FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application u/s.12 of the C.P. Act, 1986.
The father of the complainant Sri Paresh Nath Paul was admitted to the Desan Hospital and Heart Institute, Desan More, Kasba Goalpark, EM By Pass, Kolkata-700107 on 08.11.2016 for treatment of his vascular veins. A letter from the competent authority from the petitioner’s office of Gun and Shell Factory, Kolkata -700002 dated 02.11.2016 addressed to OP-2 informing that treatment/diagnostic facilities to be extended to the father of the complainant as admissible under CGHS, Kolkata. The petitioner is entitled for Semi Pvt. Ward category. On the basis of the said letter dated 02.11.2016, the OP No. 1 to 3 was agreed to under take and continue the treatment of the father of the complainant. The OPs accepted the norms of CGHS package rate and accordingly, started treatment. The complainant submitted claim amount of Rs. 47,916/- to his office and the office disallowed an amount of Rs. 38,000/- being the amount as excess payment apart from CGHS package rate. When asked about the excess of Rs. 38,000/- the OPs made a lame excuse saying that “after O T, patient, not up to mark for that reason, attending physician decided for staying this patient for another two days”. As per Central Government Health Scheme the empanelled health care organization cannot charge more than CGHS approved rates when a patient is admitted with prior permission or under emergency. In case of any instance of overcharging, the over charged amount over and above CGHS rate (except inadmissible items and difference paid due to implant/stent of a specific brand chosen by CGHS beneficiary) shall be paid to the beneficiary and shall be recovered from the pending bill of the hospital. The OP No. 1 to 3 in spite of having clear guide lines from the CGHS authority have clearly violated the norms and claimed additional amount. The complainant sent legal notice to the OPs dated 28.07.2017 to realize excess amount of Rs. 38,000/- but no result was received by him. The complainant therefore, approached the commission for relief/reliefs as per the prayer mentioned in the complaint petition.
The OP Nos. 1 and 2 has contested the case by filing WV contending inter alia that the complainant is not a consumer and the affidavit as appears from the complainant has not been affirmed by the consumer or the person competent to affirm affidavit. The complainant is represented by Sri Paresh Nath Paul but the body of the complaint does not disclose any authorization what so ever in favour of the nominated representative. Hence, the complainant is per se defective and is liable to be dismissed in limini. As per submission of the OP No. 1 and 2 the complainant admitted his father in the hospital on 08.11.2016 with a complaint of vericose veins ulcer on right leg. On admission required medical care and investigations were done which took two days before his vericose veins surgery. The surgery was done under two days package as per CGHS prescribed rate as the patient was beneficiary of CGHS. The hospital bills for patient before surgery was also raised as per the rate prescribed under the CGHS and accordingly, before the surgery under package, total hospital bills covering bed charges, doctor fees, pharmacy charges etc was raised Rs. 36684/- as detailed in the bills given to the complainant. After he was found stable and clinically fit for surgery, surgery was done under the package being listed as No. 393 (varicose brain surgery) for the period from 10.11.2016 to 12.11.2016. The package was for two days and as such no charges whatsoever for consumables, consultation, dressing medicine charges cost of surgical disposables, anesthesia charges etc was taken separately as it was under two days packages. Surgery was uneventful and 12.11.2016, the date following the surgery, he was planned to be discharged but such discharge was kept on hold since the patient developed allergic effect requiring extension of stay in the best interest of the patient which was not very common in such surgery and not foreseen. On 13.11.2016 the condition of the patient improved and there was no sign of allergic reactions and accordingly, discharged on 14.11.2016 in a aerodynamically stable condition. The patient was required to stay in the hospital for two more days for recovery after expiry of two days package period which is not a normal case. The hospital bills were raised in terms of the prescribed rate as fixed under the CGH scheme for Kolkata based NABH accredited Hospitals. The Hospital bills amounting to Rs. 47916 was settled. It is also stated by the OP 1 and 2 that there is no Company Secretary at present. Notice was received inadvertently by the OP-1. It is also stated that the vascular surgery since falls under the package of two days duration covering the day following surgery as post operative days, no charge for those days were separately raised. Complainant father admitted in executive word for the purpose of vascular surgery and not for treatment and such surgery was conducted under the prescribed package of CGHS. It was also not admitted that an amount of Rs. 38,000/- was disallowed as excess amount as alleged. The patient party was duly explained about the estimated cost of two days package of vascular surgery for which the patient was admitted and cost of hospitalization beyond the package period. The amount claimed by the complainant is misconceived having no merit at all. The OP 1 also replied to the notice denying and disputing the allegations and claimed made therein.
