Complainant by filing this complaint has submitted that due to high fever of the wife of the complainant on 09.11.2013 the wife of the complainant was admitted to Divine Nursing Hone under the Dr. Indranil Sinha Roy and at the time of admission, the complainant reported to the Nursing Home Authority that his financial condition is very poor and he has been holding a medicalim policy.  So, the Nursing Home Authority may take such step for cashless benefit of the said treatment and complainant supplied the details of his mediclaim policy and after considering that the Divine Nursing Home Authority received Rs. 5,000/- and they assured that they shall have to take all such steps for cashless benefit. 

But after lapse of 4 days, it was reported over phone that only Rs. 10,000/- has been sanctioned by the National Insurance Co. and balance amount shall be received after some days and on the date of discharge of the complainant -s wife.  But on 21.11.2013 when complainant went to bring his wife after her discharge, the Divine Nursing Home Authoritysubmitted that his cashless benefit has been cancelled and so complainant was asked to pay Rs. 62,185/- as final billing amount, otherwise his wife shall not be released.

Thereafter complainant talked with G.M. and other authorities of the Divine Nursing Home and ultimately the matter was settled and complainant was compelled to pay further amount of Rs. 38,785/- i.e. total amount of Rs. 43,785/- and thereafter his wife was discharged.  In fact the Divine Nursing Home Authority deceived the complainant and even after receipt of the said amount did not hand over the bill and details paper.  Thereafter the complainant consulted Insurance Authorities and came to learn that due to error of the Divine Nursing Home Authority about cashless benefitclaim amount was rejected and for which complainant was somehow collected the said amount and ultimately deposited the same and for not supplying the detail of the bill, treatment sheet etc., complainant is unable to submit his claim against Mediclaim Policy to the Insurance Authority.

Moreover complainant paid Rs. 1,710/- for two days at AMRI Hospital and for such sort of negligent and deficient manner of service, complainant filed this complaint for directing the Divine Nursing Home Authority to submit the entire treatment sheet, bed ticket and other bills and papers in details and also complainant for negligent and deficient manner of service on the part of the Divine Nursing Home Authority and also causing harassment to the complainant has prayed for compensation of Rs. 50,000/-.

On the other hand Divine Nursing Home Authority op no.1 after filing written statement submitted that it is completely not maintainable in the eye of law and only for the purpose to grab some money, this complaint is filed.  But it is submitted that at the time of admission of the complainant, complainant intimated the Divine Nursing Home Authority regarding his manner if facility by the Insurance Co. and accordingly for cashless facilities the Divine Nursing Home Authority prepared necessary paper work for cashless benefit to be obtained by the Insurance Co. and accordingly op no.1 made necessary arrangement for authorization from the TPA and the permission of the patient and her family members the diagnosis of the fever revealed after several tests and examinations as prescribed and advise of the doctor to the TPA.

It is further submitted that if TPA turns down the claim of the complainant it could not be countable as the failure of op no.1.  It is accepted by the complainant at the time of admitting the patient that in any case medi-claim is denied the patient is liable to pay the same.  When it is the discretion of the Mediclaim Authority and their authorized TPA, who turned down the claim only showing some lame excuses and stopped the payment though the patient was admitted with problem and it is further submitted that all the claims of the complainant is false and fabricated and the allegations are false and denied all allegations as made by the complainant and submitted that it is filed only to harass the Divine Nursing Home Authority and fact remains op rendered their full service and complainant paid initially Rs. 5,000/- and thereafter deposited the part of balance amount out of total amount and now the complainant is unwilling to pay the balance amount of total bill and for which they have submitted this false complaint against the Divine Nursing Home Authority.

On the other hand the Insurance Co. by filing written statement submitted that in this case complainant has tried to show that the cashless benefit was not considered by the op no.2 and admitted fact is that the complainant -s wife was admitted to the Divine Nursing Home and at the time of discharge it was intimated by the Divine Nursing Home Authority that the cashless facility was rejected and being aggrieved of the said same the complaint has been filed by the complainant and in fact the present complaint is filed by the complainant for refusal of cashless facilities by the Divine Nursing Home Authority.  But no relief has been sought for against the answering party.  So, op no.2 cannot be a party in this proceeding and when no relief has been paid by op no.2 Insurance Co.  So, the complaint should be dismissed.

Decision with reasons

On overall evaluation of the complaint including the written statement as filed by the Divine Nursing Home Authority op no.1 and Insurance Co. op no.2 and also considering the specific case of the complainant as averred in the complaint and further hearing the Ld. Lawyers of both the parties, it is found that there is no claim against the op no.2 the Insuarnace Co.  But from the complaint, it is found that relief has been sought for against the Divine Nursing Home Authority op no.1.  So, apparently we are convinced to hold that the present case is not tenable against the op no.2 the National Insurance Co. Ltd.

