme card at the time of admission to avail benefit under the above schemes.  Thus stating that there was no deficiency in service or unfair trade practice committed by them, the 1^st opposite party sought for the dismissal of the complaint.

The crux of the defence put forth by the 2^nd opposite party:-

5. The 2^nd opposite party filed written version stating that the complainant could have approached the Liaison Officer in Billroth Hospitals or the grievances cell in CMCHIS for appropriate relief. Complainant was suffering with severely symptomatic coronary artery disease since 2016 and had underwant angiogram on 10.12.2018.  The complainant was referred by the other colleague for bypass surgery and the complainant consulted the 2^nd opposite party on 20.12.2018 at Billroth Hospitals Private Limited.  After relevant preoperative evaluation the complainant was admitted on 26.12.2018 and surgery was performed on 27.12.2018 and it would be useful to note that since it was elective planned surgery the complainant had enough reflex time to find out from other hospitals about the line of treatment and cost factor. As per the records shared by the complainant it appears that he was suffering from dilated cardiomyopathy, renal dysfunction and stroke for long time and he has been under the care and management of private Hospitals on all those occasions.  After successful completion of surgery the complainant did report to the 2^nd opposite party for post-operative multiple reviews during which point of time the complainant never expressed any grievances either against the 2^nd opposite party or against Billroth Hospitals. Hence it could be easily inferred that the allegations set out in the complaint under reply were purely an afterthought and manifestly concocted to make unlawful gains. It was submitted that the complainant was admitted in Billroth Hospital for Cardiac Surgery on 26.12.2018 and the surgery was performed on 27.12.2018 and the complainant was discharged on 01.01.2019. Neither the complainant nor his attenders did inform the authorities/billing department/treating doctor about the availability of the CMCHIS card at the time of admission to avail benefit under CMCHIS scheme. Since the complainant and his attenders were not diligent enough to place request with the authorities/billing departments/treating doctor about the availability of the CMCHIS card at the time of admission to avail the benefit under CMCHIS scheme had proceeded to undergo surgery and got himself discharged like patients’ who opt to pay from their one source. Hence the complainant was stopped from taking advantage of his own wrong. Thus he sought for the dismissal of the complaint.

6. On the side of the complainant proof affidavit was filed with documents marked as Ex.A1 to Ex 13. The 1^st & 2^nd opposite parties filed proof affidavit but no documents were filed. Though notice was served on the 3^rd opposite party, he did not appear and hence he was called absent and set exparte on 11.05.2022 for non appearance and non filing of written version within the mandatory period as per the statue. 

Points for consideration:-

1. Whether the complaint allegations made against the opposite parties with respect to denial of the benefit provided under Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme to the complainant for the treatment undergone by the complainant amounts to deficiency in service and unfair trade practice and whether the same has been successfully proved by the complainant by admissible evidence?
2. If so, to what relief the complainant is entitled?

Point No.1:-

7. Heard both.

8. The learned counsel appearing for the complainant argued that the 1^st opposite party/Hospital refused to accept the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme card for the Heart surgery undergone by the complainant and the 2^nd opposite party threatened the complainant to undergo the Heart surgery immediately failing which it would be come life threatening for him.  Thus stating that the opposite parties had committed deficiency in service he sought for the complaint to be allowed as prayed for.

9. On the other hand the learned counsel appearing for the opposite parties 1 & 2 argued that the complainant failed to bring to the notice of the Hospital about the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medical Insurance Scheme at the time of admission to avail the benefit under the schemes.  Thus both opposite parties sought for dismissal of the complaint.

10. On perusal of the pleadings and evidence produced by the parties we could found that the entitlement of the complainant for the benefit under Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme was not at all disputed by the opposite parties.  The only defence raised by the opposite parties is that the complainant i.e. Patient/attenders did not inform the Hospital Authorities/treating Doctor about the complainant’s entitlement and possession of the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme.  There is no specific allegation against the 2^nd opposite party with regard to the treatment rendered by him and availed by the complainant. Also no allegation was raised against the 3^rd opposite party.  We are of the view that the Hospital Authorities has the bounden duty to enquire about the mode of payment and the entitlement and possession of a patient’s Insurance Scheme. A prudent man who was compelled to spend in lakhs would have definitely revealed about his entitlement for free treatment under the Insurance scheme. The version of the opposite parties could not be believed that the complainant or his attenders never revealed about the health insurance scheme and the entitlement of the complainant for the treatment at the time of admission or thereafter while taking treating or making the final payment.

11.  Further it is also to be seen that no defence was put forth by the opposite parties that the treatment undergone by the complainant was not recovered under the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme.  Therefore, mere bald defence that the entitlement of the complainant for the benefit under the insurance schemes was not brought to their knowledge could not be accepted.  In the facts and circumstances, we hold that the 1^st opposite party Hospital committed deficiency in service in not accepting the financial assistance provided under the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme as the complainant had very well established by documentary evidences that the Hospital accepts the welfare scheme (Ex.A10), the possession of the complainant Chief Minister’s Medical Insurance Scheme card (Ex.A3) and the proof for medical expenses made by him  a sum of Rs.3,64,672.76/-(Ex.A6).  Thus we answer the point accordingly in favour of the complainant and as against the 1^st opposite party.

Point No.2:-

12. As we have held above that the 1^st opposite party/Hospital Authorities had committed deficiency in service in not accepting the Chief Minister’s Medical Insurance Scheme and Prime Minister’s Medial Insurance Scheme for the treatment undergone by the complainant and making him to spend around Rs.3,64,672/- we deem it appropriate to direct the 1^st opposite party/Hospital Authorities to reimburse the said amount to the complainant.  Further for the deficiency in service committed by them we award a compensation of Rs.50,000/- to be paid to the complainant for the mental agony and hardship undergone by him. We also award Rs.5,000/- towards litigation expenses to the complainant.

In the result, the complaint is dismissed against the opposite parties 2 & 3 and partly allowed against the 1^st opposite party directing them

a) To repay the medical expenses to the complainant a sum of Rs.3,64,673/-(Rupees three lakhs sixty four thousand six hundred and seventy three only) within six weeks from the date of receipt of copy of this order;

b) To pay a sum of Rs.50,000/- (Rupees fifty thousand only) towards compensation for the mental agony and hardship caused to the complainant;

 c) To pay a sum of Rs.5,000/- (Rupees five thousand only) towards litigation expenses to the complainant;

d) Amount in clause (a) if not paid within four weeks from the date of receipt of copy of this order, interest at the rate of 12% will be levied on the said amount from the date of complaint till realization.

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this 08^th day of April 2024.

  Sd/-                                                           Sd/-                                                             Sd/-

MEMBER-II                                        MEMBER-I                                              PRESIDENT

List of document filed by the complainant:-

 List of documents filed by the 2^nd & 3^rd opposite parties:-

-Nil-

   Sd/-                                                                     Sd/-                                              Sd/-

MEMBER-II                                              MEMBER-I                                      PRESIDENT