The OP 4 has also submitted WV contending inter alia that the petition is not maintainable in its present form and admitted that permission was granted to undergo vascular surgery for the father of the complainant in Desan Hospital being the OP 1, 2 and 3 at par with CGHS rate. The complainant submitted final bill of Rs. 47916/- out of which Rs. 9916/- was passed disallowing Rs. 38,000/-. On reply to the query of the complainant regarding disallowing of Rs. 38000/- it was stated that package rate shall mean and include operation cost of inpatient treatment/day care or for treatment under emergency from time of admission to the time of discharge. The complainant submitted a letter dated 24.02.2017 enclosing a clinical justification letter from the said hospital wherein it was started the condition of the patient was not up to the mark. The complainant sent another letter dated 17.03.2017 to review the case. On reply the OP 4 explained that as per CGHS rule, the package for surgical procedure includes all routine test, medicine along with other charges but it appears from the bill that Desun Hospital has tactfully prepared the bill keeping all other charges outside the operation charges which should have actually been within the package rate. The OP 4 further stated that as per CGHS rule over stay beyond the permissible period of stay within the package rate can be justified in exceptional cases, supported by relevant medical record and certified as such by the hospital for reimbursement of charges beyond the permissible stay. This was made known to the complainant by the OP 4 vide letter dated 17.03.2017and also several tines over phone but the complainant did not comply the requirement for which the OP 4 could not have resubmitted the claim to the authority concerned for settlement of disallowed amount. Desun Hospital (OP NO. 1,2 &3 ) is one of the empanelled hospital under CGHS and well aware of the CGHS rate for Vascular Surgery But the bill raised by the OP 1 & 2 is far high from the CGHS rate. The OP 4 cannot go against the rules framed under CGH Scheme. The allegations are against the Hospital being OP no. 1,2 & 3 where they have been impleaded unnecessary party.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the Complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. The complainant & the OPs have filed their respective Evidence supported by affidavit. They have also filed replies to be questionnaire set forth by their adversaries. They have also submitted their BNAs.
Facts remain that the father of the complainant was admitted in Desun Hospital being the OP 1 and 2 and had undergone vericose vein surgery in the said OP Hospital. The admission as well as operation of the beneficiary of the complainant was based on the advice of the OP 4 to the OP 1 and 2 vide letter dated 2.11.2016 wherein it was categorically mentioned that the treatment will be under CGH Scheme and the patient is entitled to the benefits under semi private ward category according to the basic pay of Sri Arnab Paul being the complainant. The total bill for the said treatment was Rs.47,916/- which was placed before the OP – 4 for reimbursement. But OP 4 disallowed Rs.38,000/- as excess payment apart from CGHS package rate.
Now let us consider the case with the relevant clauses of the Agreement in between the OP Hospital and CGHS Authority, Govt. of India.. In respect of definitions and interpretations under clause No. 01 and sub clause 1.1.15 of the said agreement.
“CGHS Package Rate” shall mean all inclusive- including lum sum cost of in patient treatment /day care/ diagnostic procedure for which a CGHS beneficiary has been permitted by the competent authority or for treatment under emergency from the time of admission to the time fo discharge including (but not limited to)- (i) registeration charges, (ii) admission charges, (iii) accommodation charges including patients diet (iv) operation charges, (v) injection charges, (vii) Dressing charges, (vii) doctor/ consultant visit charges, (viii) ICU/ICCU charges (ix) monitoring charges, (x) transfusion charges, and blood processing charges, (xi) Pre Anesthetic check up and Anesthesia charges (xii) Operation theatre charges, (xiii) Procedureal charges/surgeon’s fee (xiv) cost of surgical disposables and all sundries used during hospitalization, (xv) cost of medicine and consumables, (xvi) Related routine and essential investigations, (xvii) physiotherapy charges, etc., (xviii) Nursing care charges, etc.