But regarding the allegation of the complainant, it is found that op no.1 Divine Nursing Home Authority has admitted that RumaMondal the wife of PradipMondal the complainant of Ashutosh Mukherjee Road, Budge Budge, Kolkata – 700137 was admitted to op no.1 -s hospital/nursing home on 19.11.2013 and was discharged on 21.11.2013 and she was under the treatment of Dr. Indranil Sinha Roy and RumaMondal was admitted to said Divine Nursing Home by her brother Tapas Makhal and during her treatment she was examined by doctors and fact remains that she was suffering from fever for last 5 days and she was vomiting for last 3 days and known case of Bronchial Asthma and during investigation on 10.11.2013 it was diagnosed that she was suffering from Typhiod fever and on investigation it was found that she was also suffering from EU Type of Typhiod and cashless benefit form was submitted along with doctor -s advice, investigation report asked by TPA, the bills during the treatment of the patient and other documents required by the TPA and truth is that for cashless benefit all papers were properly sent to TPA and on 11.11.2013 that matter was reported to TPA by the Divine Nursing Home Authority.

It was also reported that she was admitted for fever for last 5 days and vomiting for last 5 days with known case of Bronchial Asthma and it was reported that estimated expense would be for 7 days of Rs. 27,900/- and prospective date of treatment was also reported for 7 days and as per query of TPA, all papers against the patient RumaMondal was submitted by the family members of RumaMondal to the Divine Nursing Home Authority.  Cashless benefit was granted on 13.11.2013 to the extent of Rs. 10,000/- only but RumaMondalwas released on 21.11.2013after full recovery and in the discharge report it was noted that Enteric Fever and at the time of discharge the final bill was handed over to the complainant to the extent of Rs. 62,185/- and the doctor -s fees was fixed of Rs. 18,400/-, testing charge was Rs. 13,060/-,medicine charge was of Rs. 1,390/-, bed charge of Rs. 9,100/-, equipment charge of Rs. 320/-, service charge of Rs. 3,409/- and op no.1 after final bill claimed Rs. 62,185/- and it is also evident from the fact and materials that TPA denied cashless facility due to change for diagnosis in pre-authorised form and discharge summary issued by hospital.  So on 21.11.2013 TPA cancelled that claim and at the time of discharge, complainant paid only Rs. 38,785/- and in total the op no.1 Divine Nursing Home Authority received Rs. 43,785/- and that amount was taken as cashless was denied and the bill was also handed over to the complainant.

It is also proved that as per written procedure all the papers and bills were sent to TPA at before discharge but fact remains that treatment was given properly to RumaMondal by the Divine Nursing Home Authority.  Then question is what is the dispute for which the complaint is filed?

Fact remains that complainant has alleged that Divine Nursing Home Authority has not supplied the entire treatment sheet and related bills for medicines, doctor -s fees, etc. including the diagnosis reports and testing report etc.  But op has not specifically mentioned in the written version that they supplied all original of the bed head ticket, treatment sheet, tests report, final bill etc. and truth is that without those documents, complainant cannot file claim before the Insurance Company and no doubt complainant has paid Rs. 43,785/- that means service was hired by the complainant on payment of good money.

So, in that case it was the duty of the op no.1 to hand over all original documents related to bed head ticket along with bills for medicines, doctor -s fees, test report along with other reports but that has not been supplied by the op no.1 to the complainant which is no doubt an unfair trade practice on the part of the op no.1 and such sort of practice should not be continued by the hospital authority.  But Divine Nursing Home Authority has his moral and social duty to hand over all the documents to the patient.  When admitted fact is that there is mediclaim policy in respect of the patient and without filing the original documents the patient cannot get any relief from the Insurance Company.

Anyhow we have gathered that the attitude adopted by the Nursing Home Authority is not social and moral and practically for detaining all those documents by the op no.1 they have caused psychological, mental sufferings and pain to the complainant and his wife the patient and considering the above fact and circumstances, we are allowing this complaint for detaining all those documents by the op in original.  For some reasons they have not received the entire amount as claimed by the op no.1.  But fact remains that complainant already paid Rs. 43,785/-.  But no such letter was issued to the complainant that they are bound to pay balance amount i.e. out of total claim of Rs. 62,185/-.

In view of the above fact and circumstances and considering all the materials in record we are allowing this complaint.

Hence, it is

ORDERED

That the complaint be and the same is allowed on contest against op no.1 by dismissing the same against op no.2 and op no.1 shall have to pay the litigation cost of Rs. 5,000/- to the complainant.

Op no.1 is hereby directed to handover all original copy of bedded ticket, treatment sheet, medical bills, tests reports along with fees of doctor etc. within 15 days from the date of this order failing which for disobeyance and non-compliance of the Forum -s order, op no.1 shall have to pay penal damages  at the rate Rs. 200/- per day till full satisfaction of the decree and op no.1 shall have to pay the litigation cost also within 15 days from the date of this order.

Even if it is found that op no.1 is reluctant to comply the order of this Forum, in that case, legal proceeding u/s 27 of C.P. Act 1986 shall be started against op no.1 for which they shall be liable to pay further penalty and interest.

Op no.2 is directed to dispose the claim application if any filed by the complainant after getting the original copies of the treatment sheet and other papers as per spirit of this order and in that case the claim application shall be treated as valid application for settlement by the op no.2 and op no.2 shall not anyway reject the said claim on the ground on any limitation and op no.2 shall invariably act as per spirit of this order.

At the same time complainant shall get such a chance to file the claim application against such bill for such treatment of his wife before the Insurance Authority on receipt of the original documents from the op no.1 as per spirit of this order.