The patient being the beneficiary of the CGHS is admitted to the OP hospital with prior permission of the competent authority vide letter dated 02.11.2016 addressed to the OP hospital. There was clear mentioning of the treatment of vascular surgery in the said letter. The patient got admitted on 08.11.2016 and was discharged on 14.11.2016. This is admitted by all the parties involved herein.
The CGHS package rate as mentioned above is inclusive of all expenses related to Admission , room rent, medicines, Operation including operation theatre charges, Anesthesia charges, related routine and investigation charges, Doctor/Consultant visit charges, Cost of surgical disposables and all sundries used during hospitalization.
While perusing the expense details we do not find any item of expenses which is not covered under the above scheme. Moreover, the scheme covers the expenses from the time of admission to the time of discharge. The package rate also include two pre operative consultations and two post operative consultations.. It is also worthy to mention that as per the agreement no additional charge on account of extended period of stay shall be allowed if that extension is due to infection on the consequences of surgical procedure/faulty investigation procedure etc. As per Clinical Justification Certificate given by the OP 1 & 2“ After OT, Patient condition not upto the mark, for that reason attending physician decided for staying of this patient for another two days.” So the overstayal in the hospital due to infection on the consequences of the surgical procedure / faulty
investigation procedure etc. cannot be ruled out. Even for genuine reason if the overstayal is justified then that expenses are also allowed to the beneficiary
It is also mentioned in the said clause in subsequent para that
“ If the beneficiary has to stay in the hospital for his or her recovery for a period more than the period covered in package rate, in exceptional cases, supported by relevant records and certified as such by hospital, the additional reimbursement may be allowed, which shall be limited to accommodation charges as per entitlement, investigation charges at approved rates, doctors visit charges ( not more than 2 visits per day per visit by specialists / consultants ) and costs of medicines for additional stay ).
No additional charge on account of extended period of stay shall be allowed if that extension is due to infection on the consequences of surgical procedure / faulty investigation procedure etc.
The empanelled health Care Organisation cannot charge more than CGHS approved rates when a patient is admitted with valid CGHS Card with prior permission or under emergency. In case of any instance of overcharging the overcharged amount over and above CGHS rate (except inadmissible items and difference paid due to implant/stent of a specific brand choosen by CGHS beneficiary) shall be paid to the beneficiary and shall be recovered from the pending bills of the hospital.
As such payment from the beneficiary arising for overstayal is against the terms of the Agreement. In no way the beneficiary is liable to pay any overcharged amount. The agreement is very much clear and pin pointing. All aspects have been rightly covered under the scheme. One aspect we must mention that the OP 4 cannot wash out their hands by simply issuing a letter to submit all papers relevant to the treatment. Specially when there is clear admission on the part of the OP 4 that the bills of the hospital are far high and expressed their doubt in the said billings.
The patient party is really helpless in the situation. They can only request the hospital authority to supply necessary papers and nothing else. If the papers are not found in order it is the duty of the OP 4 to obtain the same from the hospital authority by exercising their own inherent power which is found absent in the instant case. The OP 4 has admitted the clever conduct of the hospital in their Evidence but did not perform their duty which is not expected of from them. In view of the above observation we are of the considered view that the complainant has been able to establish the case against the OPs.
In the result, the Consumer Complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on contests against the OPs with the following directions
- The OP 1 & 2 are directed to refund Rs.38,000/- to the complainant taken as excess payment.
- The OP 1 & 2 are further directed to pay a sum of Rs.5,000/- as compensation to the complainant for mental agony and harassment,
- The OP 1 & 2 are also directed to pay Rs.5,000/- to the complainant as litigation costs.
The above orders are to be complied with within a period of 30 days from the date of the order in default the complainant will be at liberty to put the order into execution..
